A Manual of Laboratory & Diagnostic Tests

Editors:
Fischbach, Frances Talaska T itle: Manual of Laboratory &

Diagnostic Tests, 7th Edition Copyright 2004 Lippincott Williams &
Wilkins
> Fr ont of B ook > E ditor s
EDITOR
Frances Talaska Fischbach RN, BSN, MSN
Associat e Clinical Prof essor of Nursing
Depart ment of Healt h Rest orat ion, School of Nursing, Universit y of WisconsinMilw aukee, Milw aukee, Wisconsin; Associat e Prof essor of Nursing (Ret ), School
of Nursing, Universit y of Wisconsin-Milw aukee, Milw aukee, Wisconsin
SECONDARY EDITORS
Marshall Barnett Dunning III BS, MS, PhD
Associat e Prof essor of Medicine
Depart ment of Medicine, Division of Pulmonary/ Crit ical Care Medicine, Medical
College of Wisconsin, Milw aukee, Wisconsin; Direct or, Pulmonary Diagnost ic
Laborat ory, Froedt ert Memorial Lut heran Hospit al, Milw aukee, Wisconsin
Q uincy McDonald
Acquisit ions Edit or Sharon Now ak/ Marie Rim Edit orial Assist ant Debra Schiff
Senior Product ion Edit or Helen Ew an
Senior Product ion Manager Erika Kors
Managing Edit or / Product ion Carolyn O 'Brien
Art Direct or
BJ Crim
Design
William Alberti
Manuf act uring Manager Alexandra Nickerson
I ndexer
Compositor: Circle G raphics Printer: RR DonnelleyCrawfordsville
CONSULTANTS, REVIEWERS, AND RESEARCH

ASSISTANTS
Corrinne Strandell RN, BSN, MSN, PhD
Nursing Research, Home Care and Rehabilit at ion Specialist
West Allis, WI
Bernice G estout DeBoer RN, BSN, CPAN
Parish Nurse
Covenant Heal th Care, Mi l waukee, WI
Mary Pat Haas Schmidt BS, MT
Manager
Laboratory Servi ces, Pre-i nsurance testi ng; Instructor, Medi cal technol ogy,
Waukesha, WI
Jean Schultz ES, RT, RD, MS
Direct or of Ult rasound and Radiology Educat ion
St . Luke's Medical Cent er, Milw aukee, WI
Patricia Pomohac MT (ASCP) Supervisor
Di agnosti c Immunol ogy, Department of Pathol ogy, Uni ted Regi onal Medi cal
Servi ces, Inc. , Mi l waukee, WI
Teresa Friedel Abrams RN, BSN, MSN
G eriat ric Nurse Specialist
Menomonee Falls Healt h Care Cent er, Menomonee Falls, WI
Carol Colasacco CT (ASCP), CMIAC
Cyt ot echnologist
Department of Pathol ogy, Fl etcher Al l en Heal th Care, Burl i ngton, VT
Emma Felder RN, BSN, MSN, PhD
Prof essor Emerit us
Nursi ng, Uni versi ty of Wi sconsi n-Mi l waukee, Mi l waukee, WI
Ann Shafranski Fischbach RN, BSN
O ccupati onal Heal th; Case Manager, Johnson Control s, Mi l waukee, WI
Bonnie G rahn RN, CIC
I nf ect ion Cont rol Coordinat or
Froedt ert Memorial Lut heran Hospit al, Milw aukee, WI
Roger G roth
O pht halmic Technologist
Eye I nst it ut e, Froedt ert Memorial Lut heran Hospit al, Milw aukee, WI
G ary Hoffman
Manager
Laboratory f or Newborn Screeni ng, State of Wi sconsi n, Madi son, WI
Karen Kehl PhD
Assist ant Prof essor-Pat hology
Children's Hospit al of Wisconsin, Milw aukee, WI
Susan Kirkpatrick MS
G enet ic Counselor
Wai sman Center, Madi son, WI
Stanley F. Lo PhD
Assist ant Prof essor-Pat hology
Lynn Mehlberg ES, CNMT

Direct or
Q ual i ty Assurance-Imagi ng Department, St. Luke's Medi cal Center, Mi l waukee,
WI
Deborah B. Martin RN, BSN
Communit y Healt h Nurse
Balt imore Cit y Healt h Depart ment , Mat ernal and I nf ant Program Field O ff ice,
Balt imore, MD
Lorraine Meisner PhD
Cyt ogenet ics
State Laboratory of Hygi ene, Madi son, WI
Christine Naczek MT (ASCP) Manager
Bl ood Banki ng and Pre-Transf usi on Testi ng, Department of Pathol ogy, Uni ted
Regi onal Medi cal Servi ces, Inc. , Mi l waukee, WI
Anne Witkowiak Nezworski RN, BSN
Mat ernit y and New born Specialist
Sacred Heart Hospit al, Eau Claire, WI
Joseph Nezworski ES, RN, BSN
Chief Deput y Medical Examiner
Eau Claire Count y, Eau Claire, WI
Richard Nuccio BA, MA, MBA, CNMT, RT (ASCP)
G lobal Product s, G eneral Elect ric Medical Syst ems, Milw aukee, WI
Annette O 'G orman RN, ESN, MSNCS
Family Nurse Pract it ioner
EM Care S. C. , Milw aukee, WI
Tracey Ryan RD
Chief Clinical Diet it ian
Julie Saavedra RN, BA, BSN, CG RN
Nursing Manager
Department of Endoscopy, Rush-Presbyteri an-St. Luke's Medi cal Center,
Chi cago, IL
John Shalkham
Program Direct or f or School of Cyt ot echnology
St at e Laborat ory of Hygiene, Clinical Assist ant Prof essorDepart ment of
Pat hology, Universit y of Wisconsin, Madison, WI
Eleanor C. Simms RNC, BSN
Specialist
Nursi ng Student Enri chment Program, Coppi n State Col l ege, Hel ene Ful d
School of Nursi ng, Bal ti more, MD
Nancy A. Staszak RN, BSN, CCRN
Educat ion Coordinat or-Q A & St aff Development
Frank G . Steffel BS, CNMT
Program Direct or-Nuclear Medicine Technology
Depart ment of Radiology, Froedt ert Memorial Lut heran Hospit al, Milw aukee, WI
Rosalie Wilson Steiner RN, BSN, MSN, PhD
Communit y Healt h Specialist
Milw aukee, WI
T hudung T ieu
Q A/ Saf et y Coordinat or
Unit ed Dynacare Laborat ories, Milw aukee, WI
Jean M. Trione RPh
Clinical Specialist
Wausau Hospit al, Wausau, WI
Beverly Wheeler RN, BSN, MSN, CS
Cardiology; Cardiot horacic Nurse Specialist m
Nat ional Naval Medical Cent er, Bet hesda, MD
Michael Zacharisen MD
Assist ant Prof essor-Pediat rics
Editors: Fischbach, Frances Talaska

T itle: M anual of Laboratory & D i agnosti c Tests, 7th Edi ti on
Copyright 2004 Lippincot t Williams & Wilkins
> Fr ont of B ook > D E D IC ATIO N
DEDICATION
To Michael, Mary, Paul, and Margaret
Editors: Fischbach, Frances Talaska T itle: Manual of Laboratory &

Wilkins
> Fr ont of B ook > P R E FAC E
PREFACE
PURPOSE
The purpose of A Manual of Laboratory and Di agnosti c Tests, in t his Sevent h
edit ion, is t o promot e t he delivery of saf e, eff ect ive, and inf ormed care f or
pat ient s undergoing diagnost ic t est s and procedures and also t o provide t he
clinician and st udent w it h a unique resource. This comprehensive manual
provides a f oundat ion f or underst anding t he relat ively simple t o t he most highly
complex diagnost ic t est s t hat are delivered t o varied populat ions in varied
set t ings. I t describes t he clinician's role in providing eff ect ive diagnost ic services
in dept h, t hrough aff ording t he necessary inf ormat ion f or qualit y care planning,
individualized pat ient assessment , analysis of pat ient needs, appropriat e
int ervent ions, pat ient educat ion, pat ient f ollow -up, and t imely out come
evaluat ion.
Pot ent ial risks and complicat ions of diagnost ic t est ing mandat e t hat proper t est
prot ocols, int erf ering f act ors, f ollow -up t est ing, and collaborat ion among t hose
involved in t he t est ing process be a signif icant part of t he inf ormat ion included in
t his t ext .
ORGANIZATION
This book is organized int o 16 chapt ers and 12 appendices. Chapt er 1 out lines
t he clinician's role in diagnost ic t est ing and includes int ervent ions f or saf e,
eff ect ive, inf ormed pre-, int ra-, and post t est care. This chapt er includes a
Pat ient 's Bill of Right s and Responsibilit ies, a model f or t he role of t he clinical
t eam in providing diagnost ic care and services, t est environment s,
reimbursement f or diagnost ic services, and t he import ance of communicat ion as
key t o desired out comes. The int rat est sect ion is expanded t o include
inf ormat ion about collaborat ive approaches f acilit at ing f amily presence during
invasive procedures, risk management , t he collect ion, handling, and t ransport of
specimens, inf ect ion cont rol, cont rolling pain, comf ort measures, administ rat ion
of drugs and solut ions, monit oring f luid int ake and loss, using required equipment
kit s and supplies, properly posit ioning t he pat ient f or t he procedure, managing
t he environment , and pat ient monit oring. The reader is ref erred back t o Chapt er
1, Diagnost ic Test ing, t hroughout t he t ext f or inf ormat ion about t he clinician's
role and diagnost ic services. Chapt er 2, Chapt er 3, Chapt er 4, Chapt er 5,
Chapt er 6, Chapt er 7, Chapt er 8, Chapt er 9, Chapt er 10, Chapt er 11, Chapt er
12, Chapt er 13, Chapt er 14, Chapt er 15 and Chapt er 16 f ocus upon specif ic
cat egories t hat include:
Chapter 2: Blood Studies

Ch apter 3: Urin e Stu dies
Chapter 4: Stool Studies

Ch apter 5: Cerebrospin al Flu id Stu dies
Chapter 6: Chemistry Studies

Ch apter 7: Microbiologic Stu dies
Chapter 8: Immunodiagnostic Studies

Ch apter 9: Nu clear Medicin e Stu dies
Chapter 10: X-ray Studies

Chapt er 11: Cyt ology, Hist ology, and G enet ic St udies
Chapter 12: Endoscopic Studies

Ch apter 13: Ultrasou n d Stu dies
Chapt er 14: Pulmonary Funct ion and Blood G as St udies
Chapt er 15: Prenat al Diagnosis and Test s of Fet al Well-Being
Chapt er 16: Special Syst ems, O rgan Funct ions, and Post mort em St udies
CHAPTER CONTENT AND FEATURES

Background rat ionale
Test purpose
I nt erf ering f act ors
Descript ion of t he procedure prot ocol and t ime f rames and t est complet ion
Ref erence ranges and normal values, expect at ions
Pat ient involvement (eg, hist ory of signs and sympt oms, body posit ion,
breat hing inst ruct ions, elect rode placement , compliance issues, pat ient right
t o ref use t est ing)
Met hod of specimen collect ion (biohazard guidelines), handling, and
t ransport at ion
Clinical implicat ions w it h int erpret at ion of abnormal f indings, unexpect ed
out comes, and disease pat t erns
I nt ervent ions f or pret est pat ient preparat ion (medicat ions, f ast ing),
explanat ion of benef it s and risks, int rat est pat ient care (appropriat e
monit oring, conscious sedat ion), and post t est pat ient af t ercare (includes
monit oring, explanat ion of f urt her t est ing and t reat ment modalit ies)
Special f eat ures int egrat ed int o t he f ormat include:
The clinician's role in providing diagnost ic services.
Clinical Alert s and Educat ion Alert s t hat signal special caut ions.
Specif ic guidelines list ed f or each t est phase.
Expect ed out comes w it h evidence-based pat ient expect at ions and ref erence
ranges as def ined by t he specialt y.
A user-f riendly f ormat of t he t ext t o support easy inf ormat ion ret rieval.
Bot h convent ional and SI unit s are list ed and, w here possible, age-relat ed
ref erence values are also list ed as a component of normal ref erence values.
Numerous examples of t est values and clinical considerat ions f or new born,
inf ant , child, adolescent , and older adult groups w here appropriat e.
A bibliography at t he end of each chapt er represent ing a composit e of
select ed ref erences f rom various disciplines and direct s t he clinician t o
inf ormat ion available beyond t he scope of t his book.
Ext ensive appendices providing t he clinician w it h addit ional dat a f or everyday
pract ice.
Current , complet e, and accurat e cont ent , w hich has been compiled f rom
various mult idisciplinary sources, t hen caref ully scrut inized and cont inually
reevaluat ed.
NEW INFORM ATION IN THE SEVENTH EDITION

The addit ion of many new t est s and met hodologies includes:
New born screening f or inherit ed disease
Updat ed Pap smears and prot ocols f or f urt her t est ing
Cyt okines
Met abolic aut opsy
Tissue (hist ology) biopsies and predict ive markers f or t reat ment response
Test s f or bone disease
Test s f or heart disease, congest ive and acut e MI disease
Microbiological t est ing, biot errorism agent s, det ect ing f ood poisoning,
ant hrax, plague, and hemorrhagic f ever
Breast diagnost ic and prognost ic markers
Fet al predict ive t est s of abnormal development
Breat h t est s f or ulcers, alcohol, lact ose, et c.
Fert ilit y t est s
Expanded scope of magnet ic resonance (MRI ) scans
Expanded scope of sleep/ sleepiness st udies in new borns, children, older
adult s
New nuclear t umor and inf ect ion scans
PET scans combined w it h CT spiral imaging and ult rasound
Duct al lavage f or det ermining G ail I ndex f or breast cancer risk
New sent inel node localizat ion
LEEP G Y N procedure
Eye t est s f or ret inal disorders, macular degenerat ion, visual acuit y, and
glaucoma
Expanded cont ent on keeping records of diagnost ic t est s, use of proper
f orms, and st andardized pat ient report s
Panels of mult iple t est s (e. g. , met abolic syndrome, syndrome X) w it hin
Chapt er 6 Chemist ry Test s
The appendices are complet ely revised and cont ain many addit ions. For
example, Appendix D off ers inf ormat ion regarding collect ion of saliva, breat h,
nail, sput um, and hair specimens. Appendix H provides examples of commonly
used f orms and inf requent ly used f orms (videot aping, ref usal). Appendix L deals
w it h guidelines f or collect ing evident iary specimens.
Revised chapt ers include changes in t he clinician's role and ref lect current
laborat ory and diagnost ic pract ice st andards.
Throughout t he t ext , a great er emphasis is placed upon communicat ion skills and
collaborat ion bet w een pat ient s, t heir signif icant ot hers, and healt h prof essionals
f rom diverse disciplines. When clinicians see pat ient s in t he cont ext of w hat t he
pat ient and loved ones are experiencing (ie, sit uat ional needs, expect at ions,
previous experiences, and t he environment in w hich t hey live), only t hen can t hey
off er meaningf ul support and care. When pat ient s believe t he clinician is on t heir
side, t hey have an increased sense of cont rol. I dent if ying w it h t he pat ient 's point
of view leads t o a more prof ound level of communicat ion.
CURRENT DEVELOPM ENTS IN LABORATORY AND

DIAGNOSTIC TESTING
New t echnologies f ost er new scient if ic modalit ies f or pat ient assessment and
clinical int ervent ions. Thus, t he clinician is provided a great er underst anding of
t he long chain of event s f rom diagnosis t hrough t reat ment and out comes. I n a
brief span of years, new t echnologies have int roduced great ly improved
development s in t ot al body and brain x-ray scanners; digit al and enhanced
imaging; magnet ic resonance (MR); posit ron emission t omography (PET)
scanners, combinat ion scans such as PET and CT t o diagnose cancer and
inf ect ions; great ly enhanced ult rasound and nuclear medicine procedures;
genet ic mut at ion st udies; new t est s f or cancer; new cancer markers f or
diagnosis and prognosis; sleep disorders t est s; t echnology f or f et al t est ing
bef ore birt h, and post mort em t est ing af t er deat h. Many new t echnologies are
f ast er, more pat ient -f riendly, more comf ort able, and provide an equivalent or
higher degree of accuracy (ie, HI V or hepat it is det ect ion, monit oring f or drug
abuse or managing t herapeut ic drug levels). Saliva and breat h t est ing is gaining
ground as a mirror of body f unct ion and emot ional, hormonal, immune, and
neurologic st at us, as w ell as providing clues about f ault y met abolism.
Noninvasive and minimally invasive t est ing, (ie, need only one drop of blood, nail
and hair clippings), w hich is bet t er suit ed f or t est ing in environment s such as t he
w orkplace, privat e home, and ot her nont radit ional healt h care set t ings such as
churches, is made possible by bet t er collect ion met hods and st andardized
collect ion t echniques. New est diagnost ic lab t echnologies include hand-held
nucleic acid det ect ors f or specif ic bact eria and viruses, hand-held miniat urized
chip-based DNA analyzers, reagent less diagnost ics t hat int roduce t he sample
(hand, f inger, ear lobe, et c. ) t o magnet ic f ields, and magnet ic resonance
spect roscopy (MRS). Non-invasive and minimally invasive diagnost ics include
inf rared light t o est imat e glucose, rapid oral screen f or HI V, prot einomics,
f unct ional and molecular t echniques. Managed care and it s drive f or cont rol of
cost s f or diagnost ic services exert s a t remendous eff ect on consumers' abilit y t o
access t est ing services care. This result s in mixed access t o services,
depending upon approval or denial of coverage.
A resurgence in t he use of t radit ional, t rust ed diagnost ic modalit ies, such as
elect roencephalogram (EEG ), is being seen in cert ain areas. Diseases such as
HI V, ant ibiot ic-resist ant st rains of pat hological organisms, and Type 2 diabet es
are becoming more prevalent . I n t he w orkplace, t horough diagnost ic t est ing is
more common as applicat ions are made f or disabilit y benef it s. Also,
requirement s f or periodic monit oring of exposures t o pot ent ially hazardous
w orkplace subst ances (chemicals, heavy met als), breat hing and hearing t est s,
and TB and lat ex allergy t est ing requires skill in administ ering and procuring
specimens. The number of f orensic DNA t est s being perf ormed has increased
t remendously. Concurrent ly, consumer percept ions have shif t ed f rom implicit f ait h
in t he healt h care syst em t o concerns regarding less cont rol over choices f or
healt h care and more dist rust of t he syst em in general.
These t rendscombined w it h a shif t in diagnost ic care f rom acut e care hospit al
set t ings t o out pat ient depart ment s, physicians' off ices, clinics, communit y-based
cent ers, nursing homes, and somet imes even churches, st ores and pharmacies
challenge clinicians t o provide st andards-based, saf e, eff ect ive, and inf ormed
care. Because t he healt h care syst em is becoming a communit y-based model,
t he clinician's role is also changing. Updat ed know ledge and skills, f lexibilit y, and
a height ened aw areness of t he t est ing environment (point of care t est ing) are
needed t o provide diagnost ic services in t hese set t ings.
Clinicians must also adapt t heir pract ice t o changes in ot her areas. This includes
developing, coordinat ing, and f ollow ing policies and st andards set f ort h by
inst it ut ions, government al bodies, and regulat ory agencies. Being inf ormed
regarding et hical and legal implicat ions of such t hings as inf ormed consent ,
privacy, pat ient saf et y, t he right t o ref use t est s, end-of -lif e decisions, and t rends
in diagnost ic research procedures add anot her dimension t o t he clinician's
account abilit y and responsibilit y. The consequences of cert ain t ypes of t est ing
(ie, HI V and genet ic) and t he implicat ions of conf ident ial versus anonymous
t est ing must also be kept in mind. For example, anonymous t est s do not require
t he individual t o give his or her name, w hereas conf ident ial t est s do require t he
name. This diff erence has implicat ions in t he requirement s and process of
agency report ing all pat ient s as w ell as f or select groups of inf ect ious diseases
such as HI V.
Responding t o t hese t rends, t he Sevent h edit ion of A Manual of Laboratory and
Di agnosti c Tests is a comprehensive, up-t o-dat e diagnost ic ref erence source
t hat includes inf ormat ion about new er t echnologies, t oget her w it h t he t imehonored classic t est s t hat cont inue t o be an import ant component of diagnost ic
w ork. I t meet s t he needs of clinicians, educat ors, researches, st udent s, and
ot hers w hose w ork and st udy requires t his t ype of resource or ref erence manual.
Frances Talaska Fischbach

Wilkins
> Fr ont of B ook > AC K NO W LE D GME NTS
ACKNOWLEDGM ENTS
I t is w it h sincere grat it ude and pleasure t hat I acknow ledge t he collaborat ion of
Dr. Marshall B. Dunning f or his diligence, ext ra eff ort , and graciousness in
accomplishing t he t ask of renew al and enhancement f or t he revision of t his t ext ,
f or t he 7t h edit ion, all in a t imely manner.
I w ant t o give special praise and recognit ion t o my husband, Jack Fischbach, t he
best researcher I have ever had; t o Corrinne St randell, Mary Pat Schmidt ,
Bernice DeBoer, Pat Pomohac, and Jean Schult z f or t heir dedicat ion, kindness,
support , and generous help in manuscript preparat ion; t o Kat hie G ordon,
Kat hleen Dunning, Deanne Shmit z, and Margaret Fischbach, f or caref ully
arranging, organizing, and t yping t he manuscript .
I w ould also like t o acknow ledge and t hank all t he review ers, researchers, and
consult ant s w ho provided ideas f or manuscript revision and w hose comment s t o
me have helped make t he book bet t er. This w ork w ould not have been complet e
w it hout t he help and inf ormat ion provided by t he librarians and st aff of t he Todd
Wehr Library of t he Medical College of Wisconsin, t he Marquet t e Universit y
Library, and St . Joseph's Hospit al Library; w it h t hanks t o Dynacare Laborat ories
and Medical Science Laborat ories, especially f or ref erencing t heir Laborat ory
Handbooks, and t o t he I nf ect ion Cont rol St aff , Neuroscience Cent er, Transplant
Services, Transf usion Services, Eye I nst it ut e, at Froedt ert Memorial Hospit al of
Milw aukee, Wisconsin.
Appreciat ion and recognit ion are also due t hese persons w ho helped w it h t his
and previous edit ions: my daught ers, Mary Fischbach Johnson, BS, MS Ed, and
Margaret Fischbach, BA, JD; my son-in-law, Richard Johnson, BA; my daught erin-law, Ann Shaf ranski Fischbach, BSN; and t he hard w ork on t his edit ion and in
t he past of t he ent ire st aff at Lippincot t Williams & Wilkins, especially Sharon
Now ak, Marie Rim, Q uincy McDonald, Debra Schiff , Kim Lilly, Kat hie Barrie, and,
as alw ays, Jay Lippincot t . Writ ing a book is t ruly a labor of love, and t he
process makes me humble and t hankf ul t o many, many individuals, named and
unnamed, w ho have made it possible. Thanks f or a job w ell done.
Frances Fischbach

Wilkins
> Table of C ontents > 1 - D iagnos tic Tes ting
1
Diagnostic Testing
OVERVIEW OF THE CLINICIAN'S ROLE:
RESPONSIBILITIES, STANDARDS, AND REQUISITE
KNOWLEDGE
I n t his era of high t echnology, healt h care delivery involves many diff erent
disciplines and specialt ies. Consequent ly, clinicians must have an underst anding
and w orking know ledge of modalit ies ot her t han t heir ow n area of expert ise. This
includes diagnost ic evaluat ion and diagnost ic services. Laborat ory and
diagnost ic t est s are t ools t o gain addit ional inf ormat ion about t he pat ient . By
t hemselves, t hese t est s are not t herapeut ic; how ever, w hen used in conjunct ion
w it h a t horough hist ory and physical examinat ion, t hese t est s may conf irm a
diagnosis or provide valuable inf ormat ion about a pat ient 's st at us and response
t o t herapy t hat may not be apparent f rom t he hist ory and physical examinat ion
alone. G enerally, a t iered approach t o select ing t est s is used:
1. Basic screening (f requent ly used w it h w ellness groups and case f inding)
2. Est ablishing (init ial) diagnoses
3. Diff erent ial diagnosis
4. Evaluat ing current medical case management and out comes
5. Evaluat ing disease severit y
6. Monit oring course of illness and response t o t reat ment
7. G roup and panel t est ing
8. Regularly scheduled screening t est s as part of ongoing care
9. Test ing relat ed t o specif ic event s, cert ain signs and sympt oms, or ot her
except ional sit uat ions (eg, inf ect ion and inf lammat ion [ bladder inf ect ion or
cellulit is] , sexual assault , drug screening, pheochromocyt oma, post mort em
t est s, t o name a f ew ) (Table 1. 1)
Table 1.1 Examples of Selecting Tests
Diagnostic Test
Indication
Stool occult blood
Yearly screening after 45

years of age
Serum potassium
Yearly in patients on diuretic

agents or potassium
supplements; in cases of
some cardiac arrhythmias
Liver enzyme levels
Monitoring patient on
hepatotoxic drugs; establish
baseline values
Serum amylase
In the presence of abdominal

pain, suspect pancreatitis
Thyroid-stimulating
hormone (TSH) test
Suspicion of hypothyroidism,
hyperthyroidism, or thyroid
dysfunction, 50 years of age
and older
Chlamydia and
gonorrhea
In sexually active persons

with multiple partners to
monitor for pelvic
inflammatory disease
Hematocrit and
hemoglobin
Baseline study; abnormal

bleeding; detection of
anemia (use CBC results if
they are recent)
Papanicolaou
cervical smear (Pap)
Yearly for all women 18

years of age; more often with
high-risk factors (eg,
dysplasia, human
immunodeficiency virus
[HIV], herpes simplex) now
checks for human
papillomavirus (HPV),
chlamydia, and gonorrhea,
using DNA
Urine culture
Pyuria
Syphilis serum
fluorescent
treponemal antibody
(FTA) test
Positive rapid plasma reagin

(RPR) test result
Tuberculosis (TB)
skin test
Easiest test to use for TB

screening of individuals < 35
years of age or those with
history of negative TB skin
tests, for persons in resident
homes
Fasting blood
Every 3 years starting at 45

years of age; monitor
glucose (FBG)
diabetes control
Urinalysis (UA)
Signs or history of recurrent

urinary tract disease;
pregnant women; men with
prostatic hypertrophy
Prothrombin time
(PT) (INR)
Monitoring anticoagulant
treatment
Prostate-specific
antigen (PSA) and
digital rectal
examination
Screen men 50 years of

age for prostate cancer
yearly
Chest x-ray
Monitor for lung lesions and

infiltrates; congestive heart
failure; anatomic deformities,
posttrauma, before surgery,
follow-up for positive TB skin
test and monitor treatment
Mammogram
Screen by 40 years of age in

women, then every 1218
months between 40 and 49
years of age, annually 50
years of age; follow-up for
history and treatment of
breast cancer; routine
screening when strong family
history of breast carcinoma
Screen adults for colon
Colon x-rays and

proctosigmoidoscopy
cancer beginning at age 45;

follow up for presence of
hemoglobin- or guaiacpositive stools, polyps,
diverticulosis
Computed
tomography (CT)
scans
Before and after treatment

for certain cancers, injuries,
illness (eg, suspected
transient ischemic attack,
cerebro-vascular accident;
diagnostic evaluation of
certain signs/symptoms)
DNA testing of hair,

blood, skin tissue, or
semen samples
To gather postmortem
evidence, in certain criminal
cases; to establish identity
and parentage
Some tests are mandated by government agencies

or clinical practice guidelines of professional
societies; others are deemed part of necessary care
based on the individual practitioner's judgment and
expertise or a group practitioner consensus. There
is not a consensus as to the frequency of testing
(eg, annually or after a certain age).
Test select ions are based on subject ive clinical judgment . O f t en diagnost ic t est s
or procedures are used as predict ors of surgical risk and/ or morbidit y and
mort alit y rat es (eg, maximum oxygen consumpt ion det erminat ion t o assess risk
bef ore esophageal cancer surgery) as t he risk may out w eigh t he benef it . Use of
evidence-based guidelines f or scheduling, select ing, ret aining, or eliminat ing
cert ain diagnost ic t est s may help in more eff ect ive case management and cost
cont ainment . These guidelines use a syst em t hat grades t he qualit y of scient if ic
evidence based on published report s of clinical t rials, expert consensus, or
clinical expert ise. Levels of evidence are A t o C and E, w it h A being t he best
evidence and E ref erring t o expert opinion or consensus (Chart 1. 1).
Edu cation Alert

Not all inf ormat ion on t he I nt ernet is reliable.
Ch art 1.1 Grading Guidelines for Scientific Evidence
A.
Clear evidence
from all
appropriately
conducted trials
B.
Supportive
evidence from
well-conducted
studies or
registries
C.
No published
evidence; or only
case,
observational, or
historical
evidence
D.
Expert consensus
or clinical
experience or
Internet polls
A.
Measure plasma
glucose through an
accredited lab to
diagnose or screen for
diabetes
B.
Draw fasting blood

plasma specimens for
glucose analysis
C.
Self-monitoring of
blood glucose may help
to achieve better
control
D.
Measure ketones in
urine or blood to
monitor and diagnose
diabetic ketoacidosis
(DKA) (in home or
clinic)
As an int egral part of t heir pract ice, clinicians have long support ed pat ient s and
t heir signif icant ot hers in meet ing t he demands and challenges incumbent in t he
simplest t o t he most complex diagnost ic t est ing. This t est ing begins bef ore birt h
and f requent ly cont inues af t er deat h. The clinician w ho provides diagnost ic
services must have basic requisit e know ledge t o plan pat ient care and an
underst anding of psychoneuroimmunology (eff ect s of st ress on healt h st at us),
must make caref ul judgment s, and must gat her vit al inf ormat ion about t he pat ient
and t he t est ing process, t o diagnose appropriat ely w it hin t he paramet ers of t he
clinician's prof essional st andards (Table 1. 2; Chart 1. 2).
Table 1.2 Examples of Inappropriate Tests and

Replacement Tests
Inappropriate
Replacem ent
Prostatic acid phosphatase
PSA or free
PSA
Ammonia
AST, GGT
Crossmatch (needed if blood is

actually to be given)
Type and
screen
Calcium
Ionized
calcium
CBC
Hemogram
HCV antibody
HCV RNA by
PCR
Iron
Ferritin
Lupus cell
ANA
Creatinine
Urea
CRP
ESR
PSA, prostate-specific antigen; AST, aspartate

transaminase; GGT, gamma-glutamyltransferase; CBC,
complete blood count; HCV, hepatitis C virus; PCP,
polymerase chain reaction; ANA, antinuclear antibody;
CRP, C-reactive protein; ESR, erythrocyte
sedimentation rate.
Ch art 1.2 Basics of Informed Care Man age testin g en viron men t
u sin g collaborative approach Commu n icate effectively an d
clearly
Prepare t he pat ient properly
Follow st andards
Consider cult ure, gender, and age diversit y Measure and evaluat e out comes;
modif y t reat ment as necessary Manage eff ect ive diagnost ic services using
t eam approach I nt erpret , t reat , monit or, and counsel about abnormal t est
out comes Maint ain proper t est records
The diagnost ic t est ing model incorporat es t hree phases: pret est , int rat est , and
post t est (Fig. 1. 1). The clinical t eam act ively int eract s w it h t he pat ient and his or
her signif icant ot hers
t hroughout each phase. The f ollow ing component s are included w it h each
laborat ory or diagnost ic t est in t his t ext :
FI G URE 1. 1 Model* f or t he role** of t he clinical t eam in diagnost ic care***

and services. ****
Pretest
Intratest
Posttest
Interventions:
Interventions:
Interventions:
1. Test
background
information
2. Normal
(reference
values)
3. Explanation
of test
4. Indications
for testing
1. Actual
description of
procedures
2. Specimen
collection and
transport
3. Clinical
implications of
abnormal
results
4. Interfering
factors
1. Patient
aftercare
2. Clinical,
education, and
procedure
alerts
3. Special
cautions
4. Interpretation
of test results
Each phase of t est ing requires t hat a specif ic set of guidelines and st andards be
f ollow ed f or accurat e, opt imal t est result s. Pat ient care st andards and st andards
of prof essional pract ice are key point s in developing a collaborat ive approach t o
pat ient care during diagnost ic evaluat ion. St andards of care provide clinical
guidelines and set minimum requirement s f or prof essional pract ice and pat ient
care. They prot ect t he public against less-t han-qualit y care (Table 1. 3).
Table 1.3 Standards for Diagnostic Evaluation
Source of
Standards for
Diagnostic
Service
Standards for
Diagnostic
Testing
Exam ples of
Applied
Standards for
Diagnostic
Testing
Professional
practice
parameters of
American Nurses
Association
(ANA), American
Medical
Association
(AMA), American
Society of Clinical
Pathologists
(ASCP), American
College of
Radiology,
Centers for
Disease Control
and Prevention
(CDC), JCAHO
health care
practice
requirements
Use a model as
a framework for
choosing the
proper test or
procedure and
in the
interpretation of
test results.
Use laboratory
and diagnostic
procedures for
screening,
differential
diagnoses,
follow-up, and
case
management.
Order the
correct test,
appropriately
collect and
transport
specimens.
Properly
perform tests in
Test strategies
include single
tests or
combinations/
panels of tests.
Panels can be
performed in
parallel, series,
or both.
Patients
receive
diagnostic
services based
on a
documented
assessment of
need for
The guidelines of
the major
agencies, such as
American Heart
Association,
Cancer Society,
and American
Diabetes
Association
Individual agency
and institution
policies and
procedures and
quality-control
criteria for
an accredited
laboratory or
diagnostic
facility.
Accurately
report test
results.
Communicate
and interpret
test findings.
Treat or monitor
the disease and
the course of
therapy. Provide
diagnosis as
well as
prognosis.
Observe
standard
precautions
(formerly known
as universal
precautions).
Use latex
allergy
protocols and
required
methodology of
specimen
collection. Use
standards and
statements for
diagnostic
evaluation.
Patients have
the right to
necessary
information,
benefits, or
rights, to
enable them to
make choices
and decisions
that reflect
their need or
wish for
diagnostic
care.
The clinician
wears
protective
eyewear and
gloves when
handling all
body fluids and
employs proper
handwashing
before and after
handling
specimens and
between patient
contacts.
specimen
collection,
procedure
statement for
monitoring the
patient after an
invasive
procedure, and
policy for
universal
witnessed consent
situations.
Statements on
quality
improvement
standards. Use
standards of
professional
practice and
standards of
patient care. Use
policy for
obtaining informed
consent/witnessed
consent. Use
policies for
unusual
situations.
monitoring
patients who
receive
conscious
sedation and
analgesia. Vital
signs are
monitored and
recorded at
specific times
before and after
the procedure.
Patients are
monitored for
bleeding and
respiratory or
neurovascular
changes.
Record data
regarding
outcomes when
defined care
criteria are
implemented
and practiced.
Protocols to
obtain
appropriate
consents are
employed, and
deviations from
basic consent
policies are
documented
Labeled
biohazard bags
are used for
specimen
transport. Vital
signs are
monitored and
recorded at
specific times
before and after
the procedure.
Patients are
monitored for
bleeding and
respiratory or
neurovascular
changes.
Record data
regarding
outcomes when
defined care
criteria are
implemented
and practiced.
Protocols to
obtain
appropriate
consents are
employed, and
deviations from
basic consent
policies are
documented
and reported to
and reported to
the proper
individual.
State and federal

government
communicable
disease reporting
regulations;
Centers for
Disease Control
and Prevention
(CDC), U.S.
Department of
Health and Human
Services, Agency
for Health Care
Policy and
Research
(AHCPR), and
Clinical
Laboratory
Improvement Act
(CLIA)
Clinical
laboratory
personnel and
other health
care providers
follow
regulations to
control the
spread of
communicable
diseases by
reporting
certain disease
conditions,
outbreaks, and
unusual
manifestations,
morbidity, and
mortality data.
Findings from
research
studies provide
health care
policy makers
with evidencebased
the proper
individual.
The clinician
reports
laboratory
evidence of
certain disease
classes (eg,
sexually
transmitted
diseases,
diphtheria,
Lyme disease,
symptomatic
HIV infection;
see list of
reportable
diseases).
Personnel with
hepatitis A may
not handle food
or care for
patients, young
children, or the
elderly for a
specific period
of time. Federal
government
regulates
shipment of
diagnostic
guidelines for
appropriate
selection of
tests and
procedures.
U.S. Department
of Transportation
Occupational
Safety and Health
Administration
(OSHA)
Alcohol testing
is done in
emergency
rooms in
special
situations (eg,
following a
motor vehicle
accident,
homicide, or
suicide, or an
unconscious
individual).
W orkplace
testing
specimens. MR
and CT are
used to
evaluate
persistent low
back pain
according to
AHCPR
guidelines.
Properly trained
personnel
perform blood,
saliva, and
breath alcohol
testing and use
required kits as
referenced by
federal law.
The clinician is
properly
trained, under
mandated
guidelines, to
administer
employee
medical
surveillance
and respirator
qualification
and fit testing.
JCAHO, Joint Commission on Accreditation of
Healthcare Organizations; HIV, human
immunodeficiency virus; MR, magnetic resonance; CT,
computed tomography.
I f t est result s are inconclusive or negat ive and no def init ive medical diagnosis
can be est ablished, ot her t est s and procedures may be ordered. Thus, t est ing
can become an involved and lengt hy process (see Fig. 1. 1).
Underst anding t he basics of saf e, eff ect ive, and inf ormed care is import ant .
These basics include assessing risk f act ors and modif ying care accordingly,
using a collaborat ive approach, f ollow ing proper guidelines f or procedures and
specimen collect ion, and delivering appropriat e care t hroughout t he process.
Providing reassurance and support t o t he pat ient and his or her
signif icant ot hers, int ervening appropriat ely, and clearly document ing pat ient
t eaching, observat ions, and out comes during t he ent ire process are import ant
(see Fig. 1. 1).
A risk assessment bef ore t est ing ident if ies risk-prone pat ient s and helps t o
prevent complicat ions. The f ollow ing f act ors increase a pat ient 's risk f or
complicat ions and may aff ect t est out comes:
1. Age > 70 years
2. Hist ory of f alls
3. Hist ory of serious chronic illnesses
4. Hist ory of allergies (eg, lat ex, cont rast iodine, radiopharmaceut icals, and
ot her medicat ions)
5. I nf ect ion or increased risk f or inf ect ion (eg, human immunodef iciency virus
[ HI V] , organ t ransplant at ion, chemot herapy, radiat ion t herapy)
6. Aggressive or ant isocial behavior
7. Seizure disorders
8. Uncont rolled pain

9. G ast ric mot ilit y dysf unct ion
10. Use of assist ive devices f or act ivit ies of daily living (ADLs)
11. Unst eady gait , balance problems
12. Neuromuscular condit ions
13. Weakness, f at igabilit y
14. Parest hesias
15. I mpaired judgment or illogical t hinking
16. Severe visual problems
17. Hearing impairment
18. Use of diuret ics, sedat ives, analgesics, or ot her prescript ion or over-t hecount er (O TC) drugs
19. Alcohol or illegal drug use or addict ion
The environment s in w hich diagnost ic services are provided, t he degree of
cult ural diversit y present in t he communit y, and t he physical, emot ional, social,
and spirit ual st at e of t he pat ient all inf luence t he pat ient 's response t o t he
procedure. I ncluding t he pat ient 's signif icant ot hers is a vit al component of t he
ent ire process and must not be t aken light ly or casually dismissed.
Test ing environment s vary. Cert ain t est s (eg, cholest erol screening, blood
glucose, elect rocardiogram [ ECG ] , lipid prof iles, t uberculosis [ TB] skin t est s)
can be done in t he f ield, meaning t hat t he service is brought t o t he pat ient 's
environment . O t her t est s (eg, x-rays using cont rast media and t hose t hat require
special pat ient preparat ion, invasive procedures, nuclear medicine procedures,
hormone levels, and 24-hour urine t est ing panels) must be done in a physician's
off ice, clinic, or hospit al set t ing. Magnet ic resonance (MR) imaging and
ult rasound procedures (eg, echocardiograms) are commonly perf ormed in
f reest anding or specialt y diagnost ic cent ers. Complex t est s such as endoscopic
ret rograde cholangiopancreat ography (ERCP), cardiac cat het erizat ion, or
bronchoscopy may require hospit al admission or at least out pat ient st at us. As
t est ing equipment becomes more t echnologically sophist icat ed and risks
associat ed w it h t est ing are reduced, t he environment in w hich diagnost ic
procedures t ake place w ill also shif t . I nsurance reimbursement f or t est ing also
inf luences t rends. Managed care and case management , t oget her w it h
collaborat ion among t he diverse healt h care disciplines and t he pat ient , are key
f act ors in det ermining how and t o w hat degree opt imal diagnost ic services are
used. Clear, t imely, accurat e communicat ion among all pat ient s and
prof essionals is key t o minimizing problems and f rust rat ions.
As societ ies become more cult urally blended, t he need t o appreciat e and w ork
w it hin t he realm of cult ural diversit y becomes imperat ive. I nt eract ing w it h
pat ient s and direct ing t hem t hrough diagnost ic t est ing can present cert ain
challenges if one is not f amiliar and sensit ive t o
t he healt h care belief syst em of t he pat ient and his or her signif icant ot hers.
Somet hing as basic as at t empt ing t o communicat e in t he f ace of language
diff erences may necessit at e arrangement s f or a relat ive or t ranslat or t o be
present during all phases of t he process. Special at t ent ion and communicat ion
skills are necessary f or t hese sit uat ions as w ell as w hen caring f or children and
f or comat ose, conf used, or f rail pat ient s. Considerat ion of t hese issues w ill
signif icant ly inf luence compliance, out comes, and posit ive responses t o t he
procedure. To be most eff ect ive, prof essional care providers must be open t o a
holist ic perspect ive and at t it ude t hat aff ect s t heir care giving, communicat ion,
and pat ient -empow ering behaviors. Clinicians w ho underst and t he pat ient 's basic
needs and expect at ions and st rive t o accommodat e t hose as much as possible
are t ruly act ing as pat ient advocat es.
Preparing pat ient s f or diagnost ic or t herapeut ic procedures, collect ing
specimens, carrying out and assist ing w it h procedures, and providing f ollow -up
care have long been requisit e act ivit ies of prof essional pract ice. This care may
cont inue even af t er t he pat ient 's deat h. Diagnost ic post mort em services include
deat h report ing, possible post mort em invest igat ions, and sensit ive
communicat ion w it h grieving f amilies and signif icant ot hers regarding aut opsies,
unexplained deat h, ot her post mort em t est ing, and organ donat ion (see Chap.
16).
Prof essionals need t o w ork as a t eam t o meet diverse pat ient needs, t o
f acilit at e cert ain decisions, t o develop comprehensive plans of care, and t o help
pat ient s modif y t heir daily act ivit ies t o meet t est requirement s in all t hree
phases. I t is a given t hat inst it ut ional prot ocols are f ollow ed.
PRETEST PHASE: ELEM ENTS OF SAFE, EFFECTIVE,

INFORM ED CARE
The emphasis of pret est care is on appropriat e t est select ion, obt aining proper
consent , proper pat ient preparat ion, individualized pat ient educat ion, emot ional
support , and eff ect ive communicat ion. These int ervent ions are key t o achieving
t he desired out comes and prevent ing misunderst andings and errors.
Basic Knowledge and Necessary Skills

Know t he t est t erminology, purpose, process, procedure, and normal t est
ref erence values or result s. The names of diseases are a convenient w ay of
brief ly st at ing t he endpoint of a diagnost ic process t hat begins w it h assessment
of sympt oms and signs and ends w it h know ledge of causat ion and det ect ion of
underlying disorders of st ruct ure and f unct ion.
The clinical value of a t est is relat ed t o it s sensi ti vi ty, it s speci f i ci ty, and t he
i nci dence of the di sease in t he populat ion t est ed. Sensit ivit y and specif icit y do
not change w it h diff erent populat ions of ill and healt hy pat ient s. The predi cti ve
val ue of t he same t est can vary signif icant ly w it h age, gender, and geographic
locat ion.
Specificity ref ers t o t he abilit y of a t est t o ident if y correct ly t hose individuals
w ho do not have t he disease. The division f ormula f or specif icit y is as f ollow s:
Sensitivity ref ers t o t he abilit y of a t est t o correct ly ident if y t hose individuals

w ho t ruly have t he disease. The division f ormula f or sensit ivit y is as f ollow s:
Incidence ref ers t o t he prevalence of a disease in a populat ion or communit y.

The predict ive value of t he same t est can be very diff erent w hen applied t o
people of diff ering ages, genders, geographic locat ions, and cult ures.
Predicted Values ref er t o t he abilit y of a screening t est result t o correct ly
ident if y t he disease st at e. True-posi ti ve resul ts correct ly ident if y individuals w ho
act ually have t he disease, and true-negati ve resul ts correct ly ident if y individuals
w ho do not act ually have t he disease. Posi ti ve predi cti ve val ue equals t he
percent age of posit ive t est s w it h t rue-posit ive result s (ie, t he individual does
have t he disease). Negati ve predi cti ve val ue ref ers t o t he percent age of
negat ive t est s w it h t rue-negat ive result s (ie, t he individual does not have t he
disease).
See Table 1. 4 f or an example t hat demonst rat es t he specif icit y, sensit ivit y, and
predict ive values f or a new screening t est t o ident if y t he cyst ic f ibrosis gene.
Table 1.4 Sample Test Results
Test
Result
Have Gene for

Cystic
Fibrosis
Do Not Have
Gene for Cystic
Fibrosis
Total
Positive
62
67
Negative
15
341
356
TOTAL
77
346
423
Thus, t his new screening t est w ill give a f alse-negat ive result about 20% of t he
t ime (eg, t he person does have t he cyst ic f ibrosis gene but his or her t est
result s are negat ive).
Thus, t here is about an 8% change t hat t he person w ill t est posit ive f or t he
cyst ic f ibrosis gene but does not have it .
Thus, t here is about a 5% chance t hat t he person w ill t est negat ive f or t he cyst ic
f ibrosis gene but act ually does have it .
Look at bot h current and previous t est result s and review t he most recent
laborat ory dat a f irst , t hen w ork sequent ially backw ard t o evaluat e t rends or
changes f rom previous dat a. The pat ient 's plan of care may need t o be modif ied
because of t est result s and changes in medical management .
Testing Environments
Diagnost ic t est ing occurs in many diff erent environment s. Many t est sit es have
shif t ed int o communit y set t ings and aw ay f rom hospit als and clinics.
Point-of-Care Testing ref ers t o t est s done in t he primary care set t ing. I n acut e
care set t ings (eg, crit ical care unit s, ambulances), st at e-of -t he-art t est ing can
produce rapid report ing of t est result s.
Test ing in t he home care environment requires skill in procedures such as
draw ing blood samples, collect ing samples f rom ret ent ion cat het ers, proper
specimen labeling, document at ion, specimen handling, and specimen
t ransport ing. Moreover, t eaching t he pat ient and his or her signif icant ot hers how
t o collect specimens is an import ant part of t he process.
I n occupat ional healt h environment s, t est ing may be done t o reduce or prevent
know n w orkplace hazards (eg, exposure t o lead) and t o monit or ident if ied healt h
problems. This can include preemployment baseline screening, periodic

monit oring of exposure t o pot ent ially hazardous w orkplace subst ances, and drug
screening. Skill in draw ing blood samples, perf orming breat hing t est s, monit oring
chain of cust ody (see page 226 in Chap. 3), and obt aining properly signed and
w it nessed consent f orms f or drug t est ing is required.
More pret est , post t est , and f ollow -up t est ing occurs in nursing homes because
pat ient s are more f requent ly t aken or t ransf erred t o hospit als f or more complex
procedures (eg, comput ed t omography [ CT] scans, endoscopies), w hereas t his
is not t he case w it h rout ine t est ing. I ncreasing numbers of f ull code (ie,
resuscit at ion) orders leads t o great er numbers and variet ies of t est s.
Addit ionally, conf used, combat ive, or uncooperat ive behaviors are seen more
f requent ly in t hese set t ings. An at t it ude adopt ed by nursing home pat ient s of not
w ant ing t o be bot hered or engaging in out right ref usal t o undergo prescribed
t est s can make t est ing diff icult . Consequent ly, underst anding pat ient behaviors
and using appropriat e communicat ion st rat egies and int ervent ions f or t his
populat ion are necessary skills f or pract icing in t his arena.
For t hose w ho pract ice in t he realm of public healt h, diagnost ic t est
responsibilit ies f ocus on w ellness screenings, prevent ive services, disease
cont rol, counseling, and t reat ment of individuals w it h problems. Case f inding
f requent ly occurs at healt h f airs, out reach cent ers, homeless shelt ers,
neighborhood nurse off ices, mobile healt h vans, and church set t ings.
Responsibilit ies vary according t o set t ing and may include providing t est
inf ormat ion, procuring specimens, and providing ref errals t o appropriat e
caregivers. These responsibilit ies may even ext end t o t ransport ing and preparing
specimens f or analysis or act ually perf orming specimen analysis (eg, st ool t est s
f or occult blood, TB skin t est ing, and procuring blood or saliva samples f or
HI V/ acquired immunodef iciency syndrome [ AI DS] t est ing).
History and Assessment

O bt ain a relevant , current healt h hist ory; perf orm a physical assessment if
indicat ed. I dent if y condit ions t hat could inf luence t he act ual t est ing process or
t est out comes (eg, pregnancy, diabet es, cult ural diversit y, language barrier,
physical impairment , alt ered ment al st at e).
1. Perf orm a risk assessment f or pot ent ial injury or noncompliance.
2. I dent if y cont raindicat ions t o t est ing such as allergies (eg, iodine, lat ex,
medicat ions, cont rast media). Records of previous diagnost ic procedures
may provide clues.
3. Assess f or coping st yles and know ledge or t eaching needs.
4. Assess f ears and phobias (eg, claust rophobia, panic at t acks, f ear of
needles and blood). Ascert ain w hat st rat egies t he pat ient uses t o deal w it h
t hese react ions and t ry t o accommodat e t hese.
5. O bserve st andard/ universal precaut ions w it h every pat ient (see Appendix A).
A pat ient may choose not t o disclose drug or alcohol use or HI V and
hepat it is risks.
6. Document relevant dat a. Address pat ient concerns and quest ions. This
inf ormat ion adds t o t he dat abase f or collaborat ive problem-solving act ivit ies
among t he medical, laborat ory/ diagnost ic, and nursing disciplines.
Reimbursement for Diagnostic Services

Diff erences in bot h diagnost ic care services and reimbursement may vary
bet w een privat e and government insurance. Nonet heless, qualit y of care should
not be compromised in f avor of cost reduct ion. Advocat e f or pat ient s regarding
insurance coverage f or diagnost ic services. I nf orm t he pat ient and his or her
f amily or signif icant ot hers t hat it may be necessary t o check w it h t heir
insurance company bef ore laborat ory and diagnost ic t est ing t o make cert ain t hat
cost s are covered.
Many insurance companies employ case managers as gat ekeepers f or monit oring
cost s, diagnost ic t est s ordered, and ot her care. As a result , t he insurance
company or t hird-part y payer may reimburse only f or cert ain t est s or procedures
or may not cover t est s considered by t hem t o be prevent ive care. So t hat
reimbursement complet ely covers diagnost ic services provided, be sure t o
include proper document at ion and proper Common Pract ice Terminology (CPT)
codes. Not e dat e laborat ory service is perf ormed and dat e specimen is collect ed
(must use). Based on 1999 dat a, Chart 1. 3 list s laborat ory t est s t hat are
covered by most insurance carriers, bot h privat e and government .
Ch art 1.3 Tests Covered by Most Insurance Carriers
Alpha-fetoprotein
Blood counts
Human chorionic
gonadotropin
Blood glucose testing
Lipids
Carcinoembryonic antigen
Partial thromboplastin
time
Collagen crosslinks, any

method (urine
Prostate-specific
osteoporosis)
antigen
Digoxin therapeutic drug

assay
Prothrombin time
Serum iron studies
Fecal occult blood

Thyroid testing
Gammaglutamyltransferase
Glycated
hemoglobin/glycated
protein
Tumor antigen by
immunoassayCA125
Tumor antigen by
immunoassayCA153/CA27
Hepatitis panel
HIV testing (diagnosis)
HIV testing (prognosis
including monitoring)
Tumor antigen by
immunoassayCA19-9
Urine culture
Methodology of Testing
Follow t est ing procedures accurat ely. Verif y orders and document t hem w it h
complet e, accurat e, and legible inf ormat ion. Document all drugs t he pat ient is
t aking because t hese may inf luence t est out comes (see Appendix J).
1. Ensure t hat specimens are correct ly obt ained, preserved, handled, labeled,
and delivered t o t he appropriat e depart ment . For example, it is not generally
accept able t o draw blood samples w hen an int ravenous line is inf using
proximal t o t he int ended punct ure sit e.
2. O bserve precaut ions f or pat ient s in isolat ion. Use st andard/ universal
precaut ions.
3. As much as possible, coordinat e pat ient act ivit ies w it h t est ing schedules t o
avoid conf lict s w it h meal t imes and administ rat ion of medicat ions,
t reat ment s, or ot her diagnost ic t est s and t ravel t ime.
a. Maint ain NPO (ie, not hing by mout h) st at us w hen necessary.

b. Administ er t he proper medicat ions in a t imely manner. Schedule t est s
requiring cont rast subst ances in t he proper sequence so as not t o
invalidat e succeeding t est s.
Interfering Factors
Minimize t est out come deviat ions by f ollow ing proper t est prot ocols. Make
cert ain t he pat ient and his or her signif icant ot hers know w hat is expect ed of
t hem. Writ t en inst ruct ions are very helpf ul.
Reasons f or deviat ions may include t he f ollow ing:
1. I ncorrect specimen collect ion, handling, st orage, or labeling
2. Wrong preservat ive or lack of preservat ive
3. Delayed specimen delivery
4. I ncorrect or incomplet e pat ient preparat ion
5. Hemolyzed blood samples
6. I ncomplet e sample collect ion, especially of t imed samples
7. O ld or det eriorat ing specimens
Pat ient f act ors t hat can alt er t est result s may include t he f ollow ing:
1. I ncorrect pret est diet
2. Current drug t herapy
3. Type of illness
4. Dehydrat ion
5. Posit ion or act ivit y at t ime of specimen collect ion
6. Post prandial st at us (ie, t ime pat ient last at e)
7. Time of day
8. Pregnancy
9. Level of pat ient know ledge and underst anding of t est ing process
10. St ress
11. Nonadherence or noncompliance w it h inst ruct ions and pret est preparat ion
12. Undisclosed drug or alcohol use
13. Age and gender
Avoiding Errors
To avoid cost ly mist akes, know w hat equipment and supplies are needed and
how t he t est is perf ormed. Communicat ion errors account f or more incorrect
result s t han do t echnical errors. Properly ident if y and label every specimen as
soon as it is obt ained. Det ermine t he t ype of sample needed and t he collect ion
met hod t o be used. I s t he t est invasive or noninvasive? Are cont rast media
inject ed or sw allow ed? I s t here a need t o f ast ? Are f luids rest rict ed or f orced?
Are medicat ions administ ered or w it hheld? What is t he approximat e lengt h of t he
procedure? Are consent f orms and conscious sedat ion, oxygen, analgesia, or
anest hesia required? Report t est result s as soon as possible. Crit ical or
panic values must be report ed t o t he proper persons immediat ely (STAT).
I nst ruct pat ient s and t heir signif icant ot hers regarding t heir responsibilit ies.
Accurat ely out line t he st eps of t he t est ing process and any rest rict ions t hat may
apply. Conscient ious, clear, t imely communicat ion among healt h care
depart ment s can reduce errors and inconvenience t o bot h st aff and pat ient s.
Proper Preparation
Prepare t he pat ient correct ly. This preparat ion begins at t he t ime of scheduling.
1. Provide inf ormat ion about t est ing sit e and give direct ions f or locat ing t he
f acilit y; allow t ime t o ent er t he f acilit y and f ind t he specif ic t est ing
laborat ory. I f a copy of t he w rit t en t est order w as given t o t he pat ient t o
bring t o t he laborat ory, int erpret t he t est order. For example, an order f or a
renal sonogram means t hat an ult rasound of t he kidney w ill be done t o rule
out (RO ) evidence or presence of abnormalit y or suspect ed problem. The
t erms ult rasound and sonogram are used int erchangeably.
2. Plan t o be at t he depart ment 15 minut es bef ore t est ing if t he t est is
scheduled f or a specif ic t ime. Review all pret est inst ruct ions and be cert ain
t hey are explained clearly (eg, f ast ing direct ions f or t est , t ell pat ient w hat
f ast ing act ually means).
3. Be aw are of special needs of t hose w it h condit ions such as physical
limit at ions or disabilit ies, ost omies, or diabet es; children; elderly pat ient s;
and cult urally diverse pat ient s.
4. G ive simple, accurat e, precise inst ruct ions according t o t he pat ient 's level of
underst anding. For example, t he pat ient needs t o know w hen and w hat t o eat
and drink or how long t o f ast .
5. Encourage dialogue about f ears and apprehensions. Walking a pat ient
t hrough t he procedure using imagery and relaxat ion t echniques may help
t hem t o cope w it h anxiet ies. Never underest imat e t he value of a caring
presence.
6. Assess f or t he pat ient 's abilit y t o read and underst and inst ruct ions. Poor
eyesight or hearing diff icult ies may impair underst anding and compliance.
Speak slow ly and clearly. Do not bombard t he pat ient w it h inf ormat ion.
I nst ruct t he pat ient t o use assist ive devices such as eyeglasses and hearing
aids if necessary. Clear, w rit t en inst ruct ions can reinf orce verbal inst ruct ions
and should be used w henever possible. I n some cases, a t ranslat or or
signer, or legal represent at ive may be necessary.
7. Assess f or language and cult ural barriers. Pat ient s behave according t o
personal values, percept ions, belief s, t radit ions, and cult ural and et hnic
inf luences. Take t hese int o considerat ion and value t he pat ient 's uniqueness
t o t he highest degree possible.
8. Document accurat ely in all t est ing phases.
Patient Education
Educat e t he pat ient and f amily regarding t he t est ing process and w hat w ill be
expect ed of t hem. Record t he dat e, t ime, t ype of t eaching, inf ormat ion given,
and t o w hom t he inf ormat ion w as given.
1. G iving sensory and object ive inf ormat ion t hat relat es t o w hat t he pat ient w ill
likely physically f eel and t he equipment t hat w ill be used is import ant so t hat
pat ient s can see a realist ic represent at ion of w hat w ill occur. Avoid
t echnical and medical jargon and adapt inf ormat ion t o t he pat ient 's level of
underst anding. Slang t erms may be necessary t o get a point across.
2. Encourage quest ions and verbalizat ion of f eelings, f ears, and concerns. Do
not dismiss, minimize, or invalidat e t he pat ient 's anxiet y t hrough t rivial
remarks such as Don't w orry. Develop list ening ears and eyes skills. Be
aw are of nonverbal signals (ie, body language) because t hese f requent ly
provide a more accurat e pict ure of w hat t he pat ient really f eels t han w hat he
or she says. Above all, be nonjudgment al.
3. Emphasize t hat t here is usually a w ait ing period (ie, t urn-around t ime)
bef ore t est result s are relayed back t o t he clinicians and nursing unit . The
pat ient may have t o w ait several days f or result s. O ff er list ening, presence,
and support during t his t ime of great concern and anxiet y.
4. Record t est result inf ormat ion. I nclude t he pat ient 's response. Just because
somet hing is t aught does not necessarily mean t hat it is learned or accept ed.
The possibilit y t hat a diagnosis w ill require a pat ient t o make signif icant
lif est yle changes (eg, diabet es) requires int ense support , underst anding,
educat ion, and mot ivat ion. Document specif ic names of audiovisual and
reading mat erials t o be used f or audit , reimbursement , and accredit at ion

purposes.
Testing Protocols
Develop consist ent prot ocols f or t eaching and t est ing t hat encompass
comprehensive pret est , int rat est , and post t est care modalit ies.
Prepare pat ient s f or t hose aspect s of t he procedure experienced by t he majorit y
of pat ient s. Clinicians can collaborat e t o collect dat a and t o develop a list of
common pat ient experiences, responses, and react ions.
Patient Independence
Allow t he pat ient t o maint ain as much cont rol as possible during t he diagnost ic
phases t o reduce st ress and anxiet y. I nclude t he pat ient and his or her
signif icant ot hers in decision making. Because of f act ors such as anxiet y,
language barriers, and physical or emot ional impairment s, t he pat ient may not
f ully underst and and assimilat e inst ruct ions and explanat ions. To validat e t he
pat ient 's underst anding of w hat is present ed, ask t he pat ient t o repeat
inst ruct ions given t o evaluat e assimilat ion and underst anding of present ed
inf ormat ion.
I nclude and reinf orce inf ormat ion about t he diagnost ic plan, t he procedure, t ime
f rames, and t he pat ient 's role in t he t est ing process.
Test Results
Know normal or ref erence values.
1. Normal ranges can vary t o some degree f rom laborat ory t o laborat ory.
Frequent ly, t his is because of t he part icular t ype of equipment used.
Theoret ically, normal can ref er t o t he ideal healt h st at e, t o average
ref erence values, or t o t ypes of st at ist ical dist ribut ion. Normal values are
t hose t hat f all w it hin 2 st andard deviat ions (ie, random variat ion) of t he mean
value f or t he normal populat ion.
2. The report ed ref erence range f or a t est can vary according t o t he laborat ory
used, t he met hod employed, t he populat ion t est ed, and met hods of specimen
collect ion and preservat ion.
3. The majorit y of normal blood t est values are det ermined by measuring
f ast ing specimens.
4. Be aw are of specif ic inf luences on t est result s. For example, pat ient post ure
is import ant w hen plasma volume is measured because t his value is 12% t o
15% great er in a person w ho has been supine f or several hours. Changing
f rom a supine t o a st anding posit ion can alt er values as f ollow s: increased
hemoglobin (Hb), red blood cell (RBC) count , hemat ocrit (Hct ), calcium (Ca),
pot assium (K), phosphorus (P), aspart at e aminot ransf erase (AST),
phosphat ases, t ot al prot ein, albumin, cholest erol, and t riglycerides. G oing
f rom an upright t o a supine posit ion result s in increased hemat ocrit , calcium,
t ot al prot ein, and cholest erol. A t ourniquet applied f or > 1 minut e produces
laborat ory value increases in prot ein (5%), iron (6. 7%), AST (9. 3%), and
cholest erol (5%) and decreases in K+ (6%) and creat inine (2%3%).
Laborat ories must specif y t heir ow n normal ranges. Many f act ors aff ect
laborat ory t est values and inf luence ranges. Thus, values may be normal under
one set of prevailing condit ions but may exhibit diff erent limit s in ot her
circumst ances. Age, gender, race, environment , post ure, diurnal and ot her cyclic
variat ions, f oods, beverages, f ast ing or post prandial st at e, drugs, and exercise
can aff ect derived values. I nt erpret at ion of laborat ory result s must alw ays be in
t he cont ext of t he pat ient 's st at e of being. Circumst ances such as hydrat ion,
nut rit ion, f ast ing st at e, ment al st at us, or compliance w it h t est prot ocols are only
a f ew of t he sit uat ions t hat can inf luence t est out comes.
Laboratory Reports
Scient if ic publicat ions and many prof essional organizat ions are changing clinical
laborat ory dat a values f rom convent ional unit s t o Syst me I nt ernat ional (SI )
unit s. Current ly, many dat a are report ed in bot h w ays.
The SI syst em uses seven dimensionally independent unit s of measurement t o
provide logical and consist ent measurement s. For example, SI concent rat ions
are w rit t en as amount per volume (moles or millimoles per lit er) rat her t han as
mass per volume (grams, milligrams, or milliequivalent s per decilit er, 100
millilit ers, or lit er). Numerical values may diff er bet w een syst ems
or may be t he same. For example, chloride is t he same in bot h syst ems: 95 t o
105 mEq/ L (convent ional) and 95 t o 105 mmol/ L (SI ) (see Appendix D).
Margins of Error
Recognize margins of error. For example, if a pat ient has a bat t ery of chemist ry
t est s, t he possibilit y exist s t hat some t est s w ill be abnormal ow ing purely t o
chance. This occurs because a signif icant margin of error arises f rom t he
arbit rary set t ing of limit s. Moreover, if a laborat ory t est is considered normal up
t o t he 95t h percent ile, t hen 5 t imes out of 100, t he t est w ill show an abnormalit y
even t hough a pat ient is not ill. A second t est perf ormed on t he same sample w ill
probably yield t he f ollow ing: 0. 95 0. 95, or 90. 25%. This means t hat 9. 75 t imes
out of 100, a t est w ill show an abnormalit y even t hough t he person has no
underlying healt h disorder. Each successive t est ing w ill produce a higher
percent age of abnormal result s. I f t he pat ient has a group of t est s perf ormed on
one blood sample, t he possibilit y t hat some of t he t est s w ill read abnormal due
purely t o chance is not uncommon.
Ethics and the Law

Consider legal and et hical implicat ions. These include t he pat ient 's right t o
inf ormat ion, properly signed and w it nessed consent f orms, and explanat ions and
inst ruct ions regarding chain-of -cust ody requirement s and risks as w ell as
benef it s of t est s.
1. Chain of cust ody is a legal t erm descript ive of a procedure t o ensure
specimen int egrit y f rom collect ion t o t ransport t o receipt t o analysis and
specimen st orage. A special f orm is used t o provide a w rit t en record. The
right t o inf ormed consent bef ore cert ain t est s and procedures pert ains t o
pat ient aut onomy, t he et hical right of self -det erminat ion, t he legal right t o be
f ree of procedures t o w hich one does not consent , and t o det ermine w hat
w ill be done t o one's ow n person. Risks, benef it s, and alt ernat ives are
explained and w rit t en consent obt ained w ell in advance of t he procedure.
2. The pat ient must demonst rat e appropriat e cognit ive and reasoning f acult ies
t o sign a legally valid consent . Conversely, a pat ient may not legally give
consent w hile under t he immediat e inf luence of sedat ion, anest het ic agent s,
or cert ain classes of analgesics and t ranquilizers. I f t he pat ient cannot
validly and legally sign a consent f orm, an appropriat ely qualif ied individual
may give consent f or t he pat ient .
3. G uidelines and w ishes set f ort h in advance direct ives or living w illt ype
document s must be honored, especially in lif e-t hreat ening sit uat ions. Such
direct ives may prevent more sophist icat ed invasive procedures f rom being
perf ormed. Some st at es have legislat ed t hat pat ient s can procure do-not resuscit at e (DNR) orders and medical DNR bracelet s t hat indicat e t heir
w ishes. A copy of a pat ient 's advance direct ives in t he healt h care record
can be very helpf ul in unpredict able sit uat ions.
4. A collaborat ive t eam approach is essent ial f or responsible, law f ul, and
et hical pat ient -f ocused care. The clinician w ho orders t he t est has a
responsibilit y t o inf orm t he pat ient about risks and t est result s and t o
discuss alt ernat ives f or f ollow -up care. O t her caregivers can provide
addit ional inf ormat ion and clarif icat ion and can support t he pat ient and f amily
in achieving t he best possible out comes. The dut y t o maint ain conf ident ialit y,
t o provide f reedom of choice, and t o report inf ect ious diseases may result in
et hical dilemmas.
Respect f or t he dignit y of t he individual ref lect s basic et hical considerat ions.
Pat ient s and f amily have a right t o consent , t o quest ion, t o request ot her
opinions, and t o ref use diagnost ic t est s. Conversely, caregivers have t he right t o
know t he diagnoses of t he pat ient s t hey care f or so t hat t hey can minimize t he
risks t o t hemselves.
Patient's Bill of Rights and Patient Responsibilities

Patients have a right to expect that an agency's or
institution's policies and procedures will ensure
certain rights and responsibilities for them. At all
times, the patient has the right:
1. To considerat e, honest , respect f ul care, w it h considerat ion given t o privacy
and maint enance of personal dignit y, cult ural and personal values and
belief s, and physical and development al needs, regardless of t he set t ing.
2. To be involved in decision making and t o part icipat e act ively, if so desired, in
t he t est ing process, assuming t he pat ient is compet ent t o make t hese
choices.
3. To part icipat e in t he inf ormed consent process bef ore t est ing and t o be t old
of t he benef it s, risks, and reasonable alt ernat ive approaches t o t est s
ordered.
4. To be inf ormed regarding t est cost s and reimbursement responsibilit y.
5. To ref use diagnost ic t est ing.
6. To expect t o have t he support of f amily or signif icant ot hers, if so desired
and appropriat e during t he t est ing process.
7. To expect t hat st andards of care w ill be f ollow ed by all personnel involved in
t he t est ing process.
8. To expect saf e, skilled, qualit y care provided by t rained personnel w it h
expert ise in t heir f ield.
9. To expect pat ient and f amily educat ion and inst ruct ions regarding all phases
of t he t est ing process and procedure, including t he nat ure and purpose of
t he t est , pret est preparat ion, act ual t est ing, post t est care benef it s, risks,
side eff ect s, and complicat ions. I nf ormat ion should be provided in a sensit ive
and object ive manner.
10. To expect t o be inf ormed in a t imely manner of t est result s and implicat ions,
t reat ment , and f ut ure t est ing if necessary.
11. To expect t o be counseled appropriat ely regarding abnormal t est out comes
as w ell as alt ernat ive opt ions and available t reat ment s.
12. To expect t o have accept able pain cont rol and comf ort measures provided
t hroughout t he t est ing process.
13. To expect t hat all verbal, w rit t en, and elect ronic communicat ion, medical
records, and medical record t ransf ers w ill be accurat e and conf ident ial.
Excepti on: when reporti ng of si tuati on i s requi red by l aw (eg, certai n
i nf ecti ous di seases, chi l d abuse).
The pat ient has t he f ollow ing responsibilit ies:
1. To comply w it h t est requirement s (eg, f ast ing, special preparat ions,
medicat ions, enemas) and t o inf orm t he clinician if t hey are unable t o do so.
2. To report act ive or chronic disease condit ions t hat may alt er t est out comes,
be adversely aff ect ed by t he t est ing process, or pose a risk t o healt h care
providers (eg, HI V, hepat it is).
3. To keep appoint ment s f or diagnost ic procedures and f ollow -up t est ing.
4. To disclose drug and alcohol use as w ell as use of supplement s and herbal
product s despit e being inf ormed t hat t hese product s could aff ect t est
out comes (eg, erroneous t est result s).
5. To disclose allergies and past hist ory of complicat ions or adverse react ions
t o t est s. Exampl e: Reacti on to contrast materi al s.
6. To report any adverse eff ect s at t ribut ed t o t est s and procedures af t er being
advised regarding signs and sympt oms of such.
7. To supply specimens t hat are t heir ow n.
8. To report visual or hearing impairment s or inabilit y t o read, w rit e, or
underst and English.
Cultural Sensitivity
Preserving t he cult ural w ell-being of any individual or group promot es compliance
w it h t est ing and easier recovery f rom rout ine as w ell as more invasive and
complex procedures. Sensit ive
quest ioning and observat ion may provide inf ormat ion about cert ain cult ural
t radit ions, concerns, and pract ices relat ed t o healt h. For example, t he Hmong
people believe t he soul resides in t he head and t hat no one should t ouch an
adult 's head w it hout permission. Pat t ing a Hmong child on t he head may violat e
t his belief . Healt h care personnel should make an eff ort t o underst and t he
cult ural diff erences of populat ions t hey serve w it hout passing judgment . Most
people of ot her cult ures are w illing t o share t his inf ormat ion if t hey f eel it w ill be
respect ed. Somet imes, a t ranslat or is necessary f or accurat e communicat ion.
Many cult ures have diverse belief s about diagnost ic t est ing t hat requires blood
sampling. For example, alarm about having blood specimens draw n or concerns
regarding t he disposal of body f luids or t issue may require healt h care w orkers
t o demonst rat e t he ut most pat ience, sensit ivit y, and t act w hen communicat ing
inf ormat ion about blood t est s.
INTRATEST PHASE: ELEM ENTS OF SAFE, EFFECTIVE,

INFORM ED CARE
Basic Knowledge and Required Skills
I nt rat est care f ocuses on specimen or t issue collect ion, monit oring t he t est ing
environment t issue collect ion, perf orming and/ or assist ing w it h procedures,
providing emot ional and physical comf ort and reassurance, administ ering
analgesics and sedat ives, and monit oring vit al signs and ot her paramet ers during
t est ing. The clinician must have basic know ledge about t he procedure and t est
and should have t he required skills t o perf orm t est ing or t o assist in t he process.
Saf e pract ices, proper collect ion of specimens, minimizing delays, providing
support t o t he pat ient , preparing or administ ering analgesia and sedat ives,
monit oring various paramet ers as necessary, and being alert t o pot ent ial side
eff ect s or complicat ions are int egral act ivit ies of t he int rat est phase. I nvasive
procedures place pat ient s at great er risk f or complicat ions and require ongoing
vigilance and observat ion. Monit oring f luid int ake and loss, body t emperat ure,
and respirat ory and cardiovascular syst ems and t reat ing problems in t hese
domains require crit ical t hinking and quick responses.
Infection Control
I nst it ut e accept ed inf ect ion cont rol prot ocols. O bserve special measures and
st erile t echniques as appropriat e. I dent if y pat ient s at risk f or inf ect ion. I nst it ut e
st rict respirat ory and cont act isolat ion as necessary. Q ualit y assurance requires
proper collect ion, t ransport , and receipt of specimens and use of properly
cleaned and prepared inst rument s and equipment . Appendix A off ers more
inf ormat ion on st andard precaut ions f or saf e pract ice and inf ect ion cont rol and
isolat ion. The t erm standard precauti ons ref ers t o a syst em of disease cont rol
t hat presupposes each direct cont act w it h body f luids or t issues is pot ent ially
inf ect ious and t hat every person exposed t o t hese must prot ect himself or
herself . Consequent ly, healt h care w orkers must be bot h inf ormed and
conscient ious about adhering t o st andard precaut ions and st rict inf ect ion cont rol
guidelines. I t goes w it hout saying t hat healt h care w orkers must be scrupulous
about proper hand hygiene (see Appendix A). Proper prot ect ive clot hing and
ot her devices must be w orn as necessary.
Procurement and disposal of specimens according t o U. S. O ccupat ional Saf et y
and Healt h Administ rat ion (O SHA) st andards must be adhered t o. Moreover,
inst it ut ions may have procedures and policies of t heir ow n t o ensure compliance
(eg, specimens are t o be placed direct ly int o biohazard bags).
NOTE
St andard precaut ions (f ormerly know n as universal precaut ions) prevail in all
sit uat ions in w hich risk f or exposure t o blood, t issue, and ot her body f luids is
even remot ely possible. The t erms st andard precaut ions and universal
precaut ions are of t en used int erchangeably.
Collaborative Approaches
A collaborat ive t eam approach is necessary f or most procedures. Clinicians must
assist and underst and each ot her's role in t he procedure. I nvasive procedures
(such as lumbar punct ures or cyst oscopy) place pat ient s at great er risk f or
complicat ions and usually require closer monit oring during t he t est . Frequent ly,
administ rat ion of int ravenous (I V) sedat ion and ot her drugs is part of t he
procedure. Ast ut e ongoing observat ion of t he pat ient and crit ical t hinking and
quick decision-making skills during int ense sit uat ions is a requisit e f or clinicians
in t hese set t ings.
Risk Management
Assess f or and provide a saf e environment f or t he pat ient at all t imes. I dent if y
pat ient s at risk and environment s t hat may pose a risk. Previous f alls,
cerebrovascular accident (CVA), neuromuscular disorders, loss of balance, or
use of ambulat ory and ot her assist ive devices are cont ribut ory risk f act ors.
Prevent ion of complicat ions and management of risk f act ors are an import ant
part of t he int rat est phase. As part of risk management , observe st andard
precaut ions and inf ect ion cont rol prot ocols as necessary (see Appendix A,
Appendix B, and Appendix C).
Use special care during procedures t hat include iodine and barium cont rast s,
radiopharmaceut icals, lat ex product s, conscious sedat ion, and analgesia (see
Chap. 9, Chap. 10, and Chap. 15 f or precaut ions f or imaging procedures. )
Cert ain risk f act ors cont ribut e t o a higher incidence of adverse react ions w hen
cont rast agent s and radiopharmaceut icals are used (Table 1. 5).
Table 1.5 Classification of Risk Factors
Preexisting
Contributing Elem ents
Disorders
Asthma
Allergy
Diabetes
Age-related (newborn and older

adults)
Liver insufficiency
Dehydration
Multiple myeloma
Frequent use of contrast agents
Pheochromocytoma
High dosage of contrast and

radiopharmaceuticals
Renal failure
Previous reaction to contrast

agents
Seizure history
Remove jew elry, f alse t eet h, and ot her prost het ic devices as necessary. Check
f or NPO or f ast ing st at us if appropriat e.
Specimens and Procedures

Assist w it h and/ or conduct cert ain diagnost ic procedures. Examples of t he t ypes
of assist ed procedures include endoscopy, lumbar punct ure, and cardiac
cat het erizat ion. Diagnost ic procedures of t en perf ormed independent ly of ot her
medical personnel include Papanicolaou (Pap) smears, cent rif ugat ion of blood
samples, ECG s, breat hing t est s, and pulse oximet ry. For example, t he pulse
oximet er is used t o monit or noninvasively t he oxygen sat urat ion (SpO2 ); SpO 2
ref ers t o pulse oximet ry, w hereas SaO 2 ref ers t o art erial sat urat ion measured on
an art erial blood sample. Sensors may be applied on t he index, middle, or ring
f inger; on t he nose, earlobe, t oe, or f oot ; and on t he f orehead. Be aw are of
f act ors t hat int erf ere w it h accurat e result s, such as pat ient
movement , ambient light , elect ronic int erf erence, art if icial nails and polish,
anemia, edema, or poor circulat ion t o an area. Chapt er 14 provides more
inf ormat ion on pulse oximet ry.
Collect ing specimens and conduct ing procedures are t he main int ervent ions in
t he diagnost ic pret est and int rat est phases. Procure, process, t ransport , and
st ore specimens properly. The communit y environment and healt h care set t ing in
w hich t est ing t akes place dict at e prot ocols f or doing t his. Everyone involved in
t he process must have a t horough underst anding of t est ing principles and
prot ocols and must adhere t o t hem t o ensure accurat e result s.
Det ermine specimen t ype needed and met hod of sample procurement . Special
equipment and supplies may be necessary (eg, st erile cont ainers, special kit s).
Collect ion by t he pat ient requires pat ient cooperat ion, underst anding, and
inst ruct ion. I t does not alw ays require direct supervision. Conversely, supervised
collect ion requires supervision of t he pat ient by t rained personnel during
specimen collect ion. Examples of t hese t w o t ypes of collect ion include a rout ine
urine sample collect ed by t he pat ient privat ely versus a urine sample procured in
a supervised set t ing f or drug screening.
A t hird met hod of collect ion requires t hat t he clinician perf orm t he ent ire
collect ion. An example of t his t ype of collect ion is aspirat ing a urine sample f rom
an indw elling cat het er.
Time of collect ion is also import ant . For example, result s f rom a f ast ing blood
glucose t est versus result s f rom a 2-hour-post prandial blood glucose t est are
signif icant ly diff erent as diagnost ic paramet ers.
Specimens can be reject ed f or analysis because of f act ors relat ed t o t he
specimen it self or t o t he collect ion process (Table 1. 6).
Table 1.6 Errors in Collection
Specim en Errors
Collector Errors
Insufficient volume
Transport delay
Improper type
Improper collection method
Insufficient number of
samples
W rong specimen container
W rong transport
medium or wrong or
absent preservative
W rong time
Air bubbles in tube
Incorrect storage
Storage at incorrect
temperature
Unlabeled or mislabeled
specimen and/or wrong patient
identification information
Incorrect order of
draw
Improperly completed forms or

computer data entry
Do not cut test tapes

in half
Discrepancies between test

ordered and specimen
collected
Improper
centrifugation time
Failure to properly transcribe

and process orders
Note: Observing institutional protocols can prevent

mishaps.
Blood collect ion is normally done by t rained persons. (An except ion is t he self t est f or blood glucose using equipment designed specif ically f or t hat purpose. )
The t ime of collect ion is an import ant f act or (eg, a sequence of samples f or a
cardiac panel). For example, a peak drug-level blood specimen is collect ed
w hen highest drug concent rat ion in t he blood is expect ed. This t ype of t est is
used f or t herapeut ic drug monit oring and dosing. Conversely, a t rough sample
is collect ed w hen low est drug concent rat ion is expect ed. These t ypes of t est s
are used f or t herapeut ic drug monit oring, and specimens are collect ed and
result s report ed bef ore t he next scheduled dose of medicat ion.
Legal and f orensic specimens are collect ed as evidence (see Appendix L) in
legal proceedings, criminal invest igat ions, and af t er deat h. Examples include
DNA samples and drug and alcohol levels. Fact ors such as chain-of -cust ody
sit uat ions and w it nessed collect ions may be involved.
The f ollow ing list addresses some general comment s about specimen collect ions:
1. St ool and urine collect ion requires clean, dry cont ainers and kit s.
2. Timed urine collect ion requires ref rigerat ion and/ or cont ainers w it h special
addit ives.
3. St erile, dry cont ainers and special kit s are needed f or midst ream clean-cat ch
urine specimens.
4. O ral, saliva, and sput um specimens require specif ic t echniques and kit s and,
somet imes, special preservat ives.
5. Blood collect ion equipment includes gloves, needles, collect ion t ubes,
syringes, t ourniquet s, needle disposal cont ainers, lancet s f or skin punct ure,
cleansing agent s or ant imicrobial skin preparat ions, and adhesive bandages.
6. Color-coded st oppers and t ubes indicat e t he t ype of addit ive present in t he
collect ion t ube (Table 1. 7).
Table 1.7 Blood Specimen Collections
Collection Tube Color

and Additives*
Yellow-topped tube:
Use and Precautions
For collection of blood

cultures; aseptic
technique for blood
sodium polyethylene
sulfonate (SPS)
Red or gold serum

separator tubes (SST); no
anticoagulant
draw; invert tube 710

times to prevent clot
formation
For collecting serum
samples such as
chemistry analysis.
SST tubes should be
gently inverted
(completely, end over
end) 5 times after
collection to ensure
mixing of clot activator
with blood and clotting
within 30 minutes. After
the 30-minute period,
centrifuge promptly at
designated relative
centrifugal force (rcf)
for 15 5 minutes to
separate serum from
cells. Serum can be
stored in gel separator
tubes after
centrifugation for up to
48 hours. Do not
freeze SST tubes. If
frozen specimen is
needed, separate
serum into a labeled
plastic transfer vial.
Serum separation
tubes must not be
used to obtain
therapeutic drug levels
because the gel may
lower the values.
Red-topped (plain) tube:
no anticoagulant, no
additive
For serum chemistry,

serology, blood bank,
collection of clotted
blood specimens
Royal bluetopped tube:

without
ethylenediaminetetraacetic
acid (EDTA) or sodium
heparin (no anticoagulant
blood will clot)
For aluminum, arsenic,

chromium, copper,
nickel, and zinc levels;
tube free of trace
elements
Light bluetopped tube:

with sodium citrate as
anticoagulant (removes
calcium to prevent
clotting)
For plasma-coagulation
studies (eg,
prothrombin times [PT];
PT/partial
thromboplastin time
[PTT] and factor
assays). The tube
m ust be allowed to fill
to its capacity or an
improper
blood/anticoagulant
ratio will invalidate
coagulation test
results. Invert tube 7
10 times to prevent
clotting.
Gold or red marbled

topped tube: serum gel
separator tube (SST)
Light green marbled

topped tube: gel
separator/lithium, heparin
For serum, used for

most chemistry tests;
these tubes should be
gently inverted 5 times
after collection to
ensure mixing of clot
activator with blood
and clotting within 30
minutes. After 3-minute
period, centrifuge
promptly at designated
rcf for 15 5 minutes
to separate serum from
cells. Serum can be
stored in gel separator
tubes after
centrifugation for up to
48 hours. Do not
freeze SST tubes. If
frozen specimen is
needed, separate
serum into a labeled
plastic transfer vial.
Serum separation
tubes must not be
used for therapeutic
drug levels. The gel
may lower values. Not
for blood bank use
For potassium
determination
as anticoagulant
Tan/brown-topped tube:
with heparin as
anticoagulant
For heparinized plasma

specimens for testing
lead levels (ie, leadfree tube). Invert tube
710 times.
Lavender-topped tube:
with EDTA; removes
calcium to prevent clotting
For whole blood and

plasma, for hematology
and complete blood
counts (CBCs);
prevents the filled tube
from clotting. If the
tube is less than halffilled, the proportion of
anticoagulant to blood
may be sufficiently
altered to produce
unreliable laboratory
test results. Invert tube
68 times.
Royal bluetopped tube:

no additive with EDTA or
sodium heparin
anticoagulant
For toxicology,
cadmium and mercury:
tube free of trace
elements. Invert tube
710 times.
Gray-topped tube: with

potassium oxalate and
sodium fluoride
For glucose levels,

glucose tolerance
levels, and alcohol
levels.
Plain pink tube: no

additive or anticoagulant
For blood bank
Black tube: with sodium

citrate (binds calcium)
For W estergren
sedimentation rate
Green-topped tube: with

anticoagulant heparin
(sodium, lithium, and
ammonium heparin)
For heparinized plasma

specimens, plasma
chemistries, arterial
blood gases, and
special tests such as
ammonia levels,
hormones, and
electrolytes. Invert 7
10 times to prevent
clot formation.
* List is arranged in sequence of draw according to

NCCLS guidelines.
7. Addit ives preserve t he specimen, prevent det eriorat ion and coagulat ion,
and/ or block act ion of cert ain enzymes in blood cells.
8. Tubes w it h ant icoagulant s should be gent ly and complet ely invert ed (end
over end) 7 t o 10 t imes af t er collect ion. This process ensures complet e
mixing of ant icoagulant s w it h t he blood sample and prevent s clot f ormat ion.
9. St ore specimens properly af t er collect ing or t ransport t hem t o t he laborat ory
immediat ely f or processing and analysis if possible. Failure t o do so may
result in specimen det eriorat ion. STAT-ordered t est s should alw ays be handdelivered t o t he laborat ory and t hen processed as STAT.
10. Unaccept able specimens lead t o increased cost s and t ime w ast ed in get t ing
result s t o t he clinician, pat ient , inst it ut ion, and t hird-part y payer. Exposure t o
sunlight , air, or ot her subst ances and w arming or cooling are examples of
t hings t hat can alt er specimen int egrit y (see Appendix E). Check w it h t he
laborat ory f or proper st orage (eg, ice, ice w at er, separat e f rom ice),
t ransport , and t ime limit s.

11. As environment s f or specimen collect ion become more variable, modif ied
procedures and prot ocols require t he clinician t o keep abreast of t he lat est
inf ormat ion relat ed t o t hese f act ors (see Appendix E).
Equipment and Supplies

1. Use required kit s, equipment , and supplies. Special kit s are used f or
obt aining heel st icks and f inger st icks, blood alcohol samples, saliva or oral
f luid specimens, and urine specimens.
2. Do not use if you not ice a def ect (eg, moist ure, pinholes, t ears). I n cases of
sexual assault , special rape kit s are required and a st rict procedure,
consist ing of several st eps, is f ollow ed.
3. O perat ing special equipment such as video monit ors f or endoscopic
procedures may be required in some inst ances. Familiarit y w it h current
audiovisual t echnology is necessary.
4. Taking phot ographs of injuries in suspect ed abuse sit uat ions is anot her
example.
5. Use barrier drapes as direct ed. For example, art hroscopy drapes are
posit ioned w it h t he f luid cont rol pouch at t he knee.
6. Maint ain asept ic t echnique during cert ain procedures (eg, cyst oscopy, bone
marrow biopsy).
Family Presence
I nvolving f amily members in t he diagnost ic care process has helped f amilies by
making t hem act ive part icipant s. Facilit at ing f amily presence may provide t he
opport unit y t o calm t he
pat ient , off er addit ional comf ort , and reduce anxiet y and f ear. How ever, some
f amilies may f ind t he opt ion of observing procedures t o be dist ressing or
uncomf ort able. O t her pat ient s may not w ant f amily members present . Nurses
act ing as pat ient advocat es recognize t he import ance of support ing t he pat ient 's
need f or reassurance and t he f amily's need and right t o be present during
diagnost ic procedures. The goal is t o achieve an accept able balance bet w een all
part ies.
Positioning for Procedures

Proper body posit ioning and alignment involves placing t he pat ient in t he best
possible posit ion f or t he procedure and aligning t he body correct ly f or opt imal
respirat ory and circulat ory f unct ion. Posit ions include jackknif e, prone, lit hot omy,
sit t ing, supine, and Trendelenburg. Using posit ioning devices, arranging padding,
and reposit ioning are import ant int ervent ions t o prevent skin pressure and skin
breakdow n. The pot ent ial adverse eff ect s of various posit ions, especially during
lengt hy procedures, include skin breakdow n, venous compression, sciat ic nerve
injury, muscle injury, and low back st rain. Necessary posit ioning skills include
ensuring t hat t he pat ient 's airw ay, I V lines, skin int egrit y, and monit oring devices
are not compromised and ident if ying t hose persons at pot ent ial risk f or injury
(eg, elderly, t hin, f rail, unconscious pat ient s) bef ore posit ioning. I f w ounds, skin
breakdow n, abrasions, or bruises are present bef ore t he procedure, accurat ely
document t heir presence and locat ion.
Administration of Drugs and Solutions

All drugs and solut ions administ ered during diagnost ic procedures are given
according t o accept ed prot ocols. Drugs are given by mout h, by int ubat ion,
parent erally (int ramuscularly, int ravenously, or subcut aneously), and by local or
t opical skin applicat ions. I V f luids and endoscopic irrigat ing f luids are commonly
administ ered.
Be aw are of t he pot ent ial f or adverse react ions t o drugs. Bef ore procedure
begins, conf irm previous drug problems w it h t he pat ient bef ore t he procedure.
Risks f or injury are relat ed t o hypersensit ivit y, allergic or t oxic react ions,
impaired drug t olerance due t o liver or kidney malf unct ion, ext ravasat ion of
int ravenous f luids, and absorpt ion of irrigat ing f luids int o t he syst emic
circulat ion. Required skills include managing airw ays and breat hing pat t erns;
monit oring f luid int ake and loss; monit oring body, skin, and core t emperat ure;
and observing t he eff ect s of sedat ion and analgesia (Appendix C) (eg, vit al
signs, rashes, edema). Use t ape w it h caut ion, especially w hen skin int egrit y can
be easily compromised, as in f rail elderly pat ient s.
Management of Environment
The main goal of environment al cont rol is saf e pract ice t o ensure t hat t he pat ient
is f ree f rom injury relat ed t o environment al hazards and is f ree f rom discomf ort .
Be at t ent ive t o t emperat ure and air qualit y; t he pat ient 's t emperat ure; exposure
t o noise, radiat ion, lat ex, and noxious odors; sanit at ion; and cleanliness.
1. Eliminat e or modif y sensory st imuli (eg, noise, odors, sounds).
2. Post a PATI ENT AWAKE sign if t he pat ient is aw ake during a procedure or
PATI ENT ASLEEP f or sleep st udies.
3. Be sensit ive t o conversat ion among t eam members in t he presence of t he
pat ient . At best , it can be annoying t o t he pat ient ; at w orst , it may be
misint erpret ed and have f ar-reaching negat ive eff ect s and consequences.
Pain Control, Comfort Measures, and Patient

Monitoring Provide proper information, reassurance,
and support throughout the entire procedure to allay
anxiety and fear. Administer sedatives, pain
medication, or antiemetics as ordered. Uphold the
dignity of each patient, provide privacy, and minimize
any situation that might cause embarrassment or
stress. Continue monitoring throughout procedures as
well as after completion, if indicated.
1. Do not permit t he pat ient t o remain disrobed any longer t han necessary.
Allow personal clot hing and ot her accessories such as rings or religious
medals provided t hey do not pose a risk or int erf ere w it h t he procedure.
Ensure a reasonable degree of privacy.
1. Cont rol pain and provide comf ort measures. I V conscious sedat ion and drugs
given t o reverse t he eff ect s of t est medicat ions are part of t his scenario.
Allow t he pat ient t o maint ain as much cont rol as possible during all t est ing
phases w it hout compromising saf et y, t he process and procedure, and t est
int egrit y. I f possible, plan ahead t o accommodat e persons w it h special needs
such as learning disabilit ies, visual or hearing impairment , ost omy, or
diabet es management .
2. Monit or and document vit al signs and ot her relevant paramet ers (eg, pulse
oximet ry, ECG ) t hroughout t he procedure. O bserve f or problems and
abnormal react ions and t ake appropriat e measures t o correct such
sit uat ions. Make sure emergency equipment is readily available and
f unct ional.
3. Document t he pat ient 's response t o t he procedure during all phases. Also
document signif icant event s or sit uat ions t hat occur during t est ing. Record
disposit ion of specimens.
POSTTEST PHASE: ELEM ENTS OF SAFE, EFFECTIVE,

INFORM ED CARE
Basic Knowledge and Necessary Skills
The f ocus of t he post t est phase is on pat ient af t ercare and t he f ollow -up
act ivit ies, observat ions, and monit oring necessary t o prevent or minimize
complicat ions. Evaluat ion of out comes and eff ect iveness of care, f ollow -up
counseling, discharge planning, and appropriat e post t est ref errals are t he major
component s of t his phase.
Abnormal Test Results

Report and int erpret t est out comes correct ly. Abnormal t est pat t erns or t rends
can somet imes provide more usef ul inf ormat ion t han single t est out come
deviat ions. Conversely, single t est result s can be normal in pat ient s w it h a
proven disease or illness.
1. Recognize abnormal t est result s and consider t he implicat ions f or t he pat ient
in bot h t he acut e and t he chronic st ages of t he disease as w ell as during
screening.
2. The great er t he degree of t est abnormalit y, t he more likely t he out come w ill
be more serious.
3. Consider t he role of drugs w hen t est s are abnormal. Use of O TC drugs,
vit amins, iron, and ot her minerals may produce f alse-posit ive or f alsenegat ive t est result s. Pat ient s of t en do not disclose all medicat ions t hey use,
eit her unint ent ionally or deliberat ely. Commonly prescribed drugs t hat most
of t en aff ect laborat ory t est out comes include ant icoagulant s, ant iconvulsant s,
ant ibiot ic or ant iviral agent s, oral hypoglycemics, hormones, and
psychot ropic drugs. Consult a pharmacist or Physi ci ans Desk Ref erence
(PDR) source about drugs t he pat ient is t aking (eg, current lit erat ure search,
comput erized dat a, or manuf act urer's drug insert sheet ) (see Appendix J).
Be aw are t hat pat ient s w ho are addict ed t o drugs or alcohol may not provide
accurat e, reliable inf ormat ion about t heir use of t hese agent s. I n t he same
vein, somet imes at hlet es may not disclose t heir use of perf ormanceenhancing drugs.
4. Consider biocult ural variat ions w hen int erpret ing t est result s. See Table 1. 8
f or examples of some common variat ions.
Table 1.8 Biocultural Considerations
Diagnostic Test
Biocultural Variation
Orthopedic x-rays
Body proportions and

tendencies: African
American people exhibit
longer arms and legs and
shorter trunks than
Caucasians. African
American women tend to
be wider shouldered and
more narrow hipped, but
with more abdominal
adipose tissue than
Caucasian women.
Caucasian men tend to
exhibit more abdominal
adipose tissue than do
African American men.
Native Americans and
Asian Americans have
larger trunks and shorter
limbs than do African
American and Caucasian
people. Asian American
people tend to be wider
hipped and more narrow
shouldered than do other
peoples.
African American men have
the densest bones,
followed by African
American women and
Bone density
measurements
Test for glucose-6phosphate

dehydrogenase
(G6PD) deficiency
Caucasian men, who have

similar bone densities.
Caucasian women have the
least dense bones.
Chinese, Japanese, and
Inuit bone density is less
than that of Caucasian
Americans. Additionally,
bone density decreases
with age.
G6PD deficiency may be
the cause of hemolytic
disease of newborns in
Asian Americans and those
of Mediterranean descent.
Three G6PD variants occur
frequently: type A is
common in African
Americans (10% of males);
the Mediterranean type is
common in Iraqis, Kurds,
Lebanese, and Sephardic
Jews; and the Mahedial
type is common in
Southeast Asians (22% of
males).
African American and
Caucasian ethnic groups
have similar cholesterol
levels at birth. During
childhood, African
Cholesterol levels
Hemoglobin/hematocrit
levels
Sickle cell anemia
American people develop

higher levels than do
Caucasian people;
however, African American
adults have lower
cholesterol levels than do
Caucasian adults.
The normal hemoglobin
level for African American
people is 1 g lower than
that for other groups.
Given similar
socioeconomic conditions,
Asian Americans and
Mexican Americans have
hemoglobin/hematocrit
levels higher than those of
Caucasian people.
Sickle cell anemia affects
millions of people
throughout the world. It is
particularly common among
people whose ancestors
come from sub-Saharan
Africa; Spanish-speaking
regions (South America,
Cuba, Central America),
Saudi Arabia, India, and
Mediterranean countries,
such as Turkey, Greece,
and Italy. In the United
States, it affects
approximately 72,000
people, most of whose
ancestors come from
Africa. The disease occurs
in approximately 1 in every
1,000 to 1,400 Hispanic
American births.
Approximately 2 million
Americans, or 1 in 12
African Americans, carry
the sickle cell trait.
Clin ical Alert

1. Correct t est int erpret at ion also requires know ledge of all medicat ions t he
pat ient is t aking.
2. Support t he pat ient and his or her signif icant ot hers in underst anding and
coping w it h posit ive or negat ive t est out comes.
3. Recognize t hat panic values may pose an immediat e t hreat t o t he
pat ient 's healt h st at us. Report t hese f indings t o t he at t ending physician or
ot her designat ed person immediat ely. Caref ully document result s and
act ions t aken as soon as possible.
4. Nearly all t est s have limit at ions. Some t est s cannot predict f ut ure
out comes or event s. For example, an ECG cannot predict a f ut ure
myocardial inf arct ion; it can merely t ell w hat has already occurred. No
t est is absolut e.
5. Devast at ing physical, psychological, and social consequences can result
f rom being misdiagnosed w it h a serious disease because of f alse-posit ive
or f alse-negat ive t est result s. Major alt erat ions in lif est yles and
relat ionships w it hout just cause can be a consequence of t hese clinical
aberrat ions (eg, misdiagnosis of HI V or syphilis).
Follow-Up Counseling
1. Counsel t he pat ient regarding t est out comes and t heir implicat ions f or f urt her
t est ing, t reat ment , and possible lif est yle changes. Provide t ime f or t he
pat ient t o ask quest ions and voice concerns about t he ent ire t est ing process.
2. Test out come int erpret at ion involves reassessment of int erf ering f act ors and
pat ient compliance if t he result s signif icant ly deviat e f rom normal and
previous result s.
3. No t est is perf ect ; how ever, t he great er t he degree of abnormalit y indicat ed
by t he t est result , t he more likely it is t hat t his out come deviat ion is
signif icant or represent s a real disorder.
4. Not if y t he pat ient about t est result s af t er consult at ion w it h t he clinician.
Treat ment may be delayed if t est result s are misplaced or not communicat ed
in a t imely manner.
5. Help pat ient s int erpret t he result s of communit y-based t est ing.
6. I dent if y diff erences in t he pat ient 's view of t he sit uat ion, t he clinician's view s
about t est s and disease, and t he healt h care t eam's percept ions.
7. When providing genet ic counseling, t he clinician needs t o be sensit ive t o t he
implicat ions of genet ic or met abolic disorders. I nf orming t he pat ient or f amily
about t he genet ic def ect requires special t raining in genet ic science, f amily
coping skills, and an underst anding of legal and et hical issues.
Conf ident ialit y and privacy of inf ormat ion are vit al.
8. Be f amiliar w it h crisis int ervent ion skills f or pat ient s w ho experience diff icult y
dealing w it h t he post t est phase.
9. Encourage t he pat ient t o t ake as much cont rol of t he sit uat ion as possible.
10. Recognize t hat t he diff erent st ages of behavioral responses may last several
w eeks.
Monitoring for Complications

O bserve f or complicat ions or ot her risks, and t ake appropriat e measures t o
prevent or deal w it h t hem in a saf e pat ient environment .
1. The most common complicat ions af t er invasive procedures are bleeding,
inf ect ion (f requent ly a lat er complicat ion), respirat ory diff icult ies, perf orat ion
of organs, and adverse eff ect s of conscious sedat ion and local anest hesia.
Wat ch f or relat ed signs and sympt oms such as redness, sw elling, skin
irrit at ion, pain or t enderness, dyspnea, abnormal breat h sounds, cyanosis,
decreased or increased pulse rat e, blood pressure deviat ions (eg,
hypert ension, hypot ension), laryngospasm, agit at ion or combat ive behavior,
pallor, and complaint s of dizziness. I f adverse react ions or event s occur,
cont act t he physician immediat ely and init iat e t reat ment as soon as possible.
2. Post t est assessment s include evaluat ion of pat ient behaviors, complaint s,
act ivit ies, and compliance w it hin t he emot ional, physical, psychosocial, and
spirit ual dimensions. Alt erat ions in any of t hese domains may indicat e a need
f or int ervent ions appropriat e t o t he dimension aff ect ed.
3. O lder pat ient s and children may require closer, more lengt hy monit oring and
observat ion. For example, invasive procedure sit es should be observed and
assessed f or pot ent ial bleeding and circulat ory problems in t he immediat e
post procedure phase and f or inf ect ion as a lat er event (possibly several
days lat er).
4. Pat ient s w ho receive sedat ion, drugs, cont rast media (eg, iodine, barium), or
radioact ive subst ances must be evaluat ed and t reat ed according t o
est ablished prot ocols (see Appendix C and Chapt er 9 and Chapt er 10).
5. I nf ect ion cont rol measures w it h st andard precaut ions and asept ic t echniques
must be observed.
Test Result Availability

Collaborat e w it h ot her disciplines t o ensure t hat t est result s are made available
t o t he clinician, pat ient , and st aff as soon as possible. Time-crit ical inf ormat ion
is of limit ed value if it is delayed or not received. Even t hough comput erized
communicat ion t echnologies cont ribut e t o f ast er inf ormat ion delivery, clinicians
are of t en lef t w ait ing f or crucial clinical dat a. Using f acsimile (f ax) machines,
comput ers, and w ireless net w orks properly can expedit e t he report ing of vit al
pat ient dat a t o t he healt h care provider so t hat t reat ment can begin w it hout
delay.
Clin ical Alert

The issue of conf ident ialit y demands t hat access t o records and inf ormat ion
should be on a st rict need-t o-know basis w it h secure and prot ect ed access
available t o select individuals.
Referral and Treatment

Ref errals f or f urt her t est ing and beginning t reat ment are a part of t he
collaborat ive process. For example, t he clinician ref ers pat ient s w it h abnormal
Pap smear result s t o t he specialist f or colposcopy, loop elect rocaut ery excision
procedure (LEEP), or cervical or endomet rial biopsy. The clinician ref ers t he
pat ient f or genet ic counseling and diet ary t herapy f or genet ic disorders such as
phenylket onuria (PKU) cholest erol in t he new born.
Follow-Up Care
Follow -up care should be consist ent and should provide clearly underst ood
discharge inst ruct ions. Emphasize t he import ance of and prot ocols f or f ollow -up
visit s if t hese are ordered. Schedule ordered f ollow -up visit s as appropriat e.
Follow est ablished prot ocols f or discharge t o home af t er t est ing is complet ed.
For complex procedures t hat are invasive or require sedat ion, be cert ain t hat a
responsible individual escort s t he pat ient home. Provide specif ic inst ruct ions
regarding inf ect ion cont rol, barium eliminat ion, iodine sensit ivit y, and resuming
pret est act ivit ies. Have t he pat ient repeat t his inf ormat ion back t o t he person
providing t he inf ormat ion t o ensure t hat it has been underst ood. Plan t ime f or
list ening, support , discussion, and problem solving according t o t he pat ient 's
needs and request s. Follow -up by phone may be done af t er discharge if
indicat ed.
Documentation, Record Keeping, and Reporting Record

information about all phases of the diagnostic testing
process in the patient's health care record. Accurately
document diagnostic activities and procedures during
the pretest, intratest, and posttest phases because of
legal, budgetary, reimbursement, and diagnosticrelated grouping (DRG) and common practice
terminology (CPT) code implications and constraints.
The pat ient 's healt h care record is t he only w ay t o validat e t he need f or
diagnost ic care, t he qualit y and t ype of care given, and t he pat ient 's response t o
t he care and t o ensure t hat current st andards of medical and nursing care and
diagnost ic t est ing are being met . The medical record may also be t he basis f or
reimbursement f or diagnost ic t est s by Medicare (government ), or
privat e insurance programs. Accuracy, complet eness, object ivit y, and legibilit y
are of ut most import ance in t he document at ion process. Document at ion f or
laborat ory and diagnost ic t est ing includes recording all pret est , int rat est , and
post t est care:
1. Document t hat t he purpose, side eff ect s, risks, and expect ed result s and
benef it s, as w ell as alt ernat ive met hods, have been explained t o t he pat ient ,
and not e w ho gave t he explanat ion. I nclude inf ormat ion about medicat ions,
I V conscious sedat ion, st art and end t imes, and pat ient responses. Describe
allergic or adverse react ions (see Appendix B). Record dat a regarding
disposit ion of specimens as w ell as inf ormat ion about f ollow -up care and
discharge inst ruct ions.

2. Document t he pat ient 's reasons f or ref using a t est along w it h any ot her
pert inent inf ormat ion about t he sit uat ion and w ho w as given t his report .
3. Maint ain records of laborat ory and diagnost ic t est dat a. Frequent ly, t hese
records are t ransf erred ont o compact record st orage syst ems such as
microf ilm or comput er disks. For example, w hen an individual t est s posit ive
f or HI V, it is necessary t o review donor records at blood donor cent ers t o
det ermine w het her t he individual ever donat ed blood. I f t he inf ect ed person
donat ed blood, t he recipient s of t hose blood component s must be cont act ed
and inf ormed of t he sit uat ion. This process is called look back. Because
many years may pass bet w een donat ion and t ransf usion and t he t ime t he
donor t est s HI V posit ive, medical hist ory records of blood donors must be
st ored indef init ely.
4. I ndicat e t he t ime, day, mont h, and year of ent ries. This inf ormat ion can
assume great import ance in t he off ice or clinic set t ing w hen chart s become
very lengt hy. Ent er appropriat e assessment dat a and not e t he pat ient 's
concerns and quest ions t hat help t o def ine t he nursing diagnosis and f ocus
f or care planning. Document specif ic t eaching and preparat ion of t he pat ient
bef ore t he procedure. Avoid generalizat ions.
5. When an int erpret er is present , document t he name and relat ionship t o t he
pat ient . Record t hat pat ient consent t o give conf ident ial t est inf ormat ion
t hrough an int erpret er w as obt ained bef ore revealing t he inf ormat ion. Record
any deviat ions f rom basic w it nessed consent policies (eg, illit eracy, non
English-speaking client , sedat ion immediat ely bef ore t he request f or consent
signat ure, consent per t elephone); include nurse measures employed t o
obt ain appropriat e consent f or t he procedure.
6. Record t hat t he preparat ion, side eff ect s, expect ed result s, and int erf ering
f act ors have been explained. Document t he inf ormat ion given and t he
pat ient 's response t o t hat inf ormat ion. Keep a record of all print ed and
w rit t en inst ruct ions. Record medicat ions, t reat ment s, f ood and f luids, int ake
st at us, beginning and end of specimen collect ion and procedure t imes,
out comes, and t he pat ient 's condit ion during all phases of diagnost ic care. I f
t he pat ient does not appear f or t est ing, document t his f act ; include any
f ollow -up discussion w it h t he pat ient . Complet ely and clearly describe side
eff ect s, sympt oms, adverse react ions, and complicat ions along w it h f ollow up care and inst ruct ions f or post t est care and monit oring.
7. Record t he pat ient 's ref usal t o undergo diagnost ic t est s. Not e t he reasons,
using t he pat ient 's ow n w ords if possible. Document signif icant noncompliant
behaviors such as ref usal or inabilit y t o f ast or t o rest rict or increase f luid or
f ood int ake, incomplet e t imed specimens, inadequat e or improperly self collect ed specimens, and missed or canceled t est appoint ment s. Place
copies of let t ers sent in t he pat ient 's chart .
8. Report ing includes pat ient not if icat ion regarding t est out comes in a t imely
f ashion and document at ion t hat t he pat ient or f amily has been not if ied
regarding t est result s. Document f ollow -up pat ient educat ion and counseling.
9. Report result s t o designat ed prof essionals. Report crit ical (panic) values
immediat ely, and document t o w hom result s w ere report ed, orders received,
and urgent t reat ment s init iat ed.
10. Report all communicable diseases t o appropriat e agencies.
11. Report and document sit uat ions t hat are mandat ory by st at e st at ut e (eg,
suspect ed elder abuse, child abuse as evidenced by x-rays).
Report ing inf ect ious diseases and out breaks t o st at e and f ederal government s is
part of record keeping. Chart 1. 4 and Chart 1. 5 are examples of one st at e's
(Maryland) required report ing. Check w it h your individual st at e or province f or
specif ic guidelines.
Ch art 1.4 Diseases and Conditions Reportable by Health Care

Providers and Others
Legionellosis
Poliomyelitis*
Acquired
immunodeficiency
syndrome (AIDS)
Leprosy
Psittacosis
Leptospirosis
Rabies*
Amebiasis
Lyme disease
Animal bites*
Malaria
Rocky
Mountain
spotted fever
Anthrax*
Measles
(rubeola)*
Botulism*
Brucellosis
Chancroid
Meningitis
(viral, bacterial,
parasitic, and
fungal)
Rubella
(German
measles) and
congenital
rubella
syndrome*
Salmonellosis
Cholera*
Meningococcal
disease
Septicemia in
newborns
Mumps
(infectious
parotitis)
Shigellosis
Mycobacteriosis
other than
tuberculosis
and leprosy
Tetanus
Diphtheria*
Encephalitis
Gonococcal
infection
Haemophilus
influenzae type b
invasive disease*
Hepatitis, viral (A,
B, C, all other
types and
undetermined)
Kawasaki
syndrome
Pertussis*
Pertussis
vaccine adverse
reactions
Syphilis
Trichinosis
Tuberculosis
Tularemia*
Typhoid fever
(case or
carrier)*
Plague*
* Reportable immediately by telephone.

From State of Maryland Department of Health and
Mental Hygiene. Epidemiology and Disease Control
Program. (Reviewed: December 2002.)
Ch art 1.5 Diseases and Conditions Reportable by Laboratory

Directors
Amebiasis
Microsporidiosis
Anthrax
Mumps
Bacteremia in newborns
Pertussis
Botulism
Plague
Brucellosis
Poliomyelitis
Campylobacter infection
Psittacosis
CD4+ count, if
<200/mm3 1
Q fever
Chlamydia infection
Cholera
Coccidiodomycosis
Cryptosporidiosis
Cyclosporiasis
Dengue fever
Diphtheria
Rabies
Ricin toxin
Rocky Mountain spotted
fever
Rubella and congenital
rubella syndrome
Salmonellosis
(nontyphoid fever types)
Ehrlichiosis
Shiga-like toxin
production
Encephalitis, infectious
Shigellosis
E. coli O157:H7 infection
Smallpox and other

orthopox viruses
Giardiasis
Staphylococcal
enterotoxin
Gonorrhea
Haemophilus influenza,
invasive disease1
Hansen's disease
(leprosy)
Hantavirus infection
Hepatitis, viral, types A,
B, C, & other types
Streptococcal invasive
disease, group A 2
Streptococcal invasive
disease, group B2
Streptococcus
pneumonia, invasive
disease 2
Syphilis
HIV infection1
Trichinosis
Isosporiasis
Tularemia
Legionellosis
Typhoid fever
Leptospirosis
Varicella (chickenpox),
fatal cases only
Lyme disease
Malaria
Vibriosis, noncholera3
Measles
Viral hemorrhagic fever

(all types)
Meningococcal invasive
disease 2
Yellow fever
Meningitis, infectious
Yersiniosis
Reportable by unique patient identifying number; 2

invasive disease means a disease in which an
organism is detected in a specimen taken from a
normally sterile body site; 3 need not be reported if
found in a specimen obtained from a patient's teeth,
gingival tissues, or oral mucosa.
(See the Annotated Code of Maryland, HealthGeneral Article 18-205, for further reporting
requirements.) From State of Maryland Department of
Health and Mental Hygiene Epidemiology and
Disease Control Program. (Reviewed: December
2002.)
Guidelines for Disclosure

Follow agency guidelines f or disclosure. Et hical st andards may be a source of
conf lict and anxiet y w hen t he prof essional clinician is act ing in t he role of pat ient
advocat e. Recommended guidelines f or t elling a pat ient about t est result s can
alleviat e some of t his f rust rat ion. Under normal circumst ances, t he pat ient has
t he right t o be inf ormed of t est result s. Alt hough t he clinician w ho orders t he t est
is responsible f or providing init ial t est result inf ormat ion, ot her designat ed
individuals may need t o f acilit at e and support t he pat ient 's right t o know
inf ormat ion about t heir healt h st at us.
I n cases in w hich t he pat ient brings f amily and signif icant ot hers t oget her t o
inf orm t hem about t est result s, communicat ion becomes open and shared. This
prevent s t he so-called conspiracy of silence, in w hich individuals in t he scenario
w it hhold inf ormat ion because t hey f eel t hey are prot ect ing t he pat ient or f amily
or because t hey do not know how t o deal w it h t he sit uat ion.
Patient Responses to Expected or Unexpected

Outcomes Develop crisis intervention skills to use
when communicating with the patient who experiences
difficulty dealing with abnormal test results or
confirmation of disease or illness.
1. Encourage t he pat ient t o t ake as much cont rol of t he sit uat ion as possible.
2. Recognize t hat t he diff erent st ages of behavioral responses t o negat ive
result s may last several w eeks or longer.
3. Monit or changes in pat ient aff ect , mood, behaviors, and mot ivat ion. Do not
assume t hat persons w ho init ially have a negat ive percept ion of t heir healt h
(eg, denial of diabet es) w ill not be able t o int egrat e bet t er healt h behaviors
int o daily lif e once t hey accept t he diagnosis.
4. Use t he f ollow ing st rat egies t o lessen t he impact of a t hreat ening sit uat ion:
a. O ff er appropriat e comf ort measures.
b. Allow pat ient s t o w ork t hrough f eelings of anxiet y and depression. At t he
appropriat e t ime, reassure t hem t hat t hese f eelings and emot ions are
normal init ially. Be more of a t herapeut ic list ener t han a t alker.
c. Assist t he pat ient and f amily in making necessary lif est yle and self concept adjust ment s t hrough educat ion, support groups, and ot her
means. Emphasize t hat risk f act ors associat ed w it h cert ain diseases can
be reduced t hrough lif est yle changes. Be realist ic.
I t is bet t er t o int roduce change slow ly rat her t han t rying t o promot e adjust ment s
on a grand scale in a short period of t ime (Table 1. 9).
Table 1.9 Behavioral Responses
Im m ediate
Response
Secondary Response
Acute emotional
turmoil, shock,
disbelief about
diagnosis, denial
Insomnia, anorexia, difficulty

concentrating, depression, difficulty
in performing work-related
responsibilities and tasks
Anxiety will
usually last
several days
until the person
assimilates the
information.
Depression may last several weeks

as the person begins to incorporate
the information and to participate
realistically in a treatment plan and
lifestyle adaptation.
Expected and Unexpected Outcomes

Evaluat e out comes using t he f ollow ing st eps:
1. Learn t he normal or ref erence values and expect ed out comes of t he t est .
The pat ient or his or her signif icant ot hers should be able t o describe t he
purpose of t he t est and t he t est ing process and should properly perf orm
expect ed act ivit ies associat ed w it h t est ing. O ff er assist ance if necessary. I f
t est out comes are abnormal, t he pat ient should be encouraged t o comply
w it h repeat t est ing and t o int roduce appropriat e lif est yle changes
realist ically. Deal w it h anxiet y and f ears in a t imely manner. Ref er t he pat ient
t o appropriat e counseling resources if indicat ed. Above all, do not dismiss
t he pat ient 's f eelings and concerns casually.
2. Compare normal values w it h abnormal result s and apply t hese comparisons
t o t he pat ient 's sit uat ion. Somet imes, desired out comes cannot be achieved.
For example, t he pat ient cannot , f or various reasons, f ully part icipat e in t he
t eaching/ learning process or t he act ual t est ing it self . Recommendat ions f or
f ollow -up care and lif est yle changes may not be able t o be f ollow ed. Verbal
and nonverbal cues can somet imes provide reasons (eg, Alzheimer's disease,
physical limit at ions) f or t his inabilit y. I n anot her inst ance, t he pat ient might
be noncompliant w it h pret est preparat ions and post t est act ivit ies. Denial of
t he sit uat ion is f requent ly a reason, alt hough t here are many ot her causes
f or noncompliance. Pat ient s may ref use diagnost ic t est ing because t hey f eel
t he result s may conf irm t heir w orst suspicions and f ears.
3. Numerous and varied responses can be relat ed t o lack of appropriat e
problem-solving behaviors, inappropriat e behaviors, f ears or denial, concern
about pot ent ial complicat ions, inabilit y t o cope w it h or t ake cont rol of t he
sit uat ion, depression or abnormal emot ional pat t erns of response, and lack
of support f rom signif icant ot hers and f amily. Percept ions of having
experienced uncaring act s can lead t o f rust rat ion, despair, and hopelessness
on t he pat ient 's part .
4. Adverse event s (eg, perf orat ion, anaphylaxis, deat h) and healt h hazards may
occur as a result of diagnost ic procedures or problems w it h a medical device

or product (eg, react ions t o lat ex gloves or ot her lat ex-cont aining medical
devices). Healt h prof essionals are asked t o monit or and volunt arily report
f ault y medical devices t o t he U. S. Food and Drug Administ rat ion (FDA) so
t hat act ion can be t aken t o prot ect t he public. Report ing does not
necessarily const it ut e an admission t hat medical personnel or t he product
caused or cont ribut ed t o t he adverse event .
5. Prompt act ion is necessary w hen result s are abnormally high or low and are
indicat ive of a serious sit uat ion (eg, posit ive blood cult ure, abnormally
elevat ed pot assium level).
6. Modif y, report , and collaborat e w it h ot her clinicians w hen unexpect ed or
abnormal values occur and w hen changes in medical care may be necessary
as a result of t est out comes.
7. Examples of expect ed and unexpect ed t est out comes f ollow in Table 1. 10.
Table 1.10 Test Outcomes
Expected
Outcom es
Unexpected Outcom es
Anticipated
outcomes will
be achieved.
Some anticipated outcomes may

not be achieved, possibly because
of specific patient behaviors that
interfere with care interventions
(eg, patient does not appear for
testing appointment, patient did
not fast or withhold medication
when directed before testing).
Patient, family,
and significant
others should
be able to
describe the
testing process
and purpose
and be able to
properly
perform
expected
activities.
Information
contributes to
empowerment.
Inability to fully participate in

teaching or learning process is
evidenced by verbal and nonverbal
cues. Patient cannot properly
perform expected activities.
Misinterpretation and
misinformation of diagnostic
process results in panic,
avoidance behaviors, and refusal
to have tests done.
If test
outcomes are
abnormal, the
appropriate
lifestyle
changes will be
made, and the
patient will
adopt healthy
behaviors.
Patient does not comply with test

preparation guidelines and
posttest recommended lifestyle
changes; hides test results; and
minimizes or exaggerates meaning
of test outcomes.
Does not
develop
complications
and remains
free from
injury.
Patient exhibits untoward signs

and symptoms (eg, allergic
response, shock, bleeding,
nausea, vomiting, retention of
barium).
If
complications
occur, they will
be optimally
resolved. Signs
of infection
treated
immediately
and infection
resolved.
Anxiety and
fears will be
alleviated and
will not
interfere with
the testing
process. The
patient is
helped to
balance fears
with the
recognition of
the potential
for developing
coping skills.
W ith support
and education,
able to cope
with test
outcomes
revealing a
Complications are not fully

resolved, health state is
compromised, and more extensive
testing and care are needed.
Because of anxiety, fear, or

uncertainty, the patient is unable
to collect specimens properly or to
accurately comply with procedural
steps. The nurse is unable to calm
and reassure the patient. Invasive
tests may be canceled if the
patient is too anxious or fearful.
Lack of appropriate problemsolving behaviors, uncertainty or

denial about test outcomes,
inability to cope with test
outcomes, extreme depression and
abnormal patterns of responses,
chronic or lifethreatening
disease. Hope
is inspired or
generated, and
the patient
feels cared
for.
and refusal to take control of the

situation or to cooperate with
prescribed regimens. Anxiety,
grief, guilt, or sense of social
stigma about the illness persists.
Uses alcohol or drugs. Caregivers
are seen as uncaring.
IM PORTANCE OF COM M UNICATION

At t he heart of inf ormed care is t he abilit y t o communicat e eff ect ively.
Frequent ly, communicat ion must t ake place w it hin a compressed t ime f rame
because of t ime const raint s. Thus, t he import ance of communicat ing eff ect ively
cannot be emphasized enough. Eff ect ive communicat ion is t he key t o achieving
desired out comes, prevent ing misunderst anding and errors, and helping pat ient s
f eel secure and connect ed t o t he diagnost ic process. O ne must alw ays keep in
mind t hat t he human person is an int egrat ion of body, mind, and spirit and t hat
t hese t hree ent it ies are int imat ely bound t oget her t o make each person unique.
Skillf ul assessment of physical, emot ional, psychosocial, and spirit ual dimensions
provides a sound dat abase f rom w hich t o plan communicat ion and
t eaching/ inst ruct ion st rat egies.
I ndividuals have diff erent needs and changing capacit ies f or learning as t hey
progress f rom child t o adult t o older adult . I t is import ant f or t he clinician t o
know t he diff erent development al levels and st ages and t he w ays in w hich clear
communicat ion can be achieved at any level.
For t he pediat ric pat ient , t eaching t ools might include t ours of t he diagnost ic
area, play t herapy, f ilms or videos, models of equipment t hat t he child can t ouch
or manipulat e, and w rit t en mat erials and pict ures appropriat e t o t he child's
development al st age. Short er at t ent ion spans and t he unpredict able nat ure of
children can make t eaching a challenge in t his populat ion. Ment ally ret arded or
ment ally ill pat ient s may need signif icant ot hers close by w ho can guide
communicat ion bet w een caret aker and pat ient . G ent le, simple, nurt uring
behaviors usually w ork w ell w it h children and development ally challenged
individuals.
Adolescent s may be at t he st age of developing t heir ow n unique ident it y as t hey
move t ow ard adult hood. Teaching may be more eff ect ive w it hout parent s
present ; how ever, it is import ant t o include parent s at some point . Draw ings,
illust rat ions, or videos are helpf ul. Because body image is very import ant at t his
st age, honest , support ive behaviors are necessary, especially if some alt erat ion
in physical appearance w ill be necessary (eg, removal of jew elry, no makeup
allow ed).
The opport unit y t o part icipat e act ively and t o ask quest ions is import ant f or
adult s. They bring t o t he communicat ion process t heir lif et ime of percept ions and
experiences. This can be a proverbial double-edged sw ord. List ening w ell t o
verbal cues as w ell as paying at t ent ion t o nonverbal messages cannot be
overemphasized. For example, int eract ing w it h pat ient s w ho
have Alzheimer's disease can present special challenges. The presence of a
signif icant ot her w ho has experience communicat ing w it h t his pat ient can be t he
key t o perf orming a successf ul procedure.
Provide an environment t hat is quiet , privat e, and f ree of dist ract ions t o promot e
dialogue and communicat ion. Ask by w hat name or t it le t he pat ient w ishes t o be
addressed. Ref erring t o
a pat ient as a room number, a procedure, or a disease is demeaning and
inexcusable; it reduces t he pat ient t o t he level of an object rat her t han a person.
Nonverbal communicat ion behaviors such as proper eye cont act , f irm handshake,
sense of respect , and appropri ate humor can reduce anxiet y. Do not dismiss t he
pow er of t ouch, t he sense of making t ime f or t he pat ient , and t he use of
appropriat e and posit ive verbal cues. The great er part of communicat ion (>70%)
is perceived t hrough body language. I f w ords don't mat ch body language and
behaviors, pat ient s w ill react t o t he body language t hey observe as t heir primary
f rame of ref erence. Negat ive communicat ion by caregivers of t en is experienced
by pat ient s as an uncaring at t it ude and result s in a sense of discouragement .
Every person engaged in t he enti re process of t est ing is a link in t he ongoing
communicat ion cont inuum. This cont inuum is only as eff ect ive as t he w eakest link
t hat joins all act ivit ies and all communicat ion t oget her.
CONCLUSION
As prof essionals, w e need t o remember t hat pat ient s are people just like us.
These individuals present w it h t heir percept ions, w orries, and anxiet ies regarding
t he diagnost ic process and w hat t heir illness means t o t hem and t heir loved
ones, w hat st rat egies t hey use f or coping, w hat resources are available f or t heir
use, and w hat ot her know ledge t hey have about t hemselves. As clinicians and
pat ient advocat es, w e must be w illing t o t ake on t he mind of anot hert hat is,
t o ident if y w it h t he pat ient 's point of view as much as possible and t o show
empat hy. O nce w e reach t hat point , w e can t hen begin t o underst and and
communicat e w it h each ot her at t he deeper levels necessary f or a t herapeut ic
relat ionship t o occur.
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Wilkins
> Table of C ontents > 2 - B lood S tudies ; Hem atology and C oagulation
2
Blood Studies; Hematology and Coagulation
OVERVIEW OF BASIC BLOOD HEM ATOLOGY AND
COAGULATION TESTS
Composition of Blood
The average person circulat es about 5 L of blood (1/ 13 of body w eight ), of w hich
3 L is plasma and 2 L is cells. Plasma f luid derives f rom t he int est ines and
lymphat ic syst ems and provides a vehicle f or cell movement . The cells are
produced primarily by bone marrow and account f or blood solids. Blood cells
are classif ied as w hit e cells (leukocyt es), red cells (eryt hrocyt es), and plat elet s
(t hrombocyt es). Whit e cells are f urt her cat egorized as granulocyt es,
lymphocyt es, monocyt es, eosinophils, and basophils.
Bef ore birt h, hemat opoiesis occurs in t he liver. I n midf et al lif e, t he spleen and
lymph nodes play a minor role in cell product ion. Short ly af t er birt h,
hemat opoiesis in t he liver ceases, and t he bone marrow is t he only sit e of
product ion of eryt hrocyt es, granulocyt es, and plat elet s. B lymphocyt es are
produced in t he marrow and in t he secondary lymphoid organs; T lymphocyt es
are produced in t he t hymus.
Blood Tests
Test s in t his chapt er are basic screening t est s t hat address disorders of
hemoglobin (Hb) and cell product ion (hemat opoiesis), synt hesis, and f unct ion.
Blood and bone marrow examinat ions const it ut e t he major means of det ermining
cert ain blood disorders (anemias, leukemia and porphyrias disorders, abnormal
bleeding and clot t ing), inf lammat ion, inf ect ion and inherit ed disorders of
red blood cells, w hit e blood cells, and plat elet s. Specimens are obt ained t hrough
capillary skin punct ures (f inger, t oe, heel), dried blood samples, art erial or
venous sampling, or bone marrow aspirat ion. Specimens may be t est ed by
aut omat ed or manual hemat ology inst rument at ion and evaluat ion.
BLOOD SPECIM EN COLLECTION PROCEDURES

Proper specimen collect ion presumes correct t echnique and accurat e t iming
w hen necessary. Most hemat ology t est s use liquid et hylenediaminet et raacet ic
acid (EDTA) as an ant icoagulant . Tubes w it h ant icoagulant s should be gent ly but
complet ely invert ed end over end 7 t o 10 t imes af t er collect ion. This act ion
ensures complet e mixing of ant icoagulant s w it h blood t o prevent clot f ormat ion.
Even slight ly clot t ed blood invalidat es t he t est , and t he sample must be redraw n.
For plasma coagulat or st udies, such as prot hrombin t ime (PT) and part ial
t hromboplast in t ime (PTT), t he t ube must be allow ed t o f ill t o it s capacit y or an
improper blood-t o-ant icoagulant rat io w ill invalidat e coagulat or result s. I nvert 7
t o 10 t imes t o prevent clot t ing.
Capillary Puncture (Skin Puncture) Capillary blood is

preferred for a peripheral blood smear and can also be
used for other hematology studies.
Procedure
1. O bserve st andard precaut ions (see Appendix A). Check f or lat ex allergy. I f
allergy is present , do not use lat ex-cont aining product s (see Appendix B).
2. O bt ain capillary blood f rom f ingert ips or earlobes (adult s) or f rom t he great
t oe or heel (inf ant s).
3. Disinf ect punct ure sit e, dry t he sit e, and punct ure skin w it h st erile disposable
lancet no deeper t han 2 mm. I f povidone-iodine is used, allow t o dry
t horoughly.
4. Wipe aw ay t he init ial drop of blood. Collect subsequent drops in a microt ube
or prepare a smear direct ly f rom a drop of blood.
Clin ical Alert

1. Do not squeeze t he sit e t o obt ain blood because t his alt ers blood
composit ion and invalidat es t est values.
2. Warming t he ext remit y or placing it in a dependent posit ion may f acilit at e
specimen collect ion.
Interventions
Pretest Patient Care

1. I nst ruct pat ient about purpose and procedure of t est .
2. Follow Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest care .
Posttest Patient Aftercare

1. Apply small dressing or adhesive st rip t o sit e.
2. Evaluat e punct ure sit e f or bleeding or oozing.
3. Apply compression or pressure t o t he sit e if it cont inues t o bleed.
4. Evaluat e pat ient 's medicat ion hist ory f or ant icoagulat ion or acet ylsalicylic
acid (ASA)-t ype drug ingest ion.
5. Follow Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed posttest care .
Clin ical Alert

Dried Blood Spot
I n t his met hod, a lancet is used, and t he result ing droplet s of blood are
collect ed by blot t ing t hem w it h f ilt er paper direct ly. Check t he st abilit y of
equipment and int egrit y of supplies w hen doing a f inger st ick. I f provided,
check t he humidit y indicat or pat ch on t he f ilt er paper card. I f t he humidit y
circle is pink, do not use t his f ilt er paper card. The humidit y indicat or must be
blue t o ensure specimen int egrit y.
Af t er w iping t he f irst drop of blood on t he gauze pad, f ill and sat urat e each of
t he circles in numerical order by blot t ing t he blood droplet w it h t he f ilt er
paper. Do not t ouch t he pat ient 's skin t o t he f ilt er paper; only t he blood
droplet should come in cont act w it h t he f ilt er paper. I f an adult has a cold
hand, run w arm w at er over it f or approximat ely 3 minut es. The best f low
occurs w hen t he arm is held dow nw ard, w it h t he hand below heart level,
making eff ect ive use of gravit y. I f t here is a problem w it h proper blood f low,
milk t he f inger w it h gentl e pressure t o st imulat e blood f low or at t empt a
second f inger st ick; do not at t empt more t han t w o. When t he blood circles
penet rat e t hrough t o t he ot her side of t he f ilt er paper, t he circles are f ully
sat urat ed.
Venipuncture
Veni puncture allow s procurement of larger quant it ies of blood f or t est ing.
Usually, t he ant ecubit al veins are t he veins of choice because of ease of access.
Blood values remain const ant no mat t er w hich venipunct ure sit e is select ed, so
long as it is venous and not art erial blood.
1. O bserve st andard precaut ions (see Appendix A). I f lat ex allergy is
suspect ed, use lat ex-f ree supplies and equipment (see Appendix B).
2. Posit ion and t ight en a t ourniquet on t he upper arm t o produce venous
congest ion.
3. Ask t he pat ient t o close t he f ist in t he designat ed arm. Select an accessible
vein.
4. Cleanse t he punct ure sit e and dry it properly w it h st erile gauze. Povidoneiodine must dry t horoughly.
5. Punct ure t he vein according t o accept ed t echnique. Usually, f or an adult ,
anyt hing smaller t han a 21-gauge needle might make blood w it hdraw al more
diff icult . A Vacut ainer syst em syringe or but t erf ly syst em may be used.
6. O nce t he vein has been ent ered by t he collect ing needle, blood w ill f ill t he
at t ached vacuum t ubes aut omat ically because of negat ive pressure w it hin t he
collect ion t ube.
7. Remove t he t ourniquet bef ore removing t he needle f rom t he punct ure sit e or
bruising w ill occur.
8. Remove needle. Apply pressure and st erile dressing st rip t o sit e.
9. The preservat ive or ant icoagulant added t o t he collect ion t ube depends on
t he t est ordered. I n general, most hemat ology t est s use EDTA ant icoagulant .
Even slight ly clot t ed blood invalidat es t he t est , and t he sample must be
redraw n.
10. Take act ion t o prevent t hese venipunct ure errors:
a. Pret est errors
1. I mproper pat ient ident if icat ion
2. Failure t o check pat ient compliance w it h diet ary rest rict ions
3. Failure t o calm pat ient bef ore blood collect ion
4. Use of w rong equipment and supplies
5. I nappropriat e met hod of blood collect ion
b. Procedure errors
1. Failure t o dry sit e complet ely af t er cleansing w it h alcohol
2. I nsert ing needle w it h bevel side dow n
3. Using t oo small a needle, causing hemolysis of specimen
4. Venipunct ure in unaccept able area (eg, above an int ravenous [ I V]

line)
5. Prolonged t ourniquet applicat ion
6. Wrong order of t ube draw
7. Failure t o mix blood immediat ely t hat is collect ed in addit ivecont aining t ubes
8. Pulling back on syringe plunger t oo f orcef ully
9. Failure t o release t ourniquet bef ore needle w it hdraw al
c. Post t est errors
1. Failure t o apply pressure immediat ely t o venipunct ure sit e
2. Vigorous shaking of ant icoagulat ed blood specimens
3. Forcing blood t hrough a syringe needle int o t ube
4. Mislabeling of t ubes
5. Failure t o label specimens w it h inf ect ious disease precaut ions as
required
6. Failure t o put dat e, t ime, and init ials on requisit ion
7. Slow t ransport of specimens t o laborat ory
NOTE
A blood pressure cuff inf lat ed t o a point bet w een syst olic and diast olic
pressure values can be used.
NOTE
The Vacut ainer syst em consist s of vacuum t ubes (Vacut ainer t ubes), a t ube
holder, and a disposable mult isample collect ing needle.
Interventions
1. I nst ruct pat ient regarding sampling procedure. Assess f or circulat ion or
bleeding problems and allergy t o lat ex.
2. Reassure pat ient t hat mild discomf ort may be f elt w hen t he needle is
insert ed.
3. Place t he arm in a f ully ext ended posit ion w it h palmar surf ace f acing upw ard
(f or ant ecubit al access).
4. I f w it hdraw al of t he sample is diff icult , w arm t he ext remit y w it h w arm t ow els
or blanket s. Allow t he ext remit y t o remain in a dependent posit ion f or several
minut es bef ore venipunct ure.
Clin ical Alert

I n pat ient s w it h leukemia, agranulocyt osis, or low ered resist ance, f inger-st ick
and earlobe punct ures are more likely t o cause inf ect ion and bleeding t han
venipunct ures. Should a capillary sample be necessary, t he cleansing agent
should remain in cont act w it h t he skin f or at least 5 t o 10 minut es. Povidoneiodine is t he cleansing agent of choice. I t should be allow ed t o dry. I t may
t hen be w iped off w it h alcohol and t he sit e dried w it h st erile gauze bef ore
punct ure.

1. I f oozing or bleeding f rom t he punct ure sit e cont inues f or an unusually long
t ime, elevat e t he area and apply a pressure dressing. O bserve t he pat ient
closely. Check f or ant icoagulant or ASA-t ype ingest ion.
2. Be aw are t hat t he pat ient occasionally becomes dizzy, f aint , or nauseat ed
during t he venipunct ure. The phlebot omist must be const ant ly aw are of t he
pat ient 's condit ion. I f a pat ient f eels f aint , immediat ely remove t he t ourniquet
and t erminat e t he procedure. I f t he pat ient is sit t ing, low er t he head bet w een
t he legs and inst ruct t he pat ient t o breat he deeply. A cool, w et t ow el may be
applied t o t he f orehead and back of t he neck, and, if necessary, ammonia

inhalant may be applied brief ly. I f t he pat ient remains unconscious, not if y a
physician immediat ely.
3. Prevent hemat omas by using proper t echnique (not st icking t he needle
t hrough t he vein), releasing t he t ourniquet bef ore t he needle is w it hdraw n,
applying suff icient pressure over t he punct ure sit e, and maint aining an
ext ended ext remit y unt il bleeding st ops.
Clin ical Alert

1. Never draw blood f rom t he same ext remit y being used f or I V medicat ions,
f luids, or t ransf usions. I f no ot her sit e is available, make sure t he
venipunct ure sit e is below t he sit e. Avoid areas t hat are edemat ous, are
paralyzed, are on t he same side as a mast ect omy, or have inf ect ions or
skin condit ions present . Venipunct ure may cause inf ect ion, circulat ory
impairment , or ret arded healing.
2. Prolonged t ourniquet applicat ion causes st asis and hemoconcent rat ion and
w ill alt er t est result s.
Bone Marrow Aspiration

Bone marrow is locat ed w it hin cancellous bone and long bone cavit ies. I t
consist s of a pat t ern of vessels and nerves, diff erent iat ed and undiff erent iat ed
hemat opoiet ic cells, ret iculoendot helial cells, and f at t y t issue. All of t hese are
encased by endost eum, t he membrane lining t he bone marrow cavit y. Af t er
prolif erat ion and mat urat ion have occurred in t he marrow, blood cells gain
ent rance t o t he blood t hrough or bet w een t he endot helial cells of t he sinus w all.
A bone marrow specimen is obt ained t hrough aspirat ion or biopsy or needle
biopsy aspirat ion. A bone marrow examinat ion is import ant in t he evaluat ion of a
number of hemat ologic disorders and inf ect ious diseases. The presence or
suspicion of a blood disorder is not alw ays an indicat ion f or bone marrow
st udies. A decision t o employ t his procedure is made on an individual basis.
Somet imes, t he aspirat e does not cont ain hemat opoiet ic cells. This dry t ap
occurs w hen hemat opoiet ic act ivit y is so sparse t hat t here are no cells t o be
w it hdraw n or w hen t he marrow cont ains so many t ight ly packed cells t hat t hey
cannot be suct ioned out of t he marrow. I n such cases, a bone marrow biopsy
w ould be advant ageous. Bef ore t he bone marrow procedure is st art ed, a
peripheral blood smear should be obt ained f rom t he pat ient and a diff erent ial
leukocyt e count done.
Reference Values
Normal
See Table 2. 1 f or normal values
Table 2.1 Normal Values for Bone Marrow*
Form ed Cell Elem ents
Norm al
Mean
(%)
Undifferentiated cells
0.0
0.01.0
Reticulum cells
0.4
0.01.3
Myeloblasts
2.0
0.35.0
Promyelocytes
5.0
1.08.0
Neutrophilic
12.0
5.019.0
Eosinophilic
1.5
0.53.0
Basophilic
0.3
0.00.5
Metamyelocytes
25.6
17.533.7
Neutrophilic
0.4
0.01.0
Range (%)
Myelocytes
Eosinophilic
0.0
0.00.2
Neutrophilic
20.0
11.630.0
Eosinophilic
2.0
0.54.0
Basophilic
0.2
0.03.0
Monocytes
2.0
03
Lymphocytes
10.0
820
Megakaryocytes
0.4
0.03.0
Plasma cells
0.9
0.02.0
Pronormoblasts
0.5
0.24.2
Basophilic normoblasts
1.6
0.244.8
Polychromatic normoblasts
10.4
3.520.5
Orthochromatic normoblasts
6.4
3.025
Promegaloblasts
Basophilic megaloblasts
Segmented granulocytes
Erythroid series
Polychromatic megaloblasts
Orthochromatic megaloblasts
2:14:1
(Slightly
higher in
infants)
Myeloid: erythroid ratio (ratio

of W BC to nucleated RBC)
*These values are only for adults, and should be used

as a guideline. (Each laboratory should establish its
own reference range.)
Procedure
1. Follow st andard precaut ions. Check f or lat ex allergy; if allergy is present , do
not use lat ex-cont aining product s. Posit ion t he pat ient on t he back or side
according t o sit e select ed. The post erior iliac crest is t he pref erred sit e in
all pat ient s older t han 12 t o 18 mont hs. Alt ernat e sit es include t he ant erior
iliac crest , st ernum, spinous vert ebral processes T10 t hrough L4, t he ribs,
and t he t ibia in children. The st ernum is not generally used in children
because t he bone cavit y is t oo shallow, t he risk f or mediast inal and cardiac
perf orat ion is t oo great , and t he child may be uncooperat ive.
2. Shave, cleanse, and drape t he sit e as f or any minor surgical procedure.
3. I nject a local anest het ic (procaine or lidocaine). This may cause a burning
sensat ion. At t his t ime, a skin incision of 3 mm is of t en made.
4. Remember t hat t he physician int roduces a short , rigid, sharp-point ed needle
w it h st ylet t hrough t he periost eum int o t he marrow cavit y.
5. Pass t he needle-st ylet combinat ion t hrough t he incision, subcut aneous t issue,
and bone cort ex. The st ylet is removed, and 1 t o 3 mL of marrow f luid is
aspirat ed. Alert t he pat ient t hat w hen t he st ylet needle ent ers t he marrow,
he or she may experience a f eeling of pressure. The pat ient may also f eel
moderat e discomf ort as aspirat ion is done, especially in t he iliac crest . Use
t he Jamshidi needle f or biopsy, alt hough you can also use t he West ermanJansen modif icat ion of t he Vim-Silverman needle.
6. Remove t he st ylet and advance t he biopsy needle w it h a t w ist ing mot ion
t ow ard t he ant erosuperior iliac spine.

7. Rot at e or rock t he needle in several direct ions several t imes af t er
adequat e penet rat ion of t he base (3 cm) has been achieved. This f rees up
t he specimen. Slow ly w it hdraw t he needle once t his is done.
8. Push t he biopsy specimen out backw ard f rom t he needle. Use it t o make
t ouch preparat ions or immediat ely place in f ixat ive. Make slide smears at t he
bedside.
9. Apply pressure t o t he punct ure sit e unt il bleeding ceases. Dress t he sit e.
10. Place specimens in biohazard bags, label properly, and rout e t o t he
appropriat e depart ment .
Clinical Implications
1. A specif ic and diagnost ic bone marrow pict ure provides clues t o many
diseases. The presence, absence, and rat io of cells are charact erist ic of t he
suspect ed disease.
2. Bone marrow examinat ion may reveal t he f ollow ing abnormal cell pat t erns:
a. Mult iple myeloma, plasma cell myeloma, macroglobulinemia
b. Chronic or acut e leukemias
c. Anemia, including megaloblast ic, macrocyt ic, and normocyt ic anemias
d. Toxic st at es t hat produce bone marrow depression or dest ruct ion
e. Neoplast ic diseases in w hich t he marrow is invaded by t umor cells
(met ast at ic carcinoma, myeloprolif erat ive and lymphoprolif erat ive
diseases); assist s in diagnosis and st aging
f. Agranulocyt osis (a decrease in t he product ion of w hit e cells). This
occurs w hen bone marrow act ivit y is severely depressed, usually as a
result of radiat ion t herapy or chemot herapeut ic drugs. I mplicat ions f or
t he pat ient f ocus on t he risk f or deat h f rom overw helming inf ect ion.
g. Plat elet dysf unct ion
h. Some t ypes of inf ect ious diseases, especially hist oplasmosis and
t uberculosis
i. Def iciency of body iron st ores, microcyt ic anemia
j. Lipid or glycogen st orage disease
Interventions

1. I nst ruct t he pat ient about t he t est procedure, purpose, benef it s, and risks.
2. Ensure t hat a legal consent f orm is properly signed and w it nessed. Bone
marrow aspirat ion is usually cont raindicat ed in t he presence of hemophilia
and ot her bleeding dyscrasias. How ever, risk versus benef it may dict at e t he
choice made.
3. Reassure t he pat ient t hat analgesics w ill be available if needed.
4. Be aw are t hat bone marrow biopsies or aspirat ions can be uncomf ort able.
Squeezing a pillow may be helpf ul as a dist ract ion t echnique.
5. O bserve st andard precaut ions.
Clin ical Alert

1. Complicat ions can include bleeding and st ernal f ract ures. O st eomyelit is or
injury t o heart or great vessels is rare but can occur if t he st ernal sit e is
used.
2. Manual and pressure dressings over t he punct ure sit e usually cont rol
excessive bleeding. Remove dressing in 24 hours. Redress sit e if
necessary.
3. Fever, headache, unusual pain, or redness or pus at biopsy sit e may
indicat e inf ect ion (lat er event ). I nst ruct pat ient t o report unusual
sympt oms t o physician immediat ely.

1. Monit or vit al signs unt il st able and assess sit e f or excess drainage or
bleeding.
2. Recommend bed rest f or 30 minut es; t hen normal act ivit ies can be resumed.
3. Administ er analgesics f or sedat ives as necessary. Soreness over t he
punct ure sit e f or 3 t o 4 days af t er t he procedure is normal. Cont inued pain
may indicat e f ract ure.
4. I nt erpret t est out comes and monit or appropriat ely.
BASIC BLOOD TESTS

Hemogram
A hemogram consist s of a w hit e blood cell count (WBC), red blood cell count
(RBC), hemoglobin (Hb), hemat ocrit (Hct ), red blood cell indices, and a plat elet
count . A complet e blood count (CBC) consist s of a hemogram plus a diff erent ial
WBC.
Complete Blood Count (CBC) The CBC is a basic

screening test and is one of the most frequently
ordered laboratory procedures. The findings in the CBC
give valuable diagnostic information about the
hematologic and other body systems, prognosis,
response to treatment, and recovery. The CBC consists
of a series of tests that determine number, variety,
percentage, concentrations, and quality of blood cells:
1. Whit e blood cell count (WBC): leukocyt es f ight inf ect ion
2. Diff erent ial w hit e blood cell count (Diff ): specif ic pat t erns of WBC
3. Red blood cell count (RBC): red blood cells carry O2 f rom lungs t o blood
t issues and CO2 f rom t issue t o lungs
4. Hemat ocrit (Hct ): measures RBC mass
5. Hemoglobin (Hb): main component of RBCs and t ransport s O2 and CO2
6. Red blood cell indices: calculat ed values of size and Hb cont ent of RBCs;
import ant in anemia evaluat ions
7. Mean corpuscular volume (MCV)
8. Mean corpuscular hemoglobin concent rat ion (MCHC)
9. Mean corpuscular hemoglobin (MCH)
10. St ained red cell examinat ion (f ilm or peripheral blood smear)
11. Plat elet count (of t en included in CBC): t hrombocyt es are necessary f or
clot t ing and cont rol of bleeding
12. Red blood cell dist ribut ion w idt h (RDW): indicat es degree variabilit y and
abnormal cell size.
13. Mean plat elet volume (MPV): index of plat elet product ion
These t est s are described in det ail in t he f ollow ing pages.
Normal Values for Hemogram
Age
WBC (
10 3 /m m 3 )
RBC (
10 6 /m m 3 )
Hb
(g/dL)
Hct
(%)
MC
(fL
Birth2
wk
9.030.0
4.16.1
14.5
24.5
44
64
98
112
28 wk
5.021.0
4.06.0
12.5
20.5
39
59
98
112
26 mo
5.019.0
3.85.6
10.7
17.3
35
49
83
97
6 mo1 y
5.019.0
3.85.2
9.914.5
29
43
73
87
16 y
5.019.0
3.95.3
9.514.1
30
40
70
84
616 y
4.810.8
4.05.2
10.3
14.9
32
42
73
87
1618 y
4.810.8
4.25.4
11.115.7
34
44
75
89
>18 y
(males)
5.010.0
4.55.5
14.0
17.4
42
52
84
96
>18 y
(females)
5.010.0
4.05.0
12.0
16.0
36
48
84
96
Age
MCH
(pg/cell)
MCHC
(g/dL)
Platelets
(
10 3 /m m 3 )
RDW
(%)
MP
(fL
Birth2
wk
3440
3337
150450
28 wk
3036
3236
26 mo
2733
3135
6 mo1 y
2430
3236
16 y
2329
3135
616 y
2430
3236
1618 y
2531
3236
>18 y
2834
3236
140400
11.5
14.5
7.4
10
Interventions
Pretest Patient Care for Hemogram, CBC, and
Differential (Diff) Count (All Components)
1. Explain t est procedure. Explain t hat slight discomf ort may be f elt w hen skin
is punct ured. Ref er t o venipunct ure procedure f or addit ional inf ormat ion.
2. Avoid st ress if possible because alt ered physiologic st at us inf luences and
changes normal hemogram values.

3. Select hemogram component s ordered at regular int ervals (eg, daily, every
ot her day). These should be draw n consist ent ly at t he same t ime of day f or
reasons of accurat e comparison; nat ural body rhyt hms cause f luct uat ions in
laborat ory values at cert ain t imes of t he day.
4. Dehydrat ion or overhydrat ion can dramat ically alt er values; f or example,
large volumes of I V f luids can dilut e t he blood, and values w ill appear as
low er count s. The presence of eit her of t hese st at es should be
communicat ed t o t he laborat ory.
5. Fast ing is not necessary. How ever, f at -laden meals may alt er some t est
result s as a result of lipidemia.
Posttest Patient Aftercare for Hemogram, CBC, and

Differential (Diff) Count (All Components)
1. Apply manual pressure and dressings t o t he punct ure sit e on removal of t he
needle.
2. Monit or t he punct ure sit e f or oozing or hemat oma f ormat ion. Maint ain
pressure dressings on t he sit e if necessary. Not if y physician of unusual
problems w it h bleeding.
3. Resume normal act ivit ies and diet .
4. Bruising at t he punct ure sit e is not uncommon. Signs of inf lammat ion are
unusual and should be report ed if t he inf lamed area appears larger, if red
st reaks develop, or if drainage occurs.
Clin ical Alert

NEVER apply a t ot al circumf erent ial dressing and w rap because t his may
compromise circulat ion and nerve f unct ion if const rict ion, f rom w hat ever
cause, occurs.
TESTS OF WHITE BLOOD CELLS

White Blood Cell Count (WBC; Leukocyte Count) White
blood cells (or leukocytes) are divided into two main
groups: granulocytes and agranulocytes. The
granulocytes receive their name from the distinctive
granules that are present in the cytoplasm of
neutrophils, basophils, and eosinophils. However, each
of these cells also contains a multilobed nucleus,
which accounts for their also being called
polymorphonuclear leukocytes. In laboratory
terminology, they are often called polys or PMNs.
The nongranulocytes, which consist of the
lymphocytes and monocytes, do not contain distinctive
granules and have nonlobular nuclei that are not
necessarily spherical. The term mononuclear
leukocytes is applied to these cells.
The endocrine syst em is an import ant regulat or of t he number of leukocyt es in
t he blood. Hormones aff ect t he product ion of leukocyt es in t he blood-f orming
organs, t heir st orage and release f rom t he t issue, and t heir disint egrat ion. A
local inf lammat ory process exert s a def init e chemical eff ect on t he mobilizat ion
of leukocyt es. The lif e span of leukocyt es varies f rom 13 t o 20 days, af t er w hich
t he cells are dest royed in t he lymphat ic syst em; many are excret ed f rom t he
body in f ecal mat t er.
Leukocyt es f ight inf ect ion and def end t he body by a process called
phagocytosi s, in w hich t he leukocyt es act ually encapsulat e f oreign organisms
and dest roy t hem. Leukocyt es also produce, t ransport , and dist ribut e ant ibodies
as part of t he immune response t o a f oreign subst ance (ant igen).
The WBC serves as a usef ul guide t o t he severit y of t he disease process.
Specif ic pat t erns of leukocyt e response can be expect ed in various t ypes of
diseases as det ermined by t he diff erent ial count (percent ages of t he diff erent
t ypes of leukocyt es). Leukocyt e and diff erent ial count s, by t hemselves, are of
lit t le value as aids t o diagnosis unless t he result s are relat ed t o t he clinical
condit ion of t he pat ient ; only t hen is a correct and usef ul int erpret at ion possible.
Reference Values
Normal
Black adult s: 3. 210. 0 103 / cells/ mm 3 or 109 / L or 320010, 000 cells/ mm3
Adult s: 4. 510. 5 103 / cells/ mm 3 or 109 / L or 450010, 500 cells/ mm3
Children:
02 w eeks: 9. 030. 0 103 / cells/ mm 3 or 109 / L or 900030, 000 cells/ mm3
28 w eeks: 5. 021. 0 103 / cells/ mm 3 or 109 / L or 500021, 000 cells/ mm3
2 mont hs6 years: 5. 019. 0 103 / cells/ mm 3 or 109 / L or 500019, 000
cells/ mm 3
618 years: 4. 810. 8 103 / cells/ mm 3 or 109 / L or 480010, 800 cells/ mm3
NOTE
Diff erent labs have slight ly diff erent ref erence values.
Procedure
1. O bt ain a venous ant icoagulat ed EDTA blood sample of 5 mL or a f inger-st ick
sample. Place a specimen in a biohazard bag.
2. Record t he t ime w hen specimen w as obt ained (eg, 7: 00 a. m. ).
3. Blood is processed eit her manually or aut omat ically, using an elect ronic
count ing inst rument such as t he Coult er count er or Abbot t Cell-Dyne.
1. Leukocytosi s: WBC >11, 000/ mm3 or >11. 0 103 / mm 3 (or >11 109 / L)
a. I t is usually caused by an increase of only one t ype of leukocyt e, and it
is given t he name of t he t ype of cell t hat show s t he main increase:
1. Neut rophilic leukocyt osis or neut rophilia
2. Lymphocyt ic leukocyt osis or lymphocyt osis
3. Monocyt ic leukocyt osis or monocyt osis
4. Basophilic leukocyt osis or basophilia
5. Eosinophilic leukocyt osis or eosinophilia
b. An increase in circulat ing leukocyt es is rarely caused by a proport ional
increase in leukocyt es of all t ypes. When t his does occur, it is usually a
result of hemoconcent rat ion.
c. I n cert ain diseases (eg, measles, pert ussis, sepsis), t he increase of
leukocyt es is so great t hat t he blood pict ure suggest s leukemia.
Leukocytosi s of a temporary nature (leukemoid react ion) must be
dist inguished f rom leukemia. I n leukemia, t he leukocyt osis is permanent
and progressive.
d. Leukocyt osis occurs in acut e inf ect ions, in w hich t he degree of increase
of leukocyt es depends on severit y of t he inf ect ion, pat ient 's resist ance,
pat ient 's age, and marrow eff iciency and reserve.
e. O t her causes of leukocyt osis include t he f ollow ing:
1. Leukemia, myeloprolif erat ive disorders
2. Trauma or t issue injury (eg, surgery)

3. Malignant neoplasms, especially bronchogenic carcinoma
4. Toxins, uremia, coma, eclampsia, t hyroid st orm
5. Drugs, especially et her, chlorof orm, quinine, epinephrine (Adrenalin),
colony-st imulat ing f act ors
6. Acut e hemolysis
7. Hemorrhage (acut e)
8. Af t er splenect omy
9. Polycyt hemia vera
10. Tissue necrosis
f. O ccasionally, leukocyt osis is f ound w hen t here is no evidence of clinical
disease. Such f indings suggest t he presence of :
1. Sunlight , ult raviolet irradiat ion
2. Physiologic leukocyt osis result ing f rom excit ement , st ress, exercise,
pain, cold or heat , anest hesia
3. Nausea, vomit ing, seizures
g. St eroid t herapy modif ies t he leukocyt e response.
1. When cort icot ropin (adrenocort icot ropic hormone, or ACTH) is given
t o a healt hy person, leukocyt osis occurs.
2. When ACTH is given t o a pat ient w it h severe inf ect ion, t he inf ect ion
can spread rapidly w it hout producing t he expect ed leukocyt osis;
t heref ore, w hat w ould normally be an import ant sign is obscured.
2. Leukopeni a: WBC <4000/ mm3 or <4. 0 103 / mm 3 or <4. 0 cells 109 / L
occurs during and f ollow ing:
a. Viral inf ect ions, some bact erial inf ect ions, overw helming bact erial
inf ect ions
b. Hypersplenism
c. Bone marrow depression caused by heavy-met al int oxicat ion, ionizing
radiat ion, drugs:
1. Ant imet abolit es
2. Barbit urat es
3. Benzene
4. Ant ibiot ics
5. Ant ihist amines
6. Ant iconvulsives
7. Ant it hyroid drugs
8. Arsenicals
9. Cancer chemot herapy (causes a decrease in leukocyt es; leukocyt e
count is used as a link t o disease)
10. Cardiovascular drugs
11. Diuret ics
12. Analgesics and ant iinf lammat ory drugs
d. Primary bone marrow disorders:
1. Leukemia (aleukemic)
2. Pernicious anemia
3. Aplast ic anemia
4. Myelodysplast ic syndromes
5. Congenit al disorders
6. Kost mann's syndrome
7. Ret icular agenesis
8. Cart ilage-hair hypoplasia
9. Shw achman-Diamond syndrome
10. Chdiak-Higashi syndrome
e. I mmune-associat ed neut ropenia
f. Marrow -occupying diseases (f ungal inf ect ion, met ast at ic t umor)
g. Pernicious anemia
Clin ical Alert

1. WBC <500/ mm3 or <0. 5 103 / mm 3 (or 109 / L) represent s a panic value.
2. WBC >30, 000/ mm3 or >30. 0 103 (or 109 / L) is a panic value.
Interfering Factors
1. Hourly rhyt hm: t here is an early-morning low level and lat e-af t ernoon high
peak.
2. Age: in new borns and inf ant s, t he count is high (10, 000/ mm3 t o 20, 000/ mm3
or 10 109 / L t o 20 109 / L); t he count gradually decreases in children unt il

t he adult values are reached bet w een 18 and 21 years of age.
3. Any st ressf ul sit uat ion t hat leads t o an increase in endogenous epinephrine
product ion and a rapid rise in t he leukocyt e count
Interventions
1. Explain t est purpose and procedure.
2. Ref er t o st andard pretest care f or hemogram, CBC, and diff erent ial count on
page 47. Also, see Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest
care.

1. I nt erpret t est out come and monit or appropriat ely. Ref er t o st andard posttest
care f or hemogram, CBC, and diff erent ial count on page 47. Also, f ollow
Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed posttest care .
2. I n prolonged severe granulocyt openia or pancyt openia, give no f resh f ruit s or
veget ables because t he kit chen, especially in a hospit al, may be a source of
f ood cont aminat ion. When t he WBC is low, a person can get a bact erial,
pseudomonal, or f ungal inf ect ion f rom f resh f ruit s and veget ables. Use a
minimal-bact eria or commercially st erile diet . All f ood must be served f rom a
new or single-serving package. Consider a leukemia diet . See diet ary
depart ment f or rest rict ions (eg, cooked f ood only) and caref ul f ood
preparat ion. Do not give int ramuscular inject ions. Do not t ake rect al
t emperat ure, give supposit ories, or give enemas. Do not use razor blades.
Do not give aspirin or nonst eroidal ant i-inf lammat ory drugs (NSAI Ds), w hich
cause abnormal plat elet dysf unct ion. Wat ch caref ully f or signs or sympt oms
of inf ect ion. Wit hout leukocyt es t o produce inf lammat ion, serious inf ect ions
can have very subt le f indings. O f t en, pat ient s have only a f ever.
Differential White Blood Cell Count (Diff; Differential

Leukocyte Count) The total count of circulating white
blood cells is differentiated according to the five types
of leukocytes, each of which performs a specific
function.
Function of Circulating WBCs According to Leukocyte
Type
Cell
These Cells Function to Combat
Neutrophils
Pyogenic infections (bacterial)
Eosinophils
Allergic disorders and parasitic

infestations
Basophils
Parasitic infections, some allergic

disorders
Lymphocytes
Viral infections (measles, rubella,

chickenpox, infectious mononucleosis)
Monocytes
Severe infections, by phagocytosis
Differential for Leukocyte Count

Age
Bands/Stab
(%)
Segs/Polys
(%)
Eos
(%)
Basos
(%)
Lymphs
(%)
Birth
1 wk
1018
3262
02
01
2636
12
wk
816
1949
04
00
3846
24
wk
715
1434
03
00
4353
48
wk
713
1535
03
01
4171
26
mo
511
1535
03
01
4272
6
mo1
y
612
1333
03
00
4676
16 y
511
1333
03
00
4676
616
y
511
3254
03
01
2757
16
18 y
511
3464
03
01
2545
>18 y
36
5062
03
01
2540
Bands or stab cells, immature forms of neutrophils; Segs, s

neutrophils; Polys, polymorphonuclear neutrophils; Eos, eos
basophils; Lymphs, lymphocytes; Monos, monocytes; Metas
metamyelocytes.
The diff erent ial count is expressed as a percent age of t he t ot al number of
leukocyt es (WBC). The dist ribut ion (number and t ype) of cells and t he degree of
increase or decrease are diagnost ically signif icant . The percent ages indicat e t he
rel ati ve number of each t ype of leukocyt e in t he blood. The absol ute count of
each t ype of leukocyt e is obt ained mat hemat ically by mult iplying it s relat ive
percent age by t he t ot al leukocyt e count . The f ormula is:
NOTE
This is now t he pref erred w ay of report ing.
The diff erent ial count alone has limit ed value; it must alw ays be int erpret ed in
relat ion t o t he WBC. I f t he percent age of one t ype of cell is increased, it can be
inf erred t hat cells of t hat t ype are relat ively more numerous t han normal, but it is
not know n w het her t his ref lect s an act ual increase in t he (absolut e) number of
cells t hat are relat ively increased or an absolut e decrease in cells of anot her
t ype. O n t he ot her hand, if t he relat ive (percent age) values of t he diff erent ial
count and t he t ot al WBC are bot h know n, it is possible t o calculat e absolut e
values t hat are not subject t o misint erpret at ion.
Hist orically, t he diff erent ial count has been done manually, but t he new er
hemat ology inst rument s can now do an aut omat ed diff erent ial count . The count is
based on diff erent chemical component s of each cell t ype. How ever, not all
samples can be evaluat ed by aut omat ed met hods. When a leukocyt e count is
ext remely low or high, a manual count may have t o be done. Ext remely abnormal
leukocyt es, such as t hose in leukemia, also have t o be count ed by hand. The
aut omat ed inst rument has built -in qualit y cont rol t hat senses abnormal cells and
f lags t he diff erent ial. A microscopic count must t hen be done.
Segmented Neutrophils (Polymorphonuclear

Neutrophils, PMNs, Segs, Polys) Neutrophils, the most
numerous and important type of leukocytes in the
body's reaction to inflammation, constitute a primary
defense against microbial invasion through the
process of phagocytosis. These cells can also cause
some body tissue damage by their release of enzymes
and endogenous pyogenes. In their immature stage of
development, neutrophils are referred to as stab or
band cells. The term band stems from the appearance
of the nucleus, which has not yet assumed the lobed
shape of the mature cell.
This t est det ermines t he presence of neut rophilia or neut ropenia. Neut rophilia is
an increase in t he absolut e number of neut rophils in response t o invading
organisms and t umor cells. Neut ropenia occurs w hen t oo f ew neut rophils are
produced in t he marrow, t oo many are st ored in t he blood vessel margin, or t oo
many have been called t o act ion and used up.
Reference Values
Normal
Absolut e count : 30007000/ mm 3 or 37 109 / L
NOTE
All ref erences are using t his SI unit f or report ing.
Black adult s: 1. 26. 6 109 / L
Diff erent ial: 50% of t ot al WBC
0%3% of t ot al PMNs are st ab or band cells
Procedure
1. O bt ain a 5-mL blood sample in EDTA coagulant and place it in biohazard
bag.
2. Count as part of t he diff erent ial.
1. Neut rophilia (increased absolut e number and relat ive percent age of
neut rophils) >8. 0 109 / L or 8000/ mm3 ; f or Af rican Americans: >7. 0 109 / L
or 7000/ mm3
a. Acut e, localized, and general bact erial inf ect ions. Also, f ungal and
spirochet al and some parasit ic and ricket t sial inf ect ions.
b. I nf lammat ion (eg, vasculit is, rheumat oid art hrit is, pancreat it is, gout ), and
t issue necrosis (myocardial inf arct ion, burns, t umors).
c. Met abolic int oxicat ions (eg, diabet es mellit us, uremia, hepat ic necrosis)
d. Chemicals and drugs causing t issue dest ruct ion (eg, lead, mercury,
digit alis, venoms)
e. Acut e hemorrhage, hemolyt ic anemia, hemolyt ic t ransf usion react ion
f. Myeloprolif erat ive disease (eg, myeloid leukemia, polycyt hemia vera,
myelof ibrosis)
g. Malignant neoplasmscarcinoma
h. Some viral inf ect ions (not ed in early st ages) and some parasit ic
inf ect ions
2. Rati o of segment ed neut rophils t o band neut rophils: normally 1%3% of
PMNs are band f orms (immat ure neut rophils).
a. Degenerat ive shif t t o lef t : in some overw helming inf ect ions, t here is an
increase in band (immat ure) f orms w it h no leukocyt osis (poor prognosis).
b. Regenerat ive shif t t o lef t : t here is an increase in band (immat ure) f orms
w it h leukocyt osis (good prognosis) in bact erial inf ect ions.
c. Shif t t o t he right : decreased band (immat ure) cells w it h increased
segment ed neut rophils can occur in liver disease, megaloblast ic anemia,
hemolysis, drugs, cancer, and allergies.
d. Hypersegment at ion of neut rophils w it h no band (immat ure) cells is f ound
in megaloblast ic anemias (eg, pernicious anemia) and chronic morphine
addict ion.
3. Neut ropenia (decreased neut rophils)
a. <1800/ mm 3 or <1. 8 109 / L
b. Af rican Americans: <1000/ mm3 or <40% of diff erent ial count
c. Causes associat ed w it h decreased or ineff ect ive product ion:
1. I nherit ed st em cell disorders and genet ic disorders or cellular
development
2. Acut e overw helming bact erial inf ect ions (poor prognosis) and
sept icemia
3. Viral inf ect ions (eg, mononucleosis, hepat it is, inf luenza, measles)
4. Some ricket t sial and parasit ical (prot ozoan) diseases (malaria)
5. Drugs, chemicals, ionizing radiat ion, venoms
6. Hemat opoiet ic diseases (eg, aplast ic anemia, megaloblast ic anemias,
iron-def iciency anemia, aleukemic leukemia, myeloprolif erat ive
diseases)
d. Causes associat ed w it h decreased survival:
1. I nf ect ions mainly in persons w it h lit t le or no marrow reserves, elderly
people, and inf ant s
2. Collagen vascular diseases w it h ant ineut rophil ant ibodies (eg,
syst emic lupus eryt hemat osus [ SLE] and Felt y's syndrome)
3. Aut oimmune and isoimmune causes
4. Drug hypersensit ivit y (There is an ext ensive list of drugs t hat
cont inues t o grow. Women are more likely t han men t o have a drug
sensit ivit y. Removal of off ending drug result s in ret urn t o normal. )
5. Splenic sequest rat ion
e. Neut ropenia in neonat es (<5000/ mm3 or <5. 0 109 / L or <1000/ mm3 or
<1. 0 109 / L af t er f irst w eek of lif e)
1. Mat ernal neut ropenia, mat ernal drug ingest ion, mat ernal
isoimmunizat ion t o f et al leukocyt es (mat ernal immunoglobulin G [ I gG ]
ant ibodies t o f et al neut rophils)

2. I nborn errors of met abolism (eg, maple syrup urine disease)
3. I mmune def icit sacquired
4. Def icit s and disorders of myeloid st em cell (eg, Kost mann's
agranulocyt osis, benign chronic granulocyt openia of childhood)
5. Congenit al neut ropenia
f. Pregnancyprogressive decrease unt il labor
4. O t her leukocyt e abnormalit ies and corresponding diseases are list ed in Table
2. 2.
Table 2.2 Leukocyte Abnormalities and Disease
Abnorm ality
Description
Associated Dise
Toxic
granulation
Coarse, black or
purple,
cytoplasmic
granules
Infections or
inflammatory dise
acute reactive st
Dhle bodies
Small (12 m),

blue, cytoplasmic
inclusions in
neutrophils
Infections or
inflammatory dise
burns
Neutrophil with
bilobed nucleus
or no
Pelger-Hut
anomalies
segmentation of
nucleus;
chromatin is
coarse, and
cytoplasm is pink
with normal
granulation
Hereditary
(congenital),
myelogenous leu
May-Hegglin
anomaly
Basophilic,
cytoplasmic
inclusions of
leukocytes;
similar to Dhle
bodies
May-Hegglin syn
(hereditary), incl
thrombocytopeni
giant platelets
Alder-Reilly
anomaly
Prominent
azurophilic
granulation in
leukocytes;
similar to toxic
granulation;
granulation is
seen better with
Giemsa stain
Hereditary,
mucopolysaccha
Chdiak-Higashi
anomaly
Gray-green, large
cytoplasmic
inclusions that
are fused giant
lysomes
(phospholipids)
Chdiak-Higashi
syndrome; few ca
of acute myeloid
leukemia
Lupus erythemat
and other collage

diseases, chroni
hepatitis, drug
reactions, serum
sickness (not na
occurring in the b
must be induce
form by mechani
trauma in vitro)
LE (lupus
erythematosus)
cells
Neutrophilic
leukocyte with a
homogenous redpurple inclusion
that distends the
cell's cytoplasm
Tart cell
Neutrophilic
leukocyte with a
phagocytized
nucleus of a
granulocyte that
retains some
nuclear structure
Drug reactions (e
penicillin,
procainamide) or
actual phagocyto
Presence of
bands,
myelocytes,
metamyelocytes,
or promyelocytes
Infections,
intoxications, tiss
necrosis,
myeloproliferativ
syndrome, leuke
(chronic myelocy
leukemoid reacti
pernicious anemi
hyposplenism
Myeloid shift to
left
Hypersegmented
neutrophil
Mature neutrophil
with more than
five distinct lobes
Megaloblastic an
hereditary
constitutional
hypersegmentati
neutrophils; long
chronic infection
Leukemic cells
(eg,
lymphoblasts,
myeloblasts)
Presence of
lymphoblasts,
myeloblasts,
monoblasts,
myelomonoblasts,
promyelocytes
(none normally
present in
peripheral blood)
Leukemia (acute
chronic), leukem
reaction, severe
infectious or
inflammatory dise
myeloproliferativ
syndrome,
intoxications,
malignancies, re
from bone marrow
suppression
Auer bodies
Rod-like, 16 m
long, red-purple,
refractile
inclusions in
neutrophils
Acute myelocytic
leukemia or
myelomonocytic
leukemia
Disintegrating
nucleus of a
ruptured
leukocyte
Increased numbe
leukemic blood,
particularly in ac
lymphocytic leuk
or chronic lymph
leukemia when W
count is greater
10,000/mm 3 or >
10 9 /L
Smudge cell
NOTE
An et hnic diff erence exist s only in neut rophils.
Interfering Factors
1. Physiologic condit ions such as st ress, excit ement , f ear, vomit ing, elect ric
shock, anger, joy, and exercise t emporarily cause increased neut rophils.
Crying babies have neut rophilia.
2. O bst et ric labor and delivery cause neut rophilia. Menst ruat ion causes
neut rophilia.
3. St eroid administ rat ion: neut rophilia peaks in 4 t o 6 hours and ret urns t o
normal by 24 hours (in severe inf ect ion, expect ed neut rophilia does not
occur).
4. Exposure t o ext reme heat or cold.
5. Age
a. Children respond t o inf ect ion w it h a great er degree of neut rophilic
leukocyt osis t han adult s do.
b. Some elderly pat ient s respond w eakly or not at all, even w hen inf ect ion
is severe.
6. Resist ance
a. People of any age w ho are w eak and debilit at ed may f ail t o respond w it h
a signif icant neut rophilia.
b. When an inf ect ion becomes overw helming, t he pat ient 's resist ance is
exhaust ed and, as deat h approaches, t he number of neut rophils
decreases great ly.
7. Myelosuppressive chemot herapy
8. Many drugs cause increases or decreases in neut rophils.
Interventions
care.

1. I nt erpret t est out comes and monit or appropriat ely f or neut rophilia or
neut ropenia.
2. Ref er t o st andard posttest care f or hemogram, CBC, and diff erent ial count
on page 47. Also, f ollow Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed
posttest care .
Clin ical Alert

Agranulocyt osis (marked neut ropenia and leukopenia) is ext remely dangerous
and is of t en f at al because t he body is unprot ect ed against invading agent s.
Pat ient s w it h agranulocyt osis must be prot ect ed f rom inf ect ion by means of
reverse isolat ion t echniques w it h st rict est emphasis on handw ashing
t echnique.
Eosinophils
Eosinophils, capable of phagocyt osis, ingest ant igen-ant ibody complexes and
become act ive in t he lat er st ages of inf lammat ion. Eosinophils respond t o
allergic and parasit ic diseases. Eosinophilic granules cont ain hist amine (one t hird
of all t he hist amine in t he body).
This t est is used t o diagnose allergic inf ect ions, assess severit y of inf est at ions
w it h w orms and ot her large parasit es, and monit or response t o t reat ment .
Reference Values
Normal
Absolut e count : 00. 7 109 / L
Diff erent ial: 0%3% of t ot al WBC
Procedure
1. O bt ain a 5-mL blood sample in EDTA ant icoagulant . Place it in a biohazard
bag.
2. Not e t he t ime t he blood sample is obt ained (eg, 3: 00 p. m. ).
3. Perf orm a t ot al WBC, make a blood smear, count 100 cells, and report t he
percent age of eosinophils.

4. Be aw are t hat an absolut e eosinophil count is also available. I t is done w it h
a special eosinophil st ain and manual count ing on a hemacyt omet er. I t must
be done w it hin 4 hours af t er collect ion or, if ref rigerat ed, w it hin 24 hours.
1. Eosi nophi l i a (increased circulat ing eosinophils) >5% or >500 cells/ mm3 or
>0. 5 109 / L occurs in:
a. Allergies, hay f ever, ast hma
b. Parasit ic disease and t richinosis t apew orm, especially w it h t issue
invasion
c. Some endocrine disorders, Addison's disease, hypopit uit arism
d. Hodgkin's disease and myeloprolif erat ive disorders, chronic myeloid
leukemia, polycyt hemia vera
e. Chronic skin diseases (eg, pemphigus, eczema, dermat it is herpet if ormis)
f. Syst emic eosinophilia associat ed w it h pulmonary inf ilt rat es (PI E)
g. Some inf ect ions (scarlet f ever, chorea), convalescent st age of ot her
inf ect ions
h. Familial eosinophilia (rare), hypereosinophilic syndrome (HES)
i. Polyart erit is nodosa, collagen vascular diseases (eg, SLE), connect ive
t issue disorders
j. Eosinophilic gast roint est inal diseases (eg, ulcerat ive colit is, Crohn's
disease)
k. I mmunodef iciency disorders (Wiskot t -Aldrich syndrome, immunoglobulin A
def iciency)
l. Aspirin sensit ivit y, allergic drug react ions
m. Lff ler's syndrome (relat ed t o Ascari s species inf est at ion), t ropical
eosinophilia (relat ed t o f ilariasis)
n. Poisons (eg, black w idow spider, phosphorus)
o. Hypereosinophilic syndrome (>1. 5 109 / L), persist ent ext reme
eosinophilia w it h eosinophilic inf ilt rat ion of t issues causing t issue damage
and organ dysf unct ion
1. Eosinophilic leukemia
2. Trichinosis invasion
3. Dermat it is herpet if ormis

4. I diopat hic
2. Eosi nopeni a (decreased circulat ing eosinophils) is usually caused by an
increased adrenal st eroid product ion t hat accompanies most condit ions of
bodily st ress and is associat ed w it h:
a. Cushing's syndrome (acut e adrenal f ailure): <50/ mm3
b. Use of cert ain drugs such as ACTH, epinephrine, t hyroxine,
prost aglandins
c. Acut e bact erial inf ect ions w it h a marked shif t t o t he lef t (increase in
immat ure leukocyt es)
3. Eosi nophi l i c myel ocytes are count ed separat ely because t hey have a great er
signif icance, being f ound only in leukemia or leukemoid blood pict ures.
Interfering Factors
1. Daily rhyt hm: normal eosinophil count is low est in t he morning, t hen rises
f rom noon unt il af t er midnight . For t his reason, serial eosinophil count s
should be repeat ed at t he same t ime each day.
2. St ressf ul sit uat ions, such as burns, post operat ive st at es, elect roshock, and
labor, cause a decreased count .
3. Af t er administ rat ion of cort icost eroids, eosinophils disappear.
4. See Appendix J f or drugs t hat aff ect t est out comes.
Interventions
2. Ref er t o st andard pat ient care f or hemogram, CBC, and diff erent ial count on
care.

2. Use special precaut ions if pat ient is receiving st eroid t herapy, epinephrine,
t hyroxine, or prost aglandins. Eosinophilia can be masked by st eroid use.

posttest care .
Basophils
Basophils, w hich const it ut e a small percent age of t he t ot al leukocyt e count , are
considered phagocyt ic. The basophilic granules cont ain heparin, hist amines, and
serot onin. Tissue basophils
are called mast cel l s and are similar t o blood basophils. Normally, mast cells are
not f ound in peripheral blood and are rarely seen in healt hy bone marrow.
Basophil count s are used t o st udy chronic inf lammat ion. There is a posit ive
correlat ion bet w een high basophil count s and high concent rat ions of blood
hist amines, alt hough t his correlat ion does not imply cause and eff ect . I t is
ext remely diff icult t o diagnose basopenia because a 100010, 000 count
diff erent ial w ould have t o be done t o get an absolut e count .
Reference Values
Normal
Absolut e count : 1550/ mm 3 or 0. 020. 05 109 / L
Diff erent ial: 0%1. 0% of t ot al WBC
Procedure
1. O bt ain a 5-mL blood sample in EDTA and count as part of t he diff erent ial.
2. Place t he sample in a biohazard bag.
1. Basophi l i a (increased count ) >50/ mm3 or >0. 05 109 / L is commonly
associat ed w it h t he f ollow ing:
a. G ranulocyt ic (myelocyt ic) leukemia
b. Acut e basophilic leukemia
c. Myeloid met aplasia, myeloprolif erat ive disorders
d. Hodgkin's disease
2. I t is less commonly associat ed w it h t he f ollow ing:

a. I nf lammat ion, allergy, or sinusit is
b. Polycyt hemia vera
c. Chronic hemolyt ic anemia
d. Af t er splenect omy
e. Af t er ionizing radiat ion
f. Hypot hyroidism
g. I nf ect ions, including t uberculosis, smallpox, chickenpox, inf luenza
h. Foreign prot ein inject ion
3. Basopeni a (decreased count ) <20/ mm3 or <0. 02 109 / L is associat ed w it h
t he f ollow ing:
a. Acut e phase of inf ect ion
b. Hypert hyroidism
c. St ress react ions (eg, pregnancy, myocardial inf arct ion)
d. Af t er prolonged st eroid t herapy, chemot herapy, radiat ion
e. Heredit ary absence of basophils
f. Acut e rheumat ic f ever in children
4. Presence of numbers of ti ssue mast cel l s (t issue basophils) is associat ed
w it h:
a. Rheumat oid art hrit is
b. Urt icaria, ast hma
c. Anaphylact ic shock
d. Hypoadrenalism
e. Lymphoma
f. Macroglobulinemia
g. Mast cell leukemia
h. Lymphoma invading bone marrow
i. Urt icaria pigment osa
j. Ast hma
k. Chronic liver or renal disease
l. O st eoporosis
m. Syst emic mast ocyt osis
Interfering Factors
See Appendix J f or drugs t hat aff ect t est out comes.
Interventions
1. Explain t est purpose and procedure
2. Ref er t o st andard pat ient care f or hemogram, CBC, and diff erent ial count on
care.

2. Use special precaut ions if pat ient is receiving st eroid t herapy, epinephrine,
t hyroxine, or prost aglandins. Eosinophilia can be masked by st eroid use.
posttest care .
Monocytes (Monomorphonuclear Monocytes) These

agranulocytes, the largest cells of normal blood, are
the body's second line of defense against infection.
Histiocytes, which are large macrophagic phagocytes,
are classified as monocytes in a differential leukocyte
count. Histiocytes and monocytes are capable of
reversible transformation from one to the other.
These phagocyt ic cells of varying size and mobilit y remove injured and dead
cells, microorganisms, and insoluble part icles f rom t he circulat ing blood.
Monocyt es escaping f rom t he upper and low er respirat ory t ract s and t he
gast roint est inal and genit ourinary organs perf orm a scavenger f unct ion, clearing
t he body of debris. These phagocyt ic cells produce t he ant iviral agent called
i nterf eron.
This t est count s monocyt es, w hich circulat e in cert ain specif ic condit ions such as
t uberculosis, subacut e bact erial endocardit is, and t he recovery phase of acut e
inf ect ions.
Reference Values
Normal
Absolut e count : 100500/ mm 3 or 0. 10. 5 109 / L
Diff erent ial: 3%7% of t ot al WBC or 0. 030. 07 of t ot al WBC
Procedure
1. O bt ain a 5-mL blood sample in EDTA and count as part of t he diff erent ial.
1. I n monocytosi s: a monocyt e increase of >500 cells/ mm3 or >0. 5 109 / L or
>10%. The most common causes are bact erial inf ect ions, t uberculosis,
subacut e bact erial endocardit is, and syphilis.
2. O t her causes of monocyt osis:
a. Monocyt ic leukemia and myeloprolif erat ive disorders
b. Carcinoma of st omach, breast , or ovary
c. Hodgkin's disease and ot her lymphomas
d. Recovery st at e of neut ropenia (f avorable sign)
e. Lipid st orage diseases (eg, G aucher's disease)
f. Some parasit ic mycot ic and ricket t sial diseases
g. Surgical t rauma
h. Chronic ulcerat ive colit is, ent erit is, and sprue
i. Collagen diseases and sarcoidosis
j. Tet rachloret hane poisoning
3. Phagocyt ic monocyt es (macrophages) may be f ound in small numbers in t he
blood in many condit ions:
a. Severe inf ect ions (sepsis)
b. Lupus eryt hemat osus
c. Hemolyt ic anemias
4. Decreased monocyte count (<100 cells/ mm3 or <0. 1 109 / L) is not usually
ident if ied w it h specif ic diseases:
a. Prednisone t reat ment
b. Hairy cell leukemia
c. O verw helming inf ect ion t hat also causes neut ropenia
d. Human immunodef iciency virus (HI V) inf ect ion
e. Aplast ic anemia (bone marrow injury)
Interfering Factors
Interventions
care.

1. I nt erpret t est out comes and monit or appropriat ely f or leukemia and inf ect ion.
posttest care .
Lymphocytes (Monomorphonuclear Lymphocytes);

CD4, CD8 Count; Plasma Cells Lymphocytes are small,
mononuclear cells without specific granules. These
agranulocytes are motile cells that migrate to areas of
inflammation in both early and late stages of the
process. These cells are the source of serum
immunoglobulins and of cellular immune response and
play an important role in immunologic reactions. All

lymphocytes are manufactured in the bone marrow. B
lymphocytes mature in the bone marrow, and T
lymphocytes mature in the thymus gland. B cells
control the antigen-antibody response that is specific
to the offending antigen and is said to have memory.
The T cells, the master immune cells, include CD4+
helper T cells, killer cells, cytotoxic cells, and CD8+
suppressor T cells.
Plasma cells (f ully diff erent iat ed B cells) are similar in appearance t o
lymphocyt es. They have abundant blue cyt oplasm and an eccent ric, round
nucleus. Plasma cells are not normally present in blood.
This t est measures t he number of lymphocyt es in t he peripheral blood.
Lymphocyt osis is present in various diseases and is especially prominent in viral
disorders. Lymphocyt es and t heir derivat ives, t he plasma cells, operat e in t he
immune def enses of t he body.
Reference Values
Normal
Lymphocyt es: 25%40% of t ot al leukocyt e count (relat ive value) or 15004000
cells/ mm 3 or 1. 54. 0 109 / L
Plasma cells: 0% or none
CD4 count : t ot al WBC lymphocyt es (%) lymphocyt es (%) st ained w it h CD4
CD4/ CD8 rat io: >1. 0
Procedure
1. O bt ain 5 mL of EDTA-ant icoagulat ed blood. Place t he specimen in a
biohazard bag.
2. Count lymphocyt es as part of t he diff erent ial count .
1. Lymphocytosi s: >4000/ mm 3 or >4. 0 109 / L in adult s; >7200/ mm3 or >7. 2
10 9 in children; and >9000/ mm3 or >9. 0 109 / L in inf ant s occurs in:
a. Lymphat ic leukemia (acut e and chronic) lymphoma
b. I nf ect ious lymphocyt osis (occurs mainly in children)
c. I nf ect ious mononucleosis:
1. Caused by Epst ein-Barr virus
2. Most common in adolescent s and young adult s
3. Charact erized by at ypical lymphocyt es (Dow ney cells) t hat are large,
deeply indent ed, w it h deep blue (basophilic) cyt oplasm
4. Diff erent ial diagnosisposit ive het erophil t est
d. O t her viral diseases:
1. Viral inf ect ions of t he upper respirat ory t ract (pneumonia)
2. Cyt omegalovirus
3. Measles, mumps, chickenpox
4. Acut e HI V inf ect ion
5. I nf ect ious hepat it is (acut e viral hepat it is)
6. Toxoplasmosis
e. Some bact erial diseases such as t uberculosis, brucellosis (undulant
f ever), and pert ussis
f. Crohn's disease, ulcerat ive colit is (rare)
g. Serum sickness, drug hypersensit ivit y
h. Hypoadrenalism, Addison's disease
i. Thyrot oxicosis (relat ive lymphocyt osis)
j. Neut ropenia w it h relat ive lymphocyt osis
2. Lymphopeni a: <1000 cells/ mm3 or <1. 0 109 / L in adult s; <2500 cells/ mm3 or
<2. 5 109 / L in children occurs in:
a. Chemot herapy, radiat ion t reat ment (immunosuppressive medicat ions)
b. Af t er administ rat ion of ACTH or cort isone (st eroids); w it h ACTHproducing pit uit ary t umors
c. I ncreased loss via gast roint est inal t ract ow ing t o obst ruct ion of lymphat ic
drainage (eg, t umor, Whipple's disease, int est inal lymphect asia)
d. Aplast ic anemia
e. Hodgkin's disease and ot her malignancies
f. I nherit ed immune disorders, acquired immunodef iciency syndrome
(AI DS), and AI DS-immune dysf unct ion

g. Advanced t uberculosis (miliary t uberculosis), renal f ailure, SLE
h. Severe debilit at ing illness of any king
i. Congest ive heart f ailure
3. CD4 count: t he number of CD4+ lymphocyt es is equal t o t he absolut e number
of lymphocyt es (t ot al WBC diff erent ial [ %] of lymphocyt es) t imes t he
percent age of lymphocyt es st aining posit ively f or CD4. A severely depressed
CD4 count is t he single best indicat or of imminent opport unist ic inf ect ion.
a. Decreased CD4 lymphocyt es
1. I mmune dysf unct ion, especially AI DS
2. Acut e minor viral inf ect ions
b. Increased CD4 lymphocyt es
1. Therapeut ic eff ect of drugs
2. Diurnal variat ion: peak evening values may be t w o t imes morning
values.
4. Pl asma cel l s (not normally present in blood) are i ncreased in:
a. Plasma cell leukemia
b. Mult iple myeloma
c. Hodgkin's disease
d. Chronic lymphat ic leukemia
e. Cancer of liver, breast , prost at e
f. Cirrhosis
g. Rheumat oid art hrit is, SLE
h. Serum react ion
i. Some bact erial, viral, and parasit ic inf ect ions
Interfering Factors
1. Physiologic pediat ric lymphocyt osis is a condit ion in new borns t hat includes
an elevat ed WBC and abnormal-appearing lymphocyt es t hat can be mist aken
f or malignant cells.
2. Exercise, emot ional st ress, and menst ruat ion can cause an increase in
lymphocyt es.
3. Af rican Americans normally have a relat ive (not absolut e) increase in

lymphocyt es.
4. See Appendix J f or drugs t hat aff ect out comes.
Abnormal Lymphocytes
Abnormality
Description
Associated
Diseases
Atypical
lymphocytes
Reactive
lymphocytes
Downey
cells
Turk cells
Lymphocytes, some
with vacuolated
cytoplasm, irregularly
shaped nucleus,
increased numbers of
cytoplasmic
azurophilic granules,
and peripheral
basophilia; or some
with more abundant
basophilic cytoplasm,
grossly indented
cytoplasm
Infectious
mononucleosis,
viral hepatitis,
other viral
infections,
tuberculosis,
drug (eg,
penicillin)
sensitivity,
posttransfusion
syndrome
Interventions
care.
Clin ical Alert

A decreased lymphocyt e count <500/ mm3 (<0. 5 109 / L) means t hat a pat ient
is dangerously suscept ible t o inf ect ion, especially viral inf ect ions. Insti tute
measures to protect pati ent f rom i nf ecti on.

1. I nt erpret t est out comes and monit or appropriat ely f or lymphocyt osis or
lymphopenia.
posttest care .
Lymphocyte Immunophenotyping (T and B Cells)

Lymphocytes are divided into two categories, T and B
cells, according to their primary function within the
immune system. In the body, T and B cells work
together to help provide protection against infections,
oncogenic agents, and foreign tissue, and they play a
vital role in regulating self-destruction or
autoimmunity.
Most circulat ing lymphocyt es are T cells w it h a lif e span of mont hs t o years. The
lif e span of B cells is measured in days. B cel l s (anti body) are considered
bursa or bone marrow dependent and are responsible f or humoral immunit y (in
w hich ant ibodies are present in t he serum). T cel l s (cel l ul ar) are t hymus derived
and are responsible f or cellular immunit y. T cells are f urt her divided int o helper T
(CD3 + , CD4+ ) cells and suppressor T (CD3+ , CD8+ ) cells.
Evaluat ion of lymphocyt es in t he clinical laborat ory is perf ormed by quant it at ion
of t he lymphocyt es and t heir subpopulat ions and by assessment of t heir f unct ion
act ivit y. These laborat ory analyses have become an essent ial component of t he
clinical assessment of t w o major disease st at es: l ymphoprol i f erati ve st at es (eg,
leukemia, lymphoma), in w hich charact erizat ion of t he malignant cell in t erms of
lineage and st age of diff erent iat ion provides valuable inf ormat ion t o t he
oncologist t o guide prognosis and appropriat e t herapy; and i mmunodef i ci ent
st at es (eg, HI V inf ect ion, organ t ransplant at ion), in w hich t he alt erat ions in t he
immune syst em t hat occur secondary t o inf ect ion are evaluat ed.
The met hod of lymphocyt e quant it at ion and charact erizat ion is based on t he
det ect ion of cell surf ace markers by very specif ic monoclonal ant ibodies. For cell
surf ace immunophenot yping, f low cyt omet ry has become t he met hod of choice.
Cell surf ace phenot yping is accomplished by react ing cells f rom an appropriat e
specimen w it h one or more labeled monoclonal ant ibodies and passing t hem
t hrough a f low cyt omet er, w hich count s t he proport ion of labeled cells.
Reference Values
Normal for Adult Peripheral Blood by Flow Cytometry T
and B surface markers: Total T cells (CD3+ ): 53%88%
Helper T cells (CD3+ , CD4+ ): 32%61%
Suppressor T cells (CD3+ , CD8+ ): 18%42%
B cells (CD19+ ): 5%20%
Nat ural killer cells (CD16+ ): 4%32%
Absol ute counts (based on pat hologist 's int erpret at ion): Tot al lymphocyt es: 660
4600/ mm 3 (0. 64. 6 109 / L) Tot al T cells (CD3+ ): 8122318/ mm 3
Helper T cells (CD3+ , CD4+ ): 5891505/ mm 3
Suppressor T cells (CD3+ , CD8+ ): 325997/ mm 3
B cells (CD19+ ): 92426/ mm 3
Nat ural killer cells (CD16+ ): 78602/ mm 3
Lymphocyte rati o: Helper-t o-suppressor T-cell rat io >1. 0
Procedure
1. O bt ain a 5-mL EDTA-ant icoagulat ed blood sample (lavender-t opped t ube).
2. Do not ref rigerat e or f reeze t he sample; it should remain at room
t emperat ure unt il t est ing is perf ormed. Collect a separat e 5-mL venous
EDTA-ant icoagulat ed blood sample f or hemat ology at t he same t ime.
Because t he int erpret at ion of dat a is based on absolut e values, it is
imperat ive t hat a WBC and diff erent ial count also be perf ormed so t hat t he
appropriat e dat a can be obt ained.
1. St andard immunosuppressive drug t herapy usually decreases lymphocyt e
t ot als.
2. Pat ient s w it h an absolut e helper T-lymphocyt e count <200/ mm3 are at
great est risk f or developing clinical AI DS.
3. Decreased T cells occur in congenit al immunodef iciency diseases (eg,
DiG eorge syndrome, t hymic hypoplasia).
4. Decreased T cells occur in kidney and heart t ransplant pat ient s receiving
O KT-3, an immunomodulat ory drug used t o prevent reject ion.
5. A marked i ncrease in B cells occurs in lymphoprolif erat ive disorders (eg,
chronic lymphocyt ic leukemia). I n t he t ypical case of chronic lymphocyt ic
leukemia, t he B cells w ould be posit ive f or eit her or light chains
(indicat ing monoclonalit y) and w ould express CD19 (a B-cell ant igen).
Interventions
1. Explain purpose and specimen collect ion procedure. A recent viral cold can
cause a decrease in t ot al T cells, as can medicat ions such as
cort icost eroids. Nicot ine and st renuous exercise have also been show n t o
decrease lymphocyt e count s.
2. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed pretest care .

1. I nt erpret t est out comes and possible need f or repeat t est ing. Lymphocyt e
immunophenot yping is perf ormed t o monit or pat ient s w ho are HI V posit ive
and have begun medicat ion t reat ment . Transplant at ion pat ient s are also
ret est ed at regular int ervals t o assess t he t hreat of organ reject ion or host
inf ect ion. Also, see Chapt er 8 f or f urt her discussion of CD4 and CD8 cells.
2. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed posttest care .
STAINS FOR LEUKEM IAS

Several special WBC st aining met hods are used t o diagnose leukemia, amyloid
disease, lymphoma, and eryt hroleukemia; t o diff erent iat e eryt hema myelosis
f rom sideroblast ic anemia; t o monit or progress and response t o t herapy; and t o
det ect early relapse. Amyl oi d ref ers t o st archlike subst ances deposit ed in
cert ain diseases (eg, t uberculosis, ost eomyelit is, leprosy, Hodgkin's disease,
and carcinoma).
Sudan Black B (SBB) Stain The SBB stain aids in

differentiation of the immature cells of acute
leukemias, especially acute myeloblastic leukemia. The
SBB stains a variety of fats and lipids that are present
in myeloid leukemias but not present in the lymphoid
leukemias.
Reference Values
Positive Reactions
G ranulocyt ic cells (neut rophils and eosinophils) Myeloblast s
Promyelocyt es
Neut rophilic myelocyt es
Met amyelocyt es, bands, and segment ed neut rophils Eosinophils at all st ages
Monocyt es and precursors
Variable Reactions
Basophils
Negative Reactions (Sudanophobia) Lymphocytes and

lymphocytic precursors Megakaryocytes and
thrombocytes (platelets) Erythrocytes
Eryt hroblast s may display a f ew granules t hat represent mit ochondrial
phospholipid component s
Procedure
1. O bt ain bone marrow aspirat e.

2. Prepare slide, st ain w it h SBB, and scan microscopically. Use normal smear
cont rol.
1. Posit ive st aining of primit ive (blast ) cells indicat es myelogenous origin of
cells. SBB is posit ive in acut e myelocyt ic leukemia (AML).
2. SBB is negat ive in acut e lymphocyt ic leukemia, monocyt ic leukemia, plasma
cell leukemia, and megakaryocyt e leukemia.
3. SBB is w eak t o negat ive in acut e monocyt ic leukemia.
Interfering Factors
There are cases of acut e leukemia in w hich t he cyt ochemical st ains are not
usef ul and f ail t o reveal t he diff erent iat ing f eat ures of any specif ic cell line.
Interventions
1. Explain t est purposes and procedures. I f bone marrow aspirat ion is done,
see pages f or special care.
2. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest care .

1. I nt erpret t est out comes; counsel and monit or appropriat ely f or leukemia,
amyloid disease, anemia, and inf ect ion.
Periodic AcidSchiff (PAS) Stain The PAS stain aids in

the diagnosis of acute lymphoblastic leukemia (ALL).
Early myeloid precursors and erythrocyte precursors
are negative. As granulocytes mature, they increase in
PAS positivity, whereas mature RBCs stay negative.

The PAS stain cannot be used to distinguish between
AAL and AML or between benign and malignant
lymphocytic disorders.
Reference Values
Normal
Lymphoblast s: st ain (posit ive) Myeloblast s: do not st ain (negat ive)
Procedure
1. O bt ain bone marrow aspirat e.
2. Prepare slide, st ain w it h PAS, and scan microscopically.
1. Posit ive react ion
a. Blast s in ALL in childhood of t en have coarse clumps or masses of PASposit ive mat erial w it hin t heir scent cyt oplasm. The st aining pat t ern is
usually het erogeneous, w it h some cells cont aining PAS-posit ive clumps
and ot hers virt ually unst ained.
b. Acut e monocyt ic leukemia
c. Hairy cell leukemia
d. Szary's syndrome
e. Conspicuous PAS posit ivit y in t he eryt hroid precursors is st rongly
suggest ive of eryt hroleukemia (M6 ).
2. Weakly posit ive
a. I n acut e granulocyt ic leukemia, t he blast s display eit her a negat ive or
w eakly posit ive, f inely granular pat t ern.
b. I n some cases of t halassemia and in anemias w it h blocked or def icient
iron, t he red blood cell precursors also cont ain PAS-posit ive mat erial.
c. Hodgkin's disease, now Hodgkin's lymphoma
d. I nf ect ious mononucleosis
3. Negat ive st ain
a. Lymphoblast s of Burkit t 's lymphoma

b. Megaloblast ic leukemia
Interventions
1. Explain t est purposes and procedures.

1. I nt erpret t est out comes; counsel and monit or appropriat ely.
Terminal Deoxynucleotidyl Transferase (TDT) Stain The

thymus is the primary site of TDT-positive cells, and
TDT is found in the nucleus of the more primitive T
cells. A thymus-related population of TDT-positive cells
resides in the bone marrow (normally a minor
population, 0%2%). TDT is increased in >90% of cases
of ALL of childhood. A minor (5%10%) population of
patients with acute nonlymphoblastic leukemia have
TDT-positive blasts. TDT-positive blasts are prominent
in some cases of chronic myelogenous
leukemia (CML), relating to the development of an
acute blast phase. TDT has been reported to assist in
establishing the diagnosis of ALL. TDT-positive cases
of blast-phase CML correlate with a positive response
to chemotherapy (vincristine and prednisone).
Reference Values
Normal
Negat ive in nonlymphoblast ic leukemia Negat ive in peripheral blood 0% t o 2%
posit ive in bone marrow
Procedure
1. O bt ain a 5-mL EDTA-ant icoagulat ed peripheral blood sample or a 2-mL
EDTA-ant icoagulat ed bone marrow aspirat e.
2. Dry slides (st ore at room t emperat ure f or up t o 5 days), process, and st ain,
t hen examine under t he microscope f or posit ive cells.
1. TDT is posit ive in ALL, lymphoblast ic lymphoma, and CML (blast crisis).
2. TDT is negat ive in pat ient s in remission and in t hose w it h CML or chronic
lymphat ic leukemia.
Interventions

Leukocyte Alkaline Phosphatase (LAP) Stain

Neutrophils are the only leukocytes to contain various
amounts of alkaline phosphatase.
The LAP st ain is used as an aid t o dist inguish chronic granulocyt ic leukemia f rom
a leukemoid react ion. A leukemoid react ion is a high WBC t hat may look like
leukemia but is not . I n remission of CML, t he LAP may ret urn t o normal. I n t he
blast phase of CMC, t he LAP may be elevat ed.
Reference Values
Normal
40100 LAP unit s
NOTE
Each laborat ory must est ablish it s ow n normal values.
Procedure
1. O bt ain specimen by capillary punct ure, venous blood (EDTA), or bone
marrow aspirat e. Prepare smear and air-dry; st ain w it h LAP.
2. Make a count of 100 granulocyt es and score (f rom 0 t o 4+) as t o t he degree
of LAP unit s.
1. Decreased values (015 LAP unit s):
a.
CM L
b. Paroxysmal noct urnal hemoglobinuria (PNH)

c. I diopat hic t hrombocyt openic purpura
d. Heredit ary hypophosphat asia
e. Progressive muscular dyst rophy
f. Marked eosinophilia
g. Nephrot ic syndrome
h. Siderocyt ic anemia
2. Increased values:
a. Leukemoid react ions, all kinds of neut rophilia w it h elevat ed WBC
c. Thrombocyt openia (essent ial)
d. Dow n syndrome (t risomy 21)
e. Mult iple myeloma
f. Hodgkin's disease
g. Hairy cell leukemia
h. Aplast ic leukemia, acut e and chronic lymphat ic leukemia, chronic
granulocyt ic leukemia
i. Myelof ibrosis, myeloid met aplasia
3. Normal levels of LAP:
a. Secondary polycyt hemia
b. Hemolyt ic anemia
c. I nf ect ious mononucleosis
d. I ron-def iciency anemia
e. Viral hepat it is
4. Serial LAP t est s can be a usef ul adjunct in evaluat ing t he act ivit y of
Hodgkin's disease and t he response t o t herapy.
Interfering Factors
1. Any physiologic st ress, such as t hird-t rimest er pregnancy, labor, or severe
exercise, causes an i ncreased LAP score.
2. St eroid t herapy i ncreases LAP score.

3. CML w it h inf ect ion i ncreases t he LAP score.
Interventions

1. I nt erpret t est out comes; counsel and monit or appropriat ely f or blood
diseases.
Tartrate-Resistant Acid Phosphatase (TRAP) Stain The

malignant mononuclear cells of leukemic
reticuloendotheliosis (hairy cell leukemia) are resistant
to inhibition by tartaric acid. There is evidence that the
reaction is not entirely specific because TRAP
reactions have been reported in prolymphocytic
leukemia and malignant lymphoma and in some cases
of infectious mononucleosis.
Reference Values
Normal
No TRAP act ivit y
Procedure
1. O bt ain venous blood sample (5 mL) or bone marrow smear.
2. I ncubat e blood smear w it h TRAP, count erst ain, and examine microscopically.
1. TRAP is present in t he leukemic cells of most pat ient s w it h hairy cell
leukemia; 5% of pat ient s w it h ot herw ise t ypical hairy cell leukemia lack t he
enzyme.
2. TRAP occasionally occurs in malignant cells of pat ient s w it h
lymphoprolif erat ive disorders ot her t han hairy cell leukemia.
3. Hist iocyt es have w eakly posit ive react ions.
Interventions
1. Explain t est purposes and procedures. Assess f or hist ory of signs and
sympt oms of leukemia.

TESTS OF RED BLOOD CELLS

Many t est s look at t he red blood cells: t heir number and size, amount of Hb, rat e
of product ion, and percent composit ion of t he blood. The red blood cell count
(RBC), hemat ocrit (Hct ), and hemoglobin (Hb) are closely relat ed but diff erent
w ays t o look at t he adequacy of eryt hrocyt e product ion. The same condit ions
cause an increase (or decrease) in each of t hese indicat ors.
Red Blood Cell Count (RBC; Erythrocyte Count) The

main function of the red blood cell (RBC or erythrocyte)
is to carry oxygen from the lungs to the body tissues
and to transfer carbon dioxide from the tissues to the
lungs. This process is achieved by means of the Hb in
the RBCs, which combines easily with oxygen and
carbon dioxide and gives arterial blood a bright red
appearance. To enable use of the maximal amount of
Hb, the RBC is shaped like a biconcave disk; this
affords more surface area for the Hb to combine with
oxygen. The cell is also able to change its shape when
necessary to allow for passage through the smaller
capillaries.
The RBC t est , an import ant measurement in t he evaluat ion of anemia or
polycyt hemia, det ermines t he t ot al number of eryt hrocyt es in a microlit er (cubic
millimet er) of blood.
Reference Values
Normal
See Table 2. 3
Table 2.3 Normal Values for Red Blood Cells
Men
W omen
4.25.4 106 /mm 3 or 1012 /L

(average, 4.8)
3.65.0 106 /mm 3 or 1012 /L
(average, 4.3)
Children
Birth2 wk
4.16.1 106 /mm 3 1012 /L
28 wk
4.06.0 106 /mm 3 1012 /L
26 mo
3.85.6 106 /mm 3 1012 /L
6 mo1 y
3.85.2 106 /mm 3 1012 /L
16 y
3.95.3 106 /mm 3 1012 /L
616 y
4.05.2 106 /mm 3 1012 /L
1618 y
4.25.4 106 /mm 3 1012 /L
>18 y
(males)
4.55.5 106 /mm 3 1012 /L
>18 y
(females)
4.05.0 106 /mm 3 1012 /L
Procedure
1. O bt ain 5 mL of EDTA-ant icoagulat ed venous blood. Place t he specimen in a
biohazard bag.
2. Remember t hat aut omat ed elect ronic devices are generally used t o
det ermine t he number of RBCs.
3. Not e pat ient age and t ime of day on t he laborat ory slip.
1. Decreased RBC val ues occur in:
a. Anemia, a condit ion in w hich t here is a reduct ion in t he number of
circulat ing eryt hrocyt es, t he amount of Hb, or t he volume of packed cells
(Hct ). Anemia is associat ed w it h cell dest ruct ion, blood loss, or diet ary
insuff iciency of iron or of cert ain vit amins t hat are
essent ial in t he product ion of RBCs. See Chart 2. 1 on page 79 f or a
classif icat ion of anemias based on t heir underlying mechanisms and t he
t est f or ret iculocyt e count f or a discussion of t he purpose and clinical
implicat ions of t he ret iculocyt e count .
b. Disorders such as:
1. Hodgkin's disease and ot her lymphomas
2. Mult iple myeloma, myeloprolif erat ive disorders, leukemia
3. Acut e and chronic hemorrhage
4. Lupus eryt hemat osus
5. Addison's disease
6. Rheumat ic f ever
7. Subacut e endocardit is, chronic inf ect ion
8. This list is not meant t o be all inclusive.
2. Erythrocytosi s (increased RBC) occurs in:
a. Primary eryt hrocyt osis
1. Polycyt hemia vera (myeloprolif erat ive disorder)
2. Eryt hremic eryt hrocyt osis (increased RBC product ion in bone
marrow )
b. Secondary eryt hrocyt osis
1. Renal disease
2. Ext rarenal t umors
3. High alt it ude
4. Pulmonary disease
5. Cardiovascular disease
6. Alveolar hypovent ilat ion
7. Hemoglobinopat hy
8. Tobacco/ carboxyhemoglobin
c. Relat ive eryt hrocyt osis (decrease in plasma volume)
1. Dehydrat ion (vomit ing, diarrhea)
2. G aisbck's syndrome
Clin ical Alert

Ref er t o page 76 f or a discussion of t he combined clinical implicat ions of
decreased RBC, Hct , and Hb values. The same underlying condit ions cause a
decrease in each of t hese t hree t est s of eryt hrocyt e product ion.
Clin ical Alert

Please ref er t o page 75 f or a discussion of t he combined clinical implicat ions
of i ncreased RBC, Hct , and Hb values. The same underlying condit ions cause
an i ncrease in each of t hese t hree t est s of eryt hrocyt e product ion.
Interfering Factors
1. Post ure: w hen a blood sample is obt ained f rom a healt hy person in a
recumbent posit ion, t he RBC is 5% low er. (I f t he pat ient is anemic, t he count
w ill be low er st ill. )
2. Dehydrat ion: hemoconcent rat ion in dehydrat ed adult s (caused by severe
burns, unt reat ed int est inal obst ruct ion, severe persist ent vomit ing, or diuret ic
abuse) may obscure signif icant anemia.
3. Age: t he normal RBC of a new born is higher t han t hat of an adult , w it h a
rapid drop t o t he low est point in lif e at 2 t o 4 mont hs. The normal adult level
is reached at age 14 years and is maint ained unt il old age, w hen t here is a
gradual drop (see normal values).
4. Falsely high count s may occur because of prolonged venous st asis during
venipunct ure.
5. St ress can cause a higher RBC.
6. Alt it ude: t he higher t he alt it ude, t he great er t he increase in RBC. Decreased
oxygen cont ent of t he air st imulat es t he RBC t o rise (eryt hrocyt osis).
7. Pregnancy: t here is a relat ive decrease in RBC w hen t he body f luid

increases in pregnancy, w it h t he normal number of eryt hrocyt es becoming
more dilut ed.
8. There are many drugs t hat may cause decreased or increased RBC. See
Appendix J f or drugs t hat aff ect t est out comes.
9. The EDTA blood sample t ube must be at least t hree f ourt hs f illed or values
w ill be invalid because of cell shrinkage caused by t he ant icoagulant .
10. The blood sample must not be clot t ed (even slight ly) or t he values w ill be
invalid.
Interventions
page 47.
3. Have t he pat ient avoid ext ensive exercise, st ress, and excit ement bef ore t he
t est . These cause elevat ed count s of doubt f ul clinical value.
4. Avoid overhydrat ion or dehydrat ion, if possible; eit her causes invalid result s.
I f pat ient is receiving I V f luids or t herapy, not e on requisit ion.
5. Not e any medicat ions pat ient is t aking.

1. I nt erpret t est out comes and monit or appropriat ely f or anemia and
eryt hrocyt osis.
on page 47.
3. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed posttest care .
Hematocrit (Hct); Packed Cell Volume (PCV) The word
hematocrit means to separate blood, which

underscores the mechanism of the test because the
plasma and blood cells are separated by
centrifugation.
The Hct t est is part of t he CBC. This t est indirect ly measures t he RBC mass.
The result s are expressed as t he percent age by volume of packed RBCs in
w hole blood (PCV). I t is an import ant measurement in t he det erminat ion of
anemia or polycyt hemia.
Reference Values
Normal Women: 36%48% or 0.360.48
Men: 42%52% or 0. 420. 52
Children:
02 w eeks: 44%64% or 0. 440. 64
28 w eeks: 39%59% or 0. 390. 59
26 mont hs: 35%49% or 0. 350. 49
6 mont hs1 year: 29%43% or 0. 290. 43
16 years: 30%40% or 0. 300. 40
616 years: 32%42% or 0. 320. 42
1618 years: 34%44% or 0. 340. 44
NOTE
I f blood is draw n f rom a capillary punct ure and a microhemat ocrit is done,
values are slight ly higher.
Procedure
1. O bserve st andard precaut ions. When doing a capillary punct ure (f inger
punct ure), t he microcapillary t ube is f illed t hree f ourt hs f ull w it h blood,
direct ly f rom punct ure sit e. These t ubes are coat ed w it h an ant icoagulat ive.
2. Cent rif uge t he t ubes in a microcent rif uge and measure t he height of packed
cells in t he t ube.
3. Record t he measurement as a percent age of t he t ot al amount of blood in t he
capillary t ube.
4. Remember t hat an Hct can be done on aut omat ed hemat ology inst rument s, in
w hich case a 5-mL EDTA-ant icoagulat ed venous blood sample is obt ained.
1. Decreased Hct val ues are an indicat or of anemia, a condit ion in w hich t here
is a reduct ion in t he PVC. An Hct <30% (<0. 30) means t hat t he pat ient is
moderat ely t o severely anemic. Decreased values also occur in t he f ollow ing
condit ions:
a. Leukemias, lymphomas, Hodgkin's disease, myeloprolif erat ive disorders
b. Adrenal insuff iciency
c. Chronic disease
d. Acut e and chronic blood loss
e. Hemolyt ic react ion: t his condit ion may be f ound in t ransf usion of
incompat ible blood or as a react ion t o chemicals or drugs, inf ect ious
agent s, or physical agent s (eg, severe burns, prost het ic heart valves).
2. The Hct may or may not be reliable immediat ely af t er even a moderat e loss
of blood or immediat ely af t er t ransf usion.
3. The Hct may be normal af t er acut e hemorrhage. During t he recovery phase,
bot h t he Hct and t he RBC drop markedly.
4. Usually, t he Hct parallels t he RBC w hen t he cells are of normal size. As t he
number of normal-sized eryt hrocyt es increases, so does t he Hct .
a. How ever, f or t he pat ient w it h microcyt ic or macrocyt ic anemia, t his

relat ionship does not hold t rue.
b. I f a pat ient has iron-def iciency anemia w it h small RBCs, t he Hct
decreases because t he microcyt ic cells pack t o a smaller volume. The
RBC, how ever, may be normal or higher t han normal.
5. Increased Hct val ues occur in:
a. Eryt hrocyt osis
c. Shock, w hen hemoconcent rat ion rises considerably
Clin ical Alert

of decreased Hct , Hb, and RBC values. The same underlying condit ions cause
a decrease in each of t hese t hree t est s of eryt hrocyt e product ion.
Clin ical Alert

of i ncreased Hct , Hb, and RBC values. The same underlying condit ions cause
an i ncrease in each of t hese t hree t est s of eryt hrocyt e product ion.
Interfering Factors
1. People living at high alt it udes have high Hct values as w ell as high Hb and
RBC.
2. Normally, t he Hct slight ly decreases in t he physiologic hydremia of
pregnancy.
3. The normal values f or Hct vary w it h age and gender. The normal value f or
inf ant s is higher because t he new born has many macrocyt ic red cells. Hct
values in f emales are usually slight ly low er t han in males.
4. There is also a t endency t ow ard low er Hct values in men and w omen older
t han 60 years of age, corresponding t o low er RBC values in t his age group.
5. Severe dehydrat ion f rom any cause f alsely raises t he Hct .
Interventions

care.
Clin ical Alert

An Hct <20% (<0. 20) can lead t o cardiac f ailure and deat h; an Hct >60%
(>0. 60) is associat ed w it h spont aneous clot t ing of blood.

1. I nt erpret t est result s and monit or f or anemia or polycyt hemia.
posttest care .
Hemoglobin (Hb)
Hb, t he main component of eryt hrocyt es, serves as t he vehicle f or t he
t ransport at ion of oxygen and carbon dioxide. I t is composed of amino acids t hat
f orm a single prot ein called gl obi n, and a compound called heme, w hich cont ains
iron at oms and t he red pigment porphyrin. I t is t he iron pigment t hat combines
readily w it h oxygen and gives blood it s charact erist ic red color. Each gram of Hb
can carry 1. 34 mL of oxygen per 100 mL of blood. The oxygen-combining
capacit y of t he blood is direct ly proport ional t o t he Hb concent rat ion rat her t han
t o t he RBC because some RBCs cont ain more Hb t han ot hers. This is w hy Hb
det erminat ions are import ant in t he evaluat ion of anemia.
The Hb det erminat ion is part of a CBC. I t is used t o screen f or disease
associat ed w it h anemia, t o det ermine t he severit y of anemia, t o monit or t he
response t o t reat ment f or anemia, and t o evaluat e polycyt hemia.
Hb also serves as an import ant buff er in t he ext racellular f luid. I n t issue, t he
oxygen concent rat ion is low er, and t he carbon dioxide level and hydrogen ion
concent rat ion are higher. At a low er pH, more oxygen dissociat es f rom Hb. The
unoxygenat ed Hb binds t o hydrogen ion, t hereby raising t he pH. As carbon
dioxide diff uses int o t he RBC, carbonic anhydrase convert s carbon dioxide t o
bicarbonat e and prot ons. As t he prot ons are bound t o Hb, t he bicarbonat e ions
leave t he cell. For every bicarbonat e ion leaving t he cell, a chloride ion ent ers.
The eff iciency of t his buff er syst em depends on t he abilit y of t he lungs and
kidneys t o eliminat e, respect ively, carbon dioxide and bicarbonat e. Ref er t o t he
discussion of art erial blood gases in Chapt er 14.
Reference Values
Normal
Women: 12. 016. 0 g/ dL or 120160 g/ L
Men: 14. 017. 4 g/ dL or 140174 g/ L
Children:
02 w eeks: 14. 524. 5 g/ dL or 145245 g/ L
28 w eeks: 12. 520. 5 g/ dL or 125205 g/ L
26 mont hs: 10. 717. 3 g/ dL or 107173 g/ L
6 mont hs1 year: 9. 914. 5 g/ dL or 99145 g/ L
16 years: 9. 514. 1 g/ dL or 95141 g/ L
616 years: 10. 314. 9 g/ dL or 103149 g/ L
1618 years: 11. 115. 7 g/ dL or 111157 g/ L
Procedure
1. O bt ain a venous blood EDTA-ant icoagulat ed sample of 5 mL. Fill t he
Vacut ainer t ube at least t hree f ourt hs f ull. Aut omat ed elect ronic devices are
generally used t o det ermine t he Hb; how ever, a manual colorimet ric
procedure is also w idely used.
2. Do not allow t he blood sample t o clot , or t he result s w ill be invalid. Place t he
specimen in a biohazard bag.
1. Decreased Hb l evel s are f ound in anemia st at es (a condit ion in w hich t here
is a reduct ion of Hb, Hct , and/ or RBC values). The Hb must be evaluat ed
along w it h t he RBC and Hct .
a. I ron def iciency, t halassemia, pernicious anemia, hemoglobinopat hies
b. Liver disease, hypot hyroidism
c. Hemorrhage (chronic or acut e)
d. Hemolyt ic anemia caused by:
1. Transf usions of incompat ible blood
2. React ions t o chemicals or drugs

3. React ions t o inf ect ious agent s
4. React ions t o physical agent s (eg, severe burns, art if icial heart
valves)
5. Various syst emic diseases:
a. Hodgkin's disease
b. Leukemia
c. Lymphoma
d.
SLE
e. Carcinomat osis
f. Sarcoidosis
g. Renal cort ical necrosis
h. This list is not meant t o be all inclusive.
2. Increased Hb l evel s are f ound in:
a. Polycyt hemia vera
b. Congest ive heart f ailure
c. Chronic obst ruct ive pulmonary disease (CO PD)
3. Vari ati on in Hb levels:
a. O ccurs af t er t ransf usions, hemorrhages, burns. (Hb and Hct are bot h
high during and immediat ely af t er hemorrhage. )
b. The Hb and Hct provide valuable inf ormat ion in an emergency sit uat ion if
t hey are int erpret ed not in an isolat ed f ashion but in conjunct ion w it h
ot her pert inent laborat ory dat a.
Clin ical Alert

of decreased Hb, Hct , and RBC values. The same underlying condit ions cause
a decrease in each of t hese t hree t est s of eryt hrocyt e product ion.
Clin ical Alert

Please ref er below f or a discussion of t he combined clinical implicat ions of
i ncreased Hb, Hct , and RBC values. The same underlying condit ions cause an
i ncrease in each of t hese t hree t est s of eryt hrocyt e product ion.
Clinical Implications of Polycythemia: Increased RBC,

Hct, and/or Hb Polycythemia is the term used to
describe an abnormal increase in the number of RBCs.
Although there are several tests to directly determine
the RBC mass, these tests are expensive and somew hat
cumbersome. For screening purposes, w e rely on the
Hct and Hb to evaluate polycythemia indirectly.
Polycythemias are classified as follow s:
1. Rel ati ve polycyt hemia: an increase in Hb, Hct , or RBC caused by a decrease
in t he plasma volume (eg, dehydrat ion, spurious eryt hrocyt osis f rom st ress
or smoking)
2. Absol ute or true polycyt hemia:
a. Primary (eg, polycyt hemia vera, eryt hemic eryt hrocyt osis)
b. Secondary
1. Appropriat e (an appropriat e bone marrow response t o physiologic
condit ions)
a. Alt it ude
b. Cardiopulmonary disorder
c. I ncreased aff init y f or oxygen
2. I nappropriat e (an overproduct ion of RBCs not necessary t o deliver
oxygen t o t he t issues)
a. Renal t umor or cyst
b. Hepat oma
c. Cerebellar hemangioblast oma
Clinical Implications of Anemia: Decreased RBC, Hct,

and/or Hb Anemia is the term used to describe a
condition in w hich there is a reduction in the number of
circulating RBCs, the amount of Hb, and/or volume of
packed cells (Hct). A pathophysiologic classification of
anemias based on their underlying mechanisms
follow s. Anemias are further explained in Chart 2.1.
Anemias are classified as follow s:
1. Hypoprol i f erati ve anemias (inadequat e product ion of RBCs):
a. Marrow aplasias
b. Myelopht hisic anemia
c. Anemia w it h blood dyscrasias
d. Anemia of chronic disease
e. Anemia w it h organ f ailure
2. Maturati on def ect anemias:

a. Cyt oplasmic: hypochromic anemias
b. Nuclear: megaloblast ic anemias
c. Combined: myelodysplast ic syndromes
3. Hyperprol i f erati ve anemias (decreased Hb or Hct despit e an increased
product ion of RBCs):
a. Hemorrhagic: acut e blood loss
b. Hemolyt ic: a premat ure, accelerat ed dest ruct ion of RBCs
1. I mmune hemolysis
2. Primary membrane
3. Hemoglobinopat hies
4. Toxic hemolysis (physical-chemical)
5. Traumat ic or microangiopat hic hemolysis
6. Hypersplenism
7. Enzymopat hies
8. Parasit ic inf ect ions
4. Di l uti onal anemias:
a. Pregnancy
b. Splenomegaly
Interfering Factors
1. People living at high alt it udes have increased Hb values as w ell as increased
Hct and RBC.
2. Excessive f luid int ake causes a decreased Hb.
3. Normally, t he Hb is higher in inf ant s (bef ore act ive eryt hropoiesis begins).
4. Hb is normally decreased in pregnancy as a result of increased plasma
volume.
5. There are many drugs t hat may cause a decreased Hb. Drugs t hat may
cause an i ncreased Hb include gent amicin and met hyldopa.
6. Ext reme physical exercise causes increased Hb.
Interventions
1. Explain t est purpose and procedure. Assess medicat ion hist ory.
care.

1. I nt erpret t est result s and monit or appropriat ely f or anemia or polycyt hemia.
posttest care .
Clin ical Alert

The panic Hb value is <5. 0 g/ dL (<50 g/ L), a condit ion t hat leads t o heart
f ailure and deat h. A value >20 g/ dL (>200 g/ L) leads t o clogging of t he
capillaries as a result of hemoconcent rat ion.
Red Blood Cell Indices

The red cell indices def ine t he size and Hb cont ent of t he RBC and consist of t he
mean corpuscular volume (MCV), t he mean corpuscular hemoglobin concent rat ion
(MCHC), and t he mean corpuscular hemoglobin (MCH).
The RBC indices are used in diff erent iat ing anemias. When t hey are used
t oget her w it h an examinat ion of t he eryt hrocyt es on t he st ained smear, a clear
pict ure of RBC morphology may be ascert ained. O n t he basis of t he RBC
indices, t he eryt hrocyt es can be charact erized as normal in every respect or as
abnormal in volume or Hb cont ent . I n def icient st at es, t he anemias can be
classif ied by cell size as macrocyt ic, normocyt ic, or microcyt ic, or by cell size
and color as microcyt ic hypochromic.
Procedure
1. Remember t hat t hese are calculat ed values. An explanat ion of each
measurement f ollow s.
2. O bt ain 5 mL EDTA blood so t hat RBC, Hb, and Hct det erminat ions can be
done f or calculat ions.
Interventions
Pretest Patient Care for MCV, MCHC, and MCH
1. Explain t he purpose and procedure f or t est ing. Assess f or possible causes of
anemia. No f ast ing is required.
Posttest Patient Aftercare for MCV, MCHC, and MCH

1. I nt erpret t est result s and monit or appropriat ely f or anemia. Counsel
appropriat ely f or proper diet , medicat ion, relat ed hormone and enzyme
problems, and genet ically linked disorders.
Mean Corpuscular Volume (MCV) Individual cell size is

the best index for classifying anemias. This index
expresses the volume occupied by a single erythrocyte
and is a measure in cubic micrometers (femtoliters, or
fL) of the mean volume. The MCV indicates whether the
red blood cell size appears normal (normocytic),
smaller than normal (<82 m3 , microcytic), or larger
than normal (>100 m3 , macrocytic).
Reference Values
Normal
8298 mm3 or 8298 f L (higher values in inf ant s and new borns and f or elderly
pat ient s)
Procedure
1. Calculat e t he MCV f rom t he RBC count (t he number of cells per cubic
millimet er of blood) and t he Hct (t he proport ion of t he blood occupied by t he

RBCs).
2. Use t he f ollow ing f ormula:
The MCV result s are t he basis of t he classif icat ion syst em used t o evaluat e an
anemia. The cat egorizat ions show n in Chart 2. 1 aid in orderly invest igat ion.
Ch art 2.1 Anemias Characterized by Deficient Hemoglobin

Synthesis
Microcytic An emias (MCV 5082 fL)
DISORDERS OF IRON M ETABOLISM

I ron-def iciency anemia: t he most prevalent w orldw ide cause of anemia; t he
major causes are diet ary inadequacy, malabsorpt ion, increased iron loss, and
increased iron requirement s Anemia of chronic disease, heredit ary
at ransf errinemia Congenit al hypochromic-microcyt ic anemia w it h iron overload
(Shahidi-Nat han-Diamond syndrome)
DISORDERS OF PORPHYRIN AND HEME SYNT HESIS

Acquired sideroblast ic anemias I diopat hic ref ract ory sideroblast ic anemia,
complicat ing ot her diseases associat ed w it h drugs or t oxins (et hanol,
isoniazid, lead)
Heredit ary sideroblast ic anemias X chromosomelinked, aut osomal anemias
DISORDERS OF GLOBIN SYNTHESIS

Thalassemias, hemoglobinopat hies, charact erized by unst able hemoglobins
Normocytic Normoch romic An emias (MCV 8298 fL)

ANEMIA WIT H APPROPRIAT E BONE MARROW RESPONSE
Acut e post hemorrhagic anemia Hemolyt ic anemia (may be macrocyt ic w hen
t here is pronounced ret iculocyt osis)
ANEM IA WITH IM PAIRED M ARROW RESPONSE

Marrow h ypoplasia
Aplast ic anemia, pure red cell aplasia
Marrow in filtration
I nf ilt rat ion by malignant cells, myelof ibrosis, inherit ed st orage diseases
Decreased eryth ropoietin produ ction Kidn ey an d liver disease,

en docrin e deficien cies, maln u trition , an emia of ch ron ic disease
Macrocytic An emias (MCV 100150 fL)
COBALAMIN (B12 ) DEFICIENCY
Decreased in gestion
Lack of animal product s, st rict veget arianism
Impaired absorption
I nt rinsic f act or def iciency, pernicious anemia, gast rect omy (t ot al or part ial),
dest ruct ion of gast ric mucosa by caust ics, ant i-int rinsic f act or ant ibody in
gast ric juice, abnormal int rinsic f act or molecule, int rinsic int est inal disease,
f amilial select ive malabsorpt ion (I merslnd's syndrome), ileal resect ion, ileit is,
sprue, celiac disease, inf ilt rat ive int est inal disease (eg, lymphoma,
scleroderma) drug-induced malabsorpt ion
Competitive parasites
Fish t apew orm inf est at ions (Di phyl l obothri um l atum); bact eria in divert iculum
of bow el, blind loops
In creased requ iremen ts

Chronic pancreat ic disease, pregnancy, neoplast ic disease, hypert hyroidism
Impaired u tilization
Enzyme def iciencies, abnormal serum cobalamin binding prot ein, lack of
t ranscobalamin I I , nit rous oxide administ rat ion
FOLATE DEFICIENCY
Decreased in gestion
Lack of veget ables, alcoholism, inf ancy
Impaired absorption
I nt est inal short circuit s, st eat orrhea, sprue, celiac disease, int rinsic int est inal
disease, ant iconvulsant s, oral cont racept ives, ot her drugs
In creased requ iremen t

Pregnancy, inf ancy, hypot hyroidism, hyperact ive hemat opoiesis, neoplast ic
disease, exf oliat ive skin disease
Impaired u tilization
Folic acid ant agonist s: met hot rexat e, t riamt erene, t rimet hoprim, enzyme
def iciencies
In creased loss
Hemodialysis
UNRESPONSIVE TO COBALAM IN OR FOLATE

Metabolic in h ibitors
Purine synt hesis: 6-mercapt opurine, 6-t hioguanine, azat hioprine Pyrimidine
synt hesis: 6-azauridine Thymidylat e synt hesis: met hot rexat e, 5-f luorouracil
Deoxybonucleot ide synt hesis: hydroxyurea, cyt arabine, severe iron def iciency
In born errors
Lesch-Nyhan syndrome, heredit ary orot ic aciduria, def iciency of
f ormiminot ransf erase, met hylt ransf erase, ot hers
Interfering Factors
1. Mixed (bimorphic) populat ion of macrocyt es and microcyt es can result in a
normal MCV. Examinat ion of t he blood f ilm conf irms t his.
2. I ncreased ret iculocyt es can increase t he MCV.
3. Marked leukocyt osis increases t he MCV.
4. Marked hyperglycemia increases MCV.
5. Cold agglut inins increase MBV.
Interventions

Mean Corpuscular Hemoglobin Concentration (MCHC)

The MCHC measures the average concentration of Hb
in the RBCs. The MCHC is most valuable in monitoring
therapy for anemia because the two most accurate
hematologic determinations (Hb and Hct) are used in

its calculation.
Reference Values
Normal
3236 g/ dL or 320360 g/ L
Procedure
1. Remember t hat t he MCHC is a calculat ed value. I t is an expression of t he
average concent rat ion of Hb in t he red blood cells and, as such, represent s
t he rat io of t he w eight of Hb t o t he volume of t he eryt hrocyt e.
1. Decreased MCHC val ues signif y t hat a unit volume of packed RBCs cont ains
less Hb t han normal. Hypochromic anemia (MCHC <30 g/ dL) occurs in:
a. I ron def iciency
b. Microcyt ic anemias, chronic blood loss anemia
c. Some t halassemias
2. Increased MCHC val ues (RBCs cannot accommodat e more t han 37 g/ dL or
370 g/ L Hb) occur in:
a. Spherocyt osis (heredit ary)
b. New borns and inf ant s
Interfering Factors
1. The MCHC may be f alsely high in t he presence of lipemia, cold agglut inins,
or rouleaux and w it h high heparin concent rat ions.
2. The MCHC cannot be great er t han 37 g/ dL (370 g/ L) because t he RBC
cannot accommodat e more t han 37 g/ dL (370 g/ L) Hb. (Check f or errors in

calculat ion or in Hb det erminat ion. The MCHC can be used f or laborat ory
qualit y cont rol. )
Interventions

Mean Corpuscular Hemoglobin (MCH) The MCH is a

measure of the average weight of Hb per RBC. This
index is of value in diagnosing severely anemic
patients.
Reference Values
Normal
2634 pg/ cell or 0. 400. 53 f mol/ cell (normally higher in new borns and inf ant s)
Procedure
The MCH is a calculat ed value. The average w eight of Hb in t he RBC is
expressed as picograms of Hb per RBC. The f ormula is:
1. An increase of t he MCH is associat ed w it h macrocyt ic anemia and new borns.
2. A decrease of t he MCH is associat ed w it h microcyt ic anemia.
Interfering Factors
1. Hyperlipidemia f alsely elevat es t he MCH.
2. WBC >50, 000/ mm3 f alsely raises t he Hb value and t heref ore f alsely elevat es
t he MCH.
3. High heparin concent rat ions f alsely elevat e t he MCH.
4. Cold agglut inins f alsely elevat es MCH.
Interventions

Red Cell Size Distribution Width (RDW) This automated

method of measurement is helpful in the investigation
of some hematologic disorders and in monitoring
response to therapy. The RDW is essentially an
indication of the degree of anisocytosis (abnormal
variation in size of RBCs). Normal RBCs have a slight
degree of variation.
Reference Values
Normal
11. 514. 5 coeff icient of variat ion (CV) of red cell size
Procedure
1. Remember t hat t he CV of RDW is det ermined and calculat ed by t he analyzer.
2. Use t he CV of RDW w it h caut ion and not as a replacement f or ot her
diagnost ic t est s.
3. Use t he f ollow ing calculat ion:
1. The RDW can be helpf ul in dist inguishing uncomplicat ed het erozygous
t halassemia (low MCV, normal RDW) f rom iron-def iciency anemia (low MCV,
high RDW).
2. The RDW can be helpf ul in dist inguishing anemia of chronic disease (low normal MCV, normal RDW) f rom early iron-def iciency anemia (low -normal
MCV, elevat ed RDW).
3. Increased RDW occurs in:
b. Vit amin B12 or f olat e def iciency (pernicious anemia)
c. Abnormal Hb: S, S-C, or H
d. S- -t halassemia (homogeneous)
e. I mmune hemolyt ic anemia
f. Marked ret iculocyt osis
g. Fragment at ion of RBCs
4. Normal RDWnormal in anemias w it h homogeneous red cell size
a. Chronic disease
b. Acut e blood loss
c. Aplast ic anemia
d. Heredit ary spherocyt osis
e. Hb E disease
f. Sickle cell disease
5. There is no know n cause of a decreased RDW.
Interfering Factors
1. This t est is not helpf ul f or persons w ho do not have anemia.
2. Alcoholism elevat es RDW.
3. Cold agglut inins
Interventions

1. I nt erpret t est result s and monit or appropriat ely f or anemia. Counsel
appropriat ely f or proper diet , medicat ion, relat ed hormone and enzyme
problems, and genet ically linked disorders.
Stained Red Cell Examination (Film; Stained

Erythrocyte Examination) The stained film examination
determines variations and abnormalities in erythrocyte
size, shape, structure, Hb content, and staining
properties. It is useful in diagnosing blood disorders
such as anemia, thalassemia, and other
hemoglobinopathies. This examination also serves as a
guide to therapy and as an indicator of harmful effects
of chemotherapy and radiation therapy. The leukocytes
are also examined at this time.
Reference Values
Normal
Size: normocyt ic (normal size, 78 m) Color: normochromic (normal) Shape:
normocyt e (biconcave disk) St ruct ure: normocyt es or eryt hrocyt es (anucleat ed
cells)
Procedure
1. Collect a 5-mL blood sample in EDTA. St ain a t hin smear w it h Wright 's st ain
and st udy under a microscope t o det ermine size, shape, and ot her
charact erist ics of t he RBCs.
2. Be aw are t hat a capillary smear may also be used and may be pref erred f or
det ect ion of some abnormalit ies.
Vari ati ons in st aining, color, shape, and RBC inclusions are indicat ive of RBC
abnormalit ies.
Clin ical Alert

Marked abnormalit ies in size and shape of RBCs w it hout a know n cause are
an indicat ion f or more complet e blood st udies.
Interventions

1. I nt erpret t est out come and monit or appropriat ely.
Peripheral Red Blood Cell Abnormalities
Abnormality
Description
Associated Dise
Anisocytosis
(diameter)
Abnormal variation
in size (normal
diameter = 68 m)
Any severe ane

iron-deficiency,
hypersplenism)
Small cells, <6 m

(MCV <80 fL)
Iron-deficiency
loading (siderob
anemia, thalass
lead poisoning,
B 6 deficiency
Macrocytes
Large cells, >8 m

(MCV >100 fL)
Megaloblastic a
alcoholism, live
hemolytic anem
(reticulocytes),
disease of newb
myeloma, leuke
myelophthisic a
metastatic carc
hypothyroidism
Megalocytes
Large (>9 m) oval

cells
Megaloblastic a
pernicious anem
cancer chemoth
Microcytes
Hypochromia
Pale cells with

decreased
concentration of
Severe iron-def
and iron-loading
(sideroblastic) a
hemoglobin (MCHC
<30 g/dL)
thalassemia, lea
poisoning, trans
deficiency
Abnormal variation
in shape
Any severe ane

megaloblastic, i
deficiency,
myeloproliferati
syndrome, hem
certain shapes
diagnostically h
(see entries for
Spherocytes,
Elliptocytes,
Stomatocytosis
cells, Target ce
Schistocytes, B
Acanthocytes a
Teardrop cells)
Spherocytes
Spherical cells
without pale
centers; often small
(ie,
microspherocytosis)
Hereditary sphe
Coombs'-positiv
hemolytic anem
numbers are se
hemolytic anem
after transfusion
blood
Elliptocytes
Oval cells
elongated
Hereditary ellip
(>25% on smea
deficiency
Red cells with
Congenital
Poikilocytes
slitlike (instead of
circular) areas of
central pallor
stomatocytosis,
disease, alcoho
disease, artifac
Sickle cells
Crescent-shaped
cells
Sickle cell disea
Target cells
Cells with a dark

center and
periphery and a
clear ring in
between
Liver disease,
thalassemia, iro
deficiency anem
hemoglobinopat
C, S-C, S-thala
artifact
Irregularly
contracted cells
(severe
poikilocytosis),
fragmented cells
Vasculitis, artifi
valve, dissemin
intravascular co
thrombocytopen
purpura and oth
microangiopath
anemias, toxins
phenylhydrazine
bite), severe bu
graft rejection,
hemoglobinuria
Burr-like cells,
spinous processes
Usually artifactu
uremia, stomac
pyruvate kinase
deficiency
Stomatocytosis
Schistocytes
(helmet cells)
Burr cells
(echinocytes)
Abetalipoprotein
(hereditary
Acanthocytes
Teardrop cells,
(dacrocytes)
Nucleated red
cells
Small cells with

thorny projections
acanthocytosis
Bassen-Kornzw
disease),
postsplenectom
hemolytic anem
cirrhosis, hepat
newborns, mala
states
Cells shaped like

teardrops
Myeloproliferati
syndrome, mye
anemia (neopla
granulomatous,
marrow infiltrati
thalassemia, pe
anemia, tubercu
Erythrocytes with
nuclei still present,
normoblastic or
megaloblastic
Hemolytic anem
leukemias,
myeloproliferati
syndrome, poly
vera, myelophth
anemia (neopla
granulomatous,
marrow infiltrati
multiple myelom
extramedullary
hematopoiesis,
megaloblastic a
any severe ane
Spherical purple
bodies (W right's)
Hyposplenism,
postsplenectom
Howell-Jolly
bodies
within or on
erythrocytes,
nuclear debris
pernicious anem
thalassemia, sic
anemia, other h
anemias
Heinz inclusion
bodies
Small round
inclusions of
denatured
hemoglobin seen
under phase
microscopy or with
supravital staining
Congenital hem
anemias (eg, gl
phosphate
dehydrogenase
deficiency), hem
anemia seconda
drugs (dapsone
phenacetin), tha
(Hb H),
hemoglobinopat
Zurich, Koln, Ub
so on)
Pappenheimer
bodies
(siderocytes)
Siderotic granules,
staining blue with
W right or Prussian
blue stain
Iron-loading ane
sideroblastic an
hyposplenism, l
poisoning, iron
(hemochromato
Cabot's rings
Purple, fine,
ringlike,
intraerythrocytic
structure
Pernicious anem
poisoning, seve
hemolytic anem
Basophilic
stippling
Punctate stippling
when W right
Hemolytic anem
punctate stippli
lead poisoning
(mitochondrial R
stained
iron), thalassem
megaloblastic a
alcoholism
Rouleaux
Aggregated
erythrocytes
regularly stacked
on one another
rows of coins
Multiple myelom
W aldenstrm's
macroglobulinem
blood, pregnanc
hypergammaglo
hyperfibrinogen
Polychromatophilia
(called
reticulocyes when
stained with
supravital stain)
RBCs containing
RNA, staining a
pinkish-blue color;
stains supravitally
as reticular network
with new methylene
blue
Hemolytic anem
loss, uremia, af
treatment of iro
deficiency or
megaloblastic a
NOTE
Not seen w it h Wright 's st ain. Must do supravit al st ain.
Reticulocyte Count
A reti cul ocyteyoung, immat ure, nonnucleat ed RBCcont ains ret icular mat erial
(RNA) t hat st ains gray-blue. Ret iculum is present in new ly released blood cells
f or 1 t o 2 days bef ore t he cell reaches it s f ull mat ure st at e. Normally, a small
number of t hese cells are f ound in circulat ing blood. For t he ret iculocyt e count t o
be meaningf ul, it must be view ed in relat ion t o t he t ot al number of eryt hrocyt es
(absolut e ret iculocyt e count = % ret iculocyt es eryt hrocyt e count ).
The ret iculocyt e count is used t o diff erent iat e anemias caused by bone marrow
f ailure f rom t hose caused by hemorrhage or hemolysis (dest ruct ion of RBCs), t o
check t he eff ect iveness of t reat ment in pernicious anemia and f olat e and iron
def iciency, t o assess t he recovery of bone marrow f unct ion in aplast ic anemia,
and t o det ermine t he eff ect s of radioact ive subst ances on exposed w orkers.
Reference Values
Normal
Adult s: 0. 5%1. 5% of t ot al eryt hrocyt es (w omen may be slight ly higher)
New borns: 3%6% of t ot al eryt hrocyt es (drops t o adult levels in 12 mont hs)
Absolut e count : 2585 103 / mm 3 or 109 cells/ L
Ret iculocyt e index (RI ): 1% correct ed ret iculocyt e count (CRC) Hemat ocrit
correct ion f or anemia: RI = ret iculocyt e count (pat ient 's Hct / 45 1/ 1. 85)
Procedure
1. O bt ain a 5-mL EDTA-ant icoagulat ed venous blood sample. Place t he
2. Mix t he blood sample w it h a supravit al st ain such as brilliant cresyl blue.
Allow t he st ain t o react w it h t he blood, and prepare a smear w it h t his
mixt ure and scan under a microscope. Count and calculat e t he ret iculocyt es.

45 = normal Hct ; 1. 85 = number of days f or ret iculocyt e t o mat ure
1. Increased reti cul ocyte count (ret iculocyt osis) means t hat increased RBC
product ion is occurring as t he bone marrow replaces cells lost or
premat urely dest royed. I dent if icat ion of ret iculocyt osis may lead t o t he
recognit ion of an ot herw ise occult disease, such as hidden chronic
hemorrhage or unrecognized hemolysis (eg, sickle cell anemia, t halassemia).
I ncreased levels are observed in t he f ollow ing:
a. Hemolyt ic anemia
1. I mmune hemolyt ic anemia
2. Primary RBC membrane problems
3. Hemoglobinopat hic and sickle cell disease
4. RBC enzyme def icit s
5. Malaria
b. Af t er hemorrhage (3 t o 4 days)
c. Af t er t reat ment of anemias
1. An increased ret iculocyt e count may be used as an index of t he
eff ect iveness of t reat ment .
2. Af t er adequat e doses of iron in iron-def iciency anemia, t he rise in
ret iculocyt es may exceed 20%.
3. There is a proport ional increase w hen pernicious anemia is t reat ed
by t ransf usion or vit amin B12 t herapy.
2. Decreased reti cul ocyte count means t hat bone marrow is not producing
enough eryt hrocyt es; t his occurs in:
a. Unt reat ed iron-def iciency anemia
b. Aplast ic anemia (a persist ent def iciency of ret iculocyt es suggest s a poor
prognosis)
c. Unt reat ed pernicious anemia
e. Radiat ion t herapy
f. Endocrine problems
g. Tumor in marrow (bone marrow f ailure)
h. Myelodysplast ic syndromes
i. Alcoholism
3. Ret iculocyt e index implicat ions

a. <2% indicat es hypoprolif erat ive component t o anemia
b. >2%3% indicat es increased RBC product ion
Interventions
1. Explain t est purpose and procedure. Pretest and posttest care are t he same
as f or t he hemogram (see page 47). Also, see Chapt er 1 guidelines f or saf e,
eff ect ive, inf ormed pretest care .
2. Not e medicat ions. Some drugs cause aplast ic anemia.

1. I nt erpret t est out come and monit or appropriat ely f or anemias.
Sedimentation Rate (Sed Rate); Erythrocyte

Sedimentation Rate (ESR) Sedimentation occurs when
the erythrocytes clump or aggregate together in a
column-like manner (rouleaux formation). These
changes are related to alterations in the plasma
proteins. Normally, erythrocytes settle slowly because
normal RBCs do not form rouleaux.
The ESR is t he rat e at w hich eryt hrocyt es set t le out of ant icoagulat ed blood in 1
hour. This t est is based on t he f act t hat inf lammat ory and necrot ic processes
cause an alt erat ion in blood prot eins, result ing in aggregat ion of RBCs, w hich
makes t hem heavier and more likely t o f all rapidly w hen placed in a special
vert ical t est t ube. The f ast er t he set t ling of cells, t he higher t he ESR. The ESR
should not be used t o screen asympt omat ic pat ient s f or disease. I t is most
usef ul f or diagnosis of t emporal art erit is, rheumat oid art hrit is, and polymyalgia
rheumat ica. The sediment at ion rat e is not diagnost ic of any part icular disease
but rat her is an indicat ion t hat a disease process is ongoing and must be
invest igat ed. I t is also usef ul in monit oring t he progression of inf lammat ory
diseases; if t he pat ient is being t reat ed w it h st eroids, t he ESR w ill decrease
w it h clinical improvement .
Reference Values by Westergren's M ethod
Normal
Men: 015 mm/ h (over age 50 years: 020 mm/ h) Women: 020 mm/ h (over age
50 years: 030 mm/ h) Children: 010 mm/ h
Procedure
1. O bt ain an EDTA-ant icoagulat ed venous sample of 5 mL or 3. 8% sodium
cit rat e. Place t he specimen in a biohazard bag.
2. Suct ion t he specimen int o a graduat ed sediment at ion t ube and allow t o set t le
f or exact ly 1 hour. The amount of set t ling is t he pat ient 's ESR.
1. Increased ESR is f ound in:
a. All collagen diseases, SLE
b. I nf ect ions, pneumonia, syphilis, t uberculosis
c. I nf lammat ory diseases (eg, acut e pelvic inf lammat ory disease)
d. Carcinoma, lymphoma, neoplasms
e. Acut e heavy-met al poisoning
f. Cell or t issue dest ruct ion, myocardial inf arct ion
g. Toxemia, pregnancy (t hird mont h t o 3 w eeks' post part um)
h. Waldenst rm's macroglobulinemia, increased serum globulins
i. Nephrit is, nephrosis
j. Subacut e bact erial endocardit is
k. Anemiaacut e or chronic disease
l. Rheumat oid art hrit is, gout , art hrit is, polymyalgia rheumat ica
m. Hypot hyroidism and hypert hyroidism
2. Normal ESR (no increase) is f ound in:
a. Polycyt hemia vera, eryt hrocyt osis
b. Sickle cell anemia, Hb C disease
c. Congest ive heart f ailure

d. Hypof ibrinogenemia (f rom any cause)
e. Pyruvat e kinase def iciency
f. Heredit ary spherocyt osis
g. Anemia
1. ESR is normal in iron-def iciency anemia
2. ESR is abnormal in anemia of chronic disease alone or in
combinat ion w it h iron-def iciency anemia and can be used t o
diff erent iat e t hese
h. Uncomplicat ed viral disease and inf ect ious mononucleosisnormal
i. Act ive renal f ailure w it h heart f ailurenormal
j. Acut e allergynormal
k. Pept ic ulcernormal
Clin ical Alert

Ext reme elevat ion of t he ESR is f ound w it h malignant lymphocarcinoma of
colon or breast , myeloma, and rheumat oid art hrit is.
Interfering Factors
1. Allow ing t he blood sample t o st and >24 hours bef ore t he t est is st art ed
causes t he ESR t o decrease.
2. I n ref rigerat ed blood, t he ESR is increased. Ref rigerat ed blood should be
allow ed t o ret urn t o room t emperat ure bef ore t he t est is perf ormed.
3. Fact ors leading t o an increased ESR include:
a. The presence of f ibrinogen, globulins, C-react ive prot ein, high
cholest erol
b. Pregnancy af t er 12 w eeks unt il about t he f ourt h post part um w eek
c. Young children
d. Menst ruat ion
e. Cert ain drugs (eg, heparin, oral cont racept ives; see Appendix J)
f. Anemia (low Hct )
g. Macrocyt osis
4. The ESR may be very high (up t o 60 mm/ h) in apparent ly healt hy w omen
aged 70 t o 89 years.
5. Fact ors leading t o reduced ESR include:
a. High blood sugar, high albumin level, high phospholipids
b. Decreased f ibrinogen level in t he blood in new borns, hypof ibrinogenemia
c. Cert ain drugs (eg, st eroids, high-dose aspirin; see Appendix J)
d. High Hb and RBCpolycyt hemia
e. High WBC
f. Abnormal RBCs (eg, sickle cells, spherocyt es, microcyt osis)
Interventions
1. Explain t est purpose and procedure. O bt ain appropriat e medicat ion hist ory.
Fast ing is not necessary, but a f at t y meal can cause plasma alt erat ions.

1. Have pat ient resume normal act ivit ies and diet .
2. I nt erpret t est out come; counsel and monit or appropriat ely f or rheumat ic
disorders and inf lammat ory condit ions.
TESTS FOR PORPHYRIA

Porphyri ns are chemical int ermediat es in t he synt hesis of Hb, myoglobin, and
ot her respirat ory pigment s called cytochromes. They also f orm part of t he
peroxidase and cat alase enzymes, w hich cont ribut e t o t he eff iciency of int ernal
respirat ion. I ron is chelat ed w it hin porphyrins t o f orm heme. Heme is t hen
incorporat ed int o prot eins t o become biologically f unct ional hemoprot eins.
Test s of blood, urine, and st ool are done t o diagnose porphyria, an abnormal
accumulat ion of porphyrins in body f luids. Porphyri as are a group of diseases
caused by a def icit in t he enzymes involved in porphyrin met abolism and
abnormalit ies in t he product ion of t he met alloporphyrin heme. These t est s are
indicat ed in persons w ho have unexplained neurologic manif est at ions,
unexplained abdominal pain, cut aneous blist ers, and/ or t he presence of a
relevant f amily hist ory. Test result s may ident if y clinical condit ions associat ed
w it h abnormal heme product ion, including anemia and porphyria (abnormal
accumulat ion of t he porphyrins) associat ed w it h enzyme disorders t hat may be
genet ic (heredit ary) or acquired (eg, lead poisoning, alcohol). Accumulat ion of
porphyrins occurs in blood plasma, serum, eryt hrocyt es, urine, and f eces.
A discussion of eryt hrocyt e t ot als and f ract ionat ion of eryt hrocyt es and plasma
f ollow s. For det ails of urine, serum, and st ool t est ing f or porphyrias, see
Chapt er 3, Chapt er 6, and Chapt er 4, respect ively.
Erythropoietic Porphyrins; Free Erythrocyte

Protoporphyrin (FEP) Normally, there is a small amount
of excess porphyrin at the completion of heme
synthesis. This excess is cell-free erythrocyte
protoporphyrin (FEP). The amount of FEP in the
erythrocyte is elevated when the iron supply is
diminished.
This t est is usef ul in screening RBC disorders such as iron def iciency and lead
exposure, especially in children 6 mont hs t o 5 years of age. This is t he t est of
choice t o diagnose eryt hopoiet ic prot oporphyria. This t est should not be used f or
screening f or lead poisoning in children.
Reference Values
Normal
<100 g/ dL of packed RBCs
NOTE
This depends on t he met hod. Check w it h your laborat ory.
Procedure
1. O bt ain a 5-mL sample of ant icoagulat ed venous blood. EDTA, or heparin,
may be used. Place t he specimen in a biohazard bag.
2. Prot ect t he blood sample f rom light .
3. Wash t he cells and t hen t est f or porphyrins.
4. Be aw are t hat t he Hct must be know n f or t est int erpret at ion.
1. Increased FEP is associat ed w it h:
a. I ron-def iciency anemias (elevat ed bef ore anemia)
b. Lead poisoning (chronic)
c. Halogenat ed solvent s and many drugs (see Appendix J)
e. Acquired idiopat hic sideroblast ic anemia (most cases)
f. Eryt hropoiet ic prot oporphyria
2. FEP is normal in:
a. Thalassemia minor (and t heref ore can be used t o diff erent iat e t his f rom
iron def iciency and ot her disorders of globin synt hesis)
b. Pyridoxine-responsive anemia
c. Cert ain f orms of sideroblast ic anemia due t o proximal block t o
prot oporphyrin
Interventions
1. Explain t est purpose and sampling procedure.
2. Not e on laborat ory slip or comput er any medicat ions t he pat ient is t aking
t hat cause int ermit t ent porphyria. Discont inue such medicat ions bef ore
t est ing (af t er checking w it h physician).


2. I nt erpret t est out come and monit or appropriat ely f or porphyria or lead
poisoning.
Clin ical Alert

The crit ical value is FEP >300 g/ dL.
Porphyrins; Fractionation of Erythrocytes and of

Plasma The primary porphyrins of erythrocytes are
protoporphyrin, uroporphyrin, and coproporphyrin.
Fracti onati on of eryt hrocyt es is used t o diff erent iat e congenit al eryt hropoiet ic
coproporphyria f rom eryt hropoiet ic prot oporphyria and t o conf irm a diagnosis of
prot oporphyria. This t est est ablishes a specif ic t ype of porphyria by naming t he
specif ic porphyrin in pl asma. I n persons w it h renal f ailure, plasma f ract ionat ion
can help t o det ermine w het her t he porphyria is caused by a def iciency of
uroporphyrinogenic decarboxylase or by f ailure of t he renal syst em t o excret e
porphyrinogens.
Reference Values
Normal
The value is report ed in micrograms per decilit er (g/ dL). Check w it h your
laborat ory f or ref erence values.
1. Eryt hrocyt e porphyrins:
a. Prot oporphyrin: 1660 g/ dL packed cells or 0. 31. 7 mol/ L
b. Uroporphyrin: <2 g/ dL or <24 nmol/ L
c. Hepat ocarboxylic: <1 g/ dL or <10 g/ L
d. Hexacarboxylic: <1 g/ dL or <10 g/ L
e. Pent acarboxylic: <1 g/ dL or <10 g/ L

f. Coproporphyrin: <1 g/ dL or <15 g/ L
2. Plasma porphyrins: Tot al porphyrins should not exceed 1. 0 g/ dL or 12
nmol/ L
Procedure
1. Draw a 5-mL sample of ant icoagulat ed blood. EDTA or heparin can be used
as an ant icoagulant . Place t he specimen in a biohazard bag.
2. Prot ect t he specimen f rom light .
1. Increased erythrocyte porphyri ns are associat ed w it h primary porphyrias:
a. Congenit al eryt hropoiet ic prot oporphyria
b. Prot oporphyria (aut osomal dominant def iciency of heme synt het ase)
c. Heredit ary porphobilinogen synt hase def iciency
d. I nt oxicat ion porphyria
2. Increased pl asma porphyri ns are associat ed w it h:
a. Congenit al eryt hropoiet ic prot oporphyria
b. Coproporphyria
c. Porphyria cut anea t arda
d. Parigat e porphyria
e. Chronic renal f ailure porphyria
Interventions
1. Advise pat ient of t est purpose.
2. Not e on t he requisit ion any drugs t he pat ient is t aking.
3. Bef ore t est ing, discont inue drugs t hat are know n t o cause int ermit t ent
porphyria (af t er checking w it h physician).

1. Resume medicat ions.
2. I nt erpret t est out come and monit or appropriat ely f or porphyria or lead
poisoning.
3. Caut ion persons diagnosed w it h porphyria (w it h cut aneous manif est at ions) t o
avoid sun exposure.
4. Advise persons diagnosed w it h porphyria (w it h neurologic sympt oms) t hat
at t acks can be precipit at ed by inf ect ions, various phases of t he menst rual
cycle, f ast ing st at es, and cert ain drugs. A list ing of drugs (not all inclusive)
t hat may precipit at e acut e at t acks f ollow s:
a. Barbit urat es
b. Chlordiazepoxide
c. Chloroquine
d. Chlorpropamide
e. Dichloralphenazone
f. Ergot preparat ions
g. Est rogens
h. Et hanol
i. G lut et himide
j. G riseof ulvin
k. Hydant oins
l. I mipramine
m. Meprobamat e
n. Met hsuximide
o. Met hyldopa
p. Sulf onamides
Clin ical Alert

1. A blood t est f or uroporphyrinogen I synt hase (also know n as erythrocyte
porphobi l i nogen deami nase) can be done t o ident if y persons at risk f or

acut e int ermit t ent porphyria, t o det ect lat ent -phase int ermit t ent porphyria,
and t o conf irm t he diagnosis during an acut e episode.
2. The normal value is 5. 39. 2 nmol/ L in w omen; 3. 48. 5 nmol/ L in men. A
value of <3. 5 nmol/ L is diagnost ic of acut e int ermit t ent porphyria.
ADDITIONAL TESTS FOR HEM OLYTIC ANEM IA

Several RBC enzyme and f ragilit y t est s can be done t o screen, det ect , and
conf irm t he cause of chronic hemolyt ic anemia. Many persons w it h hemolyt ic
anemia have no clinical signs or sympt oms. Abnormal t est out comes are
associat ed w it h inherit ed def iciencies, abnormal hemoglobins,
and exposure t o chemicals and drugs. Def init ive t est result s indicat e some t ype
of injury t o t he RBC, oxidat ed act ivit y t hat int erf eres w it h normal Hb f unct ion,
and/ or increased RBC f ragilit y.
Pyruvate Kinase (PK)

PK def iciency is a genet ic disorder charact erized by a low ered concent rat ion of
adenosine t riphosphat e in t he RBC and consequent ial membrane def ect . The
result is a nonspherocyt ic, chronic hemolyt ic anemia. PK def iciency is t he most
common and most import ant f orm of hemolyt ic anemia result ing f rom a def iciency
of glycolyt ic enzymes in t he RBC.
Reference Values
Normal
2. 88. 8 U/ g Hb or 46. 7146. 7 nkat / g Hb To convert t o U/ mL of packed RBCs:
U/ g Hb 0. 34 = U/ mL packed RBCs Check w it h your ref erence lab.
Procedure
1. O bt ain a venous blood sample of at least 5 mL w it h EDTA or heparin
ant icoagulant .
2. Ref rigerat e immediat ely.
PK is i ncreased in:
1. Congenit al PK def iciency: recessive, nonspherocyt ic hemolyt ic anemia.
Pat ient s t olerat e anemia w ell because of increased 2, 3-diphosphoglycerat e
(2, 3-DPG ).
2. Acquired PK def iciency caused by (level ret urns t o normal af t er t reat ing
underlying disorder):
a. Myelodysplast ic disorders
b. Acut e leukemias
c. Anemias
Interfering Factors
I n congenit al PK, int ravascular hemolysis increases during pregnancy or
f ollow ing use of oral cont racept ives.
Interventions
1. Explain t est purpose and procedure. There should be no exercising bef ore
t est s.
2. Wit hhold t ransf usion unt il af t er blood samples are draw n (especially w it h
osmot ic f ragilit y).

1. I nt erpret t est result s and monit or appropriat ely f or hemolyt ic anemia,
hypoxia, or polycyt hemia.
2. Splenect omy is indicat ed w hen anemia is severe enough t o require
t ransf usions.
Clin ical Alert

Many prescribed drugs int erf ere w it h t he normal f unct ioning of hemoglobin in
suscept ible persons, especially sulf onamides, ant ipyret ics, analgesics, large
doses of vit amin K, and nit rof urans.
Erythrocyte Fragility (Osmotic Fragility and

Autohemolysis) Spherocytes of any origin (including
conditions other than hereditary spherocytosis) are
more susceptible than normal RBCs to hemolysis in
dilute (hypotonic) saline and show increased osmotic
fragility. Generally, fully expanded cells (spheroidal

cells or spherocytes) have increased osmotic fragility,
whereas cells with higher surface area-to-volume ratios
(eg, thin cells, hypochromic cells, tart cells) have
decreased osmotic fragility.
I n heredit ary spherocyt osis, t he osmot ic f ragilit y t est may be normal init ially.
There-f ore, t he t est is incubat ed at 37C f or 24 hours, at w hich t ime t he t est is
posit ive f or heredit ary spherocyt osis.
Reference Values
Normal
Immedi ate test: Hemolysis begins at 0. 5% NaCl Hemolysis complet e at 0. 3%
NaCl 24-hour i ncubati on: Hemolysis begins at 0. 7% NaCl Hemolysis complet e at
0. 4% NaCl
Procedure
1. O bt ain a 7-mL venous blood sample using heparin as ant icoagulant . Place
t he specimen in a biohazard bag.
2. Expose eryt hrocyt es t o varying dilut ions of sodium chloride. Read hemolysis
on a spect rophot omet er (opt ical densit y measurement ). Perf orm st udies and
measure bot h bef ore and af t er 24-hour incubat ion of t he RBCs.
1. Increased osmot ic f ragilit y is f ound in:
a. Hemolyt ic anemia (acquired immune)
b. Heredit ary spherocyt osis (st omat ocyt osis)
c. Hemolyt ic disease of t he new born
d. Malaria
e. Severe pyruvat e kinase def iciency
2. Decreased osmot ic f ragilit y occurs in:
a. I ron-def iciency anemia (macrocyt ic hypochromic)
b. Thalassemias
c. Asplenia (post splenect omy)
d. Liver disease (obst ruct ive jaundice)

e. Ret iculocyt osis
f. Hemoglobinopat hies, especially Hb C, Hb S
Interventions
t est s.

2. Be aw are t hat t he usual t reat ment f or heredit ary spherocyt osis is
splenect omy, w hich removes t he agent of RBC dest ruct ion and prevent s
complicat ions such as aplast ic anemia.
Glucose-6-Phosphate Dehydrogenase (G6PD) G6PD is a

sex-linked disorder. The major variants occur in
specific ethnic groups. In a large group of African
American men, the incidence of type A G6PD deficiency
was found to be 11%. Approximately 20% of African
American women are heterozygous. With some
variants, there is chronic lifelong hemolysis, but more
commonly, the condition is asymptomatic and results
only in susceptibility to acute hemolytic episodes,
which may be triggered by certain drugs, ingestion of
fava beans, or viral or bacterial infection. G6PD
hemolysis is associated with formation of Heinz bodies
in peripheral RBCs.
The ot her t w o most common t ypes are Medit erranean, w hich is common in
I raqis, Kurds, Sephardic Jew s, and Lebanese and less common in G reeks,
I t alians, Turks, and Nort h Af ricans, and t he MAHI DO L variant , w hich is common
in Sout heast Asians (22% males).
Reference Values
Normal
G 6PD screen: G 6PD det ect ed Adul ts: 8. 618. 6 U/ g Hb or 0. 140. 31 nkat / g Hb
Chi l dren: 6. 415. 6 U/ g Hb or 0. 110. 26 nkat / g Hb Newborns: have values up t o
50% higher t han adult s I f done as a screening t est , G 6PD act ivit y is report ed as
w it hin normal limit s. Diff erent laborat ories have diff erent w ays of report ing.
To convert U/ g Hb t o U/ mL of RBCs: U/ g Hb 0. 34 = U/ mL of RBCs
Procedure
1. O bt ain a blood sample of at least 5 mL, using EDTA or heparin
ant icoagulant .
2. Place on ice in a biohazard bag. Perf orm a G 6PD screen f irst .
1. G 6PD is decreased in:
a. G 6Pd def iciency (causes hemolyt ic episodes af t er exposure t o cert ain
drugs and f ava beans)
b. Congenit al nonspherocyt ic anemia
c. Nonimmunologic hemolyt ic disease of t he new born (Asian and
Medit erranean)
2. G 6PD is i ncreased in:
a. Unt reat ed megaloblast ic anemia (pernicious anemia)
b. Thrombocyt openia purpura
c. Hypert hyroidism
d. Viral hepat it is
Interfering Factors
1. Marked ret iculocyt osis may give a f alsely high G 6PD.

2. G 6PD may be f alsely normal f or 6 t o 8 w eeks af t er a hemolyt ic episode,
especially in black persons w it h t he t ype A variant . Ret est af t er t he pat ient
recovers f rom t he episode of anemia.
Clin ical Alert

I n G 6PD-Medit erranean, G 6PD levels are grossly def icient in all RBCs.
Pat ient s w it h t his variant commonly experience hemolysis induced by diabet ic
acidosis, inf ect ions, and oxidant drugs and pot ent ially f at al hemolyt ic crises
af t er ingest ion of f ava beans.
Interventions
t est s.

2. Be aw are t hat t here are cert ain drugs and chemicals t hat should be avoided
by persons w it h G 6PD.
Heinz Bodies; Heinz Stain; Glutathione Instability Heinz

bodies are insoluble intracellular inclusions of Hb
attached to RBC membrane. Heinz bodies are
uncommon except with G6PD deficiency immediately
after hemolysis and in patients with unstable Hb
variants.
O xidat ive denat urat ion of t he Hb molecule leads t o Heinz body f ormat ion and is
probably t he mechanism f or t he precipit at ion of unst able Hb. Heinz bodies are
usually removed by t he spleen; af t er splenect omy, t hey increase in t he peripheral

blood and may appear in >50% of RBCs.
Reference Values
Normal
Not seen in normal pat ient s
Procedure
1. O bt ain a venous blood sample, ant icoagulat ed w it h heparin or EDTA. Place
t he specimen in a biohazard bag.
2. Mix cells w it h a supravit al st ain and examine microscopically. They st ain as
pale blue bodies, as opposed t o t he dark purple RNA in ret iculocyt es.
1. Increased Heinz bodies are f ound in:
a. G 6PD def iciency, especially af t er hemolysis
b. Congenit al Heinz body hemolyt ic anemia
c. Unst able Hb variant s (eg, Hb Zurich, Hb Philly)
d. Homozygous -t halassemia
2. Heinz bodies are f ound in blood of normal persons w ho have been poisoned
by cert ain drugs used in t reat ment prot ocols (eg, chlorat es, phenylhydrazine,
primaquine).
3. Heinz bodies are present in some new borns or in splenect omized pat ient s.
Interfering Factors
Interventions

2,3-Diphosphoglycerate (2,3-DPG) 2,3-DPG assists in

transporting oxygen in the RBC. 2,3-DPG increases in
response to hypoxia or anemia and decreases in
acidosis. Levels are lower in newborns and even lower
in premature newborns.
Reference Values
Normal
Adult s: 10. 414. 2 mol/ g Hb or 3. 64. 8 mol/ mL RBCs Check w it h your
ref erence lab.
Procedure
1. O bt ain a venous blood sample of at least 3 mL, ant icoagulat ed w it h heparin.
2. Place on ice immediat ely (2, 3-DPG is st able f or only 2 hours) and t ransport
t o laborat ory as soon as possible in a biohazard bag.
1. Increased 2, 3-DPG occurs in:
a. Emphysema, cyst ic f ibrosis w it h pulmonary involvement (condit ions of
hypoxia)
b. Cyanot ic heart disease
c. Pulmonary vascular disease
d. Sickle cell anemia, iron-def iciency anemia
e. Pyruvat e kinase def iciency
f. Hypert hyroidism
g. Chronic renal f ailure
h. Cirrhosis
2. Decreased 2, 3-DPG occurs in:
b. Respirat ory dist ress syndrome
c. 2, 3-DPG def iciency
d. Hexokinase def iciency
Interfering Factors
1. High alt it ude i ncreases 2, 3-DPG .
2. Exercise i ncreases 2, 3-DPG .
Clin ical Alert

I f blood w it h decreased 2, 3-DPG is used f or t ransf usion, t he Hb may not
release O2 w hen needed.
Interventions
Pretest Patient Care for Tests for Hemolytic Anemia
t est s.
Posttest Patient Aftercare for Tests for Hemolytic

Anemia
1. I nt erpret t est result s and monit or appropriat ely f or hemolyt ic anemia,
hypoxia, or polycyt hemia.
IRON TESTS
Iron (Fe), Total Iron-Binding Capacity (TIBC), and
Transferrin Tests Iron is necessary for the production
of Hb. Iron is contained in several components.
Transferrin (also called siderophilin), a transport
protein largely synthesized by the liver, regulates iron
absorption. High levels of transferrin relate to the
ability of the body to deal with infections. Total ironbinding capacity (TIBC) correlates with serum
transferrin, but the relation is not linear. A serum iron
test without a TIBC and transferrin determination has
very limited value except in cases of iron poisoning.
Transferrin saturation is a better index of iron
saturation; it is evaluated as follows:
The combined result s of t ransf errin, iron, and TI BC t est s are helpf ul in t he
diff erent ial diagnosis of anemia, in assessment of iron-def iciency anemia, and in
t he evaluat ion of t halassemia, sideroblast ic anemia, and hemochromat osis.
Reference Values
Normal
Iron
Adult men: 65175 g/ dL or 11. 631. 3 mol/ L
Adult w omen: 50170 g/ dL or 9. 030. 4 mol/ L
Children: 50120 g/ dL or 9. 021. 5 mol/ L
New borns: 100250 g/ dL or 17. 944. 8 mol/ L
Total i ron-bi ndi ng capaci ty (TIBC) Men: 250450 g/ dL or 44. 876. 1 mol/ L
Women: 250450 g/ dL or 44. 876. 1 mol/ L
Transf erri n Adult s: 250425 mg/ dL or 2. 54. 2 g/ L
Children: 203360 mg/ dL or 2. 03. 6 g/ L
New borns: 130275 mg/ dL or 1. 32. 7 g/ L
Transf erri n (i ron) saturati on Men: 10%50%

Women: 15%50%
Procedure
1. O bt ain a venous blood sample of 10 mL.
2. Place t he specimen in a biohazard bag. Serum is needed f or t hese t est s.
1. Increased transf erri n is observed in:
a. I ron-def iciency anemia (uncomplicat ed)
b. Pregnancy
c. Est rogen t herapy
2. Decreased transf erri n is f ound in:
a. Microcyt ic anemia of chronic disease
b. Prot ein def iciency or loss f rom burns or malnut rit ion
c. Chronic inf ect ion
d. Acut e liver disease
e. Renal disease (nephrosis)
f. G enet ic def iciency, heredit ary at ransf errinemia
g. I ron-overload st at es (hemochromat osis)
3. Decreased i ron occurs in:
a. I ron-def iciency anemia
b. Chronic blood loss
c. Chronic diseases (eg, lupus, rheumat oid art hrit is, chronic inf ect ions)
d. Third-t rimest er pregnancy and progest erone birt h cont rol pills
e. Remission of pernicious anemia
f. I nadequat e absorpt ion of iron
g. Hemolyt ic anemia (PNH)
4. Increased i ron occurs in:
a. Hemolyt ic anemias, especially t halassemia, pernicious anemia in relapse
(not hemolyt ic anemias)

b. Acut e iron poisoning (children)
c. I ron-overload syndromes
d. Hemochromat osis, iron overload
e. Transf usions (mult iple), int ramuscular iron, inappropriat e iron t herapy
f. Acut e hepat it is, liver damage
g. Vit amin B6 def iciency
h. Lead poisoning
i. Acut e leukemia
j. Nephrit is
5. Increased TIBC is f ound in:
b. Pregnancy (lat e)
c. Acut e and chronic blood loss
d. Acut e hepat it is
6. Decreased TIBC is observed in:
a. Hypoprot einemia (malnut rit ion and burns)
b. Hemochromat osis
c. Noniron-def iciency anemia (inf ect ion and chronic disease)
d. Cirrhosis of liver
e. Nephrosis and ot her renal diseases
f. Thalassemia
g. Hypert hyroidism
7. The iron sat urat ion index is i ncreased in:
a. Hemochromat osis
b. I ncreased iron int ake
c. Thalassemia
d. Hemosiderosis
e. Acut e liver disease
8. The iron sat urat ion index is decreased in:
a. I ron-def iciency anemias
b. Malignancy (st andard and small int est ine)

c. Anemia of inf ect ion and chronic disease
d. I ron neoplasms
Interfering Factors
1. Many drugs aff ect t est out comes (see Appendix J).
2. Drugs t hat may cause increased iron include et hanol, est rogens, and oral
cont racept ives.
3. Drugs t hat may cause decreased iron include some ant ibiot ics, aspirin, and
t est ost erone.
4. Hemolysis of t he blood sample int erf eres w it h t est ing.
5. I ron cont aminat ion of glassw are used in t est ing can give high values.
6. Menst ruat ion causes decreased iron; iron is elevat ed in t he premenst rual
period.
7. There is a diurnal variat ion in iron: normal values in t he morning, low er in
midaf t ernoon, very low in t he evening.
8. Serum iron and TI BC may be normal in iron-def iciency anemia if t he Hb is
>9. 0 g/ dL (or >90 g/ L).
Interventions
2. Draw f ast ing blood in t he morning, w hen levels are higher.
3. Draw iron sample bef ore iron t herapy is init iat ed or blood is t ransf used.
4. I f t he pat ient has received a t ransf usion, delay iron t est ing f or 4 days.
5. Avoid any iron-chelat ing drug (eg, def eroxamine [ Desf eral] ).
6. Avoid sleep deprivat ion and ext reme st ress, w hich cause low er iron levels.
7. Not e on laborat ory slip or comput er screen w het her t he pat ient is t aking oral
cont racept ives or est rogen t herapy or is pregnant .

1. Resume normal act ivit ies.
2. I nt erpret t est out come and monit or appropriat ely. The combinat ion of low
serum iron, high TI BC, and high t ransf errin levels indicat es iron def iciency.
Diagnosis of iron def iciency may lead f urt her t o det ect ion of adenocarcinoma
of t he gast roint est inal t ract , a point t hat cannot be overemphasized. A
signif icant minorit y of pat ient s w it h megaloblast ic anemias (20%40%) have
coexist ing iron def iciency. Megaloblast ic anemia can int erf ere w it h t he
int erpret at ion of iron st udies; repeat iron st udies 1 t o 3 mont hs af t er f olat e
or vit amin B12 replacement .
3. Use Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed posttest care .
Clin ical Alert

1. Crit ical iron values: int oxicat ed child, 2802550 g/ dL or 50456 mol/ L;
f at ally poisoned child, >1, 800 g/ dL or >322 mol/ L.
2. Sympt oms of iron poisoning include abdominal pain, vomit ing, bloody
diarrhea, cyanosis, and convulsions.
Ferritin
Ferrit in, a complex of f erric (Fe2+ ) hydroxide and a prot ein, apof errit in,
originat es in t he ret iculoendot helial syst em. Ferrit in ref lect s t he body iron st ores
and is t he most reliable indicat or of t ot al-body iron st at us. A bone marrow
examinat ion is t he only bet t er t est . Bone marrow aspirat ion may be necessary in
some cases, such as low -normal f errit in and low serum iron in t he anemia of
chronic disease.
The f errit in t est is more specif ic and more sensit ive t han iron concent rat ion or
TI BC f or diagnosing iron def iciency. Ferrit in decreases bef ore anemia and ot her
changes occur.
Reference Values
Normal
Men: 20250 ng/ mL or 20250 g/ L
Wit h anemia of chronic disease: <100 ng/ mL or <100 g/ L
I n absence of inf lammat ion: <20 ng/ mL or <20 g/ L

Women: 10120 ng/ mL or 10120 g/ L
Wit h anemia of chronic disease: <20 ng/ mL or <20 g/ L
I n absence of inf lammat ion: <10 ng/ mL or <10 g/ L
Chi l dren: 7140 ng/ mL or 7140 g/ L
Newborns: 25200 ng/ mL or 25200 g/ L
1 mont h: 50200 ng/ mL or 50200 g/ L
25 mont hs: 50200 ng/ mL or 50200 g/ L
Serum Tf R-f errit in index: 1. 5 in absence of anemia of chronic disease, 0. 8 w it h
anemia of chronic disease
NOTE
Tf R is t he t ransf errin recept or.
Procedure
1. O bt ain a venous sample of 6 mL.
2. Place t he specimen in a biohazard bag.
Ferritin, Iron, and Iron Saturation Changes in

Anemias
Ferritin
Iron
Iron
Saturation
Hemorrhage, acute
Hemorrhage, chronic
Iron-deficiency
Aplastic
Megaloblastic
Hemolytic
Sideroblastic
Thalassemia, major
Thalassemia, minor
N/I
N/I
Anemia
Bone marrow neoplasia
N/I
Uremia, nephrosis, or
nephrotic syndrome
N/I
D/I
Liver disease
N/I
N/I
N/I
Chronic diseases
N, no change; D, decrease; I, increase.
1. Decreased f erri ti n (<10 ng/ mL or <10 g/ L) usually indicat es iron-def iciency
anemia.
2. Increased f erri ti n (>400 ng/ mL or >400 g/ L) occurs in iron excess and in t he
f ollow ing:
a. I ron overload f rom hemochromat osis or hemosiderosis
b. O ral or parent eral iron administ rat ion
c. I nf lammat ory diseases
d. Acut e or chronic liver disease involving alcoholism
e. Acut e myoblast ic or lymphoblast ic leukemia
f. O t her malignancies (Hodgkin's disease, breast carcinoma, malignant
lymphoma)
g. Hypert hyroidism
h. Hemolyt ic anemia, megaloblast ic anemia, t halassemia, sideroblast ic
anemia
i. Renal cell carcinoma, end-st age renal disease
Interfering Factors
1. Recent ly administ ered radioact ive medicat ions cause spurious result s.
2. O ral cont racept ives and ant it hyroid t herapy int erf ere w it h t est ing (see
Appendix J).
3. Hemolyzed blood may cause high result s.
4. I ncreases w it h age.
5. Higher in red-meat eat ers t han veget arians.
6. Ferrit in is not of value t o evaluat e iron st ores in alcoholic persons w it h liver
disease.
Interventions
1. Explain t est purpose and procedure. Fast ing is not necessary.
2. Radioact ive medicat ions may not be given f or 3 t o 4 days bef ore t est ing.
3. Ref rain f rom alcohol (higher levels of f errit in occur in alcoholism).
Clin ical Alert

Cri ti cal val ue: I ron def iciency: <10 mg/ mL or <10 g/ L

2. I nt erpret t est result s and monit or appropriat ely f or iron-def iciency anemia
and f errit in increases. When iron and TI BC t est s are used t oget her w it h
f errit in, t hey can bet t er dist inguish bet w een iron-def iciency anemia and t he
anemia of chronic disease. Explain possible t reat ment w it h vit amin B12 and
f olic acid.
Iron Stain (Stainable Iron in Bone Marrow; Prussian

Blue Stain) In the bone marrow, normoblasts
containing iron granules (stainable) are known as
sideroblasts. Erythrocytes (RBCs) that contain

stainable iron are called siderocytes. Normally, about
33% of
the normoblasts are sideroblasts. Other storage iron is
readily identifiable in monophages in bone marrow
particles on the marrow slides.
The bone marrow iron st ain is t he gold st andard of iron def iciency: t he presence
of iron rules out iron def iciency. Marrow iron disappears bef ore peripheral blood
changes occur in iron-def iciency anemia. O nly pat ient s w it h decreased marrow
iron are likely t o benef it f rom iron t herapy.
Reference Values
Normal
Bone marrow : 33% sideroblast s present Peripheral blood: no siderocyt es
present
Procedure
1. Make bone marrow slides (bone marrow biopsy mat erial can be used), st ain,
and examine under t he microscope f or t he presence of iron.
2. Remember t hat t his t est may also be done on peripheral blood f or t he
det ect ion of sidero-blast ic anemias.
1. Bone marrow iron is decreased in:
a. I ron def iciency f rom all causes of chronic bleeding, hemorrhage,
malignancy
c. Pernicious anemia (early phase of t herapy)
d. Collagen diseases (eg, rheumat oid art hrit is, SLE)
e. I nf ilt rat ion of marrow by malignant lymphomas, carcinoma
f. Chronic inf ect ion
g. Myeloprolif erat ive diseases
h. Uremia
2. Bone marrow iron is i ncreased in:
a. Hemochromat osis (primary and secondary)
b. Anemia, especially t halassemia major and minor, PHN, and ot her
hemolyt ic anemias
c. Megaloblast ic anemia in relapse
d. Chronic inf ect ions
e. Chronic pancreat ic insuff iciency
Interfering Factors
I ngest ion of iron dext ran w ill bring values t o normal despit e ot her evidence of
iron-def iciency anemia.
Interventions
1. See preparat ion guidelines f or bone marrow aspirat ion (see page 45).

1. See af t ercare guidelines f or bone marrow aspirat ion (see page 46).
TESTS FOR HEM OGLOBIN DISORDERS

Hemoglobin Electrophoresis Normal and abnormal Hb
can be detected by electrophoresis, which matches
hemolyzed RBC material against standard bands for the
various Hb types known. The most common forms of
normal adult Hb are Hb A 1 , Hb A 2 , and Hb F (fetal Hb).
Of the various types of abnormal Hb
(hemoglobinopathies), the best known are Hb S
(responsible for sickle cell anemia) and Hb C (results
in a mild hemolytic anemia). The most common
abnormality is a significant increase in Hb A2 , which is
diagnostic of the thalassemias, especially thalassemia trait. More than 350 variants of Hb have
been recognized and identified.
Clin ical Alert
The result s may be quest ionable if a blood t ransf usion has been given in t he
mont hs preceding t est ing.
Reference Values
Normal
Hb A 1 : 96. 5%98. 5% or 0. 960. 985 mass f ract ion Hb A 2 : 1. 5%3. 5% or 0. 015
0. 035 mass f ract ion Hb F: 0%1% or 00. 01 mass f ract ion
Fetal Hemoglobin (Hemoglobin F; Alkali-Resistant

Hemoglobin) Hb F is a normal Hb manufactured in the
RBCs of the fetus and infant; it makes up 50% to 90% of
the Hb in the newborn. The remaining portion of the Hb
in the newborn is made up of Hb A1 and Hb A 2 , the adult
types.
Under normal condit ions, t he manuf act ure of Hb F is replaced by t he manuf act ure
of adult Hb t ypes during t he f irst year of lif e. But if Hb F persist s and const it ut es
more t han 5% of t he Hb af t er 6 mont hs of age, an abnormalit y should be

expect ed.
Det erminat ion of Hb F is used t o evaluat e t halassemia (an inherit ed abnormalit y
in t he manuf act ure of Hb), hemolyt ic anemias, heredit ary persist ence of f et al Hb,
and ot her hemoglobinopat hies.
Reference Values
Normal
Adult s: 0%2% or 00. 02 mass f ract ion Hb F
New borns: 60%90% or 0. 600. 90 mass f ract ion Hb F
By 6 mont hs of age: 2% or 0. 02 mass f ract ion Hb F
Procedure
1. Use a 5-mL venous blood EDTA-ant icoagulat ed sample f or Hb
elect rophoresis.
2. Remember t hat a blood smear st ain may also be done t o ident if y cells
cont aining Hb F (Kleihauer-Bet ke st ain).
Increased Hb F is f ound in:
1. Thalassemias (major and minor)
2. Heredit ary f amilial f et al hemoglobinemia (persist ence of Hb F)
3. Hypert hyroidism
4. Sickle cell disease
5. Hb H disease
6. Anemia, as a compensat ory mechanism (pernicious anemia, PNH,
sideroblast ic anemia)
7. Leakage of f et al blood int o t he mat ernal bloodst ream
8. Aplast ic anemia (acquired)
9. Juvenile myeloid leukemia w it h absence of Philadelphia chromosome
10. Myeloprolif erat ive disorders, mult iple myeloma, lymphoma
Clin ical Alert

I n thal assemi a mi nor, cont inued product ion of Hb F may occur on a minor
scale (5%10%), and t he pat ient usually lives. I n thal assemi a major, t he
values may reach 40%90%. This cont inued product ion of Hb F leads t o
severe anemia, and deat h usually ensues.
Interfering Factors
1. I f analysis of t he specimen is delayed f or more t han 2 t o 3 hours, t he level of
Hb F may be f alsely increased.
2. I nf ant s small f or gest at ional age or w it h chronic int raut erine anoxia have
persist ent ly elevat ed Hb F.
3. Hb F is increased during ant iconvulsant drug t herapy.
Interventions
2. Ensure t hat t he t est is done bef ore t ransf usion.

1. I nt erpret t est out come; counsel and monit or appropriat ely f or t halassemia
and anemia.
Hemoglobin A2 (Hb A 2 ) Hb A 2 levels have special

application to the diagnosis of -thalassemia trait,
which may be present even though the peripheral blood
smear is normal. The microcytosis and other
morphologic changes of -thalassemia trait must be
differentiated from iron deficiency. Low MCV may be
present in most patients with -thalassemia trait, but it

does not differentiate iron-deficient patients.
This measurement is used in t he invest igat ion of hemolyt ic anemias f or
hemoglobinopat hies, especially t halassemia and -t halassemia.
Reference Values
Normal
Adult : 1. 5%3. 5% or 0. 0150. 035 mass f ract ion New borns: 0%1. 8% or 00. 018
mass f ract ion
Procedure
1. Draw a 5-mL venous sample of blood w it h EDTA ant icoagulant .
2. Perf orm elect rophoresis.
1. Increased Hb A 2 occurs in:
a. -Thalassemia major (3%11%)
b. Thalassemia minor (3. 5%7. 5%)
c. Thalassemia int ermedia (6%8%)
d. Hb A/ S (sickle cell t rait ) (15%45%)
e. Hb S/ S (sickle cell disease) (2%6%)
f. S- -t halassemia (3. 0%8. 5%)
g. Megaloblast ic anemia
h. Hypert hyroidism
i. Vit amin B12 or f olat e def iciency
2. Decreased Hb A 2 occurs in:
a. Unt reat ed iron-def iciency anemia
b. Sideroblast ic anemia
c. Hb H disease
d. Eryt hroleukemia
Interfering Factors
1. Blood t ransf usions bef ore elect rophoresis w ill int erf ere w it h result s.
2. High levels of Hb F usually are accompanied by low levels of A 2 .
3. Hb C, Hb O , Hb E int erf ere w it h t he elect rophoric migrat ion of A 2
4. I f a pat ient w it h -t halassemia also has iron-def iciency anemia, t he A 2 may
be normal; t heref ore, ret est ing may be needed af t er iron t herapy.
Interventions
2. Provide genet ic counseling.

1. I nt erpret t est out come; counsel and monit or appropriat ely.
Hemoglobin S (Sickle Cell Test; Sickledex) Sickle cell

disease is a term for a group of hereditary blood
disorders. Sickle cell anemia is caused by an
abnormality of Hb, the red protein in red blood cells
that carries oxygen from the lungs to the tissues.
People with sickle cell disease make an abnormal Hb,
hemoglobin S (Hb S).
The red blood cells of a person with sickle cell disease
do not last as long as normal red blood cells. This
result is chronic anemia. Also, these red blood cells
lose their normal disk shape. They become rigid and
deformed and take on a sickle or crescent shape.

These oddly shaped cells are not flexible enough to
squeeze through small blood vessels. This may result
in blood vessels being blocked. The areas of the body
served by those blood vessels will then be deprived of
their blood circulation, damaging tissues and organs.
This homozygous state of Hb S disease is associated
with considerable morbidity and mortality. The
heterozygous state presents little mortality.
This blood measurement is rout inely done as a screening t est f or sickle cell
anemia or t rait and t o conf irm t hese disorders. This t est det ect s Hb S, an
inherit ed, recessive gene. An examinat ion is made of eryt hrocyt es f or t he sickleshaped f orms charact erist ic of sickle cell anemia or t rait . This is done by
removing oxygen f rom t he eryt hrocyt e. I n eryt hrocyt es w it h normal Hb, t he shape
is ret ained, but eryt hrocyt es cont aining Hb S assume a sickle shape. How ever,
t he dist inct ion bet w een sickle cell t rait and sickle cell disease is done by
elect rophoresis, w hich ident if ies an Hb pat t ern.
Reference Values
Normal
Adult : None present
Procedure
1. O bt ain a venous blood sample of 5 mL w it h EDTA. Place t he specimen in a
biohazard bag.
2. Perf orm t he Sickledex t est or Hb elect rophoresis. Elect rophoresis is more
accurat e and should be done in all posit ive Sickledex screens.
A posi ti ve test (Hb S present ) means t hat great numbers of eryt hrocyt es have
assumed t he t ypical sickle cell (crescent ) shape. Posit ive t est s are 99%
accurat e.
1. Si ckl e cel l trai t
a. Def init e conf irmat ion of sickle cell t rait by Hb elect rophoresis reveals t he
f ollow ing het erozygous (A/ S) pat t ern: Hb S, 20%40%; HB A 1 , 60%

80%; Hb F, small amount . This means t hat t he pat ient has inherit ed a
normal Hb gene f rom one parent and an Hb S gene f rom t he ot her
(het erozygous pat t ern). This pat ient does not have any clinical
manif est at ions of t he disease, but some of t he children of t his pat ient
may inherit t he disease if t he pat ient 's mat e also has t he recessive gene
pat t ern.
b. The diagnosis of sickle cell t rait does not aff ect longevit y and is not
accompanied by signs and sympt oms of sickle cell anemia. A/ S occurs in
8. 5% of Af rican Americans.
c. Sickle cell t rait can lead t o renal papillary necrosis, hemat uria, increased
risk f or pulmonary embolus, and ant erior segment ischemia.
2. Si ckl e cel l anemi a (Hb S disease)
a. Def init e conf irmat ion of sickle cell anemia by Hb elect rophoresis reveals
t he f ollow ing homozygous (S/ S) pat t ern: Hb S, 80%100%; Hb F, most of
t he rest , Hb A 1 , 0% (absent ).
b. This means t hat an abnormal Hb S gene has been inherit ed f rom bot h
parent s (homozygous pat t ern). Such a pat ient has all t he clinical
manif est at ions of t he disease.
3. Hb CHarlem (rare)
4. Hb CG eorget ow n
5. Hb S in combinat ion w it h ot her disorders, such as -t halassemia or Hb S-C
Interfering Factors
1. False-negat ive result s occur in:
a. I nf ant s younger t han 3 mont hs of age (maximum amount s reached by 6
mont hs)
b. Coexist ing t halassemias or iron def iciency
c. The solubilit y t est is unreliable in pernicious anemia and polycyt hemia
2. False-posit ive result s occur up t o 4 mont hs af t er t ransf usion w it h RBCs
having sickle cell t rait .
3. Hb D and Hb G migrat e t o same place as Hb F in elect rophoresis.
Clin ical Alert

A posit ive Sickledex t est must be conf irmed by elect rophoresis.
Interventions
2. Provide genet ic counseling.

1. I nt erpret t est out come; counsel and monit or appropriat ely.
2. A posit ive diagnosis of sickle cell disorder has genet ic implicat ions, including
t he need f or genet ic counseling.
3. A person w it h sickle cell disease should avoid sit uat ions in w hich hypoxia
may occur, such as very st renuous exercise, t raveling t o high-alt it ude
regions, or t raveling in an unpressurized aircraf t .
4. Because of t he hypoxia creat ed by general anest het ics and a st at e of shock,
surgical and mat ernit y pat ient s w it h sickle cell disease need very close
observat ion.
Methemoglobin (Hemoglobin M) Methemoglobin is

formed when the iron in the heme portion of
deoxygenated Hb is oxidized to a ferric form rather
than a ferrous form. In the ferric form, oxygen and iron
cannot combine. The formation of methemoglobin is a
normal process and is kept within bounds by the
reduction of methemoglobin to Hb. Methemoglobin
causes a shift to the left of the oxyhemoglobin
dissociation curve. When a high concentration of
methemoglobin is produced in the RBCs, it reduces
their capacity to combine with oxygen; anoxia and
cyanosis result.
This t est is used t o diagnose heredit ary or acquired met hemoglobinemia in

pat ient s w it h sympt oms of anoxia or cyanosis and no evidence of cardiovascular
or pulmonary disease. Hb M is an inherit ed disorder of t he Hb t hat produces
cyanosis.
Met hemoglobinemia is most commonly encount ered as an acquired st at e as a
result of medicat ions such as phenacet in, sulf onamides, or ingest ion of nit rat es.
Reference Values
Normal
0. 4%1. 5% or 0. 0040. 015 of t ot al Hb A value of >40% or >0. 40 is a crit ical
value.
Procedure
1. O bt ain a venous or art erial blood sample, ant icoagulat ed w it h sodium
f luoride.
2. Place on ice immediat ely and t ransport t o laborat ory in a biohazard bag.
Met hemoglobin is very unst able and must be t est ed w it hin 8 hours.
1. Heredi tary methemogl obi nemi a (uncommon) is associat ed w it h:
a. A hemoglobinopat hy, Hb M (40% [ or 0. 40] of t he t ot al Hb)
b. Def iciency of met hemoglobin reduct ase (aut osomal recessive)
c. G lut at hione def iciency (dominant mode of t ransmission)
2. Acqui red methemogl obi nemi a is associat ed w it h:
a. Black-w at er f ever
b. Paroxysmal hemoglobinuria
c. Clost ridial inf ect ion
3. Toxic eff ect of drugs or chemicals (most common cause):
a. Analgesics, phenacet in
b. Sulf onamide derivat ivessulf onamide S
c. Nit rat es and nit rit es; nit roglycerin
d. Ant imalarials
e. I soniazid
f. Q uinones
g. Pot assium chloride
h. Benzocaine, lidocaine
i. Dapsone (most common drug causing met hemoglobinemia)
Clin ical Alert

Crit ical (panic) values:
1. HbM of 30% (or 0. 30) result s in headaches, cyanosis
2. HbM of 70% (or 0. 70) is usually f at al
Interfering Factors
1. Consumpt ion of sausage, processed meat s, or ot her f oods rich in nit rit es
and nit rat es
2. Absorpt ion of silver nit rat e used t o t reat ext ensive burns
3. Excessive int ake of Bromo-Selt zer is a common cause of
met hemoglobinemia. (The pat ient appears cyanot ic but ot herw ise f eels w ell. )
4. Smoking
5. Use of bismut h preparat ions f or diarrhea (see Appendix J)
Interventions
1. Advise pat ient of purpose of t est . Assess f or hist ory of Bromo-Selt zer or
t oxic drugs or chemicals.

1. I nt erpret t est out come; counsel f or cause of cyanosis and monit or
appropriat ely f or anoxia.
2. Be aw are t hat t reat ment includes int ravenous met hylene blue and oral
ascorbic acid.
Clin ical Alert

Because f et al hemoglobin is more easily convert ed t o met hemoglobin t han t o
adult hemoglobin, inf ant s are more suscept ible t han adult s t o
met hemoglobinemia, w hich may be caused by drinking w ell w at er cont aining
nit rit es. Bismut h preparat ions f or diarrhea may also be reduced t o nit rit es by
bow el act ion.
Sulfhemoglobin
Sulf hemoglobin is an abnormal Hb pigment produced by t he combinat ion of
inorganic sulf ides w it h Hb. Sulf hemoglobinemia manif est s as a cyanosis.
Sulf hemoglobinemia of t en accompanies drug-induced met hemoglobinemia.
This t est is indicat ed in persons w it h cyanosis. Sulf hemoglobinemia may occur in
associat ion w it h t he administ rat ion of various drugs and t oxins. The sympt oms
are f ew, but cyanosis is int ense even t hough t he concent rat ion of sulf hemoglobin
seldom exceeds 10%.
Reference Values
Normal
None present or 0%1. 0% or 00. 01 of t ot al Hb
Procedure
1. Draw a 5-mL venous blood sample, ant icoagulat ed w it h EDTA or heparin.
2. Place t he specimen in a biohazard bag. Sulf hemoglobin is st able.
1. Sulf hemoglobin is observed in pat ient s w ho t ake oxidant drugs such as
phenacet in, Bromo-Selt zer, sulf onamides, and acet anilid. (See Appendix J. )
2. Sulf hemoglobin is f ormed rarely w it hout exposure t o drugs or t oxins, as in
chronic const ipat ion and purging.
3. Sulf hemoglobin can be due t o exposure t o t rinit rot oluene or zinc et hylene
bisdit hiocarbamat e (f ungicide).
Interventions
1. Explain t est purpose and procedure. Assess f or exposure t o drugs and
t oxins.

1. I nt erpret t est out come; counsel f or cause of cyanosis and use of cert ain
medicat ions.
2. Sulf hemoglobinemia persist s unt il t he RBCs cont aining it are dest royed;
t heref ore, t he levels decline slow ly over a period of w eeks. There is no
t reat ment .
Carboxyhemoglobin; Carbon Monoxide (CO)

Carboxyhemoglobin is formed when Hb is exposed to
carbon monoxide (CO). The affinity of Hb for CO is 240
times greater than for oxygen. CO poisoning causes
anoxia because the carboxyhemoglobin formed does
not permit Hb to combine with oxygen.
This t est is done t o det ect CO poisoning. Because carboxyhemoglobin is not
capable of t ransport ing oxygen, hypoxia result s, causing headache, nausea,
vomit ing, vert igo, collapse, or convulsions. Deat h may result f rom anoxia and
irreversible t issue changes. Carboxyhemoglobin produces a cherry-red or violet
color of t he blood and skin, but t his may not be present in chronic exposure. The
most common causes of CO t oxicit y are aut omobile exhaust f umes, coal gas,
w at er gas, and smoke inhalat ion f rom f ires. Smoking is a minor cause.
Reference Values
Normal
Nonsmokers: <2. 0% of t ot al Hb or <0. 02 f ract ion of Hb sat urat ion Heavy
smokers: 6. 0%8. 0% or 0. 060. 08 f ract ion of Hb sat urat ion Light smokers:
4. 0%5. 0% or 0. 040. 05 f ract ion of Hb sat urat ion New borns: 10%12% or 0. 10
0. 12 f ract ion of Hb sat urat ion
Procedure
1. Draw a heparinized or EDTA venous blood sample of 5 mL heparin or EDTA
and put on ice.
2. Keep sample t ight ly capped and t ransport t o laborat ory immediat ely in a
biohazard bag.
1. Carboxyhemoglobin is i ncreased in:
a. CO poisoning f rom many sources, including smoking, exhaust f umes,
f ires
b. Hemolyt ic disease
c. Blood in int est ines
d. New borns, because of f et al hemoglobin breakdow n t hat yields
endogenous CO
2. A direct correlat ion has been f ound bet w een CO and sympt oms of heart
disease, angina, and myocardial inf arct ion.
Interventions
1. Advise pat ient of purpose of t est .
2. Draw blood sample bef ore oxygen t herapy has st art ed.

1. I nt erpret t est out come and counsel f or cause of headache, dizziness,
vomit ing, convulsions, or coma.
2. Be aw are t hat t reat ment consist s of removal of t he pat ient f rom t he source
of CO .
3. I nit iat e oxygen t herapy eit her by supplement al oxygen at at mospheric

pressure or by hyperbaric oxygen.
Clin ical Alert

1. Wit h values of 10%20% (0. 100. 20), t he pat ient may be asympt omat ic.
2. Wit h 20%30% (0. 200. 30), headache, nausea, vomit ing, and loss of
judgment occur.
3. Wit h 30%40% (0. 300. 40), t achycardia, hyperpnea, hypot ension, and
conf usion occur.
4. Wit h 50%60% (0. 500. 60), t here is loss of consciousness.
5. Values >60% (>0. 60) cause convulsions, respirat ory arrest , and deat h.
Myoglobin (Mb)
Myoglobin (Mb) is t he oxygen-binding prot ein of st riat ed muscle. I t resembles Hb
but is unable t o release oxygen except at ext remely low t ension. I njury t o
skelet al muscle result s in release of myoglobin. I t is not specif ic t o myocardial
muscle. Myoglobin is not t ight ly bound t o prot ein and is rapidly excret ed in t he
urine.
The myoglobin t est is used as an early marker of muscle damage in myocardial
inf arct ion and t o det ect injury damage or necrosis t o skelet al muscle. Serum
myoglobin is f ound earlier t han creat ine kinase (CK) enzymes in acut e
myocardial inf arct ion.
Reference Values
Normal
570 ng/ mL or 570 g/ L
Procedure
1. Draw a venous blood sample of at least 5 mL; use serum. Lipemic or grossly
hemolyzed specimens are not accept able.
2. Remember t hat t w o or t hree samples t aken 12 hours apart give opt imal
result s in det ect ing myocardial inf arct ion.
1. Increased myogl obi n val ues are associat ed w it h:
a. Myocardial inf arct ion (elevat es 1 t o 3 hours af t er pain onset , earlier t han
creat ine kinase). Amount of myoglobin correlat es w it h size of inf arct .
b. Angina w it hout inf arct ion
c. O t her muscle injury (t rauma, exercise, open heart surgery, int ramuscular
inject ions)
d. Polymyosit is and progressive muscular dyst rophy
e. Myosit is
f. Rhabdomyolysis
g. I nf lammat ory myopat hy (eg, SLE)
h. Toxin exposure: narcot ics, Malayan sea snake t oxin
i. Malignant hypert hermia
j. Renal f ailure
k. Elect ric shock
l. Tonic-clonic seizures
2. Decreased myogl obi n val ues are f ound in:
a. Circulat ing ant ibodies t o myoglobin (many pat ient s w it h polymyosit is)
b. Rheumat oid art hrit is
c. Myast henia gravis
Interfering Factors
2. Cocaine use elevat es myoglobin.
3. Decreased eliminat ion due t o kidney insuff iciency causes increase of serum
levels.
Interventions

2. Have pat ient avoid radioisot opes unt il af t er blood is draw n.
3. Avoid vigorous exercise bef ore t he t est because it may elevat e myoglobin.

2. I nt erpret t est out comes; counsel and monit or appropriat ely f or myocardial
inf arct ion, muscle inf lammat ion, and met abolic st ress.
Clin ical Alert

Myoglobin is current ly t he earliest biologic marker of myocardial necrosis. I t
appears in t he peripheral blood 2 t o 3 hours af t er pain onset and reaches
peak levels at 6 t o 9 hours. Myoglobin is a sensit ive indicat or of acut e
myocardial inf arct ion but is not specif ic f or cardiac muscle.
Haptoglobin (Hp)
Hapt oglobin (Hp) is a t ransport glycoprot ein synt hesized solely in t he liver. I t is a
carrier f or f ree Hb in plasma; it s primary physiologic f unct ion is t he preservat ion
of iron. Hapt oglobin binds Hb and carries it t o t he ret iculoendot helial syst em.
A decrease in Hp (w it h normal liver f unct ion) is most likely t o occur w it h
increased consumpt ion of Hp due t o int ravascular hemolysis. The concent rat ion
of Hp is inversely relat ed t o t he degree of hemolysis and t o t he durat ion of
hemolyt ic episode.
Reference Values
Normal
New borns: 548 mg/ dL or 50480 mg/ L (may be absent at birt h) Children: reach
adult levels by 1 year Adult s: 40200 mg/ dL or 0. 42. 0 g/ L
Procedure
1. O bt ain a venous blood sample of at least 2 mL. Place t he specimen in a
biohazard bag.
2. Measure t he serum f or Hp by a radial immunodiff usion met hod. A single

det erminat ion is of limit ed value.
1. Hp i s decreased i n acqui red di sorders such as:
a. I nt ravascular hemolysis f rom any cause
b. Aut oimmune hemolyt ic anemia
c. O t her hemoglobinemias caused by int ravascular hemorrhages, especially
art if icial heart valves, and acut e bact erial endocardit is
d. Transf usion react ions
e. Eryt hroblast osis f et alis
f. Malarial inf est at ion
g.
PNH
h. Hemat oma, t issue hemorrhage

i. Thrombot ic t hrombocyt openic purpura
j. Drug-induced hemolyt ic anemia (met hyldopa)
k. Acut e or chronic liver disease
2. Hp i s decreased i n some i nheri ted di sorders, such as:
a. Sickle cell disease
b. G 6PD and pyruvat e kinase def iciency
c. Heredit ary spherocyt osis
d. Thalassemia and megaloblast ic anemias
e. Congenit al absence is observed in 1% of black and Asian populat ions
3. Hp i s i ncreased in:
a. I nf ect ion and inf lammat ion (acut e or chronic)
b. Neoplasias, lymphomas (advanced)
c. Biliary obst ruct ion
d. Acut e rheumat ic disease and ot her collagen diseases
e. Tissue dest ruct ion
Interfering Factors
1. Est rogen and oral cont racept ives low er Hp.
2. St eroid t herapy raises Hp.
3. Androgens increase Hp.
4. Regular st renuous exercise low ers Hp.
Clin ical Alert

Normal Hp result s measured during inf lammat ory episodes or during st eroid
t reat ment do not rule out hemolysis.
Interventions

2. Avoid use of oral cont racept ives and androgens bef ore blood is draw n.
(Check w it h physician. )
3. Avoid exercise bef ore t est .

1. Resume normal act ivit ies and medicat ions.
2. I nt erpret t est result s. Repeat t est ing may be necessary. Monit or
appropriat ely f or abnormal bleeding.
Bart's Hemoglobin
Bart 's Hb is an unst able Hb w it h high oxygen aff init y. When t here is complet e
absence of product ion of t he chain of Hb and delet ion of all f our globin genes,
t he disorder is know n as Bart's hydrops f etal i s. Bot h parent s of t he aff ect ed
inf ant have het erozygous t halassemia; t hey are almost all Sout heast Asians.
Aff ect ed inf ant s are eit her st illborn or die short ly af t er birt h.
This t est det ermines t he percent age of t he abnormal Bart 's Hb in cord blood and
ident if ies -t halassemia hemoglobinopat hies.
Reference Values
Normal
Adult s: None
Children: None
New borns: <0. 5% or <0. 005 mass f ract ion of t ot al Hb
Procedure
1. O bt ain a sample of cord blood, and perf orm Hb elect rophoresis.
2. Be aw are t hat venous blood ant icoagulat ed w it h EDTA or heparin can be
used.
Increased l evel s are associat ed w it h:
1. Homozygous -t halassemia (hydrops f et alis syndrome, w hich causes
st illbirt h)
2. Hb H disease
3. -Thalassemia minor
Interventions
1. Explain t est purpose and procedure t o parent s.
2. Be aw are t hat obst et ric complicat ions may lead t o signif icant morbidit y and
mort alit y f or t he mot hers of t hese inf ant s.
3. Provide genet ic counseling in a sensit ive manner.

1. I nt erpret t est out come and counsel parent s.
Paroxysmal Nocturnal Hemoglobinuria (PNH) Test; Acid

Hemolysis Test; Ham's Test PNH was first described by
a patient who noted hemoglobinuria after sleep. In
many patients, the hemolysis is irregular or occult.
PNH is a hemolytic anemia in which there is also
production of defective platelets and granulocytes. The
diagnostic feature of PNH is an increased sensitivity of
the erythrocytes to complement-mediated lysis.
Although patients with PNH can present with
hemoglobinuria or a hemolytic anemia, they may also
present with iron deficiency (because of urinary loss of

blood), bleeding secondary to thrombocytopenia,
thrombosis, renal abnormalities, or neurologic
abnormalities.
These t est s are carried out t o make a def init ive diagnosis of PNH. The basis of
t hese t est s is t hat t he cells peculiar t o PNH have membrane def ect s, making
t hem ext rasensit ive t o complement in t he plasma. Cells f rom pat ient s w it h PNH
undergo marked hemolysis af t er 15 minut es in t he laborat ory t est . The t est s are
perf ormed f or pat ient s w ho have hemoglobinuria, bone marrow
aplasia (hypoplasia), or undiagnosed hemolyt ic anemia; t hey may be usef ul in t he
evaluat ion of pat ient s w it h unexplained t hrombosis or acut e leukemia.
Reference Values
Normal
Negat ive or <1% hemolysis
Procedure
1. O bt ain a venous blood sample of 5 mL ant icoagulat ed w it h EDTA. Place t he
2. Mix t he pat ient 's RBCs w it h normal serum and also w it h t he pat ient 's ow n
serum, acidif y, incubat e at 37C, and examine f or hemolysis. Normally, t here
should be no lysis of t he RBCs in t his t est (also called Ham's t est ).
3. Be aw are t hat a separat e t est called t he sugar water test or sucrose
hemol ysi s test may also be done at t his t ime.
A posi ti ve test (hemolysis) is f ound in:
1. PNH: a posit ive t est (10%50% lysis) is needed f or diagnosis. The sucrose
hemolysis t est is also posit ive in PNH.
2. Heredit ary eryt hroblast ic mult inuclearit y associat ed w it h a posit ive acidif ied
serum t est (HEMPAS): t he sucrose hemolysis t est is negat ive.
Interfering Factors
1. False-posit ive result s may be obt ained w it h t he f ollow ing:

a. Blood cont aining large numbers of spherocyt es (heredit ary or acquired)
b. Dyseryt hropoiet ic anemia
c. Specimen >8 hours old, specimen hemolyzed
d. Aplast ic anemia
e. Leukemia and myeloprolif erat ive syndromes
2. These condit ions can be dist inguished f rom PNH by t he f act t hat hemolysis
occurs in bot h acidif ied serum and complement . I n PNH, hemolysis occurs
only in complement (complement dependent ).
Interventions
1. Explain t est purpose.

1. I nt erpret t est result s; counsel and monit or appropriat ely f or anemia.
OTHER BLOOD TESTS FOR ANEM IA

Vitamin B12 (VB 12 ) Vitamin B12 (VB 12 ), also known as the
antipernicious anemia factor, is necessary for the
production of RBCs. It is obtained only from ingestion
of animal protein and requires an intrinsic
factor for absorption. Both VB12 and folic acid depend
on a normally functioning intestinal mucosa for their
absorption and are important for the production of red
blood cells. Levels of VB12 and folate are usually tested
in conjunction with one another because the diagnosis
of macrocytic anemia requires measurement of both.
This det erminat ion is used in t he diff erent ial diagnosis of anemia and condit ions
marked by high t urnover of myeloid cells, as in t he leukemias. When binding
capacit y is measured, it is t he unsat urat ed f ract ion t hat is det ermined. The
measurement of unsat urat ed VB12 -binding capacit y (UBBC) is valuable in
dist inguishing bet w een unt reat ed polycyt hemia vera and ot her condit ions in w hich
t here is an elevat ed Hct .
Reference Values
Normal
Adult s: 200835 pg/ mL or 148616 pmol/ L
New borns: 1601300 pg/ mL or 118959 pmol/ L
UBBC: 6001400 pg/ mL or 4431033 pmol/ L
Procedure
1. O bt ain a f ast ing venous blood sample of at least 5 mL.
2. O bt ain t he specimen bef ore an inject ion of VB12 is administ ered and bef ore a
Schilling t est is done. Place t he specimen in a biohazard bag.
1. Decreased VB12 (<100 pg/ mL or <74 pmol/ L) is associat ed w it h:

a. Pernicious anemia (megaloblast ic anemia)
b. Malabsorpt ion syndromes and inf lammat ory bow el disease
c. Fish t apew orm inf est at ion
d. Primary hypot hyroidism
e. Loss of gast ric mucosa, as in gast rect omy and resect ion
f. Zollinger-Ellison syndrome
g. Blind loop syndromes (bact erial overgrow t h)
h. Veget arian diet s (diet ary insuff iciency)
i. Folic acid def iciency
j. I ron def iciency may be present in some pat ient s (eg, gast rect omy)
2. Increased VB12 (>700 pg/ mL or >517 pmol/ L) is associat ed w it h:
a. Chronic granulocyt ic leukemia, lymphat ic and monocyt ic leukemia
b. Chronic renal f ailure
c. Liver disease (hepat it is, cirrhosis)
d. Some cases of cancer, especially w it h liver met ast asis
e. Polycyt hemia vera
f. Congest ive heart f ailure
g. Diabet es
h. O besit y
i.
COPD
3. Increased UBBC is f ound in:

a. Sixt y percent of cases of polycyt hemia vera. (This t est is normal in
secondary relat ive polycyt hemia, aiding in t he diff erent ial diagnosis of
t hese t w o st at es. )
b. React ive leukocyt osis (leukemoid react ion)
c. Chronic myelogenous leukemia
Interfering Factors
The f ollow ing result in increased VB12 values:
1. Pregnancy
2. Blood t ransf usion
3. Aged persons
4. High vit amin C and A doses
5. Smoking
6. Drugs capable of int erf ering w it h VB12 absorpt ion (see Appendix J)
Interventions
2. Alert pat ient t hat overnight f ast ing f rom f ood is necessary. Wat er is
permit t ed.
3. Wit hhold VB12 inject ion bef ore t he blood is draw n.

2. I nt erpret t est result s; counsel and monit or appropriat ely f or anemia,
leukemia, or polycyt hemia.

3. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed posttest care . See
Appendix F f or more inf ormat ion on vit amin t est ing.
Clin ical Alert

1. Persons w ho have recent ly received t herapeut ic or diagnost ic doses of
radionuclides w ill have unreliable result s.
2. See Appendix F f or more inf ormat ion on nut rit ional st at us of vit amin B12 .
Clin ical Alert

The Schilling t est is used t o conf irm pernicious anemia and t o det ermine
w het her vit amin B12 def iciency is caused by malabsorpt ion.
Folic Acid (Folate)

Folic acid is needed f or normal RBC and WBC f unct ion and f or t he product ion of
cellular genes. Folic acid is a more pot ent grow t h promot er t han VB12 , alt hough
bot h depend on t he normal f unct ioning of int est inal mucosa f or t heir absorpt ion.
Folic acid, like VB12 , is required f or DNA product ion. Folic acid is f ormed by
bact eria in t he int est ines, is st ored in t he liver, and is present in eggs, milk,
leaf y veget ables, yeast , liver, f ruit s, and ot her element s of a w ell-balanced diet .
This t est is indicat ed f or t he diff erent ial diagnosis of megaloblast ic anemia and
in t he invest igat ion of f olic acid def iciency, iron def iciency, and hypersegment al
granulocyt es. Measurement of bot h serum and RBC f olat e levels const it ut es a
reliable means of det ermining t he exist ence of f olat e def iciency. The f inding of
low serum f olat e means t hat t he pat ient 's recent diet w as
subnormal in f olat e cont ent , t hat t he pat ient 's recent absorpt ion of f olat e w as
subnormal, or bot h. Low RBC f olat e can mean eit her t hat t here is t issue f olat e
deplet ion ow ing t o f olat e def iciency requiring f olat e t herapy or, alt ernat ively, t hat
t he pat ient has primary VB12 def iciency t hat is blocking t he abilit y of cells t o t ake
up f olat e. Serum levels are commonly high in pat ient s w it h VB12 def iciency
because t his vit amin is needed t o allow incorporat ion of f olat e int o t issue cells.
For t horoughness, t he serum VB12 should also be det ermined, because more
t han 50% of all pat ient s w it h signif icant megaloblast ic anemia have VB12
def iciency rat her t han f olat e def iciency.
Reference Values
Normal
Adult s: 220 ng/ mL (serum) or 4. 545. 3 nmol/ L
Children: 521 ng/ mL (serum) or 11. 347. 6 nmol/ L
I nf ant s: 1451 ng/ mL or 31. 7115. 5 nmol/ L
Red blood cell f olat e:
Adult s: 140628 ng/ mL or 3171422 nmol/ L
Children: >160 ng/ mL or >362 nmol/ L
Procedure
1. O bt ain a f ast ing venous sample of 10 mL. Prot ect t he sample f rom light .
Place t he specimen in a biohazard bag.
2. I f RBC f olat e is ordered, draw 5 mL of venous blood w it h EDTA
ant icoagulant . An Hct det erminat ion is also required.
1. Decreased f olic acid levels are associat ed w it h:
a. I nadequat e int ake ow ing t o alcoholism, chronic disease, malnut rit ion, diet
devoid of f resh veget ables, or anorexia
b. Malabsorpt ion of f olic acid (eg, small bow el disease)
c. Excessive use of f olic acid by t he body (eg, pregnancy, hypot hyroidism)
d. Megaloblast ic (macrocyt ic) anemia caused by VB12 def iciency
e. Hemolyt ic anemia (sickle cell, phenocyt osis, PNH)
f. Liver disease associat ed w it h cirrhosis, alcoholism, hepat oma
g. Adult celiac disease, sprue
h. Vit amin B6 def iciency
i. Carcinomas (mainly met ast at ic), acut e leukemia, myelof ibrosis
j. Crohn's disease, ulcerat ive colit is
k. I nf ant ile hypert hyroidism
l. I nt est inal resect ion, jejunal bypass procedure
m. Drugs t hat are f olic ant agonist s (int erf ere w it h nucleic acid synt hesis):
1. Ant iconvulsant s (phenyt oin)
2. Aminopt erin and met hot rexat e

3. Ant imalarials
4. Alcohol (et hanol)
5. O ral cont racept ives
6. Heavy usage of ant acids
2. Increased f olic acid levels are associat ed w it h:
a. Blind loop syndrome
b. Veget arian diet
c. Pernicious anemia, VB12 def iciency
3. Decreased RBC f olat e occurs w it h:
a. Unt reat ed f olat e def iciency
b. VB 12 def iciency (60% of uncomplicat ed cases)
Interfering Factors
1. Drugs t hat are f olic acid ant agonist s, among ot hers (see Appendix J)
2. Hemolyzed specimens (f alse elevat ion)
3. I ron-def iciency anemia (f alse increase)
Clin ical Alert

Elderly persons and t hose w it h inadequat e diet s may develop f olat e-def icient
megaloblast ic anemia.
Interventions
1. Explain t est purpose and procedure. O bt ain pert inent medicat ion hist ory.
2. Alert pat ient t hat f ast ing f rom f ood f or 8 hours bef ore t est ing is required;
w at er is permit t ed.
3. Draw blood bef ore VB12 inject ion.
4. Do not administ er radioisot opes f or 24 hours bef ore t he specimen is draw n.

Erythropoietin (Ep)
Eryt hropoiet in (Ep) is a glycoprot ein hormone t hat regulat es eryt hropoiesis. The
levels of Ep in anemia are primarily det ermined by t he degree of anemia; Ep is
inversely relat ed t o red blood cell volume and Hct .
Ep is used t o invest igat e obscure anemias. This t est is usef ul in diff erent iat ing
primary f rom secondary polycyt hemia and in det ect ing t he recurrence of Epproducing t umors. I t is also used as an indicat or of need f or Ep t herapy in
pat ient s w it h renal f ailure (end-st age renal disease).
Reference Values
Normal
536 mU/ mL or 536 U/ L
Procedure
1. O bt ain a venous blood serum sample of 5 mL. Place t he specimen in
biohazard bag.
2. Separat e serum f rom cells as soon as possible and place in polypropylene
t ube (not clear plast ic-polyst yrene). Freeze.
1. Ep is i ncreased appropri atel y in:
a. Anemias w it h very low Hb (eg, aplast ic anemia, hemolyt ic anemia);
hemat ologic cancers have very high levels.
b. Pat ient s w it h any iron-def iciency anemia have moderat ely high levels.
c. Myelodysplasia, chemot herapy, AI DS

d. Secondary polycyt hemia vera caused by t issue hypoxia (eg, high alt it ude,
CO PD)
e. Pregnancy (very high values)
2. Ep is i ncreased i nappropri atel y in eryt hropoiet in-producing t umors:
a. Renal cyst s, renal t ransplant reject ion
b. Renal adenocarcinoma
c. Pheochromocyt omas
d. Cerebellar hemangioblast omas
e. Polycyst ic kidney disease
f. O ccasionally, adrenal, ovarian, t est icular, breast , and hepat ic carcinoma
3. Ep is decreased appropri atel y in:
a. Rheumat oid art hrit is
c. Cancer
4. Ep is decreased i nappropri atel y in:
a. Polycyt hemia vera (primary)
b. Af t er bone marrow t ransplant at ion (w eeks 3 and 4)
c. AI DS bef ore init iat ing t herapy
d. Aut onomic neuropat hy
e. Renal f ailure and adult nephrot ic syndrome
Interfering Factors
1. Ep is i ncreased in:
a. Pregnancy
b. Use of anabolic st eroids
c. Administ rat ion of t hyroid-st imulat ing hormone, ACTH, epinephrine
d. G row t h hormone (see Appendix J)
2. Ep is decreased in:
a. Transf usions
b. Use of some prescribed drugs (see Appendix J)
c. Drugs t hat increase renal blood f low (eg, enalapril)

d. High plasma viscosit y
Interventions
2. Draw blood at t he same t ime f or serial det erminat ions: Circadian rhyt hm is
low est in t he morning and 40% higher in lat e evening.
3. Alert pat ient t hat f ast ing is not necessary, but a morning specimen is
needed.
4. Not e use of any drugs.

TESTS OF HEM OSTASIS AND COAGULATION

The prime f unct ions of t he coagulat ion mechanism are t o prot ect t he int egrit y of
t he blood vessels w hile maint aining t he f luid st at e of blood. Serious medical
problems or even deat h may occur w it h t he inabilit y t o st em t he loss of blood, or
f or t he inabilit y f or a normal clot t o f orm.
Hemost asis and coagulat ion t est s are generally done f or pat ient s w it h bleeding
disorders, vascular injury or t rauma, or coagulopat hies. Ref lex vasoconst rict ion
is t he normal response t o vascular insult once t he f irst -line def enses (skin and
t issue) are breached. I n larger vessels, vasoconst rict ion may be t he primary
mechanism f or hemost asis. Wit h smaller vessels, vasoconst rict ion reduces t he
size of t he area t hat must be occluded by t he hemost at ic plug. Part of t his
cascade of sequent ial clot t ing event s relat es t o t he f act t hat plat elet s adhere t o
t he injured and exposed subendot helial t issues. This phenomenon init iat es t he
complex clot t ing mechanism w hereby t hrombin and f ibrin are f ormed and
deposit ed t o aid in int ravascular clot t ing (Table 2. 4).
Table 2.4 The Complex Chain of Coagulation

Reactions
A balance normally exists between the factors that

stimulate formation of thrombin and forces acting to
delay thrombin formation. This balance maintains
circulating blood as a fluid. W hen injury occurs or
blood is removed from a vessel, this balance is upset
and coagulation occurs. Blood clotting involves four
progressive stages. The Roman numerals assigned to
the coagulation factors identify their order of discovery
rather than their involvement in the stages of clot
formation.
Stage
Com ponents of Stages
STAGE I (35 MIN)
Phase Iplatelet
activity; platelets serve
as a source of
thromboplastin.
90% of all coagulation

disorders are caused by
defects in phase I. Platelet
counts <1 106 /mm 3 indicate
moderate interference with
phase I activity.
Phase II
thromboplastin; factor
III, an enzyme thought
to be liberated by
damaged cells, is
formed by six different
factors plus calcium.
Calcium
Factor
V
Factor
VIII
Factor
IX
Factor
X
Factor
XI
Factor
XII
are involved in
the formation
of tissue
thromboplastin
(intrinsic
prothrombin
activation)
STAGE II (815 SEC)
Prothrombin factor II is
converted to thrombin
in the presence of
calcium.
Factor
II
Factor
X
Factor
VII
Factor
are involved in
the conversion
of fibrinogen
to fibrin
V
STAGE III (1 SEC)
Thrombin interacts with
fibrinogen (factor I) to
form the framework of
the clot.
At the end stage III, factor

XIII functions in the
stabilization of the clot.
STAGE IV
Fibrinolytic system
(antagonistic checkand-balance to the
clotting mechanism) is
activated.
Removal of fibrin clot through

fibrinolysis. Plasminogen is
converted to plasmin, which
breaks clot into fibrin split
products.
The ent ire mechanism of coagulat ion and f ibrinolysis (removal of f ibrin clot ) is
one of balance. I t may best be underst ood by ref erring t o t he diagrams in t his
sect ion. Abnormal bleeding does not alw ays indicat e coagulopat hy, in much t he
same w ay t hat lack of bleeding does not necessarily indicat e absence of a
bleeding disorder.
The most common causes of hemorrhage are t hrombocyt openia (plat elet
def iciency) and ot her acquired coagulat ion disorders, including liver disease,
uremia, disseminat ed int ravascular coagulat ion (DI C), and ant icoagulant
administ rat ion. Toget her, t hey account f or most hemorrhagic problems.
Hemophilia and ot her inherit ed f act or def iciencies are seen less f requent ly.
Bleeding t endencies are associat ed w it h delays in clot f ormat ion or premat ure
clot lysis. Thrombosis is associat ed w it h inappropriat e clot act ivat ion or
localizat ion of t he blood coagulat ion process. Finally, clot t ing disorders are
divided int o t w o classes: t hose caused by impaired coagulat ion and t hose
caused by hypercoagulabilit y.
Hypercoagulability States Two general forms of

hypercoagulability exist: hyperreactivity of the platelet
system, which results in arterial thrombosis, and
accelerated activity of the clotting system, which

results in venous thrombosis. Hypercoagulability
refers to an unnatural tendency toward thrombosis. The
thrombus is the actual insoluble mass (fibrin or
platelets) present in the bloodstream or chambers of
the heart.
Condit ions and classif icat ions associat ed w it h hypercoagulabilit y include t he
f ollow ing: Platelet Abnormalities. These condit ions are associat ed w it h
art eriosclerosis, diabet es mellit us, increased blood lipids or cholest erol levels,
increased plat elet levels, and smoking. Art erial t hrombosis may be relat ed t o
blood f low dist urbances, vessel w all changes, and increased plat elet sensit ivit y
t o f act ors causing plat elet adherence and aggregat ion.
Clotting System Abnormalities. These are associat ed w it h congest ive heart
f ailure, immobilit y, art if icial surf aces (eg, art if icial heart valves), damaged
vasculat ure, use of oral cont racept ives or est rogen, pregnancy and t he
post part um st at e, and t he post surgical st at e. O t her inf luences include
malignancy, myeloprolif erat ive (bone marrow ) disorders, obesit y, lupus
disorders, and genet ic predisposit ion.
Venous T hrombosis. This can be relat ed t o st asis of blood f low, t o coagulat ion
alt erat ions, or t o increases in procoagulat ion f act ors or decreases in
ant icoagulat ion f act ors (Table 2. 5).
Table 2.5 Proteins Involved in Blood Coagulation
Protein*
Synonym
Plasm a
Concentration
(m g/dL)
Function
Converte
fibrin alo
Fibrinogen
Factor I
200400
with
platelets
form clot
1015
Is conver
to thromb
(IIa), whi
splits
fibrinoge
into fibrin
Factor V
Proaccelerin;
labile factor
0.51.0
Supports
activation
II to IIa
Factor VII
Stable factor;
proconvertin
0.2
Activates
Factor
VIII:C
Antihemophilic
factor (AHF)
platelet
cofactor I
1.02.0
Supports
IXa
activation
X
Factor IX
Christmas
factor; plasma
thromboplastin
component
(PTC)
0.30.4
Activates
Factor X
Stuart-Prower
factor (AVTD
prothrombin
III)
0.60.8
Activates
Factor II
Prothrombin
(prethrombin)
Factor XI
Plasma
thromboplastin
antecedent
(antihemophilic
factor C)
Factor XII
Hageman
factor
Factor XIII
Fibrinstabilizing
factor; LakiLorand factor
von
W illebrand's
factor
Prekallikrein
Highmolecularweight
kininogen
(HMW K)
Factor VIII
related antigen
VIII:VW D
Fletcher factor
Fitzgerald
factor
0.4
Activates
and
prekallikr
2.9
Activates
and
prekallikr
2.5
Crosslink
fibrin and
other
proteins
1.0
Stabilize
VIII,
mediates
platelet
adhesion
5.0
Activates
and
prekallikr
cleaves
HMW K
4.712.2
Supports
reciproca
activation
XII, XI an
prekallikr
2040
Mediates
cell
adhesion
2040
Inhibits I
Xa, XIa,
XIIa, and
kallikrein
0.5
Complex
with prot
S,
inactivate
and VIII
Plasminogen
20
Forms
plasmin,
which lys
the fibrin
clot and
inhibits
other fac
2Antiplasmin
9.613.5
Inhibits
plasmin
245335
W eak
inhibitor
thrombin
potent
inhibitor
XIa
Fibronectin
Major
antithrombin
Protein C
1Antitrypsin
Cold insoluble
globulin
Antithrombin
III
Tissue
plasminogen
Activates
plasmino
Plasminogen
activator
inhibitor I
Inactivat
tissue
plasmino
activator
(tPA)
Plasminogen
activator
inhibitor II
Inactivat
urokinase
*The clotting factors of the blood are proteins; they are pres
in the blood plasma in an inactive form called zymogens.
Disorders of Hemostasis
Congenital Vascular Abnormalities (Vessel Wall Structure Defects). Def ect s
of t he act ual blood vessel are poorly def ined and diff icult t o t est . Heredit ary
t elangiect asia is t he most commonly recognized vascular abnormalit y. Laborat ory
st udies are normal, so t he diagnosis must be made f rom clinical signs and
sympt oms. Pat ient s f requent ly report epist axis and sympt oms of anemia. Anot her
abnormalit y is congenit al hemangiomas (Kasabach-Merrit t syndrome).
Acquired Abnormalities of the Vessel Wall Structure. Causes include HenochSchnlein purpura as an allergic response t o inf ect ion or drugs, diabet es
mellit us, ricket t sial diseases, sept icemia, and amyloidosis present w it h some
degree of vascular abnormalit ies. Purpura can also be associat ed w it h st eroid
t herapy and easy bruising in f emales (inf ect ious purpura), or it can be a result of
drug use.
Hereditary Connective T issue Disorders. These include Ehlers-Danlos
syndrome (hyperplast ic skin and hyperf lexible joint s) and pseudoxant homa
elast icum (rare connect ive t issue disorder).
Acquired Connective T issue Defects. These can be caused by scurvy (vit amin
C def iciency) or senile purpura.

Q ualitative Platelet Abnormalities. These disorders can be divided int o
subclasses:
1. Thrombocytopeni a (plat elet count <150 103 / mm 3 ) is caused by decreased
product ion of plat elet s, increased use or dest ruct ion of plat elet s, or
hypersplenism. Cont ribut ing f act ors include bone marrow disease,
aut oimmune diseases, DI C, bact erial or viral inf ect ion, chemot herapy,
t herapy radiat ion, mult iple t ransf usions, and cert ain drugs (eg, NSAI Ds
t hiazides, est rogens).
2. Thrombocytosi s (elevat ed plat elet count ) is caused by hemorrhage, irondef iciency anemia, inf lammat ion, or splenect omy.
3. Thrombocythemi a (plat elet count >1000 103 / mm 3 or >1000 109 / L) is
caused by granulocyt ic leukemia, polycyt hemia vera, or myeloid met aplasia.
Clin ical Alert

An increased plat elet count predisposes t he pat ient t o art erial t hrombosis.
Paradoxically, a subst ant ially elevat ed plat elet count can also cause easy
bleeding af t er dent al surgery, gast roint est inal bleeding, and epist axis.
Clin ical Alert

When t he plat elet count is subst ant ially decreased, bleeding can occur in t he
nose, gast roint est inal t ract , skin, and gums.
Q uantitative Platelet Abnormalities. These are associat ed w it h G lanzmann's
t hrombast henia, a heredit ary aut osomal-recessive disorder t hat can produce
severe bleeding, especially w it h t rauma and surgical procedures. Plat elet f act or
3 diff erences associat ed w it h aggregat ion, adhesion, or release def ect s may be
manif est ed in st orage-pool disease, May-Hegglin anomaly, Bernard-Soulier
syndrome, and Wiskot t -Aldrich syndrome. Dialysis and use of drugs such as
aspirin, ot her ant iinf lammat ory agent s, dipyridamole, and prost aglandin E also
can be t ied t o plat elet abnormalit ies.
Congenital Coagulation Abnormalities. These include hemophilia A and B
(def iciencies of f act ors VI I I and I X, respect ively), rare aut osomal recessive
t rait s (hemophilia C), and aut osomal dominant t rait s (eg, von Willebrand's
disease).
Acquired Coagulation Abnormalities. These are associat ed w it h several
disease st at es and are much more common t han inherit ed def iciencies.
1. Circulat ory ant icoagulant act ivit y may be evident in t he presence of

ant if act or VI I I , rheumat oid art hrit is, immediat e post part um period, SLE, or
mult iple myeloma.
2. Vit amin D def iciency may be caused by oral ant icoagulant s, biliary
obst ruct ion and malabsorpt ion syndrome, or int est inal st erilizat ion by
ant ibiot ic t herapy. New borns are prone t o vit amin D def iciency.
3. DI C causes cont inuous product ion of t hrombin, w hich, in t urn, consumes t he
ot her clot t ing f act ors and result s in uncont rolled bleeding.
4. Primary f ibrinolysis is t he sit uat ion w hereby isolat ed act ivat ion of t he
f ibrinolyt ic mechanism occurs w it hout prior coagulat ion act ivit y, as in
st rept okinase t herapy, severe liver disease, prost at e cancer, or, more rarely,
elect roshock.
5. Most coagulat ion f act ors are manuf act ured in liver. Consequent ly, in liver
disease, t he ext ent of coagulat ion abnormalit ies is direct ly proport ional t o
t he severit y of t he liver disease.
Tests for Disseminated Intravascular Coagulation (DIC)

DIC is an acquired hemorrhagic syndrome
characterized by uncontrolled formation and deposition
of fibrin thrombi. Continuous generation of thrombin
causes depletion (consumption) of the coagulation
factors and results in uncontrolled bleeding. Also,
fibrinolysis is activated in DIC. This further adds to the
hemostasis defect caused by the consumption of
clotting factors. The many coagulation test
abnormalities found in acute DIC include the following:
1. Prolonged
a. Prot hrombin t ime (PT)
b. Part ial t hromboplast in t ime (PTT) or act ivat ed part ial t hromboplast in t ime
(APTT)
c. Bleeding t ime
d. Thrombin t ime (TT)
2. Decreased
a. Fibrinogen
b. Plat elet count
c. Clot t ing f act ors I I , V, VI I I , and X

d. Ant it hrombin I I I (AT-I I I )
3. I ncreased
a. Fibrinolysin t est
b. Fibrinopept ide A
4. Posit ive
a. Fibrin split product s
b. D-Dimer
I n chronic DI C, t he result s are variable, especially t he PT, PTT, TT, and
f ibrinogen, making t he diagnosis much more diff icult . No single t est or group of
t est s is diagnost ic, and diagnosis usually depends on a combinat ion of f indings.
Normal levels do not rule out DI C, and a repeat prof ile should be done a f ew
hours lat er t o look f or changes in plat elet count and f ibrinogen.
Causes of DIC include sept icemia, malignancies and cancer, obst et ric
emergencies, cirrhosis of liver, sickle cell disease, t rauma or crushing injuries,
malaria, incompat ible blood t ransf usion, cold hemoglobinuria or PNH, connect ive
t issue diseases, snake bit es, and brow n recluse spider bit es.
Paradoxically, t he t reat ment of uncont rolled bleeding in DI C is heparin
administ rat ion. The heparin blocks t hrombin f ormat ion, w hich blocks consumpt ion
of t he ot her clot t ing f act ors and allow s hemost asis t o occur.
Laboratory Investigation of Hemostasis Usually, a blood

sample of at least 20 mL is obtained by the tw o-tube
technique. In the first tube, a 5-mL blood sample is
obtained and discarded. Then 15 to 20 mL of blood is
draw n into Vacutainer tubes w ith sodium citrate as the
anticoagulant. A butterfly needle may be used to
prevent backflow or to make sampling easier in the
case of a difficult draw. Coagulation studies
(coagulation profiles, coag panels, coagulograms) are
used for screening or as diagnostic tools for evaluation
of symptoms such as easy or spontaneous bruising,
petechiae, prolonged bleeding (eg, from cuts),
abnormal nosebleeds, heavy menstrual flow, family
history of coagulopathies, or gastrointestinal bleeding

(Table 2.6).
Table 2.6 Laboratory Tests to Measure Hemos
Nam e of Test
Vascular
Function
Platelet
Function
Bleeding time
Platelet count
Platelet
adhesiveness
Platelet
aggregation
Aspirin
tolerance
Activated
Stage
II
Platelet factor
III assay
Activated
clotting
Stage
I
S
II
recalcification
time
Activated
partial
thromboplastin
Prothrombin
time
Stypven**
time
Circulating
anticoagulant
factor I.D.
substitution
Factor assay
Thrombin time
Reptilase time
Fibrinogen
assay
Factor XIII
assay
Euglobulin
lysis time
Thrombin time
diluted
Plasminogen
assay
Protamine
sulfate
(ethanal
gelation)
D-Dimer
Fibrin
monomer
Fibrinopeptide
A
Latex
agglutination
for fibrin split
products
*These tests measure all facets of hemostasis: vascular fun

platelets, and clotting factors.
**Activates factor X.
Many of t he more common screening t est s are now aut omat ed and easily done.
Plat elet count s are included in t he aut omat ed CBC w it h most inst rument s
prot ime, and PTT can be done on phot oopt ical inst rument s t hat sense t he change
in opt ical densit y w hen a clot f orms. Test s f or f ibrinogen are on inst rument s t hat
det ect f ibrin st rands. Many pat ient s can undergo t est ing at t he same t ime w it h
t he help of aut omat ion. Some of t he more specialized t est s st ill must be done
manually or using semiaut omat ed met hods.
1. These f ive primary screening t est s are init ially perf ormed t o diagnose
suspect ed coagulat ion disorders:
a. Plat elet count , size, and shape
b. Bleeding t imeref lect s dat a about t he abilit y of plat elet s t o f unct ion
normally and t he abilit y of t he capillaries t o const rict t heir w alls
c. PTTdet ermines t he overall abilit y of t he blood t o clot
d. PTmeasures t he f unct ion of second-st age clot t ing f act ors
e. Fibrinogen level
2. Fact or assays are def init ive coagulat ion st udies of a specif ic clot t ing f act or
(eg, f act or VI I I f or hemophilia). These are done if t he screening t est
indicat es a problem w it h a specif ic f act or or f act ors.
3. Fibrinolysis is used t o address problems of t he f ibrinolyt ic syst em and
includes t he f ollow ing st udies:
a. Euglobulin clot lysisident if ies increased plasminogen act ivat or act ivit y.
(Plasmin is not usually present in t he blood plasma. )
b. Fact or XI I I (f ibrin-st abilizing f act or)
c. Fibrin split product s (eg, prot amine sulf at e t est )
4. The invest igat ion of hypercoagulable st at us (t hrombot ic t endency,
t hromboembolic disorders) covers bot h primary causes (def iciencies of ATI I I , prot ein C, prot ein S, and f act or XI I ; f ibrinolyt ic mechanisms) and
secondary causes (acquired plat elet disorders and acquired diseases of
coagulat ion and f ibrinolyt ic impairment ) and includes t he f ollow ing t est s:
a.
PT
b. PT T
c. Fibrinogen t est
d. Ant iplat elet f act ors (eg, prost acyclin)
e. Ant icoagulant f act ors (eg, AT-I I I , prot ein C, prot ein S, lupus
ant icoagulant )
f. Fibrinolysis t est s (eg, f ibrin degradat ion product s [ FDPs] , euglobulin
lysis t ime, f ibrin monomers)
g.
TT
NOT E
The lupus inhibit or (lupus ant icoagulant ) is an ant ibody (against t he
phospholipid used in t he PT and PTT t est s) t hat is responsible f or inhibit ion of
t he PT, PTT, Russell viper venom t ime (dRVVT), and kaolin clot t ing t ime
(kCT). To demonst rat e it s presence, 1 mL of t he pat ient 's plasma is mixed
w it h 1 mL of normal plasma, and a PTT t est of t he mixt ure is done. When an
inhibit or of any sort is present , t he PTT w ill not ret urn t o normal range. An
P.
P.
inhibit or of t he lupus t ype can be show n by correct ing t he PTT t hrough use of
plat elet s as a phospholipid source or by demonst rat ing a charact erist ic
pat t ern in t he PTT t hat result s f rom sequent ial dilut ion of t he phospholipid
reagent . Lupus ant icoagulant s may be associat ed w it h f alse-posit ive Venereal
Disease Research Laborat ory (VDRL) t est report s and w it h anot her
ant iphospholipidt he ant icardiolipin ant ibody (2 -glycoprot ein I ).
Clin ical Alert

Condit ions associat ed w it h t he presence of t he lupus ant icoagulant include:
1.
2.
3.
4.
SLE (one f if t h of pat ient s)

Mult iple myeloma
O t her aut oimmune diseases (rheumat oid art hrit is, Raynaud's syndrome)
Spont aneous abort ions (associat ed w it h presence of ant icardiolipin
aut oant ibody) and post part um complicat ions
5. Lupus ant icoagulant is more of t en associat ed w it h t hromboembolism t han
w it h bleeding problems.
6. Most lupus ant icoagulant ant ibodies are direct ed against prot hrombin or
2 -glycoprot ein I .
Clin ical Alert

1. All pat ient s w it h hemorrhagic or t hrombot ic t endencies, or undergoing
coagulat ion st udies, should be observed closely f or possible bleeding
emergencies. A comprehensive hist ory and physical examinat ion should be
done.
2. Blood samples f or coagulat ion st udies should be draw n last if ot her blood
st udies are indicat ed.

3. Procedure alert : w hen a blood sample is obt ained f or PT, PTT, and TT,
sodium cit rat e is used as t he ant icoagulant in t he sampling t ubes.
Patient Assessment for Bleeding Tendency

1. Examine all skin f or bruising.
2. Record pet echiae associat ed w it h use of blood pressure cuff s or t ourniquet s.
3. Not e bleeding f rom t he nose or gums w it h no apparent cause.
4. Est imat e blood quant it y in vomit us, expect orat ed mucus, urine, st ools, and
menst rual f low.
5. Not e prolonged bleeding f rom inject ion sit es.
6. Wat ch f or sympt oms, especially changes in levels of consciousness or
neurologic checks t hat may signal an int racranial bleed.
7. Det ermine w het her t he pat ient is t aking ant icoagulant s or aspirin.
Bleeding Time (Ivy Method; Template Bleeding Time)

Bleeding time measures the primary phase of
hemostasis: the interaction of the platelet with the
blood vessel wall and the formation of a hemostatic
plug. Bleeding time is the best single screening test for
platelet function disorders and is one of the primary
screening tests for coagulation disorders.
This t est is of value in det ect ing vascular abnormalit ies and plat elet
abnormalit ies or def iciencies. I t is not recommended f or rout ine presurgical
w orkup.
A small st ab w ound is made in eit her t he earlobe or t he f orearm; t he bleeding
t ime (t he amount of t ime it t akes t o f orm a clot ) is recorded. The durat ion of
bleeding f rom a punct ured capillary depends on t he quant it y and qualit y of
plat elet s and t he abilit y of t he blood vessel w all t o const rict .
The principal use of t his t est t oday is in t he diagnosis of von Willebrand's
disease, an inherit ed def ect ive molecule of f act or VI I I and a t ype of
pseudohemophilia. I t has been est ablished t hat aspirin may cause abnormal
bleeding in some normal persons, but t he bleeding t ime t est has not proved
consist ent ly valuable in ident if ying such persons.
Reference Values
Normal
310 minut es in most laborat ories Duke met hod (earlobe): 5 minut es (not
recommendednot very reproducible w it h a w ide range of normal values) I vy
met hod (f orearm w it h t emplat e): 2590 minut es Mielke's met hod (Surgicut ):
Adult s: 17 minut es
Teens: 3. 08 minut es
Children: 2. 513 minut es
Procedure (Ivy M ethod)

1. Cleanse t he area t hree f ingerw idt hs below t he ant ecubit al space w it h alcohol
and allow t o dry.
2. Place a blood pressure cuff on t he arm above t he elbow and inf lat e t o 40 mm
Hg.
3. Select a cleansed area of t he f orearm w it hout superf icial veins. St ret ch t he
skin lat erally and t aut ly bet w een t he t humb and f oref inger.
4. St art a st opw at ch. Use t he edge of a 4 4 f ilt er paper t o blot t he blood
t hrough capillary act ion by gent ly t ouching t he drop every 30 seconds. Do
not dist urb t he w ound it self . Remove t he blood pressure gauge w hen
bleeding st ops and a clot has f ormed. Apply a st erile dressing w hen t he t est
is complet ed.
5. Remember t hat t he end point (by t he I vy or t he earlobe met hod) is reached
w hen blood is no longer blot t ed f rom t he f orearm punct ure. Report in minut es
and half minut es (eg, 5 minut es, 30 seconds).
1. Bleeding t ime is prol onged w hen t he level of plat elet s is decreased or w hen
plat elet s are qualit at ively abnormal:
a. Thrombocyt openia (plat elet count <80 103 / mm 3 )
b. Plat elet dysf unct ion syndromes
c. Decrease or abnormalit y in plasma f act ors (eg, von Willebrand's f act or,
f ibrinogen)
d. Abnormalit ies in t he w alls of t he small blood vessels, vascular disease
e. Advanced renal f ailure
f. Severe liver disease

g. Leukemia, ot her myeloprolif erat ive diseases
h. Scurvy
i. DI C disease (ow ing t o t he presence of FDPs)
2. I n von Willebrand's disease, bleeding t ime can be variable; it w ill def init ely
be prolonged if aspirin is t aken bef ore t est ing (aspirin t olerance t est ).
3. A single prolonged bleeding t ime does not prove t he exist ence of
hemorrhagic disease. Because a larger vessel can be punct ured, t he
punct ure should be repeat ed on an alt ernat e body sit e, and t he t w o values
obt ained should be averaged.
4. Bleeding t ime is normal in t he presence of coagulat ion disorders ot her t han
plat elet dysf unct ion, vascular disease, or von Willebrand's disease.
5. Aspirin t herapy (ant iplat elet f unct ion t herapy): w hen t hrombus f ormat ion is
t hought t o be mediat ed by plat elet act ivat ion, t he pat ient f requent ly is given
agent s t o int errupt normal plat elet f unct ion, w hich may be monit ored by
bleeding t imes or plat elet aggregat ion st udies. Aspirin is t he most commonly
used inhibit or; it inhibit s plat elet adhesion or st ickiness.
Interfering Factors
1. Normal values f or bleeding t ime vary w hen t he punct ure sit e is not of unif orm
dept h and w idt h.
2. Touching t he punct ure sit e during t his t est w ill break off f ibrin part icles and
prolong t he bleeding t ime.
3. Excessive alcohol consumpt ion (as in alcoholic pat ient s) may cause
increased bleeding t ime.
4. Prolonged bleeding t ime can ref lect ingest ion of 10 g of aspirin as long as 5
days bef ore t he t est .
5. O t her drugs t hat may cause increased bleeding t imes include dext ran,
st rept okinase-st rept odornase (f ibrinolyt ic agent s), mit hramycin, pant ot henyl
alcohol (see Appendix J).
6. Ext reme hot or cold condit ions can alt er t he result s.
7. Edema of pat ient 's hands or cyanot ic hands w ill invalidat e t he t est .
Interventions

1. Explain t est purpose and procedure. See Pat ient Assessment f or Bleeding
Tendency on page 131.
2. I nst ruct pat ient t o abst ain f rom aspirin and aspirin-like drugs f or at least 7
days bef ore t he t est .
3. Advise t he pat ient t o abst ain f rom alcohol bef ore t he t est .
4. I nf orm t he pat ient t hat scar t issue may f orm at t he punct ure sit e (keloid
f ormat ion).
5. I f t he pat ient has an inf ect ious skin disease, post pone t he t est .

1. I nt erpret t est out come and monit or appropriat ely f or prolonged bleeding. See
Pat ient Assessment f or Bleeding Tendency on page 131.
Clin ical Alert

1. The crit ical value f or bleeding t ime is >15 minut es.
2. I f t he punct ure sit e is st ill bleeding af t er 15 minut es, discont inue t he t est
and apply pressure t o t he sit e. Document and report t he result s t o t he
clinician.
Platelet Count; Mean Platelet Volume (MPV) Platelets

(thrombocytes) are the smallest of the formed elements
in the blood. These cells are nonnucleated, round or
oval, flattened, disk-shaped structures. Platelet activity
is necessary for blood clotting, vascular integrity and
vasoconstriction, and the adhesion and aggregation
activity that occurs during the formation of platelet
plugs that occlude (plug) breaks in small vessels.
Thrombocyte development takes place primarily in the

bone marrow. The life span of a platelet is about 7.5
days. Normally, two thirds of all the body platelets are
found in the circulating blood and one third in the
spleen.
The plat elet count is of value f or assessing bleeding disorders t hat occur w it h
t hrombocyt openia, uremia, liver disease, or malignancies and f or monit oring t he
course of disease associat ed w it h bone marrow f ailure. This t est is indicat ed
w hen t he est imat ed plat elet count (on a blood smear) appears abnormal. I t is
also part of a coagulat ion prof ile or w orkup.
The mean plat elet volume (MPV) is somet imes ordered in conjunct ion w it h a
plat elet count . The MPV indicat es t he unif ormit y of size of t he plat elet
populat ion. I t is used f or t he diff erent ial diagnosis of t hrombocyt openia.
Reference Values
Normal
Pl atel et count: Adult s: 140400 103 / mm 3 or 140400 109 / L
Children: 150450 103 / mm 3 or 150450 109 / L
Mean pl atel et vol ume: Adult s: 7. 410. 4 m3 or f L
Children: 7. 410. 4 m3 or f L
Procedure
1. Mix a 7-mL venous blood sample w it h an EDTA ant icoagulant t ube.
2. Count t he plat elet s by phase microscopy or by an aut omat ed count ing
inst rument . The MPV is also calculat ed by many inst rument s at t he t ime of
t he plat elet count .
3. Make a blood smear and not e t he size, shape, and clumping of t he plat elet s.
1. Abnormal l y i ncreased numbers of plat elet s (t hrombocyt hemia,
t hrombocyt osis) occur in:
a. Essent ial t hrombocyt hemia
b. Chronic myelogenous and granulocyt ic leukemia, myeloprolif erat ive

diseases
c. Polycyt hemia vera and primary t hrombocyt osis
d. Splenect omy
e. I ron-def iciency anemia
f. Asphyxiat ion
g. Rheumat oid art hrit is and ot her collagen diseases, SLE
h. Rapid blood regenerat ion caused by acut e blood loss, hemolyt ic anemia
i. Acut e inf ect ions, inf lammat ory diseases
j. Hodgkin's disease, lymphomas, malignancies
k. Chronic pancreat it is, t uberculosis, inf lammat ory bow el disease
l. Renal f ailure
m. Recovery f rom bone marrow suppression (t hrombocyt openia)
2. Abnormal l y decreased numbers of plat elet s (t hrombocyt openia) occur in:
a. I diopat hic t hrombocyt openic purpura, neonat al purpura
b. Pernicious, aplast ic, and hemolyt ic anemias
c. Af t er massive blood t ransf usion (dilut ion eff ect )
d. Viral, bact erial, and ricket t sial inf ect ions
e. Congest ive heart f ailure, congenit al heart disease
f. Thrombopoiet in def iciency
g. During cancer chemot herapy and radiat ion, exposure t o dichlorodiphenylt richloroet hane (DDT) and ot her chemicals
h. HI V inf ect ion
i. Lesions involving t he bone marrow (eg, leukemias, carcinomas,
myelof ibrosis)
j. DI C and t hrombot ic t hrombocyt openic purpura
k. I nherit ed syndromes such as Bernard-Soulier syndrome, May-Hegglin
anomaly, Wiskot t -Aldrich syndrome, Fanconi's syndrome
l. Toxemia of pregnancy, eclampsia
m. Alcohol t oxicit y, et hanol abuse
n. Hypersplenism
o. Renal insuff iciency
p. Ant iplat elet ant ibodies

3. Increased MPV is observed in:
a. I diopat hic t hrombocyt openic purpura (aut oimmune)
b. Thrombocyt openia caused by sepsis
c. Prost het ic heart valve
d. Massive hemorrhage
e. Myeloprolif erat ive disorders
f. Acut e and chronic myelogenous leukemia
g. Splenect omy
h. Vasculit is
i. Megaloblast ic anemia
4. Decreased MPV occurs in Wiskot t -Aldrich syndrome.
Clin ical Alert

1. I n 50% of pat ient s w ho exhibit unexpect ed plat elet increases, a
malignancy is f ound.
2. I n pat ient s w it h an ext remely elevat ed plat elet count (>1000 103 / mm 3 or
>1000 109 / L) as a result of a myeloprolif erat ive disorder, assess f or
bleeding caused by abnormal plat elet f unct ion.
NOTE
Many drugs have t oxic eff ect s. The dosage does not have t o be high t o be
t oxic. Toxic t hrombocyt openia depends on t he inabilit y of t he body t o
met abolize and secret e t he t oxic subst ance.
Clin ical Alert

1. Panic values: a decrease in plat elet s t o <20 103 / mm 3 or <20 109 / L is
associat ed w it h a t endency f or spont aneous bleeding, prolonged bleeding
t ime, pet echiae, and ecchymosis.
2. Plat elet count s >50 103 / mm 3 or >50 109 / L are not generally
associat ed w it h spont aneous bleeding.
Interfering Factors
1. Plat elet count s normally increase at high alt it udes; af t er st renuous exercise,
t rauma, or excit ement ; and in w int er.
2. Plat elet count s normally decrease bef ore menst ruat ion and during pregnancy.
3. Clumping of plat elet s may cause f alsely low ered result s.
4. O ral cont racept ives cause a slight increase.
Interventions
2. Avoid st renuous exercise bef ore blood is draw n.
3. Not e w hat medicat ions and w hat t reat ment s t he pat ient is receiving.

1. I nt erpret t est out comes and monit or appropriat ely. O bserve f or signs and
sympt oms of gast roint est inal bleeding, hemolysis, hemat uria, pet echiae,
vaginal bleeding, epist asis, and bleeding f rom t he gums. When hemorrhage is
apparent , use emergency measures t o cont rol bleeding and not if y t he
at t ending physician.
2. Use plat elet t ransf usions if t he plat elet count is <20 103 / mm 3 (<20 109 / L)
or if t here is a specif ic bleeding lesion. O ne unit of plat elet concent rat e
raises t he count by 15 103 / mm 3 (15 109 / L).
Platelet Aggregation
Plat elet aggregat ion is used t o evaluat e congenit al qualit at ive f unct ional
disorders of adhesion, release, or aggregat ion. I t is rarely used t o evaluat e
acquired bleeding disorders.
Reference Values
Normal
Full plat elet aggregat ion in response t o t he f ollow ing: Adenosine diphosphat e
Collagen
Epinephrine
Thrombin
Rist ocet in
Procedure
1. O bt ain a 5-mL venous blood sample (ant icoagulat ed in a t ube cont aining
sodium cit rat e).
2. Place it in biohazard bag. The sample is kept at room t emperat ure (never
ref ri gerate) and must be run w it hin 30 minut es af t er t he blood is draw n.
3. I ncrease t he t ransmission of light t hrough a sample of plat elet -rich plasma
w hen plat elet s aggregat e. This increase in light t ransmission can be used as
an index t o t he aggregat ion in response t o various agonist s.
1. Decreased plat elet aggregat ion occurs in congeni tal di seases:
a. Bernard-Soulier syndrome
b. G lanzmann's t hrombast henia

c. St orage pool diseases (eg, Chdiak-Higashi syndrome, gray plat elet
disease)
d. Cyclooxygenase def iciency
e. Wiskot t -Aldrich syndrome
f. Albinism
g. -Thalassemia major
h. May-Hegglin anomaly
i. Various connect ive t issue disorders (eg, Marf an's syndrome)
j. von Willebrand's disease
2. Decreased plat elet aggregat ion also occurs in acqui red di sorders:
a. Uremia
b. Ant iplat elet ant ibodies
c. Cardiopulmonary bypass
d. Myeloprolif erat ive disorders
e. Dysprot einemias (macroglobulinemia)
f. I diopat hic t hrombocyt openic purpura
g. Polycyt hemia vera
h. Use of drugs and aspirin, some ant ibiot ics, ant i-inf lammat ory drugs,
psychot ropic drugs, and ot hers (see Appendix J)
i.
DIC
3. Increased aggregat ion occurs in primary and secondary Raynaud's

syndrome.
Interfering Factors
1. Plat elet count <100, 000/ mm3
2. Pat ient cannot be t aking drugs t hat int erf ere w it h aggregat ion (see Appendix
J).
3. Lipemia w ill int erf ere w it h t est ing.
Interventions
2. Be aw are t hat f or 10 days bef ore t est , drugs t hat inhibit plat elet aggregat ion
are cont raindicat ed. These include aspirin, ant ihist amines, st eroids, cocaine,
ant i-inf lammat ories, t heophylline, and ant ibiot ics.
3. O n t he day of t he t est , avoid caff eine.
4. Avoid w arf arin (Coumadin) f or 2 w eeks and heparin t herapy f or 1 w eek
bef ore t est ing.

1. I nt erpret t est out come and counsel appropriat ely f or congenit al disorders.
2. Resume medicat ions and normal diet .
Thrombin Time (TT); Thrombin Clotting Time (TCT)

Stage III fibrinogen defects can be detected by the TT
test. It can detect DIC and hypofibrinogenemia and may
also be used for monitoring streptokinase therapy. The
test actually measures the time needed for plasma to

clot when thrombin is added. Normally, a clot forms
rapidly; if it does not, a stage III deficiency is present
(Fig. 2.1). A TT test is often included as part of a panel
for coagulation defects.
FI G URE 2. 1 I nt rinsic, ext rinsic, and common pat hw ays of coagulat ion. Vessel
injury init iat es int rinsic pat hw ay t hrough cont act act ivat ion by exposed
collagen. Ext rinsic pat hw ay is init iat ed by endot helial release of t issue f act or
(ie, t issue t hromboplast in). Ext rinsic and int rinsic pat hw ays each init iat e
common pat hw ay t o creat e st able f ibrin clot . (Lot speich-St eininger, C. A. , et
al. [ 1992] . Cl i ni cal Hematol ogy, Philadelphia: JB Lippincot t Co. )
Reference Values
Normal
7. 012. 0 seconds (varies w idely by laborat ory) Check w it h your laborat ory f or
values.
Procedure
1. Use t he procedure f or t w o-t ube specimen collect ion t o ant icoagulat e a 7-mL
venous blood sample w it h sodium cit rat e and put on ice. Take care not t o
cont aminat e t he specimen w it h heparin f rom I V apparat us or ot her sources.
2. Ensure t hat t he specimen is t est ed w it hin 2 hours, or it must be f rozen f or
lat er t est ing.
1. Prol onged TT occurs in:
a. Hypof ibrinogenemia
b. Therapy w it h heparin or heparin-like ant icoagulant s
c.
DIC
d. Fibrinolysis
f. Presence of large amount s of f ibrin split product s (FSPs) or FDPs, as in
DI C
g. Uremia
h. Severe liver diseases
2. Shortened TT occurs in:
a. Hyperf ibrinogenemia
b. Elevat ed Hct (>55%)
3. Therapy w it h plasminogen act ivat orsst rept okinase, urokinase, or t issue
plasminogen act ivat or (t PA). Ant icoagulant t herapy is an at t empt eit her t o
prevent t hrombus f ormat ion or t o promot e t hrombus lysis. The t ype and
locat ion of t he t hrombus usually det ermine t he t ype of ant icoagulant t o be
administ ered and t he t reat ment prot ocol. The new est t reat ment f or lif et hreat ening t hrombus f ormat ion uses plasminogen act ivat ors t o accelerat e
f ibrinolysis, w hich is t he enzymat ic dissolut ion of already organized clot s
(Fig. 2. 2). The act ion of some of t hese agent s produces a lyt ic st at e t hat
can be monit ored by t he TT.
FI G URE 2. 2 St age Four Act ivat ion of t he Fibrinolyt ic Syst em
Alt hough several t est s are sensit ive t o t he eff ect s of t hrombolyt ic drugs, many
require lengt hy assay procedures or special t echniques. O f t he laborat ory
procedures t hat have been recommended (PT, TT, APTT, quant it at ive f ibrinogen,
euglobulin clot lysis, and plasminogen levels), t he TT has become w idely
accept ed because it is f ast and pract ical, does not require special equipment ,
and can det ect t he decrease in f ibrinogen levels as w ell as t he presence of f ibrin
and FDPs.
The half -lif e f or t hese act ivat ors is relat ively short (1090 minut es); t heref ore,
t he ant idot e f or overdose is t o hold giving t he next dose.
Clin ical Alert

TT is severel y prolonged in t he presence of af ibrinogenemia (<80 mg/ dL or
<0. 8 g/ L of f ibrinogen). Crit ical value: >60 seconds.
Interfering Factors
1. Heparin prolongs t hrombin t ime. I nt erpret t est result s w it hin t his cont ext .
2. Plasminogen act ivat or t herapy prolongs TCT.
Interventions
2. I f possible, ensure t hat no heparin is t aken f or 2 days bef ore t est ing.

1. Resume normal act ivit ies and medicat ions as ordered.
2. I nt erpret t est out comes and monit or appropriat ely. Check f or excess
bleeding. I f plasminogen act ivat or is being monit ored, see Post t est Pat ient
Af t ercare f or APTT, pages 142143.
Partial Thromboplastin Time (PTT); Activated Partial

Thromboplastin Time (APTT) The PTT, a one-stage
clotting test, screens for coagulation disorders.
Specifically, it can detect deficiencies of the intrinsic
thromboplastin system and also reveals defects in the
extrinsic coagulation mechanism pathway.
NOTE
The PTT and APTT t est f or t he same f unct ions. APTT is a more sensit ive
version of PTT t hat is used t o monit or heparin t herapy.
The APTT is used t o det ect def iciencies in t he int rinsic coagulat ion syst em, t o
det ect incubat ing ant icoagulant s, and t o monit or heparin t herapy. I t is part of a
coagulat ion panel w orkup.
Reference Values
Normal
APTT: 2135 seconds
Check w it h your laborat ory f or t herapeut ic range values during heparin t herapy
(22. 5 t imes normal).
Procedure
1. O bt ain a 5-mL venous blood sample and ant icoagulat e w it h sodium cit rat e.
Use t he t w o-t ube met hod. Place t he specimen in a biohazard bag.
2. Do not draw blood samples f rom a heparin lock or heparinized cat het er.
3. Be aw are t hat t he sample may be t ransport ed at room t emperat ure, but t he
vacuum must be int act (do not remove st opper). I t is st able f or 12 hours.
1. Prol onged APTT occurs in:
a. All congenit al def iciencies of int rinsic syst em coagulat ion f act ors,
including hemophilia A and hemophilia B
b. Congenit al def iciency of Fit zgerald's f act or, Flet cher's f act or
(prekallikrein)
c. Heparin t herapy, st rept okinase, urokinase
d. Warf arin (Coumadin)-like t herapy
e. Vit amin K def iciency
f. Hypof ibrinogenemia
g. Liver disease
h. DI C (chronic or acut e)
i. Fibrin breakdow n product s
2. When APTT is perf ormed in conjunct ion w it h PT, a f urt her clarif icat ion of
coagulat ion def ect s is possible. For example, a normal PT w it h an abnormal
APTT means t hat t he def ect lies w it hin t he f irst st age of t he clot t ing cascade
(f act ors VI I I , I X, X, XI , and/ or XI I ). The pat t ern of a normal PTT w it h an
abnormal PT suggest s a possible f act or VI I def iciency. I f bot h PT and APTT
are prolonged, a def iciency of f act or I , I I , V, or X is suggest ed. Used
t oget her, APTT and PT w ill det ect approximat ely 95% of coagulat ion def ect s.
3. Shortened APTT occurs in:
a. Ext ensive cancer, except w hen t he liver is involved
b. I mmediat ely af t er acut e hemorrhage
c. Very early st ages of DI C
4. Ci rcul ati ng anti coagul ants (inhibit ors) usually occur as inhibit ors of a specif ic
f act or (eg, f act or VI I I ). These are most commonly seen in t he development
of ant if act or VI I I or ant if act or I X in 5% t o 10% of hemophiliac pat ient s.
Ant icoagulant s t hat develop in t he t reat ed hemophiliac are det ect ed t hrough
prolonged APTT. Circulat ing ant icoagulant s are also associat ed w it h ot her
condit ions:
a. Af t er many plasma t ransf usions
b. Drug react ions
c. Tuberculosis
d. Chronic glomerulonephrit is
e.
SLE
f. Rheumat oid art hrit is

5. Hepari n therapy: I n deep vein t hrombosis or acut e myocardial inf arct ion, t he
usual prot ocol requires inject ion of heparin (monit ored by t he APTT),
f ollow ed by long-t erm t herapy w it h oral ant icoagulant s (monit ored by t he PT,
APTT, or bot h).
a. I n t he blood, heparin combines w it h an -globulin (heparin cof act or) t o
f orm a pot ent ant it hrombin. I t is a direct ant icoagulant .
b. I nt ravenous heparin inject ion produces an immediat e ant icoagulant eff ect ;
it is chosen w hen rapid ant icoagulant eff ect s are desired.
c. Because t he half -lif e of heparin is 3 hours, t he APTT is measured 3 hours
af t er heparin administ rat ion, or 1 hour bef ore t he next dose.
d. Therapeut ic APTT levels are ordinarily maint ained at 2 t o 2. 5 t imes t he
normal values.
e. To evaluat e heparin eff ect s, blood is t est ed:
1. For baseline values bef ore t herapy is init iat ed
2. O ne hour bef ore t he next dose is due (w hen a 4-hour administ rat ion
cycle is ordered)
3. According t o t he pat ient 's st at us (eg, bleeding)
NOTE
Mixing equal part s of pat ient plasma and normal plasma correct s t he APTT if it
is caused by a coagulat ion f act or def ect but does not correct t he APTT t o
normal if it is caused by a circulat ing inhibit or. A more sensit ive t est is t he
Russell viper venom t est , w hich demonst rat es t he presence of t he lupus
ant icoagulant . This t est is unaff ect ed by inhibit ors of f act or VI I I or
def iciencies of f act ors VI I I , I X, XI , or is aff ect ed by def iciencies of f act ors I I ,
V, or X and by t he use of sodium, w arf arin, or heparin. Because lupus-t ype
ant icoagulant s vary great ly in t heir react ivit y in various t est syst ems, it is
recommended t hat t his t est be done in conjunct ion w it h t he APTT and t he
ant icardiolipin ant ibody assay. The ref erence range is 33. 541. 5 seconds.
Clin ical Alert

Panic value: APTT >70 seconds signif ies spont aneous bleeding.
NOTE
Not all individuals respond ideally or predict ably t o heparin. Anaphylaxis and
eryt hemat ous may occur. There is no short cut t o adequat e and saf e
ant icoagulat ion.
Interfering Factors
2. Hemolized plasma short ens APTT in normal pat ient s but not in abnormal
(heparinized) pat ient s.
3. Very increased or decreased Hct
4. I ncorrect rat io of blood t o cit rat e (short f ill of blood in collect ion t ube)
Interventions
1. Explain t est purpose, procedure, benef it s, and risks.
2. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed, pretest care .
3. Draw blood sample 1 hour bef ore next dose of heparin. The heparin dose
given relat es t o t he APTT result .

1. I nt erpret t est out come and monit or appropriat ely. Prot amine sulf at e is t he
ant idot e f or heparin overdose or f or reversal of heparin ant icoagulat ion
t herapy.
3. Wat ch f or signs of spont aneous bleeding; not if y physician immediat ely and
t reat accordingly.
4. Alert t he pat ient t o w at ch f or bleeding gums, hemat uria, oozing f rom w ounds,
and excessive bruising.
5. I nst ruct t he pat ient t o use an elect ric shaver inst ead of a blade and t o
exercise caut ion in all act ivit ies.
6. Avoid use of aspirin or ASA-like drugs (unless specif ically prescribed)

because t hey cont ribut e t o bleeding t endencies.
7. Be aw are t hat long-t erm use of heparin can cause development of
ost eoporosis w it h f ract ures.
8. Remember t hat t hrombocyt openia can also develop w it h high-dose heparin
t herapy, along w it h progressive t homboembolyt ic syndrome. This plat elet
abnormalit y quickly reverses w hen heparin is discont inued.
Activated Coagulation Time (ACT) The ACT test

evaluates coagulation status. The ACT responds
linearly to heparin level changes and responds to wider
ranges of heparin concentrations than does the APTT.
The ACT however, assays overall coagulation activity.
Therefore, prolonged values may not be exclusively the
result of heparin.
The ACT can be a bedside procedure and requires only 0. 4 mL of blood. Heparin
inf usion or reversal w it h prot amine can t hen be t it rat ed almost immediat ely
according t o t he ACT result s. ACT also is rout inely used during dialysis, coronary
art ery bypass procedures, art eriograms, and percut aneous t ransluminal coronary
art eriography. This t est is hard t o st andardize, and no cont rols are available;
t heref ore, it is used w it h caut ion mainly in cardiac surgery. The result s are
backed up by t he APTT.
Reference Values
Normal
ACT: 70120 seconds
Therapeut ic range: 180240 seconds (t w o t imes normal range)
Prothrombin Time (Pro Time; PT) Prothrombin is a

protein produced by the liver for clotting of blood.
Prothrombin production depends on adequate vitamin
K intake and absorption. During the clotting process,
prothrombin is converted to thrombin. The prothrombin
content of the blood is reduced in patients with liver
disease.
The PT is one of t he f our most import ant screening t est s used in diagnost ic
coagulat ion st udies. I t direct ly measures a pot ent ial def ect in st age I I of t he
clot t ing mechanism (ext rinsic coagulat ion syst em) t hrough analysis of t he clot t ing
abilit y of f ive plasma coagulat ion f act ors (prot hrombin, f ibrinogen, f act or V,
f act or VI I , and f act or X). I n addit ion t o screening f or def iciency of prot hrombin,
t he PT is used t o evaluat e disf ibrinogenemia, evaluat e t he heparin eff ect and
coumarin eff ect , liver f ailure, and vit amin K def iciency.
Reference Values
Normal
PT: 11. 013. 0 seconds (can vary by laborat ory) Therapeut ic levels are at a P/ C
rat io of 2. 02. 5. Recommended t herapeut ic ranges are show n in Table 2. 7.
Table 2.7 Therapeutic Context
INR
Target
Preoperative oral anticoagulant started 2 weeks before

surgery
Nonhip surgery
1.5
2.5
2.0
Hip surgery
2.0
3.0
2.5
Primary and secondary prevention of

deep vein thrombosis
2.0
3.0
2.5
Prevention of systemic embolism in

patients with atrial fibrillation
2.0
3.0
2.5
Recurrent systemic embolism
3.0
4.5
3.5
Prevention of recurrent deep vein

thrombosis (two or more episodes)
2.5
4.0
3.0
Cardiac stents
3.0
4.5
3.5
Prevention of arterial thrombosis,

including patients with mechanical
heart valves
3.0
4.5
3.5
P/ C rati o (prothrombi n ti me rati o): t he observed pat ient PT divided by t he

laborat ory PT mean normal value
INR (Internati onal Normal i zed Rati o): a comparat ive rat ing of PT rat ios
(represent ing t he observed PT rat io adjust ed by t he I nt ernat ional Ref erence
Thromboplast in) ISI (Internati onal Sensi ti vi ty Index): a comparat ive rat ing of
t hromboplast in (supplied by t he manuf act urer of t he reagent )
Procedure
1. Draw a 5-mL venous blood sample (by t he t w o-t ube t echnique) int o a t ube
cont aining a calcium-binding ant icoagulant (sodium cit rat e). The rat io of
sodium cit rat e t o blood is crit ical.
2. Use blue-t opped vacuum t ubes t hat keep prot hrombin levels st able at room
t emperat ure f or 12 hours if lef t capped (vacuum int act ). Place t he specimen
in biohazard bag.
Oral Anticoagulant Therapy Oral anticoagulant drugs

(eg, Coumadin, dicumarol) are commonly prescribed to
treat blood clots. These are indirect anticoagulants

(compared w ith heparin, w hich is a direct
anticoagulant). How ever, if necessary, heparin is the
anticoagulant of choice for initiating treatment because
it acts rapidly and also partially lyses the clot.
1. These drugs act via t he liver t o delay coagulat ion by int erf ering w it h t he
act ion of t he vit amin Krelat ed f act ors (I I , VI I , I X, and X), w hich promot e
clot t ing.
2. O ral ant icoagulant s delay vit amin K f ormat ion and cause t he PT t o increase
as a result of decreased f act ors I I , VI I , I X, and X.
3. The usual procedure is t o run a PT t est every day w hen beginning t herapy.
The ant icoagulant dose is adjust ed unt il t he t herapeut ic range is reached.
Then, w eekly t o mont hly PT t est ing cont inues f or t he durat ion of t herapy.
4. Coumadin t akes 48 t o 72 hours t o cause a measurable change in t he PT (34
days of drug t herapy).
Drug Therapy and PT Protocols

1. Pat ient s w it h cardiac problems are usually maint ained at a PT level 2 t o 2. 5
t imes t he normal (baseline) values.
2. Use of t he I NR values allow s more sensit ive cont rol. A reasonable I NR t arget
f or virt ually all t hromboembolic problems is 2. 0 t o 3. 0. See Table 2. 7 more
specif ic guidelines.
3. For t reat ment of blood clot s, t he PT is maint ained w it hin t he 2 t o 2. 5 t imes
normal range. I f t he PT drops below t his range, t reat ment may be
ineff ect ive, and old clot s may expand or new clot s may f orm. Conversely, if
t he PT rises above 30 seconds, bleeding or hemorrhage may occur.
1. Condit ions t hat cause i ncreased PT include:
a. Def iciency of f act ors I I (prot hrombin), V, VI I , or X
b. Vit amin K def iciency, new borns of mot her w it h vit amin K def iciency
c. Hemorrhagic disease of t he new born
d. Liver disease (eg, alcoholic hepat it is), liver damage
e. Current ant icoagulant t herapy w it h w arf arin (Coumadin)

f. Biliary obst ruct ion
g. Poor f at absorpt ion (eg, sprue, celiac disease, chronic diarrhea)
h. Current ant icoagulant t herapy w it h heparin
i.
DIC
j. Zollinger-Ellison syndrome
k. Hypof ibrinogenemia (f act or I def iciency), dysf ibrinogenemia
l. (Circulat ing ant icoagulant s), lupus ant icoagulant
m. Premat ure new borns
2. Condit ions t hat do not af f ect the PT include:
b. Tannin disease
c. Christ mas disease (f act or I X def iciency)
d. Hemophilia A (f act or VI I I def iciency)
e. von Willebrand's disease
f. Plat elet disorders (idiopat hic t hrombocyt openic purpura)
Interfering Factors
1. Diet : ingest ion of excessive green, leaf y veget ables increases t he body's
absorpt ion of vit amin K, w hich promot es blood clot t ing.
2. Alcoholism or excessive alcohol ingest ion prolongs PT levels.
3. Diarrhea and vomit ing decrease PT because of dehydrat ion.
4. Q ualit y of venipunct ure: PT can be short ened if t echnique is t raumat ic and
t issue t hromboplast in is int roduced t o t he sample and if collect ion t ube is not
f illed properly.
5. I nf luence of prescribed medicat ions: ant ibiot ics, aspirin, cimet idine,
isoniazid, phenot hiazides, cephalosporins, cholest yramines, phenylbut azone,
met ronidazole, oral hypoglycemics, phenyt oin
6. Prolonged st orage of plasma at 4Cact ivat es f act or VI I and short ens PT
Interventions
1. Explain t he purpose, procedure, and need f or f requent t est ing. Emphasize
t he need f or regular monit oring t hrough f requent blood t est ing if long-t erm
t herapy is prescribed. Do not ref er to anti coagul ants as bl ood thi nners.
O ne explanat ion might be, Your blood w ill be t est ed periodically t o

det ermine t he pro t ime, w hich is an indicat ion of how t he blood clot s. The
ant icoagulant dose w ill be adjust ed according t o PT result s.
2. Caut ion against self -medicat ion. Ascert ain w hat drugs t he pat ient has been
t aking. Many drugs, including over-t he-count er medicat ions, alt er t he eff ect s
of ant icoagulant s and t he PT
value. Aspirin, acet aminophen, and laxat ive product s should be avoided
unless specif ically ordered by t he physician.
3. I nst ruct t he pat ient never t o st art or discont inue any drug w it hout t he
doct or's permission. This w ill aff ect PT values and may also int erf ere w it h
t he healing process.
4. Counsel regarding diet . Excessive amount s of green, leaf y veget ables (eg,
spinach, broccoli) w ill increase vit amin K levels and could int erf ere w it h
ant icoagulant met abolism. Caut ion against using razor blades; elect ric
shavers should be used.
5. Remember t hat t hese guidelines also apply t o af t ercare.

1. I nt erpret t est out comes and monit or appropriat ely w it h f ollow -up t est ing and
observat ion.
2. Avoid int ramuscular inject ions during ant icoagulant t herapy because
hemat omas may f orm at t he inject ion sit e. As t he PT increases t o upper
limit s (>30 seconds), assess caref ully f or bleeding f rom diff erent areas; t his
may require neurologic assessment (if cranial bleeding is suspect ed), lung
assessment and auscult at ion, gast roint est inal and genit ourinary
assessment s, or ot her assessment s as appropriat e. I nst ruct t he pat ient t o
observe f or bleeding f rom gums, blood in t he urine, or ot her unusual
bleeding. Advise t hat care should be exercised in all act ivit ies t o avoid
accident al injury.
3. Alert pat ient s w ho are being monit ored by PT f or long-t erm ant icoagulant
t herapy t hat t hey should not t ake any ot her drugs unless t hey have been
specif ically prescribed.
4. Remember t hat w hen unexpect ed adjust ment s in ant icoagulant doses are
required t o maint ain a st able PT, or w hen t here are errat ic changes in PT
levels, a drug int eract ion should be suspect ed and f urt her invest igat ion
should t ake place.
5. Make changes in exercise int ensit y gradually or not at all. Act ive sport s and
cont act sport s should be avoided because of t he pot ent ial f or injury.
Clin ical Alert

1. Cri ti cal val ue: I f P/ C is >2. 5 or >30. 0 seconds, not if y clinician (f or
pat ient s on ant icoagulant ).
2. I f PT is excessively prolonged (>30 seconds), vit amin K may be ordered.
3. Cri ti cal val ue: >20 seconds (f or nonant icoagulat ed persons)
4. Baseline PT levels should be det ermined bef ore ant icoagulant
administ rat ion.
5. Cri ti cal val ue: I NR >3. 6; not if y clinician (f or pat ient s on ant icoagulant s)
Coagulant Factors (Factor Assay) Assay of specific

factors of coagulation is done in the investigation of
inherited and acquired bleeding disorders. For
example, tests of factor VIIIrelated antigen are used in
the differential diagnosis of classic hemophilia and von
Willebrand's disease in cases in which there is no
family history of bleeding and bleeding times are
borderline or abnormal. A test for ristocetin cofactor is
done to help diagnose von Willebrand's disease by
determining the degree or rate of platelet aggregation
that is taking place.
Reference Values
Normal
Fact or I I prot hrombin: 80%120% of normal Fact or Vlabile f act or: 50%
150% of normal
Fact or VI I st able f act or: 65%140% of normal or 65135 AU
Fact or VI I I ant ihemophilic f act or: 55%145% of normal or 55145 AU
Fact or I XChrist mas f act or: 60%140% of normal or 60140 AU
Fact or X: 45%155% of normal or 45155 AU
Fact or XI : 65%135% of normal or 65135 AU
Fact or XI I Hageman f act or: 50%150% of normal or 50150 AU

Rist ocet in (von Willebrand's f act or): 45%140% of normal or 45140 AU
Fact or VI I I ant igen: 100 g/ L or 50%150% of normal or 50150 AU
Fact or VI I I relat ed ant igen: 45%185% of normal or 45185 AU
Flet cher's f act or (prekallikrein): 80%120% of normal or 0. 801. 20
Cri ti cal val ue f or any coagulat ion f act or: <10% of normal
Procedure
1. Draw a 5-mL venous blood sample by t he t w o-t ube met hod and add t o a
collect ion t ube cont aining sodium cit rat e as t he ant icoagulant .
2. Cap samples, put on ice, and send t o t he laborat ory as soon as possible.
1. Inheri ted def i ci enci es:
a. Any of t he specif ic f act orsI , I I , V, VI I , VI I I , I X, X, XI , XI I , and XI I I
may be def icient on a f amilial basis.
b. Fact or VI I is decreased in hypoproconvert inemia (aut osomal recessive).
c. Fact or VI I I is decreased in classic hemophilia A and von Willebrand's
disease (inherit ed aut osomally).
d. Fact or I X is decreased in Christ mas disease or hemophilia B (sex-linked
recessive).
e. Fact or XI is decreased in hemophilia C (aut osomal dominant , occurring
predominant ly in Jew s).
2. Acqui red di sorders:
a. Fact or I I is decreased in:
1. Liver disease
2. Vit amin K def iciency
3. O ral ant icoagulant s (last f act or t o decrease af t er st art ing Coumadin
t herapy)
4. Normal new borns
5. Circulat ing inhibit ors or lupus-like ant icoagulant s
b. Fact or V is decreased in:
1. Liver disease
2. Fact or V inhibit ors
3. Myeloprolif erat ive disorders
4. DI C and f ibrinolysis
5. Normal new borns (mildly decreased)
c. Fact or VI I is decreased in:
1. Liver disease
2. Treat ment w it h coumarin-t ype drugs (f irst f act or t o decrease)
3. Normal new borns
4. Kw ashiorkor
d. Fact or VI I I is increased in:
1. Lat e normal pregnancy
2. Thromboembolic condit ions
3. Liver disease
4. Post operat ive period
5. Rebound act ivit y af t er sudden cessat ion of a coumarin-t ype drug
6. Normal new borns
e. Fact or VI I I is decreased in:
1. Presence of f act or VI I I inhibit ors (ant icoagulant s capable of
specif ically neut ralizing a coagulat ion f act or and t hereby disrupt ing
hemost asis), associat ed w it h hemophilia A and immunologic
react ions, and post part um
2. von Willebrand's disease
3. DI C, f ibrinolysis
4. Myeloprolif erat ive disorders
f. Fact or I X is decreased in:
1. Uncompensat ed cirrhosis, liver disease
2. Nephrot ic syndrome
3. Development of circulat ing ant icoagulant s against f act or I X (rare)
4. Normal new borns
5. Dicumarol and relat ed ant icoagulant drugs
6.
DIC

g. Fact or X is decreased in:
2. Liver disease
3. O ral ant icoagulant s
4. Amyloidosis
5.
DIC
6. Normal new borns

h. Fact or XI is decreased in:
1. Liver disease
2. I nt est inal malabsorpt ion (vit amin K)
3. O ccasional development of circulat ory ant icoagulant s against f act or
IX
4.
DIC
5. New borns (do not reach adult levels f or up t o 6 mont hs)

i. Fact or XI I is decreased in:
2. Liver disease
3. Chronic granulocyt ic leukemia
4. Normal new borns
j. Fact or XI I I is decreased in:
1. Post operat ive pat ient s
2. Liver disease
3. Persist ent increased f ibrinogen levels
4. O bst et ric complicat ions w it h hypof ibrinogenemia
5. Acut e myelogenous leukemia
6. Circulat ing ant icoagulant s
7.
DIC
Interventions

Plasminogen (Plasmin; Fibrinolysin) Plasminogen is a

glycoprotein, synthesized in the liver, present in
plasma. Under normal circumstances, plasminogen is a
part of any clot because of the tendency of fibrin to
absorb plasminogen from the plasma. When
plasminogen activators perform their function, plasmin
is formed within the clot; this gradually dissolves the
clot while leaving time for tissue repair. Free plasmin
also is released to the plasma; however, antiplasmins
there immediately destroy any plasmin released from
the clot (see Fig. 2.2).
This t est is done t o det ermine plasminogen act ivit y in persons w it h t hrombosis or
DI C. When pat hologic coagulat ion processes are involved, excessive f ree
plasmin is released t o t he plasma. I n t hese sit uat ions, t he available ant iplasmin
is deplet ed, and plasmin begins dest roying component s ot her t han f ibrin,
including f ibrinogen, f act ors V and VI I I , and ot her f act ors. Plasmin act s more
quickly t o dest roy f ibrinogen because of f ibrinogen's inst abilit y.
For t herapeut ic dest ruct ion of t hrombi, urokinase, a t rypsin-like prot ease purif ied
f rom urine, may be administ ered t o a pat ient t o act ivat e plasminogen t o plasmin
and induce f ibrinolysis. St rept okinase is anot her t herapeut ic agent used f or t he
same purpose.
Reference Values
Normal
Pl asmi nogen acti vi ty Males: 76%124% of normal f or plasma or 0. 761. 24
f ract ion of normal Females: 65%153% of normal f or plasma or 0. 651. 53
f ract ion of normal I nf ant s: 27%59% of normal f or plasma or 0. 270. 59 f ract ion
of normal
Procedure
1. Add a 5-mL venous blood sample t o a collect ion t ube cont aining sodium
cit rat e. Use t he t w o-t ube met hod. Place t he specimen in a biohazard bag.
2. Put t he sample on ice and t ransport t o t he laborat ory immediat ely.
3. Be aw are t hat t he t est must be st art ed w it hin 30 minut es af t er t he blood is
draw n.
1. Decreased plasminogen act ivit y occurs in:
a. Some f amilial or isolat ed cases of idiopat hic deep vein t hrombosis
b. DI C and syst emic f ibrinolysis
c. Liver disease and cirrhosis
d. Neonat al hyaline membrane disease
e. Therapy w it h plasminogen act ivat ors
2. Decreased levels of plasminogen or abnormally f unct ioning plasminogen can
lead t o venous and art erial clot t ing (t hrombosis).
3. Increased plasminogen act ivit y occurs in:
a. Pregnancy (t hird t rimest er)
b. Regular vigorous physical exercise
Interfering Factors
Interventions
Pretest Patient Preparation

1. I nt erpret t est out comes and monit or appropriat ely f or t hrombot ic t endency.
Fibrinolysis (Euglobulin Lysis Time; Diluted Whole

Blood Clot Lysis) Primary fibrinolysis, without any sign
of intravascular coagulation, is extremely rare.
Secondary fibrinolysis is usually seen and follows or
occurs simultaneously with intravascular coagulation.
This secondary fibrinolysis is a protective mechanism
against generalized clotting.
This t est is done t o evaluat e a f ibrinolyt ic act ivit y. Short ened t ime indicat es
excessive f ibrinolyt ic act ivit y. Lysis is marked and rapid w it h primary f ibrinolysis
but can be minimal in secondary f ibrinolysis. The dilut ed w hole blood is used t o
monit or urokinase and st rept okinase t herapy.
Reference Values
Normal
Euglobulin lysisno lysis of plasma clot at 37C in 60120 minut es. The clot is
observed f or 24 hours.
Dilut ed w hole blood clot lysis: no lysis of clot in 120 minut es at 37C.
Procedure
NOTE
To avoid release of plasminogen act ivat or, do not massage vein, pump f ist , or
leave t ourniquet on f or a prolonged period of t ime.
1. Collect a 5-mL venous blood sample in a t ube cont aining sodium cit rat e using
t he t w o-t ube met hod. Place t he specimen in a biohazard bag.
2. Put t he sample on ice and t ransport t o t he laborat ory immediat ely, or st art at
bedside.
3. Be aw are t hat t he t est must be st art ed w it hin 90 minut es af t er t he blood is
cent rif uged.
Clin ical Alert

A lysis t ime <1 hour signif ies t hat abnormal f ibrinolysis is occurring.
1. Increased f ibrinolysis t ime occurs in t he f ollow ing condit ions:
a. Primary f ibrinolysis
b. Wit hin 48 hours af t er surgery
c. Cancer of prost at e or pancreas
d. Circulat ory collapse, shock
e. During lung and cardiac surgery
f. O bst et ric complicat ions (eg, ant epart um hemorrhage, amniot ic embolism,
sept ic abort ion, deat h of f et us, hydat idif orm mole)
g. Long-t erm DI C (may be normal if plasminogen is deplet ed)
h. Liver disease
i. Administ rat ion of plasminogen act ivat ors (t PA, st rept okinase, urokinase)
2. Heparin does not int erf ere w it h t he euglobulin lysis t est .
Interfering Factors
1. I ncreased f ibrinolysis occurs w it h moderat e exercise and increasing age.
2. Decreased f ibrinolysis occurs in art erial blood, compared w it h venous blood.
This diff erence is great er in art eriosclerosis (especially in young persons).

3. Decreased f ibrinolysis occurs in post menopausal w omen and in normal
new borns.
4. FDPs int erf ere w it h f ibrinolysis.
5. Normal result s can occur if f ibrinolysis is f ar advanced (plasminogen
deplet ed).
6. Fibrinolysis is increased by very low f ibrinogen levels (<80 mg/ dL or <0. 8
g/ L) and decreased by high f ibrinogen levels.
7. I ncreased f ibrinolysis can be caused by t raumat ic venipunct ure or a
t ourniquet t hat is t oo t ight .
Interventions
Patient Preparation
1. Advise pat ient of t est purpose and procedure; no exercise bef ore t est .
Patient Aftercare
1. I nt erpret t est result s and monit or appropriat ely f or f ibrinolyt ic crisis.
Fibrin Split Products (FSPs); Fibrin Degradation

Products (FDPs) When fibrin is split by plasmin,
positive tests for fibrin degradation (split) products,
identified by the letters X, Y, D, and E, are produced.
These products have an anticoagulant action and
inhibit clotting when they are present in excess in the
circulation. Increased levels of FDPs may occur with a
variety of pathologic processes in which clot formation
and lysis occur.
This t est is done t o est ablish t he diagnosis of DI C and ot her t hromboembolic
disorders.
Reference Values
Normal
Negat ive at 1: 4 dilut ion or <10 g/ mL (<10 mg/ L)
Procedure
1. Place a venous blood sample of at least 4. 5 mL in a t ube cont aining t hrombin
and an inhibit or of f ibrinolysis (rept ilase, aprot inin, and calcium). Place t he
2. Be aw are t hat blood must be complet ely clot t ed bef ore t he t est is st art ed f or
t he t est t o be valid because f ibrinogen is broken dow n int o ident ical
f ragment s. Theref ore, no f ibrinogen can be present w hen t he t est is done.
Increased FSP and FDP is associat ed w it h any condit ion associat ed w it h DI C
(see page 128 f or examples) and in:
1. Primary f ibrinolysis
2. Venous t hrombosis
3. Thoracic and cardiac surgery or renal t ransplant at ion
4. Acut e myocardial inf arct ion
5. Pulmonary embolism
6. Carcinoma
7. Liver disease
Interfering Factors
1. Because all of t he laborat ory met hods are sensit ive t o f ibrinogen as w ell as
FDP, it is essent ial t hat no unclot t ed f ibrinogen be lef t in t he serum
preparat ion. False-posit ive react ions can result if any f ibrinogen is present .
2. False-posit ive result s occur w it h heparin t herapy.
3. The presence of rheumat oid f act or (rheumat oid art hrit is) may cause f alsely
high FSP and FDP values.
Interventions
Patient Preparation
Patient Aftercare
1. I nt erpret t est result s and monit or appropriat ely f or DI C and t hrombosis.
Clin ical Alert

1. Pat ient s w it h very high levels of FSP/ FDP have blood t hat does not clot or
clot s poorly.
2. Cri ti cal val ue: >40 g/ mL (>40 mg/ L)
D-Dimer
D-Dimers are produced by t he act ion of plasmin on cross-linked f ibrin. They are
not produced by t he act ion of plasmin on unclot t ed f ibrinogen or FDPs and
t heref ore are specif ic f or f ibrin. The presence of D-dimer conf irms t hat bot h
t hrombin generat ion and plasmin generat ion have occurred.
This t est is used in t he diagnosis of DI C disease and t o screen f or venous
t hrombosis and acut e myocardial inf arct ion. The D-dimer t est is more specif ic f or
DI C t han are t est s f or FSPs. The t est verif ies in vivo f ibrinolysis because Ddimers are produced only by t he act ion of plasmin on cross-linked f ibrin, not by
t he act ion of plasmin on unclot t ed f ibrinogen. A posit ive D-dimer t est is
presumpt ive evidence f or DI C but is not diagnost ic.
Reference Values
Normal
<250 g/ L or <1. 37 nmol/ L
Q ualit at ive: no D-dimer f ragment s present
Procedure
A venous blood sample or 5 mL is collect ed int o a t ube cont aining sodium cit rat e
and apot inin. Place t he specimen in biohazard bag and ret urn t o lab immediat ely.
1. Increased D-dimer values are associat ed w it h:
a. DI C (secondary f ibrinolysis)
b. Art erial or venous t hrombosis (deep vein t hrombosis)
c. Renal or liver f ailure
d. Pulmonary embolism
e. Lat e in pregnancy, preeclampsia
f. Myocardial inf arct ion
g. Malignancy, inf lammat ion, and severe inf ect ion
2. D-Dimer values are increased w it h t PA ant icoagulant t herapy.
NOTE
D-Dimer analysis of spinal f luid can rapidly and accurat ely diff erent iat e cases
of subarachnoid hemorrhage (SAH) f rom a t raumat ic t ap. Posit ive in SAH.
Interfering Factors
1. False-posit ive t est s are obt ained w it h high t it ers of rheumat oid f act or.
2. False-posit ive D-dimer levels increase as t he t umor marker CA-125 f or
ovarian cancer increases.
3. The D-dimer t est w ill be posit ive in all pat ient s af t er surgery or t rauma.
4. False-posit ive result s f ound in est rogen t herapy, normal pregnancy
Interventions
Patient Preparation
Patient Aftercare
1. I nt erpret t est out come and monit or appropriat ely f or DI C or t hrombin.
Fibrinopeptide A (FPA)
Fibrinopept ides A and B are f ormed by t he act ion of t hrombin on f ibrinogen;
t heref ore, t he presence of FPA indicat es t hat t hrombin has act ed on f ibrinogen.
The measurement is t he most sensit ive assay done t o det ermine t hrombin act ion.
FPA ref lect s t he amount of act ive int ravascular blood clot t ing; t his occurs in a
subclinical DI C, w hich is common in pat ient s w it h leukemia of various t ypes and
may be associat ed w it h t umor progression. FPA elevat ions can occur w it hout
int ravascular t hrombosis, decreasing t he value of a posit ive t est .
Reference Values
Normal
Male: 0. 42. 6 mg/ mL
Female: 0. 731 mg/ mL
Procedure
1. Collect a venous blood sample of 5 mL in special Vacut ainer t ube cont aining
aprot inin EDTA and t hrombin t o prevent act ivat ion in vit ro. Use a t w o-t ube
met hod of draining blood.
2. Draw t he specimen in a prechilled t ube and place immediat ely on ice.
3. Place t he specimen in a biohazard bag. Clean venipunct ure and gent le
handling of specimen are required. The specimen must be t ransport ed t o t he
lab w it hin 30 minut es.
1. Increased FPA occurs in:
a.
DIC
b. Leukemia of various t ypes

c. Venous t hrombosis and pulmonary embolus
d. Myocardial inf arct ion
e. Post operat ive pat ient s
f. Pat ient s w it h w idespread solid t umors, malignancies
2. Decreased FPA occurs in:
a. Clinical remission of leukemia achieved w it h chemot herapy
b. Therapeut ic heparinizat ion
Interfering Factors
1. A t raumat ic venous punct ure may result in f alsely increased levels.
2. The biologic half -lif e (st able f or 2 hours or more) imposes limit at ions on t he
int erpret at ion of a negat ive FPA t est .
Clin ical Alert

DI C occurs commonly in associat ion w it h deat h of t umor cells in acut e
promyelocyt ic leukemia. For t his reason, heparin is used prophylact ically and
in associat ion w it h t he init iat ion of chemot herapy f or promyelocyt ic leukemia.
DI C occurs less commonly during t he t reat ment of acut e myelomonocyt ic
leukemia and acut e lymphocyt e leukemia. Evidence of DI C should be sought in
every pat ient w it h leukemia bef ore init iat ion of t reat ment .
Interventions
Patient Preparation
2. Avoid prolonged use of t ourniquet .
Patient Aftercare
1. I nt erpret t est out come and monit or appropriat ely f or DI C and t hrombosis.
Prothrombin Fragment (F1 + 2) The prothrombin F1 + 2

fragment is liberated from the prothrombin molecule
when it is activated by factor Xa to form thrombin.
Thrombin may be rapidly inactivated by antithrombin
III. The F1 + 2 fragment, however, has a half-life of
about 1.5 hours, making it a useful marker for activated
coagulation.
Prot hrombin F1 + 2 is used t o det ect act ivat ion of t he coagulat ion syst em bef ore
act ual t hrombosis occurs. I t is used t o ident if y pat ient s w it h low -grade
int ravascular coagulat ion (DI C) and t o judge t he eff ect iveness of oral
ant icoagulant t herapy. F1 + 2 levels may assist in t he st udy of t he
hypercoagulable st at es and in t he assessment of t hrombot ic risk.
Reference Values
Normal
7. 4102. 9 g/ L or 0. 22. 78 nmol/ L
Levels rise slight ly w it h age over 45 years.
Procedure
1. Draw a 5-mL sample of venous blood int o a blue-t opped (sodium cit rat e
ant icoagulant ) Vacut ainer.
2. Use t he t w o-t ube t echnique. (Some met hods may use lit hium heparin. )
Increased prot hrombin F1 + 2 is f ound in:
1. DI C (early)
2. Congenit al def iciencies of ant it hrombin I I I
3. Congenit al def iciencies of prot ein S and prot ein C
4. Leukemias
5. Severe liver disease
6. Post myocardial inf arct ion
NOTE
Failure t o achieve a reduct ion in prot hrombin F1 + 2 levels during oral
ant icoagulant t herapy, despit e an adequat ely prolonged PT, suggest s
inadequat e ant icoagulat ion.
Interfering Factors
1. Levels w ill be high in t he immediat e post operat ive period.
2. Decreased w it h oral ant icoagulant s (Coumadin)
3. Decreased in pat ient s t reat ed w it h AT-I I I
Interventions

Fibrin Monomers (Protamine Sulfate Test; Fibrin Split

Products) A positive test result reflects the presence of
fibrin monomers, indicative of thrombin activity and
consistent with a diagnosis of intravascular
coagulation. A negative result does not mean that
intravascular coagulation is not present. A positive
result may also be seen in some cases of severe liver
disease and in inflammatory disorders caused by
accumulation of products of coagulation in the

circulation.
The det ect ion of f ibrin monomers and early-st age FSPs in plasma is usef ul in t he
diagnosis of DI C. Heparin t herapy does not int erf ere w it h t his t est .
Reference Values
Normal
Negat ive; no f ibrin monomer present
Procedure
1. O bt ain a 5-mL venous blood sample ant icoagulat ed w it h sodium cit rat e (bluet opped t ube). The t w o-t ube t echnique is used.
2. Place t he specimen on ice and t ransport t o t he laborat ory. The t est must be
perf ormed w it hin 1 hour af t er collect ion.
1. A posit ive t est is indicat ive of DI C.
2. Pat ient s w it h deep vein t hrombosis occasionally have posit ive result s.
3. The t est may be posit ive in severe liver disease or met ast at ic cancer.
Interfering Factors
False-posit ive result s may occur in t he f ollow ing sit uat ions:
1. Traumat ic venipunct ure
2. During or immediat ely bef ore menst ruat ion
3. During st rept okinase t herapy (t hrombolyt ic t herapy)
Interventions
1. Explain t est purpose and procedure. I f possible, drain blood bef ore heparin
t herapy is st art ed.


Fibrinogen
Fibrinogen is a complex prot ein (polypept ide) t hat , w it h enzyme act ion, is
convert ed t o f ibrin. The f ibrin, along w it h plat elet s, f orms t he net w ork f or t he
common blood clot . Alt hough it is of primary import ance as a coagulat ion prot ein,
f ibrinogen is also an acut e-phase prot ein react ant . I t is increased in diseases
involving t issue damage or inf lammat ion.
This t est is done t o invest igat e abnormal PT, APTT, and TT and t o screen f or
DI C and f ibrin-f ibrinogenolysis. I t is part of a coagulat ion panel.
Reference Values
Normal
200400 mg/ dL or 2. 04. 0 g/ L
Procedure
1. O bt ain a 5-mL venous blood sample using t he t w o-t ube t echnique w it h a
collect ion t ube cont aining sodium cit rat e.
1. Increased f ibrinogen values occur in:
a. I nf lammat ion and inf ect ions (rheumat oid art hrit is, pneumonia,
t uberculosis, st rept omycin)
b. Acut e myocardial inf arct ion

c. Nephrot ic syndrome
d. Cancer, mult iple myeloma, Hodgkin's disease
e. Pregnancy, eclampsia
f. Various cerebral accident s and diseases
2. Decreased f ibrinogen values occur in:
a. Liver disease
b. DI C (secondary f ibrinolysis)
c. Cancer
d. Primary f ibrinolysis
e. Heredit ary and congenit al hypof ibrinogenemia
f. Dysf ibrinogenemia
Interfering Factors
1. High levels of heparin int erf ere w it h t est result s.
2. High levels of FSP and FDP cause low f ibrinogen values.
3. O ral cont racept ives cause high f ibrinogen values.
4. Elevat ed AT-I I I may cause decreased f ibrinogen.
5. See Appendix J f or ot her drugs t hat aff ect t est out comes.
Clin ical Alert

<100 mg/ dL or 1. 0 g/ Lpossible panic value, not if y physician
1. Values <50 mg/ dL or <0. 5 g/ L can result in hemorrhage af t er t raumat ic
surgery.
2. Values >700 mg/ dL or >7. 0 g/ L const it ut e a signif icant risk f or bot h
coronary art ery and cerebrovascular disease.
Interventions
2. Have t he pat ient avoid aggressive muscular exercise bef ore t he t est .

1. I nt erpret t est out come and monit or appropriat ely f or DI C and response t o
t reat ment . I f f ibrinogen is low, cryoprecipit at e is t he pref erred product f or
t herapeut ic replacement .
Protein C (PC Antigen)

Prot ein C, a vit amin Kdependent prot ein t hat prevent s t hrombosis, is produced
in t he liver and circulat ed in t he plasma. I t f unct ions as an ant icoagulant by
inact ivat ing f act ors V and VI I I . Prot ein C is also a prof ibrinolyt ic agent (ie, it
enhances f ibrinolysis). The prot ein C mechanism t heref ore f unct ions t o prevent
ext ension of int ravascular t hrombi. This t est is used f or evaluat ion of pat ient s
suspect ed of having congenit al prot ein C def iciency. Resist ance t o prot ein C is
caused by an inherit ed def ect in t he f act or V gene (f act or V Leiden) and causes
signif icant risk f or t hrombosis. I t is t he underlying def ect in up t o 60% of
pat ient s w it h unexplained t hrombosis and is t he most common cause of
pat hologic t hrombosis. I f f unct ional prot ein C is abnormal, a prot ein C resist ance
t est should be perf ormed.
This t est evaluat es pat ient s w it h severe t hrombosis and t hose w it h an increased
risk or predisposit ion t o t hrombosis. Pat ient s w it h part ial prot ein C or part ial
prot ein S def iciency (het erozygot es) may experience venous t hrombot ic
episodes, usually in early adult years. There may be deep vein t hromboses,
episodes of t hrombophlebit is or pulmonary emboli (or bot h), and manif est at ions
of a hypercoagulable st at e. Pat ient s w ho are het erozygous may have t ype I
prot ein C def iciency, w it h decreased prot ein C ant igen, or t ype I I def iciency, w it h
normal prot ein C ant igen levels but decreased f unct ional act ivit y.
NOTE
The prot ein S level should alw ays be det ermined w hen a prot ein C t est is
ordered.
NOTE
Prot ein C resist ance (f act or V Leiden) should be t est ed in all pat ient s w it h
abnormal prot ein C act ivit y.
Reference Values
Normal
Q ualit at ive: 70%150% or 0. 701. 50 of increased f unct ional act ivit y
Q uant it at ive: 60%125% or 0. 601. 25 of normal PC ant igen
Procedure
1. Ant icoagulat e a 5-mL venous blood sample w it h sodium cit rat e (blue-t opped
t ube). The t w o-t ube met hod is used.
2. Cap t he specimen and place on ice.
1. Decreased prot ein C is associat ed w it h:
a. Severe t hrombot ic complicat ions in t he neonat al period (neonat al purpura
f ulminans)
b. I ncreased risk f or venous t hrombot ic episodes
c. Warf arin (Coumadin)-induced skin necroses (pat hognomonic f or prot ein C
def iciency)
d. DI C, especially w hen it occurs w it h cancer (presumably ow ing t o
consumpt ion by cof act or t hrombin-t hrombomodulin cat alyst act ivit ies)
e. Thrombophlebit is and pulmonary embolism, especially in early adult
years
f. O t her acquired causes of prot ein C def iciency include:
1. Liver disease
2. Acut e respirat ory dist ress syndrome
3. L-Asparaginase t herapy
4. Malignancies
2. A def iciency of prot ein C may also be congeni tal (35%58%).
Clin ical Alert

Homozygous prot ein Cdef icient pat ient s have absent or almost absent prot ein
C ant igen and usually succumb in inf ancy w it h t he pict ure of purpura f ulminans
neonat alis, including low er ext remit y skin ecchymoses, anemia, f ever, and
shock.
Interfering Factors
1. Decreased prot ein C is f ound in t he post operat ive st at e.
2. Pregnancy or use of oral cont racept ives decreases prot ein C.
3. A t ransient drop in prot ein C occurs w it h a high loading dose of w arf arin
(Coumadin).
4. Prot ein C decreases w it h age.
5. High doses of heparin decrease prot ein C.
6. Lipemic serum may int erf ere w it h t he assay.
Interventions
1. Explain t est purpose and procedure. Pat ient should be f ast ing.

1. I nt erpret t est out come and monit or appropriat ely f or t hrombosis. I n t he case
of a prot ein C def iciency, educat e t he pat ient concerning t he sympt oms and
implicat ions of t he disease. The risk f act ors include obesit y, oral
cont racept ives, varicose veins, inf ect ion, t rauma, surgery, pregnancy,
immobilit y, and congest ive heart f ailure.
Protein S
Bot h prot ein S and prot ein C are dependent on vit amin K f or t heir product ion and
f unct ion. A def iciency of eit her one is associat ed w it h a t endency t ow ard
t hrombosis. Prot ein S serves as a cof act or t o enhance t he ant icoagulant eff ect s
of act ivat ed prot ein C. Slight ly more t han half of prot ein S is complexed w it h C4
binding prot ein and is inact ive. Act ivat ed prot ein C in t he presence of prot ein S
rapidly inact ivat es f act ors V and VI I I .
This t est is done t o diff erent iat e acquired f rom congenit al prot ein S def iciency.
Congenit al def iciency of prot ein S is associat ed w it h a high risk f or
t hromboembolism. Acquired def iciency of prot ein S can be seen in various
aut oimmune disorders and inf lammat ory st at es ow ing t o elevat ion of C4-binding
prot ein. This prot ein f orms an inact ive complex w it h prot ein S. C4-binding prot ein
levels should be det ermined in all pat ient s w ho demonst rat e a reduced level of
prot ein S.
Reference Values
Normal
Males: 60%130% or 0. 601. 30 of normal act ivit y Females: 50%120% or 0. 50
1. 20 of normal act ivit y New borns: 15%50% or 0. 150. 50 of normal act ivit y
Procedure
1. Ant icoagulat e a 5-mL venous blood sample w it h sodium cit rat e (blue-t opped
t ube). The t w o-t ube met hod is used.
2. Keep t he specimen capped and on ice. Place in biohazard bag and t ake t o
laborat ory immediat ely.
1. Decreased val ues are associat ed w it h prot ein S def iciency. Familial prot ein
S def iciency is associat ed w it h recurrent t hrombosis. Abnormal plasma
dist ribut ion of prot ein S occurs in f unct ional prot ein S def iciency. I n t ype I ,
f ree prot ein S is decreased, alt hough t he level of t ot al prot ein may be
normal; in t ype I I , t ot al prot ein is markedly reduced.
2. Hypercoagulable-st at e acquired prot ein S def iciency is f ound in:
a. Diabet ic nephropat hy
b. Chronic renal f ailure caused by hypert ension
c. Cerebral venous t hrombosis
d. Coumarin-induced skin necrosis
e.
DIC
f. Thrombot ic t hrombocyt openia purpura

g. Acut e inf lammat ion
Interfering Factors
The f ollow ing f act ors cause decreased prot ein S:
1. Heparin t herapy or specimen cont aminat ed w it h heparin
2. Pat ient on unst able w arf arin (Coumadin should be discont inued f or 30 days
f or a t rue prot ein S det erminat ion)
3. Pregnancy
4. Cont racept ives (oral)
5. First mont h of lif e
6. L-Asparaginase t herapy
NOTE
This t est is not usef ul in diagnosing DI C.
Interventions

1. I nt erpret t est out come and monit or appropriat ely f or t hrombot ic t endency.
Antithrombin III (AT-III; Heparin Cofactor Activity) AT-III

inhibits the activity of activated factors XII, XI, IX, and
X as well as factor II. AT-III is the main physiologic
inhibitor of activated factor X, on which it appears to
exert its most critical effect. AT-III is a heparin
cofactor. Heparin interacts with AT-III and thrombin,
increasing the rate of thrombin neutralization
(inhibition) but decreasing the total quantity of
thrombin inhibited.
This t est det ect s a decreased level of ant it hrombin t hat is indicat ive of
t hrombot ic t endency. O nly t he t est of f unct ional act ivit y gives a direct clue t o
t hrombot ic t endency. I n some f amilies, several members may have a combinat ion
of recurrent t hromboembolism and reduced plasma ant it hrombin (30%60%). A
signif icant number of pat ient s w it h mesent eric venous t hrombosis have AT-I I I
def iciency. I t has been recommended t hat pat ient s w it h such t hrombot ic disease
be screened f or AT-I I I levels t o ident if y t hose pat ient s w ho may benef it f rom
coumarin ant icoagulant prophylaxis rat her t han heparin t herapy.
Reference Values
Normal
Functi onal assay I nf ant s (130 days): 26%61% or 0. 260. 61 (premat ure);
44%76% or 0. 440. 76 (f ull-t erm) Adult s and inf ant s older t han 6 mont hs: 80%
120% or 0. 801. 20
Immunol ogi c assay Adult s and inf ant s older t han 6 mont hs: 1730 mg/ dL or 170
300 mg/ L
Procedure
1. Ant icoagulat e a venous blood sample (5 mL) w it h sodium cit rat e. Mix gent ly.
2. Use t he t w o-t ube met hod.
3. Place t he sample on ice and t ransport t o laborat ory immediat ely.
1. Increased AT-III val ues are associat ed w it h:
a. Acut e hepat it is
b. Renal t ransplant at ion
c. I nf lammat ion, pat ient s w it h increased ESR
d. Menst ruat ion
e. Use of w arf arin (Coumadin) ant icoagulant
f. Hyperglobulinemia
2. Decreased AT-III val ues are associat ed w it h:
a. Congenit al def iciency (heredit ary)
b. Liver t ransplant at ion and part ial liver removal, cirrhosis, nephrot ic
syndrome, liver f ailure
c. DI C, f ibrinolyt ic disorders (not diagnost ically usef ul)
d. Acut e myocardial inf arct ion
e. Act ive t hrombot ic disease (deep vein t hrombosis), t hrombophlebit is
f. Carcinoma, t rauma, severe inf lammat ions
g. Pulmonary embolism
h. Heparin f ailure (low levels of AT-I I I exhibit heparin resist ance)
i. Prot ein-w ast ing diseases
Interfering Factors
1. Ant it hrombin decreases af t er 3 days of heparin t herapy.
2. Use of oral cont racept ives int erf eres w it h t he t est (decreased values).
3. Result s are unreliable in t he last t rimest er of pregnancy and in t he early
post part um period.
4. Decreased af t er surgery, prolonged bed rest .
5. Decreased in L-asparaginase t herapy.
Interventions

1. I nt erpret t est out come and monit or appropriat ely f or t hrombot ic t endency.
2. I f pat ient has decreased levels of AT-I I I , coumarin ant icoagulant w ould be
used as a prophylaxis.
BIBLIOGRAPHY
Bick R, et al: Blood prot ein def ect s associat ed w it h t hrombosis. Clin Lab Med
15(1), 1995
Bick R: Laborat ory evaluat ion of plat elet dysf unct ion, t hrombosis and
hemost asis f or t he clinical laborat ory. Clin Lab Med 15(1), 1995
Dahlback B: Resist ance t o act ivat ed prot ein C as risk f act or f or t hrombosis:
Molecular mechanisms, laborat ory invest igat ion, and clinical management .
Semin Hemat ol 34(3): 217234, 1997
Freeman J, Rodgers BA: Lupus: A Pat ient Care G uide f or Nurses and O t her
Healt h Prof essionals. Bet hesda, MD, Nat ional I nst it ut es of Healt h, Nat ional
I nst it ut e of Art hrit is and Musculoskelet al and Skin Diseases, 1999
G oroll AH, May LA, Mulley G A: Primary Care Medicine: O ff ice Evaluat ion and
Management of t he Adult Pat ient , 4t h ed. Philadelphia, Lippincot t Williams &
Wilkins, 2000
Handin RI , Lux SE, St ossel TP: Blood: Principles and Pract ice of Hemat ology,
2nd ed. , Philadelphia, Lippincot t Williams & Wilkins, 2002
Henry J, et al: Clinical Diagnosis and Management by Laborat ory Met hods,
20t h ed. Philadelphia, WB Saunders, 2001
Jacobs D, et al: Laborat ory Test Handbook, 4t h ed. Hudson, O H, Lexi-Comp,
1996
Kjeldsberg C: Pract ical Diagnosis of Hemat ologic Disorders, revised ed.
Chicago, ASCP Press, 1991
Koepke J: I s ESR usef ul? Med Lab O bserv 29(1): 1997
Krenzischek DA, Tanseco FV: Comparat ive st udy of bedside and laborat ory
measurement s of hemoglobin. Am J Crit Care 5(6): 427, 1996
Leavelle D: I nt erpret ive Dat a f or Diagnost ic Laborat ory Test s. Rochest er, MN,
Mayo Clinic Laborat ories, 2001
Lee G R, Foerst er J, Lukens J, et al: Wint robe's Clinical Hemat ology, 10t h
ed. , Philadelphia, Lippincot t Williams & Wilkins, 1999
Looker AC, Dallman PR, Carroll MD, et al: Prevalence of iron def iciency in t he
Unit ed St at es. JAMA 277: 973, 1997
Samama M: Laborat ory monit oring of unf ract ionat ed heparin t reat ment ,
t hrombosis and hemost asis f or t he clinical laborat ory. Clin Lab Med 15(1),
1995
St amat oyannopoulos G , Majerus PW, Perlmut t er RM, Varmus H: The
Molecular Basis of Blood Diseases, 3rd ed. , Philadelphia, WB Saunders, 2001
St at land B: Tips f rom clinical expert s. Med Lab O bserv 29(1): 1997
St eine-Mart in EA, Lot speich-St eininger CA, Koepke JA: Clinical Hemat ology:
Principles, Procedures, Correlat ions. Philadelphia, Lippincot t -Raven, 1997
Tiet z N: Clinical G uide t o Laborat ory Test s, 3rd ed. Philadelphia, WB
Saunders, 1995
Tkachuk D, Hirschmann JV, McArt hur JR: At las of Clinical Hemat ology,
Philadelphia, WB Saunders, 2002
Turgeon ML: Clinical Hemat ology Theory & Procedures, 3rd ed. Philadelphia,
Wallach J: I nt erpret at ion of Diagnost ic Test s, 7t h ed. Philadelphia, Lippincot t
Williams & Wilkins, 2000

Wilkins
> Table of C ontents > 3 - Ur ine S tudies
3
Urine Studies
OVERVIEW OF URINE STUDIES

Urine Formation
Urine is cont inuously f ormed by t he kidneys. I t is act ually an ult raf ilt rat e of
plasma f rom w hich glucose, amino acids, w at er, and ot her subst ances essent ial
t o body met abolism have been reabsorbed. The physiologic process by w hich
approximat ely 170, 000 mL of f ilt ered plasma is convert ed t o t he average daily
urine out put of 1200 mL is complex.
Urine f ormat ion t akes place in t he kidneys, t w o f ist -sized organs locat ed out side
t he perit oneal cavit y on each side of t he spine, at about t he level of t he last
t horacic and f irst t w o lumbar vert ebrae. The kidneys, t oget her w it h t he skin and
t he respirat ory syst em, are t he chief excret ory organs of t he body. Each kidney
is a highly discriminat ory organ t hat maint ains t he int ernal environment of t he
body by select ive secret ion or reabsorpt ion of various subst ances according t o
specif ic body needs.
The main f unct ional unit of t he kidney is t he nephron. There are about 1 t o 1. 5
million nephrons per kidney, each composed of t w o main part s: a glomerulus,
w hich is essent ially a f ilt ering syst em, and a t ubule t hrough w hich t he f ilt ered
liquid passes. Each glomerulus consist s of a capillary net w ork surrounded by a
membrane called Bowman's capsul e, w hich cont inues on t o f orm t he beginning of
t he renal t ubule. The kidney's abilit y t o clear w ast e product s select ively f rom t he
blood w hile maint aining t he essent ial w at er and elect rolyt e balances in t he body
is cont rolled in t he nephron by renal blood f low, glomerular f ilt rat ion, and t ubular
reabsorpt ion and secret ion.
Blood is supplied t o t he kidney by t he renal art ery and ent ers t he nephron
t hrough t he aff erent art eriole. I t f low s t hrough t he glomerulus and int o t he
eff erent art eriole. The varying size of t hese art erioles creat es t he hydrost at ic
pressure diff erence necessary f or glomerular f ilt rat ion and serves t o maint ain
glomerular capillary pressure and consist ent renal blood f low w it hin t he
glomerulus. (The smaller size of t he eff erent art eriole produces an increase in
t he glomerular capillary pressure, w hich aids in urine f ormat ion. ) As t he f ilt rat e
passes along t he t ubule, more solut es are added by excret ion f rom t he capillary
blood and secret ions f rom t he t ubular epit helial cells. Essent ial solut es and
w at er pass back int o t he blood t hrough t he mechanism of t ubular reabsorpt ion.
Finally, urine concent rat ion and dilut ion occur in t he renal medulla. The kidney
has t he remarkable abilit y t o dilut e or concent rat e urine, according t o t he needs
of t he individual, and t o regulat e sodium excret ion. Blood chemist ry, blood
pressure, f luid balance, and nut rient int ake, t oget her w it h t he general st at e of
healt h, are key element s in t his ent ire met abolic process.
Urine Constituents
I n general, urine consist s of urea and ot her organic and inorganic chemicals
dissolved in w at er. Considerable variat ions in t he concent rat ions of t hese
subst ances can occur as a result of t he inf luence of f act ors such as diet ary
int ake, physical act ivit y, body met abolism, endocrine f unct ion,
and even body posit ion. Urea, a met abolic w ast e product produced in t he liver
f rom t he breakdow n of prot ein and amino acids, account s f or almost half of t he
t ot al dissolved solids in urine. O t her organic subst ances include primarily
creat inine and uric acid. The major inorganic solid dissolved in urine is chloride,
f ollow ed by sodium and pot assium. Small or t race amount s of many addit ional
inorganic chemicals are also present in urine. The concent rat ions of t hese
inorganic compounds are great ly inf luenced by diet ary int ake, making it diff icult
t o est ablish normal levels. O t her subst ances f ound in urine include hormones,
vit amins, and medicat ions. Alt hough t hey are not a part of t he original plasma
f ilt rat e, t he urine may also cont ain f ormed element s such as cells, cast s,
cryst als, mucus, and bact eria. I ncreased amount s of t hese f ormed element s are
of t en indicat ive of disease.
Types of Urine Specimens

During t he course of 24 hours, t he composit ion and concent rat ion of urine
changes cont inuously. Urine concent rat ion varies according t o w at er int ake and
pret est act ivit ies. To obt ain a specimen t hat is t ruly represent at ive of a pat ient 's
met abolic st at e, it is of t en necessary t o regulat e cert ain aspect s of specimen
collect ion, such as t ime of collect ion, lengt h of collect ion period, pat ient 's
diet ary and medicinal int ake, and met hod of collect ion. I t is import ant t o inst ruct
pat ient s w hen special collect ion procedures must be f ollow ed. See Appendix A:
St andard Precaut ions, Appendix B: Lat ex Precaut ions, and Appendix E:
G uidelines f or Specimen Transport f or addit ional guidelines.
URINE TESTING
Urinalysis (UA) is an essent ial procedure f or pat ient s undergoing hospit al
admission or physical examinat ion. I t is a usef ul indicat or of a healt hy or
diseased st at e and has remained an int egral part of t he pat ient examinat ion. Tw o
unique charact erist ics of urine specimens can account f or t his cont inued
popularit y:
1. Urine is a readily available and easily collect ed specimen.
2. Urine cont ains inf ormat ion about many of t he body's major met abolic
f unct ions, and t his inf ormat ion can be obt ained by simple laborat ory t est s.
These charact erist ics f it in w ell w it h t he current t rends t ow ard prevent ive
medicine and low er medical cost s. By off ering an inexpensive w ay t o t est large
numbers of people, not only f or renal disease but also f or t he asympt omat ic
beginnings of condit ions such as diabet es mellit us and liver disease, t he UA can
be a valuable met abolic screening procedure.
Should it be necessary t o det ermine w het her a part icular f luid is act ually urine,
t he specimen can be t est ed f or it s urea and creat inine cont ent . I nasmuch as bot h
of t hese subst ances are present in much higher concent rat ions in urine t han in
ot her body f luids, t he demonst rat ion of a high urea and creat inine cont ent can
ident if y a f luid as urine (Chart 3. 1).
Ch art 3.1 Urinary System and Related Tests

Organ s an d Fu n ction
The kidneys, uret er, bladder, and uret hra compose t he urinary syst em.
Kidneys must be able t o excret e diet ary and w ast e product s (not eliminat ed by
ot her organs) t hrough t he urine. Urine is f ormed w it hin t he f unct ional unit of
t he kidneys, t he nephron, w hich consist s of glomeruli and t ubules.
KIDNEY GLOM ERULUS

Format ion of f ilt rat e
Filt rat ion
KIDNEY TUBULE
Secret ion of w ast e product s Reabsorpt ion of w ast e product s needed by t he
body Reabsorpt ion of w at er, sodium chloride, bicarbonat es, pot assium, and
calcium, among ot hers
KIDNEY: PELVIS, URET ERS, AND BLADDER

Excret ion and st orage of f ormed urine Main urine const it uent s: w at er, urea,
uric acid, creat inine, sodium, pot assium, chloride, calcium, magnesium,
phosphat es, sulf at es, and ammonia
Examples of Selective Filtration , Reabsorption , an d Excretion by

th e Urin ary System
Filtered
(g/24 h)
Reabsorbed
(g/24 h)
Excreted
(g/24 h)
Sodium
540
537
3.3
Chloride
630
625
5.3
Bicarbonate
300
300
0.3
28
24
3.9
140
140
0.0
Urea
53
28
25
Creatinine
1.4
0.0
1.4
Uric acid
8.5
7.7
0.8
Constituent
Potassium
Glucose
Laboratory Testing for Routine Urinalysis First, the

physical characteristics of the urine are noted and
recorded. Second, a series of chemical tests is run. A

chemically impregnated dipstick can be used for many
of these tests. Standardized results can be obtained by
processing the urine-touched dipstick through special
automated instruments. Third, the urine sediment is
examined under the microscope to identify the
components of the urinary sediment.
Dipstick Testing
Alt hough laborat ory f acilit ies allow f or a w ide range of urine t est s, some t ypes
of t ablet , t ape, and dipst ick t est s are available f or UA out side t he laborat ory
set t ing. They can be used and read direct ly by pat ient s and clinicians.
Similar in appearance t o pieces of blot t er paper on a plast ic st rip, dipst icks
act ually f unct ion as miniat ure laborat ories. Chemically impregnat ed reagent
st rips (UA Chemst rip Screen) provide quick det erminat ions of pH, prot ein,
glucose, ket ones, bilirubin, hemoglobin (blood), nit rit e, leukocyt e est erase,
urobilinogen, and specif ic gravit y. The dipst ick is impregnat ed w it h chemicals
t hat react w it h specif ic subst ances in t he urine t o produce color-coded visual
result s. The dept h of color produced relat es t o t he concent rat ion of t he
subst ance in t he urine. Color cont rols are provided against w hich t he act ual color
produced by t he urine sample can be compared. The react ion t imes of t he
impregnat ed chemicals are st andardized f or each cat egory of dipst ick; it is vit al
t hat color changes be mat ched t o t he cont rol chart at t he correct elapsed t ime
af t er each st ick is dipped int o t he urine specimen. I nst ruct ions t hat accompany
each t ype of dipst ick out line t he procedure. When more t han one t ype of t est is
incorporat ed on a single st ick
(eg, pH, prot ein, and glucose), t he chemical reagent s f or each t est are
separat ed by a w at er-impermeable barrier made of plast ic so t hat result s do not
become alt ered (Table 3. 1). An example of a f orm used t o record dipst ick (UA
Chemst rip Screen) t est ing result s is show n on t he f ollow ing page.
Table 3.1 Urine Testing by Dipstick/Reagent Strip
Possible Reaction
Interference
Correlati
with Othe
Tests
FalsePositive
FalseNegative
pH
None
Runover from
the protein
pad may
lower
Nitrite
Leukocyte
Microscop
examinati
Protein
Highly
alkaline urine,
ammonium
compounds
(antiseptics),
detergents
High salt
concentration
Blood
Nitrite
Leukocyte
Microscop
examinati
Peroxide,
oxidizing
detergents
Ascorbic
acid, 5-HIAA,
homogentisic
acid, aspirin,
levodopa,
ketones, high
specific
gravity with
low pH
Ketones
None
Glucose
Measurem ent
Glucose
Ketones
Levodopa,
phenylketones
Blood
Oxidizing
agents,
vegetable and
bacterial
peroxidases
Ascorbic
acid, nitrite,
protein pH <
5.0, high
specific
gravity,
captopril
Protein
Microscop
examinati
Bilirubin
Lodine,
pigmented
urine, indican
Ascorbic
acid, nitrite
Urobilinog
Urobilinogen
Ehrlichreactive
compounds
(Multistix),
medication
color
Nitrite,
formalin
Bilirubin
Nitrite
Pigmented
urine on
automated
readers
Ascorbic
acid, high
specific
gravity
Protein
Leukocyte
Microscop
examinati
Leukocytes
Oxidizing
detergents
Glucose,
protein, high
specific
gravity,
oxalic acid,
gentamycin,
tetracycline,
Protein
Nitrite
Microscop
examinati
cephalexin,
cephalothin
Specific
gravity
Protein
Alkaline
urine
None
I n addit ion t o dipst icks, reagent st rips, t ablet s, and t reat ed slides f or special
det erminat ions such as bact eria, phenylket onuria (PKU), mucopolysaccharides,
salicylat e, and cyst inuria are available f or urine analysis.
Figure. No capt ion available.
NOTE
Tablet s are becoming obsolet e but are st ill used f or cert ain t est s, such as
glucose and reducing agent s.
Procedure
1. Use a f resh urine sample w it hin 1 hour of collect ion or a sample t hat has
been ref rigerat ed; bring t o room t emperat ure and mix specimen.
2. Read or review direct ions f or use of t he reagent . Periodically check f or
changes in procedure.
3. Dip a reagent st rip int o w ell-mixed urine, t hen remove it , blot , and compare
each reagent area on t he dipst ick w it h t he corresponding color cont rol chart
w it hin t he est ablished t ime f rame. Correlat e color comparisons as closely as
possible using good light ing.
Interfering Factors
1. I f t he dipst ick is kept in t he urine sample t oo long, t he impregnat ed
chemicals in t he st rip might be dissolved and could produce inaccurat e
readings and values.
2. I f t he reagent chemicals on t he impregnat ed pad become mixed, t he readings
w ill be inaccurat e. To avoid t his, blot off excess urine af t er w it hdraw ing t he
dipst ick f rom t he sample.
Clin ical Alert

1. Precise t iming is essent ial. I f t he t est is not t imed correct ly, color changes
may produce invalid or f alse result s.
2. When not in use, t he cont ainer of dipst icks should be kept t ight ly closed
and st ored in a cool, dry environment . I f t he reagent s absorb moist ure
f rom t he air bef ore t hey
P.
are used, t hey w ill not produce accurat e result s. A desiccant comes w it h
t he reagent s and should be kept in t he cont ainer.
3. Q ualit y cont rol prot ocols must be f ollow ed:
a. The expirat ion dat e must be honored even if t here is no det ect able
det eriorat ion of st rips.
b. Bot t les must be discarded 6 mont hs af t er opening, regardless of
expirat ion dat e.

c. Know n posit ive and negat ive (abnormal and normal) cont rols must be
run f or each new bot t le of reagent st rips w hen it is opened and
w henever t here is a quest ion of det eriorat ion.
COLLECTION OF URINE SPECIM ENS

St andard UA specimens can be collect ed any t ime, w hereas f irst morning,
f ast ing, and t imed specimens require collect ion at specif ic t imes of day. Pat ient
preparat ion and educat ion needs vary according t o t he t ype of specimen
required (Table 3. 2) and t he pat ient 's abilit y t o cooperat e w it h specimen
collect ion. Clear inst ruct ions and assessment of t he pat ient 's underst anding of
t he process are key t o a successf ul out come. Assess t he pat ient 's usual
urinat ing pat t erns and encourage f luid int ake (unless cont raindicat ed). Provide
verbal and w rit t en direct ions f or self -collect ion of specimens. Assess f or
presence of int erf ering f act ors: f ailure t o f ollow collect ion inst ruct ions,
inadequat e f luid int ake, cert ain medicat ions, and pat ient use of illegal drugs may
aff ect t est result s. Cert ain f oods, or any t ype of f ood consumpt ion in some
inst ances, may also aff ect t est result s.
Table 3.2 Collection of Urine Specimens*
Type of Specim en
Characteristics
FIRST MORNING SPECIMEN

Most concentrated
Free of dietary
influences
Bladder-incubated
Best for nitrate, protein,
pregnancy tests;
microscopic examination;
routine screening
Formed elements may

disintegrate if pH is high
and/or specific gravity is
low
RANDOM SPECIMEN
Most convenient
Collected any time
Good for chemical
screening, routine
screening, microscopic
examination
Most common
CLEAN-CAT CH (MIDST REAM)

Used for random collection
and bacterial culture
Minimizes bacterial
counts
SECOND (DOUBLE-VOIDED) SPECIMEN
The first morning specimen

is discarded; the second
specimen is collected and
tested
Diabetic monitoring
Reflects blood
glucose/usually fasting;
less concentrated urine
Formed elements remain
intact
Accurately reflects
components
POST PRANDIAL
Used for glucose
determination, diabetic
monitoring
Collected 2 hours after a

meal
T IMED
Requires collection at
Total specimen must be
certain time
collected
T IMED 2-HOUR VOLUME

Used for urobilinogen
determination
All urine saved for 2hour period
T IMED 24-HOUR VOLUME

Necessary for accurate
quantitative results
Chemical testing
All urine saved for 24hour period
CAT HET ER SPECIMEN

Clamp catheter 15 to 30
minutes before collection
Cleanse sample port with
alcohol
Insert needle into sample
port; after aspirating
sample, transfer to
specimen container
ALERT: Unclamp catheter
Bacterial culture
SUPRAPUBIC ASPIRAT ION

Sterile bladder urine
Bacterial culture
cytology
*Place urine specimens in a biohazard bag.
Single, Random Urine Specimen This is the most

commonly requested specimen. Because the
composition of urine changes over the course of the
day, the time of day when the specimen is collected
may influence the findings. The first voided morning
specimen is particularly valuable because it is usually
more concentrated and therefore more likely to reveal
abnormalities as well as the presence of formed
substances. It is also relatively free of dietary
influences and of changes caused by physical activity
because the specimen is collected after a period of
fasting and rest.
Procedure
1. I nst ruct t he pat ient t o void direct ly int o a clean, dry cont ainer or bedpan.
Transf er t he specimen direct ly int o an appropriat e cont ainer. Disposable
cont ainers are recommended. Women should alw ays have a clean-cat ch
specimen if a microscopic examinat ion is ordered (see Chap. 7).
2. Collect specimens f rom inf ant s and young children int o a disposable
collect ion apparat us consist ing of a plast ic bag w it h an adhesive backing
around t he opening t hat can be f ast ened t o t he perineal area or around t he
penis t o permit voiding direct ly int o t he bag. The specimen bag is caref ully
removed, and t he urine is t ransf erred t o an appropriat e specimen cont ainer.
3. Cover all specimens t ight ly, label properly, and send immediat ely t o t he
laborat ory. Place t he label on t he cup, not on t he lid.
4. O bt ain a clean specimen using t he same procedure as f or bact eriologic
examinat ion (see Chap. 7) if a urine specimen is likely t o be cont aminat ed
w it h drainage, vaginal discharge, or menst rual blood.
5. I f a urine specimen is obt ained f rom an indw elling cat het er, it may be
necessary t o clamp off t he cat het er f or about 15 t o 30 minut es bef ore
obt aining t he sample. Clean t he specimen port (in t he t ubing) w it h ant isept ic
bef ore aspirat ing t he urine sample w it h a needle and syringe.
6. O bserve st andard precaut ions w hen handling urine specimens (see Appendix
A).
7. I f t he specimen cannot be delivered t o t he laborat ory or t est ed w it hin 1 hour,

it should be ref rigerat ed or have an appropriat e preservat ive added.
Interfering Factors
1. Feces, discharges, vaginal secret ions, and menst rual blood w ill cont aminat e
t he urine specimen. A clean voided specimen must be obt ained.
2. I f t he specimen is not ref rigerat ed w it hin 1 hour of collect ion, t he f ollow ing
changes in composit ion may occur:
a. I ncreased pH f rom t he breakdow n of urea t o ammonia by ureaseproducing bact eria
b. Decreased gl ucose f rom glycolysis and bact erial ut ilizat ion
c. Decreased ketones because of volat ilizat ion
d. Decreased bi l i rubi n f rom exposure t o light
e. Decreased urobi l i nogen as a result of it s oxidat ion t o urobilin
f. I ncreased ni tri te f rom bact erial reduct ion of nit rat e
g. I ncreased bacteri a f rom bact erial reproduct ion
h. I ncreased turbi di ty caused by bact erial grow t h and possible precipit at ion
of amorphous mat erial
i. Disint egrat ion of red bl ood cel l s (RBCs) and casts, part icularly in dilut e
alkaline urine
j. Changes in col or caused by oxidat ion or reduct ion of met abolit es
Long-Term, Timed Urine Specimen (2-Hour, 24-Hour)

Some diseases or conditions require a second morning
specimen or a 2-hour or 24-hour urine specimen to
evaluate kidney function accurately (see Table 3.2).
Substances excreted by the kidney are not excreted at
the same rate or in the same amounts during different
periods of the day and night; therefore, a random urine
specimen might not give an accurate picture of the
processes taking place over a 24-hour period. For
measurement of total urine protein, creatinine,
electrolytes, and so forth, more accurate information is
obtained from a long-term specimen. All urine voided in

a 24-hour period is collected into a suitable receptacle;
depending on the intended test, a preservative is
added, the collection is kept refrigerated, or both
(Table 3.3).
Table 3.3 24-Hour Collection: Standards for Timed
Urine Specimen Collection
Preservative
Specim en
Handling
and
Storage
Acid
mucopolysaccharides
inherited enzyme
deficiency in infants with
mental retardation or
failure to thrive
20 mL toluene
(add at start
of collection)
Refrigerate
during
collection;
include
patient's
age
Aldosterone (cause of
hypertension)
1 g boric acid
per 100 mL
urine
Refrigerate
Test Elem ent and

Purpose
Amino acids,
quantitative
(aminoaciduria, screen
None
Refrigerate
during
for inborn errors of

metabolism and genetic
abnormalities)
collection
25 mL of 50%
acetic acid;
for children <
5 y, use 15
mL of 50%
acetic acid
Refrigerate
or ice;
protect
from light
Amylase (differentiates
acute pancreatitis from
other abdominal
diseases)
None
Refrigerate
during
collection
Arsenic (arsenic
poisoningoccupational
exposure)
20 mL of 6N
HNO 3 in a
metal-free
container
Refrigerate
during
collection
Cadmium (toxic levels,

including occupational
exposure)
20 mL of 6N
HNO 3 in a
metal-free
container
Refrigerate
during
collection
30 mL of 6N
HCl
Refrigerate
during
collection
Aminolevulinic acid
(porphyria and lead
poisoning)
Calcium, quantitative
Sulkowitch
(hypercalciuria as in
hyperparathyroidism,
hyperthyroidism, vitamin
D toxicity, Paget's
disease, osteolytic
diseases, and renal

tubular acidosis)
Catecholamine
fractions, urinary free
catecholamines
(measure
adrenomedullary
function, to diagnose
pheochromocytoma)
25 mL of 50%
acetic acid;
for children <
5 y, use 15
mL of 50%
acetic acid
Refrigerate
or freeze,
pH 13
Chloride (electrolyte
imbalance, dehydration,
metabolic alkalosis)
None
Refrigerate
during
collection
Chromium (toxic levels,

including occupational
exposure)
20 mL of 6N
HNO 3 in a
metal-free
container
Refrigerate
Citrate/citric acid (renal

disease)
10 g boric
acid
Refrigerate
Copper (W ilson's
disease)
20 mL of 6N
HNO 3 in a
metal-free
container
Refrigerate
during
collection
Cortisol, free
(hydrocortisone levels in
adrenal hormone
function)
30 mL of 6N
HCl
Refrigerate
during
collection
Creatinine (to evaluate

disorders of kidney
function)
None
Refrigerate
during
collection
None
Refrigerate
during
collection
None
Refrigerate
during
collection;
freeze a
portion
after
collection
20 mL of
toluene
Refrigerate
during
collection,
pH 23; if
not
acidified
freeze
-Aminolevulinic acid
(porphyria and lead
poisoning)
30 mL of 33%
glacial acetic
acid
Protect
from light;
refrigerate
during
collection
Electrolytes, sodium,
potassium (electrolyte
None, or 1.0
Creatinine clearance
(measures kidney
function, primarily
glomerular filtration)
Cyclic adenosine
monophosphate
Cystine, quantitative (to

diagnose cystinuria,
inherited disease
characterized by bladder
calculi)
Refrigerate
imbalance)
g boric acid
Estriol, estradiol
(menstrual and fertility
problems, male
feminization
characteristics,
estrogen-producing
tumors, and pregnancy)
1.0 g boric
acid
Refrigerate
during
collection
Estrogens, total,
nonpregnancy or third
trimester (estrogen
levels for menstrual and
fertility problems,
pregnancy and
estrogen-producing
tumors)
1.0 g boric
acid
Refrigerate
during
collection
Folliclestimulating/luteinizing
hormone (gonadotropic
hormones, FSH and LH
to determine cause of
gonadal deficiency)
1.0 g boric
acid or none
Store
frozen
Glucose (glucosuria to
screen, confirm, or
monitor diabetes
mellitus, rapid intestinal
absorption)
1.0 g boric
acid or NaF
Store in
dark bottle
Histamine (chronic
myelogenous leukemia,
carcinoids, polycythemia
vera)
None
Refrigerate;
freeze
portion
after
collection
Homogentisic acid
None
Freeze
portion
after
collection
Homovanillic acid (to

diagnose
neuroblastoma,
pheochromocytoma,
ganglioblastoma)
15 mL of 50%
acetate acid
<5 yrs of age,
25 mL of 50%
acetic acid >5
years of age,
to maintain
pH 2.04.0
Refrigerate
during
collection
1.0 g boric
acid
Refrigerate,
pH 57;
freeze
portion
after
collection
17Hydroxycorticosteroids
(adrenal function by
measuring urine
excretion of steroids to
diagnose endocrine
disturbances of the
adrenal androgens,
Cushing's, Addison's,
and so forth)
5-Hydroxyindoleacetic
15 mL of 50%
acetate acid
Refrigerate
during
acid, serotonin
(carcinoid tumors) 5HIAA
<5 yrs of age,

25 mL of 50%
acetic acid >5
years of age,
to maintain
pH 2.04.0
collection;
freeze
portion
after
collection
10 mL 6N HCl
per liter of
urine,
maintain pH <
3
Refrigerate
during
collection;
store
frozen
Hydroxyproline, total 24hour collection (bone

collagen reabsorption
and the degree of bone
destruction from bone
tumors)
10 mL 6N HCl
per liter of
urine,
maintain pH <
3
Refrigerate
during
collection;
use gelatinfree and
lowcollagen
diet
Immunofixation
electrophoresis
(measures immune
status and competence
by identifying
monoclonal and particle
protein band
immunoglobulins)
None
Refrigerate
Hydroxyproline, free
(measures the free
hydroxyproline [less
than 10% normally];
rapid growth and
increased collagen
turnover)
and chains
quantitative, also in
serum (monoclonal
gammopathies, myeloma
tumor burden)
None
Refrigerate
17-Ketogenic steroids
(Porter-Silber and
Cushing's syndrome,
adrenogenital syndrome)
1.0 g boric
acid
Do not
refrigerate
17-Ketosteroid, fractions
(adrenal and gonadal
abnormalities)
1.0 g boric
acid
Do not
refrigerate
Lead (lead poisoning

and chelation therapy)
20 mL of 6N
HNO 3 in a
metal-free
container
Refrigerate
Lipase (acute
pancreatitis and to
differentiate pancreatitis
from other abdominal
disorders)
None
Refrigerate
Lysozyme, muramidase
(to differentiate acute
myelogenous or
monocytic leukemia from
acute lymphatic
leukemia)
None
Refrigerate
Magnesium (magnesium
metabolism, electrolyte
status, and
nephrolithiasis)
20 mL of 6N
HCl in a
metal-free
container
Refrigerate
Manganese (toxicity,
parenteral nutrition)
None
Refrigerate
during
collection
Mercury (toxicity,
industrial and dental
overexposure; inorganic
mercury)
20 mL of 6N
HNO 3 in a
metal-free
container
Refrigerate;
pH 2 with
nitric acid
Metanephrine, total
(assays of
catecholamines and
vanillylmandelic acid;
frequently to diagnose
pheochromocytoma)
30 mL of 6N
HCl
pH 13
30 mL of 6N
HCl, final pH
< 3
Refrigerate;
no caffeine
before or
during
testing
Metanephrine, fractions
(to diagnose and
monitor
pheochromocytoma and
ganglioneuroblastoma)
Metanephrine, total
(pheochromocytoma,
children with
neuroblastoma,
25 mL of 50%
acetic acid;
for children
<5 y, use 15
mL of 50%
acetic acid;
Refrigerate;
no caffeine
before or
during
ganglioneuroma)
or 30 mL of
6N HCl
testing
MHPG (3-methoxy-4hydroxyphenylglycol) (to

classify bipolar manic
depression for drug
therapy)
None
Refrigerate,
ship frozen
Microalbumin, 24-hour
(diabetic nephropathy)
None
Refrigerate
Osmolality, 24-hour
(diabetes insipidus,
primary polypepsia)
None
Refrigerate
Oxalate (nephrolithiasis
and inflammatory bowel
diseases)
20 mL of 6N
HCl
Refrigerate,
pH 23
Acid-washed,
detergent-free
container
Refrigerate
during
collection;
acidify after
collection
None
Refrigerate
during
collection;
freeze a
portion;
protect
from light
Phosphorous, 24-hour
(renal losses;
hyperparathyroidism and
hypoparathyroidism)
Porphobilinogens
Porphyrins, quantitative
(to diagnose porphyrias
and lead poisoning)
5 g sodium
carbonate (do
not use
sodium
bicarbonate)
Refrigerate;
protect
specimen
from light
Porphyrins (to diagnose

porphyrias and lead
poisoning)
None
(preservative
is added on
receipt in
laboratory)
Refrigerate;
protect
specimen
from light
None
Refrigerate
during
collection
Pregnanediol, 24-hour
(measures ovarian and
placental function)
Boric acid
Refrigerate
during
collection
Pregnanetriol
(adrenogenital
syndrome)
25 mL of 50%
acetic acid;
for children
<5 y, use 15
mL of 50%
acetic acid
Refrigerate
during
collection;
pH 44.5
after
receipt in
laboratory
Protein electrophoresis,
24-hour
None
Refrigerate
Potassium, 24-hour
(electrolyte imbalance,
renal and adrenal
disorders)
Protein, total
(proteinuria, differential
diagnosis of renal
disease)
None
Refrigerate
during
collection
None
Refrigerate;
transport
entire
specimen
to
laboratory
Sodium, 24-hour
(electrolyte imbalance,
acute renal failure,
oliguria and
hyponatremia, sodium
excreted for diagnosis of
renal and adrenal
imbalances)
None
Refrigerate
during
collection
Substance abuse screen

(specific drugs and
alcohol involved in
substance abuse)
None
Refrigerate
or freeze
Thallium (thallium
toxicity, occupational
exposure)
None
Refrigerate
None
Refrigerate
during
collection
Selenium (nutritional
deficiency, industrial
exposure)
Thiocyanate (short-term
nitroprusside therapy,
cyanide poisoning)
Total protein (renal

disease)
None
Refrigerate
during
collection
Urea nitrogen, 24-hour

(kidney function,
hyperalimentation)
10 g boric
acid
Refrigerate
Uric acid, 24-hour (uric

acid metabolism in gout
and renal calculus
formation)
None
Refrigerate
during
collection
Urobilinogen (liver
function and liver cell
damage)
5 g sodium
carbonate
and 100 mL
petroleum
ether (do not
use sodium
bicarbonate)
Refrigerate
during
collection;
protect
specimen
from light;
check with
laboratory
Vanillylmandelic acid,
quantitative
(adrenomedular
pheochromocytoma,
hypertension)
15 mL of 50%
acetate acid
<5 yrs of age,
25 mL of 50%
acetic acid >5
years of age
Refrigerate,
pH 13;
protect
from light
Zinc (industrial
exposure, toxicity,
nutritional,
20 mL 6N
HNO 3 in a
Refrigerate
acrodermatitis
enteropathies)
metal-free
container
Procedure
1. Ask t he pat ient t o void at t he beginning of a 24-hour t imed urine specimen
collect ion (or any ot her t imed specimen collect ion). Di scard t his f irst
specimen, and not e t he t ime.
2. Mark t he t ime t he t est begins and t he t ime t he collect ion should end on t he
cont ainer. As a reminder, it may be helpf ul t o post a sign above t he t oilet
(eg, 24-Hour Collect ion in Progress), w it h t he beginning and ending t imes
not ed.
3. Collect all urine voided over t he next 24 hours int o a large cont ainer (usually
glass or polyet hylene), and label it w it h t he pat ient 's name, t he t imef rame f or
collect ion, t he t est ordered, and ot her pert inent inf ormat ion. I t is not
necessary t o measure t he volume of individual voidings, unless specif ically
ordered.
4. Ask t he pat ient t o void 24 hours af t er t he f irst voiding, t o conclude t he
collect ion. Add urine f rom t his last voiding t o t he specimen in t he cont ainer.
5. St orage
a. Keep nonref rigerat ed samples in a specif ied area or in t he pat ient 's
bat hroom.
b. Ref rigerat e t he collect ion bot t le immediat ely af t er t he pat ient has voided
or place it int o an iced cont ainer if ref rigerat ion is necessary.
NOTE
Because t he pat ient may not alw ays be able t o void on request , t he last
specimen should be obt ained as closely as possible t o t he st at ed end-t ime of
t he t est .
Special Considerations
1. I n a healt h care f acilit y, responsibilit y f or t he collect ion of urine specimens
should be specif ically assigned.
2. When inst ruct ing a pat ient about 24-hour urine collect ions, make cert ain t he
pat ient underst ands t hat t he bladder must be empt ied just bef ore t he 24-hour
collect ion st art s and t hat t his preliminary specimen must be discarded; t hen,
all urine voided unt il t he ending t ime is saved.
3. Do not predat e and pret ime requisit ions f or serial collect ions. I t is diff icult
f or some pat ient s t o void at specif ic t imes. I nst ead, mark t he act ual t imes of
collect ion on cont ainers.
4. Document at ion of t he exact t imes at w hich t he specimens are obt ained is
crucial t o many urine t est s.
5. I nst ruct t he pat ient t o urinat e as near t o t he end of t he collect ion period as
possible.
6. When a preservat ive is added t o t he collect ion cont ainer (eg, HCl
preservat ive in 24-hour urine collect ion f or vanillylmandelic acid [ VMA] ), t he
pat ient must t ake precaut ions against spilling t he cont ent s and receiving an
acid burn. I nst ruct ions regarding spillage need t o be provided bef ore t he t est
begins.
7. The preservat ive used is det ermined by t he urine subst ance t o be t est ed f or.
The laborat ory usually provides t he cont ainer and t he proper preservat ive
w hen t he t est is ordered. I f in doubt , verif y t his w it h t he laborat ory
personnel.
Interfering Factors
1. Failure of pat ient or at t ending personnel t o f ollow t he procedure is t he most

common source of error.
a. The pat ient should be given bot h verbal and w rit t en inst ruct ions. I f t he
pat ient is unable t o comprehend t hese direct ions, a signif icant ot her
should be inst ruct ed in t he process.
b. I f required, t he proper preservat ive must be used.
2. I nst ruct t he pat ient t o use t oilet paper af ter t ransf erring t he urine t o t he 24hour collect ion cont ainer. Toilet paper placed in t he specimen decreases t he
act ual amount of urine available and cont aminat es t he specimen.
3. The presence of f eces cont aminat es t he specimen. Pat ient s should void f irst
and t ransf er t he urine t o t he collect ion recept acle bef ore def ecat ing.
4. I f heavy menst rual f low or ot her discharges or secret ions are present , t he
t est may have t o be post poned, or an indw elling cat het er may need t o be
insert ed t o keep t he specimen f ree of cont aminat ion. I n some cases,
t horough cleansing of t he perineal or uret hral area bef ore voiding may be
suff icient . I f in doubt , communicat e w it h laborat ory personnel and t he
pat ient 's physician.
Interventions
Pretest Patient Preparation Most 24-hour urine
specimen collections start in the early morning at
about 7:00 a.m. (0700). Instruct the patient to do the
following:
1. Empt y t he bladder complet ely on aw akening and t hen discard t hat urine
specimen. Record t he t ime t he voided specimen is discarded and t he t ime
t he t est is begun.
2. Save all urine voided during t he next 24 hours, including t he f irst specimen
voided t he next morning.
3. Add t he urine voided t he next morning (as close t o t he ending t ime as
possible) t o t he collect ion cont ainer. The 24-hour t est is t hen t erminat ed, and
t he ending t ime is recorded.
4. Use a urinal, w ide-mout h cont ainer, special t oilet device, bedpan, or t he
collect ion cont ainer it self t o cat ch urine. I t is probably easier f or w omen t o
void int o anot her w ide-mout h recept acle
f irst and t hen t o t ransf er t he ent ire specimen caref ul l y t o t he collect ion
bot t le. Men may f ind it simpler t o void direct ly int o t he 24-hour collect ion
cont ainer.
5. I t is most import ant t hat al l urine be saved in t he 24-hour cont ainer. I deally,
t he cont ainer should be ref rigerat ed or placed on ice.
6. Test result s are calculat ed on t he basis of a 24-hour out put . Unless al l urine
is saved, result s w ill not be accurat e. Moreover, t hese t est s are usually
expensive, complicat ed, and necessary f or t he evaluat ion and t reat ment of
t he pat ient 's condit ion.
7. I f t he laborat ory request s an aliquot , record t ot al amount , mix w ell, and
aliquot t he request ed amount .
8. Alw ays check w it h your laborat ory as t o t he preservat ive neededdiff erent
laborat ories may have diff erent requirement s.

ROUTINE URINALYSIS (UA) AND RELATED TESTS

The process of UA det ermines t he f ollow ing propert ies of urine: color, odor,
t urbidit y, specif ic gravit y, pH, glucose, ket ones, blood, prot ein, bilirubin,
urobilinogen, nit rit e, leukocyt e est erase, and ot her abnormal const it uent s
revealed by microscopic examinat ion of t he urine sediment . A 10-mL urine
specimen is usually suff icient f or conduct ing t hese t est s (Table 3. 4).
Table 3.4 Normal Values in Urinalysis
General
Characteristics
and
Measurem ents
Chem ical
Determ inations
Microscopic
Exam ination
of Sedim ent
Color: pale yellow

to amber
Glucose:
negative
Casts
negative:
occasional
hyaline casts
Appearance: clear
to slightly hazy
Ketones:
negative
Red blood
cells: negative
or rare
Specific gravity:
1.0051.025 with a
normal fluid intake
Blood: negative
Crystals:
negative
(none)
pH: 4.58.0;
average person
has a pH of about
5 to 6
Protein:
negative
W hite blood
cells: negative
or rare
Volume: 6002,500
mL/24 h; average
1200 mL/24 h
Bilirubin:
negative
Urobilinogen:
0.54.0 mg/d
Nitrate for
bacteria:
negative
Leukocyte
esterase:
negative
Epithelial
cells: few;
hyaline casts
01/lpf (lowpower field)
Urine Volume
Urine volume measurement s are part of t he assessment f or f luid balance and
kidney f unct ion. The normal volume of urine voided by t he average adult in a 24-
hour period ranges f rom 600 t o

2500 mL; t he t ypical amount is about 1200 mL. The amount voided over any
period is direct ly relat ed t o t he individual's f luid int ake, t he t emperat ure and
climat e, and t he amount of perspirat ion t hat occurs. Children void smaller
quant it ies t han adult s, but t he t ot al volume voided is great er in proport ion t o
t heir body size.
The volume of urine produced at night is <700 mL, making t he day-t o-night rat io
approximat ely 2: 1 t o 4: 1.
Urine volume depends on t he amount of w at er excret ed by t he kidneys. Wat er is
a major body const it uent ; t heref ore, t he amount excret ed is usually det ermined
by t he body's st at e of hydrat ion. Fact ors t hat inf luence urine volume include f luid
int ake, f luid loss f rom nonrenal sources, variat ions in t he secret ion of ant idiuret ic
hormone (ADH), and t he necessit y t o excret e increased amount of solut es such
as glucose or salt s. Pol yuri a is marked increase of urine product ion. O l i guri a is
decreased urinary out put . The ext reme f orm of t his process is anuri a, a t ot al
lack of urine product ion.
Reference Values
Normal
6002500 mL in 24 hours or 6002500 mL/ day
Procedure
1. Collect a 24-hour urine specimen and keep it ref rigerat ed or on ice.
2. Record t he exact collect ion st art ing t ime and collect ion ending t ime on t he
specimen cont ainer and in t he pat ient 's healt h care record.
3. Transf er t he specimen cont ainer t o t he laborat ory ref rigerat or w hen t he
collect ion is complet ed. Complet e t he proper f orms and document
accordingly.
4. Ascert ain volume by measuring t he ent ire urine amount in a graduat ed and
appropriat ely calibrat ed pit cher or ot her recept acle. The t ot al volume is
recorded as urine volume in millilit ers (cubic cent imet ers) per 24 hours.
1. Pol yuri a (increased urine out put ) w it h elevat ed blood urea nit rogen (BUN)
and creat inine levels
a. Diabet ic ket oacidosis
b. Part ial obst ruct ion of urinary t ract

c. Some t ypes of t ubular necrosis (aminoglycoside)
2. Pol yuri a w it h normal BUN and creat inine
a. Diabet es mellit us and diabet es insipidus
b. Neurot ic st at es (compulsive w at er drinking)
c. Cert ain t umors of brain and spinal cord
3. O l i guri a (<200 mL in adult s, or <1520 mL/ kg in children, per 24 hours)
a. Renal causes
1. Renal ischemia
2. Renal disease due t o t oxic agent s (cert ain drugs are t oxic t o t he
renal syst em)
3. G lomerulonephrit is
b. Dehydrat ion caused by prolonged vomit ing, diarrhea, excessive
diaphoresis, or burns
c. O bst ruct ion (mechanical) of some area of t he urinary t ract or syst em
d. Cardiac insuff iciency
4. Anuri a (<100 mL in 24 hours)
a. Complet e urinary t ract obst ruct ion
b. Acut e cort ical necrosis (cort ex of t he kidney)
c. G lomerulonephrit is (acut e, necrot izing)
d. Acut e t ubular necrosis
e. Hemolyt ic t ransf usion react ion
Interfering Factors
1. Polyuria
a. I nt ravenous glucose or saline
b. Pharmacologic agent s such as t hiazides and ot her diuret ics
c. Coff ee, alcohol, t ea, caff eine
2. O liguria
a. Wat er deprivat ion, dehydrat ion
b. Excessive salt int ake
Interventions
1. Explain t he purpose and procedure of t he t est .
2. Wit hhold diuret ics f or 3 days bef ore t he t est . Check w it h clinician.
3. Avoid excessive w at er (liquid) int ake and excessive salt int ake. Advise
pat ient s t o avoid salt y f oods and added salt in t he diet . Eliminat e caff eine
and alcohol. Det ermine t he pat ient 's usual liquid int ake and request t hat
int ake not be increased beyond t his daily amount during t est ing.
4. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, pretest care.

1. Pat ient can resume normal f luid and diet ary int ake and medicat ions, unless
specif ically ordered ot herw ise.
2. I nt erpret t est out comes and counsel appropriat ely.
3. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, posttest care.
Urine Specific Gravity (SG) Specific gravity (SG) is a

measurement of the kidneys' ability to concentrate
urine. The test compares the density of urine against
the density of distilled water, which has an SG of 1.000.
Because urine is a solution of minerals, salts, and
compounds dissolved in water, the SG is a measure of
the density of the dissolved chemicals in the specimen.
As a measurement of specimen density, SG is
influenced by both the number of particles present and
the size of the particles. Osmolality is a more exact
measurement and may be needed in certain
circumstances.
The range of urine SG depends on t he st at e of hydrat ion and varies w it h urine
volume and t he load of solids t o be excret ed under st andardized condit ions;
w hen f luid int ake is rest rict ed or increased, SG measures t he concent rat ing and
dilut ing f unct ions of t he kidney. Loss of t hese f unct ions is an indicat ion of renal
dysf unct ion.
Reference Values
Normal
Normal hydrat ion and volume: 1. 0051. 030 (usually bet w een 1. 010 and 1. 025)
Concent rat ed urine: 1. 0251. 030+
Dilut e urine: 1. 0011. 010
I nf ant < 2 years old: 1. 0011. 018
Procedure
1. Test SG w it h t he use of a mult iple-t est di psti ck t hat has a separat e reagent
area f or SG . An indicat or changes color in relat ion t o ionic concent rat ion,
and t his result is t ranslat ed int o a value f or SG .
2. Det ermine SG w it h a ref ractometer or t ot al solids met er. The ref ract ive index
is t he rat io of t he velocit y of light in air t o t he velocit y of light in t he t est
solut ion. A drop of urine is placed on a clear glass plat e of t he urinomet er
and anot her plat e is pressed on t op of t he urine sample. The pat h of light is
deviat ed w hen it ent ers t he solut ion, and t he degree of deviat ion (ref ract ion)
is direct ly proport ional t o t he densit y of t he solut ion.
3. The uri nometer (hydromet er) is t he least accurat e met hod. I t consist s of a
bulb-shaped inst rument t hat cont ains a scale calibrat ed in SG readings.
Urine (1020 mL) is t ransf erred int o a small t est t ubelike cylinder, and t he
urinomet er is f loat ed in t he urine. The SG is read off t he urinomet er at t he
meniscus level of t he urine. This met hod is becoming obsolet e ow ing t o t he
ease of dipst ick t est ing.
4. Specimen collect ion
a. For regular UA t est ing, about 20 mL of a random sample is needed f or
t est ing (UA including SG ).
b. When a special evaluat ion of SG is ordered separat ely f rom t he UA, t he
pat ient should f ast f or 12 hours bef ore specimen collect ion.
1. Normal SG : SG values usually vary inversely w it h t he amount of urine
excret ed (decreased urine volume = increased SG ). How ever, t his
relat ionship is not valid in cert ain condit ions, including:

a. Diabet esincreased urine volume, increased SG
b. Hypert ensionnormal volume, decreased SG
c. Early chronic renal diseaseincreased volume, decreased SG
2. Hyposthenuri a (low SG , 1. 0011. 010) occurs in t he f ollow ing condit ions:
a. Diabet es insipidus (low SG w it h large urine volume). I t is caused by
absence or decrease of ADH, a hormone t hat t riggers kidney absorpt ion
of w at er. Wit hout ADH, t he kidneys produce excessive amount s of urine
t hat are not reabsorbed (somet imes 1520 L/ day).
b. G lomerulonephrit is (kidney inf lammat ion w it hout inf ect ion) and
phelonephrit is (kidney inf lammat ion w it h bact erial inf ect ion, but not in t he
acut e t ype of t his disease). SG can be low in glomerulonephrit is, w it h
decreased urine volume. Tubular damage aff ect s t he kidneys' abilit y t o
concent rat e urine.
c. Severe renal damage w it h dist urbance of bot h concent rat ing and dilut ing
abilit ies of urine. The SG is low (1. 010) and f ixed (varying lit t le f rom
specimen t o specimen); t his is t ermed i sosthenuri a.
3. Hypersthenuri a (increased SG , 1. 0251. 035) occurs in t he f ollow ing
condit ions:
a. Diabet es mellit us
b. Nephrosis
c. Excessive w at er loss (dehydrat ion, f ever, vomit ing, diarrhea)
d. I ncreased secret ion of ADH and diuret ic eff ect s relat ed t o t he st ress of a
surgical procedure
e. Congest ive heart f ailure
f. Toxemia of pregnancy
Interfering Factors
1. Radiopaque x-ray cont rast media, minerals, and dext ran may cause f alsely
high SG readings on t he ref ract omet er. The reagent dipst ick met hod is not
aff ect ed by high-molecular-w eight subst ances.
2. Temperat ure of urine specimens aff ect s SG ; cold specimens produce f alsely
high values using t he hydromet er.
3. Highly buff ered alkaline urine may also cause low readings (w it h dipst icks
only).
4. Elevat ed readings may occur in t he presence of moderat e amount s of prot ein

(100750 mg/ dl) or w it h pat ient s receiving int ravenous albumin.
5. Det ergent residue (on specimen cont ainers) can produce elevat ed SG
result s.
6. Diuret ics and ant ibiot ics cause high readings.
Intervention
1. Explain t he purpose and procedure f or urine collect ion.

1. I nt erpret t est out comes, counsel, and monit or appropriat ely f or condit ions
associat ed w it h alt ered SG .
Urine Osmolality
O smolalit y, a more exact measurement of urine concent rat ion t han SG , depends
on t he number of part icles of solut e in a unit of solut ion. More inf ormat ion
concerning renal f unct ion can be obt ained if serum and urine osmolalit y t est s are
run at t he same t ime. The normal rat io bet w een urine and serum osmolalit y is
3: 1. A high urine-t o-serum rat io is seen w it h concent rat ed urine. Wit h poor
concent rat ing abilit y, t he rat io is low.
Whenever a precise measurement is indicat ed t o evaluat e t he concent rat ing and
dilut ing abilit y of t he kidney, t his t est is done. Urine osmolalit y during w at er
rest rict ion is an accurat e t est of decreased kidney f unct ion. I t is also used t o
monit or t he course of renal disease; t o monit or f luid and elect rolyt e t herapy; t o
est ablish t he diff erent ial diagnosis of hypernat remia, hyponat remia, and polyuria;
and t o evaluat e t he renal response t o ADH.
Reference Values
Normal
24-hour specimen: 300900 mO sm/ kg of H2 O

Random specimen: 501200 mO sm/ kg of H2 O
Urine-t o-serum rat io: 1: 1 t o 3: 1
Procedure
1. Tell pat ient t hat t his is a 24-hour urine collect ion t est .
2. For t he 24-hour t est , t he pat ient voids at approximat ely 7: 00 a. m. (0700). All
of t he urine voided is saved in a special 24-hour collect ion cont ainer kept on
ice or ref rigerat ed. A high-prot ein diet may be ordered.
3. At t he end of t he t est , t he specimen is labeled and sent t o t he laborat ory.
4. Simult aneous det erminat ion of serum osmolalit y may be done. A high urinet o-serum rat io is seen w it h concent rat ed urine.
1. O smolalit y is i ncreased in:
a. Prerenal azot emia
c. Addison's disease
d. Syndrome of inappropriat e ADH secret ion (SI ADH)
e. Dehydrat ion
f. Amyloidosis
g. Hyponat remia
2. O smolalit y is decreased in:
a. Acut e renal f ailure
b. Diabet es insipidus
c. Hypokalemia
d. Hypernat remia
e. Primary polydipsia
f. Hypercalcemia
g. Compulsive w at er drinking (increased f luid int ake)
3. Urine-t o-serum rat io is:
a. Increased in prerenal azot emia

b. Decreased in acut e t ubular necrosis
Interfering Factors
1. I nt ravenous sodium administ rat ion
2. I nt ravenous dext rose and w at er administ rat ion
Interventions
1. Explain purpose and procedure of t he t est t o t he pat ient .
2. A normal diet is prescribed f or 3 days bef ore t est ing.
3. To increase sensit ivit y of t he osmolalit y t est , a high-prot ein diet may be
ordered f or 3 days bef ore t he t est . No liquids w it h t he evening meal and no
f ood or liquids should be t aken af t er t he evening meal unt il collect ion. Check
w it h your laborat ory if t he pat ient has diabet es.

1. Provide t he pat ient w it h f oods and f luids as soon as t he last urine sample is
obt ained.
3. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, posttest care.
Urine Appearance
The f irst observat ion made about a urine specimen is usually it s appearance,
w hich generally ref ers t o t he clarit y of t he specimen.
Cloudy urine signals a possible abnormal const it uent , such as w hit e blood cells
(WBCs), RBCs, or bact eria. O n t he ot her hand, excret ion of cloudy urine may not
be abnormal because a change in urine pH can cause precipit at ion, w it hin t he
bladder, of normal urinary component s. Alkaline urine may appear cloudy
because of phosphat es; acid urine may appear cloudy because of urat es.
Reference Values
Normal
Fresh urine is clear t o slight ly hazy.
Procedure
1. O bserve t he clarit y of a f resh urine sample by visually examining a w ellmixed specimen in f ront of a light source.
2. Use common t erms t o report appearance, including t he f ollow ing: clear, hazy,
slight ly cloudy, cloudy, t urbid, and milky.
3. Document result s. The degree of t urbidit y should correspond t o t he amount
of mat erial observed under t he microscope.
1. Pat hologic urines are of t en t urbid or cloudy; how ever, normal urine can also
appear cloudy.
2. Urine t urbidit y may result f rom urinary t ract inf ect ions (UTI s).
3. Urine may be cloudy because of t he presence of RBCs, WBCs, epit helial
cells, or bact eria.
Interfering Factors
1. Af t er ingest ion of f ood, urat es, carbonat es, or phosphat es may produce
cloudiness in normal urine on st anding.
2. Semen or vaginal discharges mixed w it h urine are common causes of
t urbidit y.
3. Fecal cont aminat ion causes t urbidit y.
4. Ext raneous cont aminat ion (eg, t alcum, vaginal creams, radiographic cont rast
media) can cause t urbidit y.
5. G reasy cloudiness may be caused by large amount s of f at .
6. O f t en, normal urine develops a haze or t urbidit y af t er ref rigerat ion or
st anding at room t emperat ure because of precipit at ion of cryst als of calcium
oxalat e or uric acid.
Urine Color
The yellow color of urine is caused by t he presence of t he pigment urochrome, a
product of met abolism t hat under normal condit ions is produced at a const ant
rat e. The act ual amount of urochrome produced depends on t he body's met abolic
st at e, w it h increased amount s being produced in t hyroid condit ions and f ast ing
st at es.
Urine specimens may vary in color f rom pale yellow t o dark amber. Variat ions in
t he yellow color are relat ed t o t he body's st at e of hydrat ion. The darker amber
color may be direct ly relat ed t o t he urine concent rat ion or SG .
Reference Values
Normal
The normal color of urine is pale yellow t o amber.
Straw-col ored urine is normal and indicat es a low SG , usually < 1. 010. (The
except ion may be a pat ient w it h an elevat ed blood glucose concent rat ion, w hose
urine is very pale yellow but has a high SG . )
Amber-col ored urine is normal and indicat es a high SG and a small out put of
urine.
Procedure
O bserve and record t he color of f reshly voided urine.
1. Almost col orl ess (st raw -colored) urine:
a. Large f luid int ake
b. Chronic int erst it ial nephrit is
c. Unt reat ed diabet es mellit us
d. Diabet es insipidus
e. Alcohol and caff eine ingest ion
f. Diuret ic t herapy
g. Nervousness
2. O range-col ored (amber) urine:
a. Concent rat ed urine caused by f ever, sw eat ing reduced f luid int ake, or
f irst morning specimen
b. Bilirubin (yellow f oam w hen shaken)

c. Carrot s or vit amin A ingest ion (large amount s)
d. Cert ain urinary t ract medicat ions (eg, phenazopyridine [ Pyridium] ,
nit rof urant oin)
3. Browni sh-yel l ow or greeni sh-yel l ow urine may indicat e bilirubin in t he urine
t hat has been oxidized t o biliverdin (greenish f oam w hen shaken).
4. G reen urine:
a. Pseudomonal inf ect ion
b. I ndican
c. Chlorophyll
5. Pi nk to red urine:
a. RBCs
b. Hemoglobin, met hemoglobin, oxyhemoglobin
c. Myoglobin
d. Porphyrins
6. Brown-bl ack urine:
a. RBCs oxidized t o met hemoglobin
b. Met hemoglobin
c. Homogent isic acid (alkapt onuria)
d. Melanin or melanogen
e. Phenol poisoning (Lysol)
7. Smoky urine may be caused by RBCs.
8. Mi l ky urine is associat ed w it h f at , cyst inuria, many WBCs, or phosphat es
(not pat hologic).
Interfering Factors
1. Normal urine color darkens on st anding because of t he oxidat ion of
urobilinogen t o urobilin. This decomposit ion process st art s about 30 minut es
af t er voiding.
2. Some f oods cause changes in urine color:
a. Beet s t urn t he urine red.
b. Rhubarb can cause brown urine.
3. Many drugs alt er t he color of urine:

a. Cascara and senna laxat ives in t he presence of acid urine t urn t he urine
reddi sh brown; in t he presence of alkaline urine, t hey t urn t he urine red.
b. Bri ght-yel l ow color in alkaline urine may be a result of ribof lavin or
phenazopyridine.
c. Urine t hat darkens on st anding may indicat e ant iparkinsonian agent s such
as levodopa (Sinemet ).
d. Bl ack urine may be caused by cascara, chloroquine, iron salt s (f errous
sulf at e, f errous f umarat e, f errous gluconat e), met ronidazole,
nit rof urant oin, quinine, or senna.
e. Bl ue urine may be caused by t riamt erene.
f. Bl ue-green urine may be caused by amit ript yline, met hylene blue, or
mit oxant rone.
g. O range urine may be caused by heparin, phenazopyridine, rif ampin,
sulf asalazine, or w arf arin.
h. Red-pi nk urine may be caused by chloroxazone, daunorubicin,
doxorubicin, heparin, ibuprof en, met hyldopa, phenyt oin, rif ampin, or
senna.
i. Pi nk to brown urine may be caused by laxat ives.
j. Brown urine may be caused by chloroquine, f urazolidone, or primaquine.
k. G reen urine may be caused by indomet hacin.
Interventions
Pretest Patient Preparation Assess color of urine;
instruct patient to monitor and to report abnormal urine
colors.
Clin ical Alert
1. I f t he urine is a red color, do not assume drug causat ion. Check t he urine
f or hemoglobin. Q uest ion t he pat ient regarding hemat uria and recent
act ivit y, injury, or inf ect ion. Somet imes, vigorous exercise can bring on
hemat uria.
2. Red urine t hat is negat ive f or occult blood is an indicat ion t hat porphyria
may be present . Report at once and document t est result s.
3. O t her grossly abnormal colors (eg, black, brow n) should be document ed
and report ed.

1. I nt erpret abnormal urine colors and counsel appropriat ely.
2. Explain t hat f ollow -up t est ing may be needed.
Urine Odor
Normal, f reshly voided urine has a f aint odor ow ing t o t he presence of volat ile
acids. I t is not generally off ensive. Alt hough not part of t he rout ine UA, abnormal
odors should be not ed.
Reference Values
Normal
Fresh urine f rom most healt hy persons has a charact erist ic aromat ic odor.
Procedure
Smell t he urine and record percept ions.
1. The urine of pat ient s w it h diabet es mellit us may have a f ruit y (acet one) odor
because of ket osis.
2. UTI s result in f oul-smelling urine because of t he presence of bact eria, w hich
split urea t o f orm ammonia.
3. The urine of inf ant s w it h an inherit ed disorder of amino acid met abolism
know n as maple syrup urine disease smells like maple or burnt sugar.
4. Cyst inuria and homocyst inuria result in a sulf urous odor.
5. O ast house urine (Smit h-St rang) disease causes an odor associat ed w it h t he
smell of a brew ery (yeast s, hops).
6. I n phenylket onuria, a must y, mousy smell may be evident .
7. Tyrosinemia is charact erized by a cabbage-like or f ishy urine odor.
8. But yric/ hexanoic acidemia produces a urine odor resembling t hat of sw eat y
f eet .
Interfering Factors
1. Some f oods, such as asparagus, produce charact erist ic urine odors.
2. Bact erial act ivit y produces ammonia f rom t he decomposit ion of urea, w it h it s
charact erist ic pungent odor.
Urine pH
The symbol pH expresses t he urine as a dilut e acid or base solut ion and
measures t he f ree hydrogen ion (H+ ) concent rat ion in t he urine; 7. 0 is t he point
of neut ralit y on t he pH scale. The low er t he pH, t he great er t he acidit y; t he
higher t he pH, t he great er t he alkalinit y. The pH is an indicat or of t he renal
t ubules' abilit y t o maint ain normal hydrogen ion concent rat ion in t he plasma and
ext racellular f luid. The kidneys maint ain normal acid-base balance primarily
t hrough reabsorpt ion of sodium and t ubular secret ion of hydrogen and ammonium
ions. Secret ion of an acid or alkaline urine by t he kidneys is one of t he most
import ant mechanisms t he body has f or maint aining a const ant body pH.
Urine becomes increasingly acidic as t he amount of sodium and excess acid
ret ained by t he body increases. Alkaline urine, usually cont aining bicarbonat ecarbonic acid buff er, is normally excret ed w hen t here is an excess of base or
alkali in t he body.
The import ance of urinary pH lies primarily in det ermining t he exist ence of
syst emic acid-base disorders of met abolic or respirat ory origin and in t he
management of urinary condit ions t hat require t he urine t o be maint ained at a
specif ic pH.
Control of Urine pH
Cont rol of urinary pH is import ant in t he management of several diseases,
including bact eriuria, renal calculi, and drug t herapy in w hich st rept omycin or
met henamine mandelat e is being administ ered.
1. Renal cal cul i
a. Renal st one f ormat ion part ially depends on t he pH of urine. Pat ient s
being t reat ed f or renal calculi are f requent ly given diet s or medicat ion t o
change t he pH of t he urine so t hat kidney st ones w ill not f orm.
b. Calcium phosphat e, calcium carbonat e, and magnesium phosphat e st ones
develop in alkaline urine. I n such inst ances, t he urine must be kept acidic
(see Diet , number 4, below ).
c. Uric acid, cyst ine, and calcium oxalat e st ones precipit at e in acid urines.
Theref ore, as part of t reat ment , t he urine should be kept alkaline (see
Diet , number 4, below ).

2. Drug treatment
a. St rept omycin, neomycin, and kanamycin are eff ect ive f or t reat ing
genit ourinary t ract inf ect ions, provided t he urine is alkaline.
b. During sulf a t herapy, alkaline urine should help prevent f ormat ion of
sulf onamide cryst als.
c. Urine should also be kept persist ent ly alkaline in t he presence of
salicylat e int oxicat ion (t o enhance excret ion) and during blood
t ransf usions.
3. Cl i ni cal condi ti ons
a. The urine should be kept acidic during t reat ment of UTI or persist ent
bact eriuria and during management of urinary calculi t hat develop in
alkaline urine.
b. An accurat e measurement of urinary pH can be made only on a f reshly
voided specimen. I f t he urine must be kept f or any lengt h of t ime bef ore
analysis, it must be ref rigerat ed.
c. Highly concent rat ed urine, such as t hat f ormed in hot , dry environment s,
is st rongly acidic and may produce irrit at ion.
d. During sleep, decreased pulmonary vent ilat ion causes respirat ory
acidosis; as a result , urine becomes more acidic.
e. Chlorot hiazide diuret ic administ rat ion causes acid urine t o be excret ed.
f. Bact eria f rom a UTI or f rom bact erial cont aminat ion of t he specimen
produce alkaline urine. Urea is convert ed t o ammonia.
4. Di et
a. A veget arian diet t hat emphasizes cit rus f ruit s and most veget ables,
part icularly legumes, helps keep t he urine alkaline. Alkaline urine af t er
meals is a normal response t o t he secret ions of hydrochloric acid in
gast ric juice (alkaline t ide).
b. A diet high in meat and prot ein keeps t he urine acidic.
c. Cranberry juice is t he only f ruit t hat w ill maint ain an acidic urine, and it
has long been used as a remedy f or minor UTI s.
Reference Values
Normal
The pH of normal urine can vary w idely, f rom 4. 6 t o 8. 0.
The average pH value is about 6. 0 (acidic).
Procedure
1. Use reagent st rips f or a dipst ick measurement . They produce a spect rum of
color changes f rom orange t o green-blue t o ident if y pH ranges f rom 5. 0 t o
9. 0.
2. Dip t he reagent st rip int o a f reshly voided urine specimen, and compare t he
color change w it h t he st andardized color chart on t he bot t le t hat correlat es
color result s w it h pH values.
3. Maint enance of t he urine at a consist ent pH requires f requent urine pH
t est ing.
To be usef ul , the uri ne pH measurement must be used i n conjuncti on wi th other
di agnosti c i nf ormati on. For example, in renal t ubular necrosis, t he kidney is not
able t o excret e a urine t hat is st rongly acidic. Theref ore, if t he urine pH is 5. 0,
renal t ubular necrosis is eliminat ed as a possible diagnosis.
1. Aci di c uri ne (pH < 7. 0) occurs in:
a. Met abolic acidosis, diabet ic ket osis, diarrhea, st arvat ion, uremia
b. UTI s caused by Escheri chi a col i
c. Respirat ory acidosis (carbon dioxide ret ent ion)
d. Renal t uberculosis
e. Pyrexia
2. Al kal i ne uri ne (pH > 7. 0) occurs in:
a. UTI s caused by urea-split t ing bact eria (Proteus and Pseudomonas)
b. Renal t ubular acidosis, chronic renal f ailure
c. Met abolic acidosis (vomit ing)
d. Respirat ory alkalosis involving hypervent ilat ion (blow ing off carbon
dioxide)
e. Pot assium deplet ion
Interfering Factors
1. Wit h prolonged st anding, t he pH of a urine specimen becomes alkaline
because bact eria split urea and produce ammonia.

2. Ammonium chloride and mandelic acid may produce acid urines.
3. Runover bet w een t he pH t est ing area and t he highly acidic prot ein area on
t he dipst icks may cause alkaline urine t o give an acidic reading.
4. Sodium bicarbonat e, pot assium cit rat e, and acet azolamide may produce
alkaline urine.
5. Urine becomes alkaline af t er eat ing because of excret ion of st omach acid;
t his is know n as t he alkaline t ide.
Clin ical Alert

The pH of urine never reaches 9, eit her in normal or abnormal condit ions.
Theref ore, a pH f inding of 9 indicat es t hat a f resh specimen should be
obt ained t o ensure t he validit y of t he UA.
Interventions
1. Explain t est purpose and specimen collect ion procedure.

1. I nt erpret t est out comes and monit or pat ient appropriat ely (see Cont rol of
Urine pH).
Urine Blood or Hemoglobin (Hb) The presence of free

hemoglobin in the urine is referred to as
hemoglobinuria. Hemoglobinuria can be related to
conditions outside the urinary tract and occurs when
there is such extensive or rapid destruction
(intravascular hemolysis) of circulating erythrocytes
that the reticuloendothelial system cannot metabolize
or store the excess free hemoglobin. The hemoglobin

is then filtered through the glomerulus. Hemoglobinuria
may also occur as a result of lysis of RBCs in the
urinary tract.
When int act RBCs are present in t he urine, t he t erm hematuri a is used.
Hemat uria is most closely relat ed t o disorders of t he renal or genit ourinary
syst ems in w hich bleeding is t he result of t rauma or damage t o t hese organs or
syst ems.
This t est det ect s RBCs, hemoglobin, and myoglobin in urine. Blood in urine is
al ways an indicat or of damage t o t he kidney or urinary t ract .
The use of bot h a urine dipst ick measurement and microscopic examinat ion of
urine provides a complet e clinical evaluat ion of hemoglobinuria and hemat uria.
New er f orms of dipst icks cont ain a lysing reagent t hat react s w it h occult blood
and det ect s int act as w ell as lysed RBCs.
When urine sediment is posit ive f or occult blood but no RBCs are seen
microscopically, myogl obi nuri a can be suspect ed. Myoglobinuria is caused by
excret ion of myoglobin, a muscle prot ein, int o t he urine as a result of (1)
t raumat ic muscle injury, such as may occur in aut omobile accident s, f oot ball
injuries, or elect ric shock; (2) a muscle disorder, such as an art erial occlusion t o
a muscle or muscular dyst rophy; (3) cert ain kinds of poisoning, such as carbon
monoxide or f ish poisoning; or (4) malignant hypert hermia relat ed t o
administ rat ion of cert ain anest het ic agent s. Myoglobin can be dist inguished f rom
f ree hemoglobin in t he urine by chemical t est s.
Reference Values
Normal
Negat ive/ none
Procedure
1. Collect a f resh, random urine specimen.
a. Hemogl obi nuri a (hemoglobin in urine)
1. Dip reagent st icks int o t he urine; t he color change on t he dipst ick
correlat es w it h a st andardized color chart specif ically used w it h t hat
part icular t ype of dipst ick.
2. The color chart indicat es color gradient s f or negat ive, moderat e, and
large amount s of hemoglobin.
b. Hematuri a (RBCs in urine)

1. This dipst ick met hod allow s det ect ion of int act RBCs w hen t he
number is great er t han 10 cells/ L of urine. The color change
appears st ippled on t he dipst ick.
2. The degree of hemat uria can be est imat ed by t he int ensit y of t he
speckled pat t ern.
2. Cent rif uge t he urine sample and examine t he sediment microscopically (see
Microscopic Examinat ion of Urine Sediment) t o verif y t he presence of RBCs.
a. Hemoglobinuria is suspect ed w hen no RBCs are seen or t he number seen
does not correspond t o t he degree of color on t he dipst ick.
b. Myoglobinemia may be suspect ed if t he urine is cherry-red, no RBCs are
seen, and blood serum enzymes f or muscle dest ruct ion are elevat ed.
1. Hematuri a is f ound in:
a. Acut e UTI (cyst it is)
b. Lupus nephrit is
c. Urinary t ract or renal t umors
d. Urinary calculi (int ermit t ent hemat uria)
e. Malignant hypert ension
f. G lomerulonephrit is (acut e or chronic)
g. Pyelonephrit is
h. Trauma t o kidneys
i. Polycyst ic kidney disease
j. Leukemia
k. Thrombocyt openia
l. St renuous exercise
m. Benign f amilial or recurrent hemat uria (asympt omat ic hemat uria w it hout
prot einuria; ot her clinical and laborat ory dat a are normal)
n. Heavy smokers
2. Hemogl obi nuri a is f ound in:
a. Ext ensive burns
b. Transf usion react ions (incompat ible blood product s)
c. Febrile int oxicat ion

d. Cert ain chemical agent s and alkaloids (poisonous mushrooms, snake
venom)
e. Malaria
f. Bleeding result ing f rom operat ive procedures on t he prost at e (can be
diff icult t o cont rol, especially in t he presence of malignancies)
g. Hemolyt ic disorders such as sickle cell anemia, t halassemia, and
glucose-6-phosphat e dehydrogenase def iciency
h. Paroxysmal hemoglobinuria (large quant it ies of hemoglobin appear in
urine at irregular int ervals)
i. Kidney inf arct ion
j. Hemolysis occurring w hile t he urine is in t he urinary t ract (RBC lysis f rom
hypot onic urine or alkaline urine)
k. Fava bean sensit ivit y (causes severe hemolyt ic anemia)
l. Disseminat ed int ravascular coagulat ion (DI C)
m. St renuous exercise (march hemoglobinuria)
Clin ical Alert

O ne of t he early indicat ors of possible renal or urinary t ract disease is t he
appearance of blood in t he urine. This does not mean t hat blood w ill be
present in every voided specimen, but in most cases of renal or urinary t ract
disease, occult blood w ill appear in t he urine w it h a reasonable degree of
f requency. Any posit ive t est f or blood should be rechecked on a new urine
specimen. I f blood st ill appears, t he pat ient should be f urt her evaluat ed.
Interfering Factors
1. Drugs causing a posit ive result f or blood or hemoglobin include:
a. Drugs t oxic t o t he kidneys (eg, bacit racin, amphot ericin)
b. Drugs t hat alt er blood clot t ing (w arf arin [ Coumadin] )
c. Drugs t hat cause hemolysis of RBCs (aspirin)
d. Drugs t hat may give a f alse-posit ive result (eg, bromides, copper,
iodides, oxidizing agent s)
2. High doses of ascorbic acid or vit amin C may cause a f alse-negat ive result .
3. High SG or elevat ed prot ein reduces sensit ivit y.
4. Myoglobin produces a f alse-posit ive result .

5. Hypochlorit es or bleach used t o clean urine cont ainers causes f alse-posit ive
result s.
6. Menst rual blood may cont aminat e t he specimen and alt er result s.
7. Prost at ic inf ect ions may cause f alse-posit ive result s.
8. See Appendix J f or a complet e list of drugs t hat aff ect t est out comes.
Interventions
1. Explain t est purpose and procedure f or urine specimen collect ion.

1. I nt erpret t est out comes and explain possible need f or f ollow -up t est ing.
Urine Protein (Albumin), Qualitative and 24-Hour The

presence of increased amounts of protein in the urine
can be an important indicator of renal disease. It may
be the first sign of a serious problem and may appear
before any other clinical symptoms. However, there are
other physiologic conditions (eg, exercise, fever) that
can lead to increased protein excretion in urine. Also,
there are some renal disorders in which proteinuria is
absent.
I n a healt hy renal and urinary t ract syst em, t he urine cont ains no prot ein or only
t race amount s. These consist of albumin (one t hird of normal urine prot ein is
albumin) and globulins f rom t he plasma. Because albumin is f ilt ered more readily
t han t he globulins, it is usually abundant in pat hologic condit ions. Theref ore, t he
t erm al bumi nuri a is of t en used synonymously w it h protei nuri a.
Normally, t he glomeruli prevent passage of prot ein f rom t he blood t o t he
glomerular f ilt rat e. Theref ore, t he presence of prot ein in t he urine is t he si ngl e
most i mportant i ndi cati on of renal disease. I f more t han a t race of prot ein is
f ound persist ent ly in t he urine, a quant it at ive 24-hour evaluat ion of prot ein
excret ion is necessary.
Reference Values for 24-Hour Urine
Normal
Adult male: 10140 mg/ L or 114 mg/ dL
Adult f emale: 30100 mg/ L or 310 mg/ dL
Child: <10 years old: 10100 mg/ L or 110 mg/ dL
Reference ValuesQualitative
Normal
Negat ive
Procedure
Qualitative Protein Collection
1. Collect a random urine sample in a clean cont ainer and t est it as soon as
possible.
2. Use a prot ein reagent dipst ick and compare t he t est result color w it h t he
color comparison chart provided on t he reagent st rip bot t le. Prot ein can also
be det ect ed by t urbidimet ric met hods using sulf osalicylic acid.
3. Test a new second specimen and invest igat e any int erf ering f act ors if one of
t hese met hods produces posit ive result s. A 24-hour urine t est may t hen be
ordered f or a quant it at ive measurement of prot ein.
24-Hour Urine Protein Collection

1. Label a 24-hour urine cont ainer w it h t he name of t he pat ient , t he t est , and
t he dat e and t ime t he t est is st art ed.
2. Ref rigerat e t he specimen as it is being collect ed.
3. See general inst ruct ions f or 24-hour urine collect ion list ed (see Long-Term,
Timed Urine Specimen, page 171).
4. Record t he exact st art ing and ending t imes f or t he 24-hour collect ion on t he
specimen cont ainer and on t he pat ient 's record. (The usual st art ing and
ending t imes are 0700 t o 0700. )
1. Prot einuria occurs by t w o main mechanisms: damage t o t he glomeruli or a
def ect in t he reabsorpt ion process t hat occurs in t he t ubules.
a. G l omerul ar damage
1. G lomerulonephrit is, acut e and chronic
2. Syst emic lupus eryt hemat osus (SLE)
3. Malignant hypert ension
4. Amyloidosis
5. Diabet es mellit us
7. Polycyst ic kidney disease
b. Di mi ni shed tubul ar reabsorpti on
1. Renal t ubular disease
2. Pyelonephrit is, acut e and chronic
3. Cyst inosis
4. Wilson's disease
5. Fanconi's syndrome (def ect of proximal t ubular f unct ion)
6. I nt erst it ial nephrit is
2. I n pat hologic st at es, t he level of prot einuria is rarely const ant , so not every
sample of urine is abnormal in pat ient s w it h renal disease, and t he
concent rat ion of prot ein in t he urine is not necessarily indicat ive of t he
severit y of renal disease.
3. Prot einuria may result f rom glomerular blood f low changes w it hout t he
presence of a st ruct ural abnormalit y, as in congest ive heart f ailure.
4. Prot einuria may be caused by increased serum prot ein levels.
a. Mult iple myeloma (Bence Jones prot ein)
b. Waldenst rm's macroglobulinemia
c. Malignant lymphoma
5. Prot einuria can occur in ot her nonrenal disease (f unct ional prot einuria)
a. Acut e inf ect ion, sept icemia

b. Trauma, st ress
c. Leukemia, hemat ologic disorders
d. Toxemia, preeclampsia of pregnancy
e. Hypert hyroidism
f. Vascular disease (hypert ension), cardiac disease
g. Renal t ransport reject ion
h. Cent ral nervous syst em lesions
i. Poisoning f rom t urpent ine, phosphorus, mercury, gold, lead, phenol,
opiat es, or ot her drugs
j. Heredit ary, sickle cell, oxalosis
6. Large numbers of leukocyt es accompanying prot einuria usually indicat e
inf ect ion at some level in t he urinary t ract . Large numbers of bot h leukocyt es
and eryt hrocyt es indicat e a noninf ect ious inf lammat ory disease of t he
glomerulus. Prot einuria associat ed w it h pyelonephrit is may have as many
RBCs as WBCs.
7. Prot einuria does not alw ays accompany renal disease.
a. Pyelonephrit is
b. Urinary t ract obst ruct ions
c. Nephrolit hiasis
d. Tumors
e. Congenit al malf ormat ions
f. Renal art ery st enosis
8. Prot einuria is of t en associat ed w it h t he f inding of cast s on sediment
examinat ion because prot ein is necessary f or cast f ormat ion.
9. Post ural prot einuria result s f rom t he excret ion of prot ein by some pat ient s
w hen t hey st and or move about . This t ype of prot einuria is int ermit t ent and
disappears w hen t he pat ient lies dow n. Post ural prot einuria occurs in 3% t o
15% of healt hy young adult s. I t is also know n as orthostati c protei nuri a.
Collecting the Specimen for Orthostatic Proteinuria

1. The pat ient is inst ruct ed t o void at bedt ime and t o discard t his urine.
2. The next morning, a urine specimen is collect ed immediat ely af t er t he pat ient
aw akens and bef ore t he pat ient has been in an upright posit ion f or longer
t han 1 minut e. This may involve t he use of a bedpan or urinal.

3. A second specimen is collect ed af t er t he pat ient has been st anding or
w alking f or at least 2 hours.
4. Wit h post ural prot einuria, t he f irst specimen cont ains no prot ein, but t he
second one is posit ive f or prot ein.
5. The urine looks microscopically normal; no RBCs or WBCs are apparent .
O rt host at ic prot einuria is considered a benign condit ion and slow ly
disappears w it h t ime. Progressive renal impairment usually does not occur.
Clin ical Alert

1. Prot einuria of > 2000 mg/ 24 hours in an adult or 40 mg/ 24 hours in a
child usually indicat es a glomerular cause.
2. Prot einuria of > 3500 mg/ 24 hours point s t o a nephrot ic syndrome.
Interfering Factors for Qualitative Protein Test

1. Because of renal vasoconst rict ion, t he presence of a f unct ional, mild, and
t ransit ory prot einuria is associat ed w it h:
a. St renuous exercise up t o 300 mg/ 24 hours
b. Severe emot ional st ress, seizures
c. Cold bat hs, exposure t o very cold t emperat ures
2. I ncreased prot ein in urine occurs in t hese benign st at es:
a. Fever and dehydrat ion (salt deplet ion)
b. Nonimmunoglobulin E f ood allergies
c. Salicylat e t herapy
d. I n t he premenst rual period and immediat ely af t er delivery
3. False or accident al prot einuria may occur because of a mixt ure of pus and
RBCs in t he urinary t ract relat ed t o inf ect ions, menst rual or vaginal
discharge, mucus, or semen.
4. False-posit ive result s can occur f rom incorrect use and int erpret at ion of t he
color reagent st rip t est .
5. Alkaline, highly buff ered urine can produce f alse-posit ive result s on t he
dipst ick t est .
6. Very dilut e urine may give a f alsely low prot ein value.
7. Cert ain drugs may cause f alse-posit ive or f alse-negat ive urine prot ein t est s
(see Appendix J).
8. Radiographic cont rast agent s may produce f alse-posit ive result s w it h
t urbidimet ric measurement s.
Interventions
1. I nst ruct t he pat ient about t he purpose and procedure f or collect ion of t he 24hour urine specimen. Emphasize t he import ance of compliance w it h t he
procedure.
2. Food and f luids are permit t ed; how ever, f luids should not be f orced because
very dilut e urine can produce f alse-negat ive values.

1. I nt erpret t est out comes and explain t he possible need f or f ollow -up t est ing
(eg, urine diff erent ial/ elect rophoresis) and t reat ment (t o prevent progression
t o renal f ailure).
2. See guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed posttest care .
3. See Chapt er 8 f or prot ein elect rophoresis.
Microalbuminuria/Albumin (24-Hour Urine)

Microalbuminuria is an increase in urinary albumin that
is below the detectable range of the standard protein
dipstick test. It is not a different chemical form of
albumin. Microalbuminuria occurs long before clinical
proteinuria becomes evident.
This t est allow s f or t he rout ine det ect ion of low concent rat ions of albumin in t he
urine. This t est has become a st andard f or t he screening, monit oring, and
det ect ion of det eriorat ing renal f unct ion in diabet ic pat ient s. St udies have show n
t hat diabet ic pat ient s w ho progress t o renal
f ailure f irst excret e micro amount s of albumin and t hat , at t his st age, int ervening
t reat ment can reverse t he prot einuria and t hus prevent progression t o renal
f ailure. This t est is also used t o monit or compliance of blood pressure cont rol,
glucose cont rol, and prot ein rest rict ion.
Reference Values
Normal
<30 mg/ 24 hours (<30 mg/ day) or < 20 mg/ L (10-hour collect ion)
Procedure
1. 24-hour: Same as f or t ot al urine prot ein
2. 10-hour: O vernight collect ion
a. Last voiding bef ore sleep (10: 00 p. m. )
b. Collect all urine at f irst morning voiding (8: 00 a. m. )
These result s approximat e 24-hour collect ion.
I ncreased microalbuminuria is associat ed w it h:
1. Diabet es w it h early diabet ic nephropat hy
2. Hypert ensionheart disease
3. G eneralized vascular disease
4. Preeclampsia
Interfering Factors
1. St renuous exercise
2. Hemat uria (menses)
3. High-prot ein diet or high salt levels
Interventions
Pretest Patient Preparation The pretest care is the
same as for 24-hour protein.

1. Albumin excret ion > 30 mg/ 24 hours or > 20 mg/ L/ 10 hours indicat es an
abnormal excret ion.
a. Pat ient management should be review ed.
b. Pat ient compliance can be checked by glycosylat ed hemoglobin t o
det ermine f urt her cont rol.
2. Pat ient s w it h borderline result s should be assessed on more t han one
occasion bef ore t he signif icance of a given urine measurement is f inally
judged.
3. The posttest care is t he same as f or 24-hour t ot al prot ein.
Urine 2 -Microglobulin 2 -Microglobulin, an amino acid

peptide component of the lymphatic human lymphocyte
antibody (HLA) complex, is found on the outside of the
plasma membrane. It is structurally related to the
immunoglobulins.
This t est measures 2 -microglobulin, w hich is nonspecif ically increased in
inf lammat ory condit ions and in act ive chronic lymphat ic leukemia. I t may be used
t o diff erent iat e glomerular f rom t ubular dysf unct ion. I n glomerular disease, 2 microglobulin is increased in serum and decreased in urine, w hereas in t ubular
disorders, it is decreased in serum and increased in urine. I n aminoglycoside
t oxicit y, 2 -microglobulin levels become abnormal bef ore creat inine levels begin
t o show abnormal values. Serum is also used t o evaluat e t he prognosis of
mult iple myeloma.
Reference Values
Normal
Urine 24-hour specimen: <1 mg/ day Blood serum specimen: <2. 7 g/ mL or <2. 7
mg/ L
Procedure
1. Collect a 24-hour urine specimen or a serum sample.
2. Keep t he pH neut ral or alkaline (pH > 6. 0)

3. Freeze specimen if not analyzed immediat ely. Not st able at room
t emperat ure.
1. I ncreased urine 2 -microglobulin occurs in:
a. Renal t ubular disorders (>50 mg/ day)
b. Heavy-met al poisoning (mercury, cadmium)
c. Drug t oxicit y (aminoglycosides, cyclosporine)
d. Fanconi's syndrome, Wilson's disease
e. Pyelonephrit is
f. Renal allograf t reject ion
g. Lymphoid malignancies associat ed w it h B-lymphocyt e lineage
h. Acquired immunodef iciency syndrome (AI DS) (can be used as a predict or
of t he progression t o AI DS)
2. I ncreased serum 2 -microglobulin occurs in:
a. Mult iple myeloma (associat ed w it h a poor survival prognosis)
b. Renal dialysis
c. Amyloidosis
d. Viral inf ect ion
Interfering Factors
1. Acid urinenot st able, pH < 6. 0
2. Cert ain ant ibiot ics (eg, gent amicin, t obramycin)
3. Recent nuclear medicine scan
4. I ncreased synt hesis in cert ain diseases (eg, Crohn's disease, hepat it is,
sarcoidosis) decreases t he usef ulness of t he blood serum t est .
5. Random specimens are not recommended.
Interventions

1. I nst ruct pat ient regarding t he purpose of and procedure f or t est .
2. See inst ruct ions f or 24-hour urine collect ion (see Long-Term, Timed Urine
Specimen, page 171).

Urine Glucose (Sugar)

G lucose is present in glomerular f ilt rat e and is reabsorbed by t he proximal
convolut ed t ubule. I f t he blood glucose level exceeds t he reabsorpt ion capacit y
of t he t ubules, glucose w ill appear
in t he urine. Tubular reabsorpt ion of glucose is by act ive t ransport in response t o
t he body's need t o maint ain an adequat e concent rat ion of glucose. The blood
level at w hich t ubular reabsorpt ion st ops is t ermed t he renal threshol d, w hich f or
glucose is bet w een 160 and 180 mg/ dL (910 mmol/ L).
Types of Glucose Tests

1. Reducti on tests (Clinit est )
a. These are based on reduct ion of cupric ions by glucose. When t he
compounds are added t o urine, a heat react ion t akes place. This result s
in precipit at ion and a change in t he color of t he urine if glucose is
present .
b. These t est s are nonspecif ic f or glucose because t he react ion can also be
caused by ot her reducing subst ances in t he urine, including:
1. Creat inine, uric acid, ascorbic acid
2. O t her sugars, such as galact ose, lact ose, f ruct ose, pent ose, and
malt ose
c. These t est s have a low er sensit ivit y t han enzyme t est s.
2. Enzyme tests (Clinist ix, Diast ix, Tes-Tape)
a. These t est s are based on int eract ion bet w een glucose oxidase (an
enzyme) and glucose. When dipped int o urine, t he enzyme-impregnat ed
st rip changes color according t o t he amount of glucose in t he urine. The
manuf act urer's color chart provides a basis f or comparison of colors
bet w een t he sample and t he manuf act urer's cont rol.
b. These t est s are specif ic f or glucose only.
Reference Values
Normal
Random specimen: Negat ive
24-hour specimen: 115 mg/ dL (60830 mol/ L) or <0. 5 g/ 24 hours (<2. 8
mmol/ day)
Procedure
1. Use a f reshly voided specimen.
2. Follow direct ions on t he t est cont ainer exact ly. Timing must be exact ; t he
color react ion must be compared w it h t he closest mat ching cont rol color on
t he manuf act urer's color chart t o ascert ain accurat e result s.
3. Record t he result s on t he pat ient 's record.
4. Ref rigerat e or ice t he ent ire urine sample during collect ion if a 24-hour urine
specimen is also ordered. See Table 3-3 f or proper preservat ive.
Clin ical Alert

1. Urine glucose > 1000 mg/ dL (>55 mmol/ L) (4+) is a crit ical value.
2. Det ermine exact ly w hat drugs t he pat ient is t aking and w het her t he
met abolit es of t hese drugs can aff ect t he urine glucose result s. Frequent
updat ing in regard t o t he eff ect s of drugs on blood glucose levels is
necessary in light of t he many new drugs int roduced and prescribed.
3. Test result s may be report ed as plus (+) or as percent ages.
Percent ages are more accurat e.
4. When screening f or galact ose (galact osuria) in inf ant s, t he reduct ion t est
must be used. The enzyme t est s do not react w it h galact ose.
5. New borns should alw ays be t est ed by bot h met hods (reduct ion and
enzymat ic).
1. Increased gl ucose occurs in:
b. Endocrine disorders (t hyrot oxicosis, Cushing's syndrome, acromegaly)
c. Liver and pancreat ic disease
d. Cent ral nervous syst em disorders (brain injury, st roke)
e. I mpaired t ubular reabsorpt ion
1. Fanconi's syndrome
2. Advanced renal t ubular disease
f. Pregnancy w it h possible lat ent diabet es (gest at ional diabet es)
2. Increase of other sugars (react only w it h reduct ion t est s, not dipst ick t est s):
a. Lact osepregnancy, lact at ion, lact ose int olerance
b. G alact oseheredit ary galact osuria (severe enzyme def iciency in inf ant s;
must be t reat ed prompt ly)
c. Xyloseexcessive ingest ion of f ruit
d. Fruct oseheredit ary f ruct ose int olerance, hepat ic disorders
e. Pent osecert ain drug t herapies and rare heredit ary condit ions
Interfering Factors
1. I nt erf ering f act ors f or reduct ion t est (f alse-posit ive result s):
a. Presence of nonsugar-reducing subst ances such as ascorbic acid,
homogent isic acid, creat inine
b. Tyrosine
c. Nalidixic acid, cephalosporins, probenecid, and penicillin
d. Large amount s of urine prot ein (slow s react ion)
2. I nt erf ering f act ors f or dipst ick enzyme t est s:
a. Ascorbic acid (in large amount s) may cause a f alse-negat ive result
b. Large amount of ket ones may cause a f alse-negat ive result
c. Peroxide or st rong oxidizing agent s may cause a f alse-posit ive result .
3. St ress, excit ement , myocardial inf arct ion, t est ing af t er a heavy meal, and
t est ing soon af t er t he administ rat ion of int ravenous glucose may all cause
f alse-posit ive result s, most f requent ly t race react ions.
4. Cont aminat ion of t he urine sample w it h bleach or hydrogen peroxide may
invalidat e result s.
5. False-negat ive result s may occur if urine is lef t t o sit at room t emperat ure
f or an ext ended period, ow ing t o t he rapid glycolysis of glucose.
6. High specif ic gravit y depresses color development , low specif ic gravit y
int ensif ies it . See Appendix J f or ot her drugs t hat aff ect t est out comes.
Interventions
1. I nst ruct t he pat ient about t he t est purpose, t he procedure, and t he doublevoiding t echnique.
a. Discard t he f irst voided morning specimen, t hen void 30 t o 45 minut es
lat er f or t he t est specimen. This second specimen ref lect s t he immediat e
st at e of glucosuria more accurat ely because t he f irst morning specimen
consist s of urine t hat has been present in t he bladder f or several hours.
b. Advise t he pat ient not t o drink liquids bet w een t he f irst and second
voiding so as not t o dilut e t he glucose present in t he specimen.
c. A urine glucose t est combined w it h a blood glucose t est gives a more
complet e assessment of diabet es.
2. I nst ruct t he pat ient about t he 24-hour urine collect ion procedure w hen
applicable (see Long-Term, Timed Urine Specimen, page 171).

Clin ical Alert

Urine glucose > 1000 mg/ dL (>55 mmol/ L)t est blood glucose, not if y
physician, and begin appropriat e t reat ment .
Urine Ketones (Acetone; Ketone Bodies) Ketones,

which result from the metabolism of fatty acid and fat,
consist mainly of three substances: acetone, hydroxybutyric acid, and acetoacetic acid. The last two
substances readily convert to acetone, in essence
making acetone the main substance being tested.
However, some testing products measure only
acetoacetic acid.
I n healt hy persons, ket ones are f ormed in t he liver and are complet ely
met abolized so t hat only negligible amount s appear in t he urine. How ever, w hen
carbohydrat e met abolism is alt ered, an excessive amount of ket ones is f ormed
(acidosis) because f at becomes t he predominant body f uel inst ead of
carbohydrat es. When t he met abolic pat hw ays of carbohydrat es are dist urbed,
carbon f ragment s f rom f at and prot ein are divert ed t o f orm abnormal amount s of
ket one bodies. I ncreased ket ones in t he blood lead t o elect rolyt e imbalance,
dehydrat ion, and, if not correct ed, acidosis and event ual coma.
The excess presence of ket ones in t he urine (ket onuria) is associat ed w it h
diabet es or alt ered carbohydrat e met abolism. Some f ad diet s t hat are low in
carbohydrat es and high in f at and prot ein also produce ket ones in t he urine.
Test ing f or urine ket ones in pat ient s w it h diabet es may provide t he clue t o early
diagnosis of ket oacidosis and diabet ic coma.
Indications for Ketone Testing

1. G eneral : Screening f or ket onuria is f requent ly done in hospit alized pat ient s,
presurgical pat ient s, pregnant w omen, children, and persons w it h diabet es.
2. G l ycosuri a (diabet es):
a. Test ing f or ket ones is indicat ed in any pat ient show ing elevat ed urine and
blood sugars.
b. When t reat ment is being sw it ched f rom insulin t o oral hypoglycemic
agent s, t he development of ket onuria w it hin 24 hours af t er w it hdraw al of
insulin usually indicat es a poor response t o t he oral hypoglycemic
agent s.
c. The urine of diabet ic pat ient s t reat ed w it h oral hypoglycemic agent s
should be t est ed regularly f or glucose and ket ones because oral
hypoglycemic agent s, unlike insulin, do not cont rol diabet es w hen acut e
complicat ions such as inf ect ion develop.
d. Ket one t est ing is done t o diff erent iat e bet w een diabet ic comaposit ive
ket ones and insulin shocknegat ive ket ones.
3. Aci dosi s:
a. Ket one t est ing is used t o judge t he severit y of acidosis and t o monit or
t he response t o t reat ment .
b. Urine ket one measurement f requent ly provides a more reliable indicat or
of acidosis t han blood t est ing (it is especially usef ul in emergency
sit uat ions).
c. Ket ones appear in t he urine bef ore t here is any signif icant increase of
ket ones in t he blood.
4. Pregnancy: During pregnancy, t he early det ect ion of ket ones is essent ial
because ket oacidosis is a prominent f act or t hat cont ribut es t o int raut erine
deat h.
Reference Values
Normal
Urine: Negat ive
Serum or plasma:
Acet one: <2. 0 mg/ dL or <0. 34 mmol/ L
Acet oacet at e: <1 mg/ dL or <0. 1 mmol/ L
-hydroxybut yric acid: 0. 212. 81 mg/ dL or 20270 mol/ L
Procedure
1. Dip t he ket one reagent st rip in f resh urine, t ap off excess urine, t ime t he
react ion accurat ely, and t hen compare t he st rip w it h t he cont rol color chart
on t he cont ainer.
2. Follow t he manuf act urer's direct ions exact ly if procedure diff ers f rom t he
t echnique just described.
3. Do not use dipst icks t o t est f or ket ones in blood. Special t est ing product s
are designed f or blood.
1. Ket osis and ket onuria may occur w henever increased amount s of f at are
met abolized, carbohydrat e int ake is rest rict ed, or t he diet is rich in f at s
(eit her hidden or obvious). This st at e can occur in t he f ollow ing sit uat ions:
a. Met abolic condit ions

1. Diabet es mellit us (diabet ic acidosis)
2. Renal glycosuria
3. G lycogen st orage disease (von G ierke's disease)
b. Diet ary condit ions
1. St arvat ion, f ast ing
2. High-f at diet s
3. Prolonged vomit ing, diarrhea
4. Anorexia
5. Low -carbohydrat e diet
6. Eclampsia
c. I ncreased met abolic st at es caused by:
1. Hypert hyroidism
2. Fever
3. Pregnancy or lact at ion
2. I n nondiabet ic persons, ket onuria occurs f requent ly during acut e illness,
severe st ress, or st renuous exercise. Approximat ely 15% of hospit alized
pat ient s have ket ones in t heir urine even t hough t hey do not have diabet es.
3. Children are part icularly prone t o developing ket onuria and ket osis.
4. Ket onuria occurs af t er anest hesia (et her or chlorof orm).
Interfering Factors
1. Drugs t hat may cause a f alse-posit ive result include:
a. Levodopa
b. Phenot hiazines
c. Et her
d. I nsulin
e. I sopropyl alcohol
f. Met f ormin
g. Penicillamine
h. Phenazopyridine (Pyridium)
i. Capt opril
2. False-negat ive result s occur if urine st ands t oo long, ow ing t o loss of
ket ones int o t he air.
3. See Appendix J f or ot her drugs t hat aff ect t est out comes.
Clin ical Alert

Ket onuria signals a need f or caut ion, rat her t han crisis int ervent ion, in eit her a
diabet ic or a nondiabet ic pat ient . How ever, t his condit ion should not be t aken
light ly.
1. I n t he diabet ic pat ient , ket one bodies in t he urine suggest t hat t he
diabet es is not adequat ely cont rolled and t hat adjust ment s of eit her t he
medicat ion or t he diet should be made prompt ly.
2. I n t he nondiabet ic pat ient , ket one bodies indicat e a reduced carbohydrat e
met abolism and excessive f at met abolism.
3. Posit ive urine ket ones in a child younger t han 2 years of age is a crit ical
alert .
Interventions

Urine Nitrite (Bacteria)

This t est is a rapid, indirect met hod f or det ect ing bact eria in t he urine.
Signif icant UTI may be present in a pat ient w ho does not experience any
sympt oms. Common gram-negat ive organisms cont ain enzymes t hat reduce t he
nit rat e in t he urine t o nit rit e.
Clinicians f requent ly request t he urine nit rat e t est t o screen high-risk pat ient s:
pregnant w omen, school-aged children (especially girls), diabet ic pat ient s,

elderly pat ient s, and pat ient s w it h a hist ory of recurrent inf ect ions.
The majorit y of UTI s are believed t o st art in t he bladder as a result of ext reme
cont aminat ion; if lef t unt reat ed, t hey can progress upw ard all t he w ay t o t he
kidneys. Pyelonephrit is is a f requent complicat ion of unt reat ed cyst it is and can
lead t o renal damage. Det ect ion of bact eria using t he nit rat e t est and
subsequent ant ibiot ic t herapy can prevent t hese serious complicat ions. The
nit rat e t est can also be used t o evaluat e t he success of ant ibiot ic t herapy.
Reference Values
Normal
Negat ive f or bact eria
Procedure
1. O bt ain a f irst morning specimen because urine t hat has been in t he bladder
f or several hours is more likely t o yield a posit ive nit rat e t est t han a random
urine sample t hat may have been in t he bladder f or only a short t ime. A
clean-cat ch (midst ream) urine specimen is needed t o minimize bact erial
cont aminat ion f rom adjacent areas.
2. Follow t he exact t est ing procedure according t o prescribed guidelines f or
reliable t est result s. Any shade of pink is posit ive f or nit rit e-producing
bact eria.
3. Compare t he react ed reagent area on t he dipst ick w it h a w hit e background
t o aid in t he det ect ion of a f aint pink hue t hat might ot herw ise be missed.
4. Perf orm a microscopic examinat ion t o verif y result s, if at all possible.
1. Under t he light microscope, t he presence of > 20 bact eria per high-pow er
f ield (hpf ) may indicat e a UTI . Unt reat ed bact eriuria can lead t o serious
kidney disease.
2. The presence of a f ew bact eria suggest s a UTI t hat cannot be conf irmed or
excluded unt il more def init ive st udies, such as cult ure and sensit ivit y t est s,
are perf ormed. Again, t his f inding merit s serious considerat ion f or t reat ment .
3. A posit ive nit rat e t est is a reliable indicat or of signif icant bact eriuria and is a
cue f or perf orming urine cult ure.
4. A negat ive result should never be int erpret ed as indicat ing absence of
bact eriuria, f or t he f ollow ing reasons:
a. I f an overnight urine sample is not used, t here may not have been enough
t ime f or t he nit rat e t o convert t o nit rit e in t he bladder.
b. Some UTI s are caused by organisms t hat do not convert nit rat e t o nit rit e
(eg, st aphylococci, st rept ococci).
c. Suff icient diet ary nit rat e may not be present f or t he nit rat e-t o-nit rit e
react ion t o occur.
Interfering Factors
1. Azo dye met abolit es and bilirubin can produce f alse-posit ive result s.
2. Ascorbic acid can produce f alse-negat ive result s.
3. False-posit ive result s can be obt ained if t he urine sit s t oo long at room
t emperat ure, allow ing cont aminant bact eria t o mult iply.
4. High specif ic gravit y w ill reduce t he sensit ivit y.
Clin ical Alert

A negat ive urine nit rat e t est should never be int erpret ed as indicat ing t he
absence of bact eria.
Interventions
1. Explain t he t est purpose and urine specimen collect ion procedure. I nst ruct
t he pat ient in t he procedure necessary f or a clean-cat ch (midst ream)
specimen.

Urine Leukocyte Esterase

Usually, t he presence of leukocyt es (WBCs) in t he urine indicat es a UTI . The
leukocyt e est erase t est det ect s est erase released by t he leukocyt es int o t he
urine. This is a st andardized means f or t he det ect ion of WBCs.
Microscopic examinat ion and chemical t est ing are used t o det ermine t he
presence of leukocyt es in t he urine. The chemical t est is done w it h a leukocyt e
est erase dipst ick. This t est can also det ect int act leukocyt es, lysed leukocyt es,
and WBC cast s.
Reference Values
Normal
Negat ive
Procedures
1. Collect a f resh, random urine specimen w it h a clean-cat ch or midst ream
t echnique.
2. Follow direct ions f or dipst ick use exact ly. Timing is crit ical f or accurat e
result s.
3. Not e t hat a posit ive result causes a purple color on t he dipst ick. The t est is
not designed t o measure t he amount of leukocyt es.
1. Posit ive result s are clinically signif icant and indicat e:
a. Cyst it is (UTI )
b. Acut e pyelonephrit is
c. Acut e Bright 's disease
d. Bladder t umor
e. Syst emic lupus eryt hemat osus (SLE)
f. Tuberculosis inf ect ion
2. Urine w it h posit ive result s f rom t he dipst ick should be examined
microscopically f or WBCs and bact eria.
Interfering Factors
1. False-posit ive result s

a. Vaginal discharge, parasit es, hist ocyt es
b. Drug t herapies (eg, ampicillin, kanamycin)
c. Salicylat e t oxicit y
d. St renuous exercise
2. False-negat ive result s
a. Large amount s of glucose or prot ein
b. High specif ic gravit y
c. Cert ain drugs (eg, t et racycline)
Clin ical Alert

A urine sample t hat t est s posit ive f or bot h nit rit e and leukocyt e est erase
should be cult ured f or pat hogenic bact eria.
Interventions

Urine Bilirubin
Bilirubin is f ormed in t he ret iculoendot helial cells of t he spleen and bone marrow
as a result of t he breakdow n of hemoglobin; it is t hen t ransport ed t o t he liver.
Urinary bilirubin levels are increased t o signif icant levels in t he presence of any
disease process t hat increases t he amount of conjugat ed bilirubin in t he
bloodst ream (see Chap. 6). Elevat ed amount s appear w hen t he normal
degradat ion cycle is disrupt ed by obst ruct ion of t he bile duct or w hen t he
int egrit y of t he liver is damaged.
Urine bilirubin aids in t he diagnosis and monit oring of t reat ment f or hepat it is and
liver damage. Urine bilirubin is an early sign of hepat ocellular disease or
int rahepat ic or ext rahepat ic biliary obst ruct ion. I t should be a part of every UA
because bilirubin of t en appears in t he urine bef ore ot her signs of liver
dysf unct ion (eg, jaundice, w eakness) become apparent . Not only does t he
det ect ion of urinary bilirubin provide an early indicat ion of liver disease, but also
it s presence or absence can be used in det ermining t he cause of clinical
jaundice.
Reference Values
Normal
Negat ive (00. 02 mg/ dL or 00. 34 mol/ L)
Procedure
1. Examine t he urine w it hin 1 hour of collect ion because urine bilirubin is
unst able, especially w hen exposed t o light . I f t he urine is yellow -green t o
brow n, shake t he urine. I f a yellow -green f oam develops, bilirubin is probably
present . Bilirubin alt ers t he surf ace t ension and allow s f oam t o f orm. The
yellow color is t he bilirubin.
2. Chemical st rip t est ing:
a. Dip a chemically react ive dipst ick int o t he urine sample according t o t he
manuf act urer's direct ions.
b. Close comparison of color changes on t he dipst ick w it h cont rol colors on
t he color chart is an absolut e necessit y. Failure t o make a close
approximat ion of color may result in f ailure t o recognize urine bilirubin.
G ood light ing is required.
c. I nt erpret result s as negat ive t o 3+ or as small, moderat e, or
large amount s of bilirubin.
3. When it is crucial t o det ect even very small amount s of bilirubin in t he urine,
as in t he earliest phase of viral hepat it is, I cot est t ablet s are pref erred f or
t est ing because t hey are more sensit ive t o urine bilirubin. When elevat ed
amount s of urine bilirubin are present , a blue t o purple color f orms on t he
absorpt ive mat . The int ensit y of t he color and t he rapidit y of it s development
are direct ly proport ional t o t he amount of bilirubin in t he urine.
1. Even t race amount s of bilirubin are abnormal and w arrant f urt her
invest igat ion. Normally, t here is no det ect able bilirubin in t he urine.
2. I ncreased bilirubin occurs in:
a. Hepat it is and liver diseases caused by inf ect ions or exposure t o t oxic
agent s (cirrhosis)
b. O bst ruct ive biliary t ract disease
c. Liver or biliary t ract t umors
d. Sept icemia
e. Hypert hyroidism
NOTE
Urine bilirubin is negat ive in hemolyt ic disease.
Interfering Factors
1. Drugs may cause f alse-posit ive or f alse-negat ive result s (see Appendix J).
2. Bilirubin rapidly decomposes w hen exposed t o light ; t heref ore, urine should
be t est ed immediat ely.
3. High concent rat ions of ascorbic acid or nit rat e cause decreased sensit ivit y.
Clin ical Alert

Pyridium-like drugs or urochromes may give t he urine an amber or reddish
color and can mask t he bilirubin react ion.
Interventions

1. I nt erpret t est out comes and monit or appropriat ely f or liver disease.
Urine Urobilinogen, Random and Timed Bilirubin, which

is formed from the degradation of hemoglobin, is
transformed through the action of bacterial enzymes
into urobilinogen after it enters the intestines. Some of
the urobilinogen formed in the intestine is excreted as
part of the feces, where it is oxidized to urobilin;
another portion is absorbed into the portal bloodstream
and carried to the liver, where it is metabolized and

excreted in the bile. Traces of urobilinogen in the blood
that escape removal by the liver are carried to the
kidneys and excreted in the urine. This is the basis of
the urine urobilinogen test. Unlike bilirubin,
urobilinogen is colorless.
Urine urobilinogen is one of t he most sensit ive t est s available t o det ermine
impaired liver f unct ion. Urinary urobilinogen is increased by any condit ion t hat
causes an increase in t he product ion of bilirubin and by any disease t hat
prevent s t he liver f rom normally removing t he reabsorbed urobilinogen f rom t he
port al circulat ion. An increased urobilinogen level is one of t he earliest signs of
liver disease and hemolyt ic disorders.
Alt hough it cannot be det ermined by reagent st rip, t he absence of urobilinogen is
also diagnost ically signif icant and represent s an obst ruct ion of t he bile duct .
Reference Values
Normal
Random specimen: 0. 11 Ehrlich U/ dL or <1 mg/ dL
2-hour specimen: 0. 11. 0 Ehrlich U/ 2 hours or <1 mg/ 2 hours 24-hour specimen:
0. 54. 0 Ehrlich U/ 24 hours or 0. 54. 0 mg/ day
Procedure
1. Follow inst ruct ions f or collect ing a t imed 24-hour, 2-hour, or random
specimen. Check w it h t he laborat ory f or specif ic prot ocols.
2. Perf orm t he 2-hour t imed collect ion f rom 1: 00 p. m. t o 3: 00 p. m. (1300 t o
1500) or f rom 2: 00 p. m. t o 4: 00 p. m. (1400 t o 1600) f or best result s
because peak excret ion occurs during t his t ime. No preservat ives are
necessary. Record t he t ot al amount of urine voided. Prot ect t he collect ion
recept acle f rom light . Test immediat ely af t er specimen collect ion is
complet ed.
1. Urine urobilinogen is i ncreased w hen t here is:
a. I ncreased dest ruct ion of RBCs
1. Hemolyt ic anemias
2. Pernicious anemia (megaloblast ic)
3. Malaria
b. Hemorrhage int o t issues
1. Pulmonary inf arct ion
2. Excessive bruising
c. Hepat ic damage
1. Biliary disease
2. Cirrhosis (viral and chemical)
3. Acut e hepat it is
d. Cholangit is
2. Urine urobilinogen is decreased or absent w hen normal amount s of bilirubin
are not excret ed int o t he int est inal t ract . This usually indicat es part ial or
complet e obst ruct ion of t he bile duct s. The st ool is pale in color. Decreased
urinary urobilinogen is associat ed w it h:
a. Cholelit hiasis
b. Severe inf lammat ion of t he biliary duct s
c. Cancer of t he head of t he pancreas
3. During ant ibiot ic t herapy, suppression of normal gut f lora may prevent t he
breakdow n of bilirubin t o urobilinogen; t heref ore, urine levels w ill be
decreased or absent .
4. More comprehensive inf ormat ion is obt ained w hen t he t est s f or urobilinogen
and bilirubin are correlat ed (see Table 3. 5 f or comparisons).
Table 3.5 Comparison of Urine Urobilinogen and Uri

Bilirubin Values
Test
In
Health
In
Hem olytic
Disease
In
Hepatic
Disease
In Bilia
Obstruc
Urine
urobilinogen
Urine
bilirubin
Normal
Negative
Increased
Increased
Low or
absent
Negative
Positive
or
negative
Positive
Clin ical Alert

Urine urobilinogen rapidly decomposes at room t emperat ure or w hen exposed
t o light .
Interfering Factors
1. Drugs t hat may aff ect urobilinogen levels include t hose t hat cause
cholest asis and t hose t hat reduce t he bact erial f lora in t he gast roint est inal
t ract . Check w it h t he pharmacist f or specif ic drugs pat ient is t aking.
2. Peak excret ion is know n t o occur f rom noon t o 4: 00 p. m. The amount of
urobilinogen in t he urine is subject t o diurnal variat ion.
3. St rongly alkaline urine show s a higher urobilinogen level, and st rongly acidic
urine show s a low er urobilinogen level.
4. Drugs t hat may cause i ncreased urobilinogen include drugs t hat cause
hemolysis. Check w it h t he pharmacist f or specif ic drugs t he pat ient is t aking.
5. I f t he urine is highly colored, t he st rip w ill be diff icult t o read.
Interventions
1. Explain t est purpose and urine collect ion procedures.

1. I nt erpret t est out comes and monit or appropriat ely f or anemia and
gast roint est inal disorders. Advise concerning need f or f ollow -up t est ing.
M ICROSCOPIC EXAM INATION OF URINE SEDIM ENT

I n healt h, t he urine cont ains small numbers of cells and ot her f ormed element s
f rom t he ent ire genit ourinary t ract : cast s and epit helial cells f rom t he nephron;
epit helial cells f rom t he kidney, pelvis, uret ers, bladder, and uret hra; mucous
t hreads and spermat ozoa f rom t he prost at e; and possibly RBCs or WBCs and an
occasional cast . I n renal parenchymal disease, t he urine usually cont ains
increased numbers of cells and cast s discharged f rom an organ t hat is ot herw ise
accessible only by biopsy or surgery (Table 3. 6). Urinary sediment provides
inf ormat ion usef ul f or bot h diagnosis and prognosis. I t provides a direct sampling
or urinary t ract morphology.
Table 3.6 Microscopic Examination of Urine Sediment
Urine
Sedim ent
Com ponent
Clinical Significance
Bacteria
Urinary tract infection
Casts
Tubular or glomerular disorders
Broad casts
Formation occurs in collecting tubules;

serious kidney disorder, extreme stasis
of flow
Epithelial
(renal) casts
Tubular degeneration
Fatty casts
Nephrotic syndrome
Granular
Renal parenchymal disease
W axy
Stasis of flow
Hyaline
casts
Chronic renal failure, chronic renal

disease, congestive heart failure; stress
or exercise
Red blood
cell casts
Acute glomerulonephritis
W hite blood
cell casts
Pyelonephritis, acute interstitial

nephritis
Epithelial
cells
Damage to various parts of urinary tract
Renal cells
Tubular damage
Squamous
cells
Normal or contamination
Erythrocytes
Most renal disorders, menstruation;

strenuous exercise
Fat bodies
(oval)
Nephrotic syndrome
Leukocytes
Most renal disorders; urinary tract

infection; pyelonephritis
The urinary sediment is obt ained by pouring 1 mL of f resh, w ell-mixed urine int o
a conical t ube and cent rif uging t he sample at a specif ic speed f or 10 minut es.
The supernat ant is poured off , and 1 mL of t he sediment is resuspended. A small
drop is placed on a slide, cover-slipped, and examined microscopically.
The urine sediment can be broken dow n int o cellular element s (RBCs, WBCs,
and epit helial cells), cast s, cryst als, and bact eria. These may originat e
anyw here in t he urinary t ract . When cast s do occur in t he urine, t hey may
indicat e t ubular or glomerular disorders.
Cast s are t he only element s f ound in urinary sediment t hat are unique t o t he
kidneys. They are f ormed primarily w it hin t he lumen of t he dist al convolut ed
t ubule and collect ing duct , providing a microscopic view of condit ions w it hin t he
nephron. Their shapes are represent at ive of t he t ubular lumen.
Cast w idt h is signif icant in det ermining t he sit e of origin and may indicat e t he
ext ent of renal damage. The w idt h of t he cast indicat es t he diamet er of t he
t ubule responsible f or it s f ormat ion. Cast w idt h is described as narrow (as w ide
as 1 t o 2 RBCs), medi um-broad (3 t o 4 RBCs), or broad (5 RBCs). The broad
cast s f orm in t he collect ing t ubule and may be of any composit ion. Their
presence usually indicat es a marked reduct ion in t he f unct ional capacit y of t he
nephron and suggest s severe renal damage or end-st age renal disease.
The major const it uent of cast s is Tamm-Horsf all prot ein, a glycoprot ein excret ed
by t he renal t ubular cells. I t is f ound in normal and abnormal urine and is not
det ect ed by t he urine dipst ick met hod.
Clin ical Alert

Microscopic examinat ion of urine sediment can provide t he f ollow ing
inf ormat ion:
1. Evidence of renal disease as opposed t o inf ect ion of t he low er urinary
t ract .
2. Type and st at us of a renal lesion or disease.
Urine Red Blood Cells and Red Blood Cell Casts In

health, erythrocytes (RBCs) occasionally appear in the
urine. However, persistent findings of even small
numbers of RBCs should be thoroughly investigated
because these cells come from the kidney and may
signal serious renal disease. They are usually
diagnostic of glomerular disease.
Reference Values
Normal
RBCs: 03/ hpf (high-pow er f ield) RBC cast s: 0/ lpf (low -pow er f ield)
Procedure for M icroscopic Urine Examination

1. Collect a random urine specimen. Transport t he specimen t o t he laborat ory
as soon as possible.
2. Urinary sediment is microscopically examined under bot h t he low -pow er f ield
(lpf ) and t he high-pow er f ield (hpf ). Low pow er is used t o f ind and count
cast s; RBCs, WBCs, and bact eria show up and are count ed under high
pow er. Amount s present are def ined in t he f ollow ing t erms: f ew, moderat e,
packed, and packed solid; or 1+, 2+, 3+, and 4+. Cryst als and ot her
element s are also not ed.
3. Microscopic result s should be correlat ed w it h t he physical and chemical
f indings t o ensure t he accuracy of t he report (Table 3. 7).
Table 3.7 Common Correlations in Urinalysis
Microscopic
Elem ents
Physical
Exam ination
Dipstick
Measurem ent*
Red blood cells
Turbidity, red to
brown color
Blood
Turbidity
Protein
Nitrite
Leukocytes
W hite blood
cells
Epithelial cast
cells
Turbidity
Protein
Bacteria
Turbidity, odor
pH
Nitrite
Leukocytes
Crystals
Turbidity, odor
pH
*Positive result.
1. RBC casts indicat e hemorrhage in t he nephron.
a. RBC cast s are f ound in t hree f orms:
1. I nt act RBCs
2. Degenerat ing cells w it hin a prot ein mat rix
3. Homogenous blood cast s (hemoglobin cast s)
b. RBC cast s indicat e acut e inf lammat ory or vascular disorders in t he
glomerulus and are f ound in:
1. G lomerulonephrit is (acut e and chronic)
2. Renal inf arct ion
3. Lupus nephrit is
4. G oodpast ure's syndrome
5. Severe pyelonephrit is
6. Congest ive heart f ailure
7. Renal vein t hrombosis
8. Acut e bact erial endocardit is
10. Periart erit is nodosa
c. RBCs shoul d be present if RBC cast s are in t he sediment .
2. Red bl ood cel l s

a. The f inding of more t han 1 or 2 RBCs/ hpf is abnormal and can indicat e:
1. Renal or syst emic disease (glomerulonephrit is)
2. Trauma t o t he kidney (vascular injury)
b. I ncreased numbers of RBCs occur in:
1. Pyelonephrit is
3. Renal st ones
4. Cyst it is (acut e or chronic)
5. Prost at it is
6. Tuberculosis (renal)
7. G enit ourinary t ract malignancies
8. Hemophilia, coagulat ion disorders
9. Malaria
10. Polyart erit is nodosa
12. Acut e f ebrile episodes
c. G reat er numbers of RBCs t han WBCs indicat e bleeding int o t he urinary
t ract , as may occur w it h:
1. Trauma
2. Tumors of rect um, colon, pelvis
3. Aspirin overdose or ot her t oxic drugs
4. Ant icoagulant t herapy overdose
5. Thrombocyt openia
Clin ical Alert

1. I n healt h, RBCs are occasionally f ound in t he urine. How ever, persist ent
f indings of even small numbers of RBCs should be t horoughly invest igat ed,
t he f irst st ep being t o request a f resh urine specimen f or repeat t est ing.
2. Rule out t he possible presence of menst rual blood, vaginal bleeding, or
t rauma t o t he perineal area in a f emale pat ient .
Interfering Factors
1. I ncreased numbers of RBCs may be f ound af t er a t raumat ic cat het erizat ion
and af t er passage of urinary t ract or kidney st ones.
2. Alkaline urine hemolyzes RBCs and dissolves cast s (ghost s).
3. Some drugs can cause increased numbers of RBCs in t he urine (see
Appendix J).
4. RBC cast s and RBCs may appear af t er very st renuous physical act ivit y or
part icipat ion in cont act sport s.
5. Heavy smokers show small numbers of RBCs in t he urine.
6. Yeast or oil droplet s may be mist aken f or RBCs.
Interventions
1. Explain t est purpose and procedure f or random urine sample collect ion.

Urine White Blood Cells and White Blood Cell Casts

Leukocytes (WBCs) may originate from anywhere in the
genitourinary tract. They are also capable of amoeboid
migration through the tissues to sites of infection or
inflammation. An increase in urinary WBCs is called
pyuria and indicates the presence of an infection or
inflammation in the genitourinary system. However,
WBC casts always come from the kidney tubules.
Reference Values
Normal
WBCs: 04/ hpf
Normal w omen may have slight ly more WBCs.
WBC cast s: 0/ lpf
Procedure
1. Collect a random urine specimen and t ransport it t o t he laborat ory as soon
as possible.
2. Urinary sediment is microscopically examined under high pow er f or cells and
under low pow er f or cast s.
1. Whi te bl ood cel l s
a. Large numbers of WBCs (>30/ hpf ) usually indicat e acut e bact erial
inf ect ion w it hin t he urinary t ract .
b. I ncreased WBCs are seen in:
1. All renal disease
2. Urinary t ract disease (eg, cyst it is, prost at it is uret hrit is)
3. Appendicit is, pancreat it is
4. St renuous exercise
5. Chronic pyelonephrit is
6. Bladder t umors
7. Tuberculosis
10. G lomerulonephrit is
c. I n bladder inf ect ions, WBCs t end t o be associat ed w it h bact eria,
epit helial cells, and relat ively f ew RBCs.
d. Large numbers of lymphocyt es and plasma cells in t he presence of a
kidney t ransplant may indicat e early t issue reject ion (acut e renal
allograf t reject ion).
e. Eosinophils are associat ed w it h t ubuloint erst it ial disease and

hypersensit ivit y t o penicillin.
f. WBC clumps suggest renal origin of WBCs and should be report ed w hen
present .
2. WBC casts
a. WBC cast s indicat e renal parenchymal inf ect ion and may occur in:
1. Pyelonephrit is (most common cause)
2. Acut e glomerulonephrit is
4. Lupus nephrit is
b. I t can be very diff icult t o diff erent iat e bet w een WBC cast s and epit helial
cell cast s.
Clin ical Alert

A urine cult ure (see Chap. 7) should be done if elevat ed urine WBCs are
f ound.
Interfering Factors
Vaginal discharge can cont aminat e a specimen w it h WBCs. Eit her a clean-cat ch
urine specimen or a cat het erized urine specimen should be obt ained t o rule out
cont aminat ion as t he cause f or WBCs in t he urine.
Clin ical Alert

Pyelonephrit is may remain complet ely asympt omat ic even t hough renal t issue
is being progressively dest royed. Theref ore, caref ul examinat ion (using low
pow er) of urinary sediment f or leukocyt e cast s is vit al.
Interventions
Pretest Patient Preparation The pretest care is the
same as for the urine RBC test.
Posttest Patient Aftercare The posttest care is the
same as for the urine RBC test.
Urine Epithelial Cells and Epithelial Casts Renal

epithelial cell casts are formed from cast-off tubule
cells that slowly degenerate, first into coarse and then
into fine granular material. Epithelial casts are the
most rare casts.
Urine epit helial cells are of t hree kinds:
1. Renal tubul e epi thel i al cel l s are round and slight ly larger t han WBCs. Each
cell cont ains a single large nucleus. These are t he t ypes of epit helial cells
associat ed w it h renal disease. How ever, t he presence of an occasional renal
epit helial cell is not unusual because t he renal t ubules are cont inually
sloughing old cells. I n cases of acut e t ubular necrosis, renal t ubular
epit helial cells cont aining large nonlipid vacuoles may be seen. These are
ref erred t o as bubbl e cel l s. When lipids cross t he glomerular membrane, t he
renal epit helial cells absorb t he lipids and become highly ref ract ive. These
are called oval f at bodi es. Bot h of t hese f indings are signif icant and should
be report ed.
2. Bl adder epi thel i al cel l s are larger t han renal epit helial cells. They range f rom
round t o pear-shaped t o columnar. Also know n as t ransit ional epit helial
cells, t hey line t he urinary t ract f rom t he renal pelvis t o t he proximal t w o
t hirds of t he uret hra.
3. Squamous epi thel i al cel l s are large, f lat cells w it h irregular borders, a single
small nucleus, and abundant cyt oplasm. Most of t hese cells are uret hral and
vaginal in origin and do not have much diagnost ic import ance.
Reference Values
Normal
Renal t ubule epit helial cells: 03/ hpf Squamous epit helial cells are common in
normal urine sample.
Renal t ubule epit helial cast s: 0 (not seen)
Procedure
1. Collect a random urine specimen.
2. Examine t he urine sediment microscopically.
1. Epit helial cell cast s are f ound w hen t hey are also present in t he urine af t er
exposure t o t oxic agent s or viruses.
2. Renal t ubular epit helial cells are f ound in:
a. Acut e t ubular necrosis
b. Acut e glomerulonephrit is (secondary eff ect s)
c. Pyelonephrit is
d. Salicylat e overdose (t oxic react ion)
e. I mpending allograf t reject ion
f. Viral inf ect ions (eg, cyt omegalovirus)
g. Poisoning f rom heavy met als or ot her t oxins
Urine Hyaline Casts

Hyaline cast s are clear, colorless cast s t hat are f ormed w hen a renal prot ein
w it hin t he t ubules (Tamm-Horsf all prot ein) precipit at es and gels. Tamm-Horsf all
prot ein is excret ed at a f airly const ant rat e by t he t ubule cells and provides
immunologic prot ect ion f rom inf ect ion. Hyaline cast s can be seen in physiologic
st at es such as st renuous exercise and even in t he mildest renal disease. They
are not associat ed w it h any one part icular disorder.
Reference Values
Normal
O ccasional (02/ lpf )
Procedure
1. O bt ain a f resh urine sample.
2. Examine urinary sediment microscopically f or cast s under low pow er.
3. Examine cast s w hen t he light int ensit y is reduced because t hey are colorless
and t ransparent .
4. Not e t hat w rinkling and convolut ing of t he cast occurs as it ages.
1. Hyaline cast s indicat e possible damage t o t he glomerular capillary

membrane. These cast s appear in:
a. G lomerulonephrit is, pyelonephrit is
b. Malignant hypert ension
c. Chronic renal disease
d. Congest ive heart f ailure
e. Diabet ic nephropat hy
2. Hyaline cast s may be a t emporary phenomenon in t he presence of :
a. Fever (dehydrat ion)
b. Post ural ort host at ic lordot ic st rain
c. Emot ional st ress
e. Heat exposure
3. Nephrot ic syndrome may be suspect ed w hen large numbers of hyaline cast s
appear in t he urine t oget her w it h signif icant prot einuria, f ine granular cast s,
f at t y cast s, oval bodies, or f at droplet s.
4. I n cylindroiduria, large numbers of hyaline cast s may be present , but prot ein
in t he urine is absent . Cylindroids are hyaline cast s t hat have been f ormed at
t he junct ion of t he ascending loop of Henle and t heref ore have t apered ends.
Clin ical Alert

Cast s may not be f ound even w hen prot einuria is signif icant if t he urine is
dilut e (1. 010 SG ) or alkaline. I n t hese cases, t he cast s are dissolved as soon
as t hey are f ormed.
Interventions
The pretest and posttest care are t he same as f or t he urine RBC t est .
Urine Granular Casts

G ranular cast s appear homogeneous, coarsely granular, colorless, and very
dense. They t hen f urt her degenerat e int o f inely granular cast s. I t is not
necessary t o dist inguish t he diff erent granular cast s. G ranular cast s may result
f rom degradat ion of cellular cast s, or t hey may represent direct aggregat ion of
serum prot eins int o a mat rix of Tamm-Horsf all microprot ein.
Reference Values
Normal
O ccasional (02/ lpf )
Procedure
1. Collect a random urine specimen and t ransport it t o t he laborat ory as soon
as possible.
2. Examine urinary sediment microscopically under low pow er.
1. G ranular cast s are f ound in:
b. Advanced glomerulonephrit is
c. Pyelonephrit is
d. Malignant nephrosclerosis
2. G ranular cast s are f ound w it h hyaline cast s af t er st renuous exercise or
severe st ress.
Interventions
Urine Waxy Casts or Broad Casts (Renal Failure Casts)

and Fatty Casts Casts are formed in the collecting
tubules under conditions of extreme renal stasis. Waxy
casts form from the degeneration of granular casts.
Broad, waxy casts are 2 t o 6 t imes t he w idt h of ordinary cast s and appear w axy
and granular. Cast s may vary in size as disease dist ort s t he t ubular st ruct ure
(t hey get w ider because t hey are a mold of t he t ubules). Also, as urine f low f rom
t he t ubules becomes compromised, cast s are more likely t o f orm. The f inding of
broad, w axy cast s suggest s a serious prognosishence, t he t erm renal f ai l ure
casts.
Fatty casts are f ormed f rom t he at t achment of f at droplet s and degenerat ing oval
f at bodies int o a prot ein mat rix. Fat t y cast s are highly ref ract ile and cont ain
yellow -brow n f at droplet s, or oval f at bodies.
Reference Values
Normal
Negat ive (not seen)
Procedure
Examine urine sediment microscopically under low pow er.
1. Broad and w axy cast s occur in:
a. Severe renal f ailure
b. Tubular inf lammat ion and degenerat ion (nephrot ic syndrome)
c. Localized nephron obst ruct ion (ext reme st asis of urine f low )
d. Malignant hypert ension
e. Renal amyloidosis
f. Diabet ic nephropat hy
g. Renal allograf t reject ion
2. Fat t y cast s are f ound in:
a. Disorders causing lipiduria, such as nephrot ic syndrome and lipoid
nephrosis
b. Chronic glomerulonephrit is
c. Kimmelst iel-Wilson syndrome
d. Lupus
e. Toxic renal poisoning
Clin ical Alert

The presence of broad, w axy cast s signals very serious renal disease.
Interventions
Urine Crystals
A variet y of cryst als may appear in t he urine. They can be ident if ied by t heir
specif ic appearance and solubilit y charact erist ics. Cryst als in t he urine may
present no sympt oms, or t hey may be associat ed w it h t he f ormat ion of urinary
t ract calculi and give rise t o clinical manif est at ions associat ed w it h part ial or
complet e obst ruct ion of urine f low.
The t ype and quant it y of cryst alline precipit at e varies w it h t he pH of t he urine.
Amorphous cryst alline mat erial has no signif icance and f orms as normal urine
cools.
Procedure
1. Collect a random urine specimen. Cryst al ident if icat ion should be done on
f reshly voided specimens.
2. Examine t he urinary sediment microscopically under high pow er.
3. The pH of t he urine is an import ant aid t o ident if icat ion of cryst als and must
be not ed.
4. The problems associat ed w it h t he ident if icat ion of abnormal cryst als can be
resolved by a check on t he medicat ions t he pat ient is receiving, saving
considerable t ime and energy.
Table 3. 8 describes t he meaning of urine cryst al f indings.
Table 3.8 Urine Crystals
Type of
Crystal
Color
Shape
Clinical
Im plications
Acid Urine
Amorphous
urates
Pink to
brick red
Granules
Normal
Uric acid
Yellowbrown
Polymorphous
whetstones,
rosettes or
prisms,
rhombohedral
prisms,
hexagonal
plate
Normal;
increased
purine
metabolism,
gout, LeschNyhan
syndrome
Sodium
urate
Colorless
to yellow
Fan of
slender
prisms
No clinical
significance
Colorless,
highly
refractile
Flat
hexagonal
plates with
well-defined
edges, singly
or in clusters
Cystinuria;
cystinosis
cystine
stones in
kidney,
crystals also
in spleen and
eyes
Colorless
Broken
window
panes with
notched
corners
Nephritis,
nephrotic
syndrome,
chyluria
Cystine
(rare)
Cholesterol
(rare)
Leucine
(rare)
Tyrosine
(rare)
Bilirubin
Spheroids
with
striations;
pure form
hexagonal
Protein
breakdown,
severe liver
disease,
Fanconi's
syndrome
Colorless
or yellow
Fine, silky
needles in
sheaves or
rosettes
Protein
breakdown,
severe liver
disease,
oasthouse
urine
disease,
tyrosinosis
Reddishbrown
Cubes,
rhombic
plates,
amorphous
needles
Elevated
bilirubin
Yellow or
brown,
highly
refractile
Acid, Neutral, or Slightly Alkaline Urine
Calcium
oxalate
Colorless
Octahedral
dumbbells,
often small
use high
Normal; large
amounts in
fresh urine
may indicate
severe
chronic renal
disease, liver
disease,
ethylene
power
Hippuric
acid (rare)
Colorless
Rhombic
plates, foursided prisms
glycol
poisoning,
diabetes
mellitus,
large doses
of vitamin C
No
significance
Alkaline, Neutral, or Slightly Acid Urine
Triple
phosphate
Colorless
Coffin lids,
36 sided
prism;
occasionally
fern-leaf
Urine stasis
and chronic
cystitis,
chronic
pyelitis and
enlarged
prostate
Colorless
Needles,
spheres,
dumbbells
Normal
Yellow
opaque
brown
Thorn apple
spheres,
dumbbells,
sheaves of
needles
Normal
Alkaline Urine
Calcium
carbonate
Ammonium
biurate
Calcium
phosphate
Colorless
Prisms,
plates,
needles
Amorphous
phosphates
W hite
Granules
Normal
Normal
Clin ical Alert

Specif ic drugs (most commonly, ampicillin and sulf onamides) can cause
increased levels of t heir ow n cryst als, w hich could be a sign of improper
hydrat ion.
Interfering Factors
1. Ref rigerat ed urine w ill precipit at e out many cryst als because t he solubilit y
propert ies of t he compound are alt ered.
2. Urine lef t st anding at room t emperat ure w ill also cause precipit at ion of
cryst als or t he dissolving of t he cryst als.
3. Radiographic dye can cause cryst als in improperly hydrat ed pat ient s. These
resemble uric acid cryst als and can be suspect ed in specimens t hat have an
abnormally high specif ic gravit y (>1. 030).
Interventions
Patient Preparation and Aftercare The pretest and
posttest care are the same as for the urine RBC test.
Urine Shreds
Shreds consist of a mixt ure of mucus, pus, and epit helial (squamous) cells. They
can be seen on gross examinat ion.
Procedure
1. Examine a f resh urine specimen by visually checking f or a hazy mass.
2. Cent rif uge t he specimen and examine t he sediment microscopically t o verif y

t he presence of f ormed element s (Table 3. 9).
Table 3.9 Interpreting Urine Laborato
Disease
Acute
glomerulonephritis
Cause
Antibasement
membrane
antibodies
associated
with strep
infection,
variety of
infectious
agents,
toxins,
allergens
Inflammation
of the
glomeruli by
which they
become
abnormally
permeable
and leak
Laboratory
Findings
Signs
Rapid
appearance
of hematuria,
proteinuria,
and casts
Varying
degree of
hypertension,
renal
insufficiency,
and edema
Frequently
seen in
children and
young adults
Gross
hematu
turbid,
smoky
plasma
proteins and
blood into
the renal
tubules
Chronic
glomerulonephritis
Nephrotic
syndrome
Represents
end-stage
result of
persistent
glomerular
damage with
continuing
and
irreversible
loss of renal
function
Progress to
end-stage
renal
disease
Glomeruli
whose
basement
membrane
has become
highly
permeable
to plasma
proteins of
large
molecular
Symptoms
include
edema,
hypertension,
anemia,
metabolic
acidosis,
oliguria
progressing
to anuria
Massive
protein,
edema, high
levels of
serum lipids,
and low
levels of
Hematu
Cloudy
weight and
lipids,
allowing
them to
pass in the
tubules
Acute tubular
necrosis
Cystitis (lower
urinary tract)
Urethritis (urethra
in males)
Destruction
of renal
tubular
epithelial
cells
Usually
following a
hypotensive
event
(shock),
toxic
element, or
drugs and
heavy
metals
Infection of
the bladder
most
commonly
caused by
bacteria;
Escherichia
coli most
common
serum
albumin
Oliguria and
complete
renal failure
Slightly
cloudy
Frequent and
painful
urination
Cloudy,
foul
smellin
(85%)
Acute
pyelonephritis
(upper urinary
tract)
Chronic
pyelonephritis
An infection
of the
kidney or
renal pelvis
Caused by
infectious
organism
that has
traveled
through the
urinary tract
and invaded
the kidney
tissue
More
frequently in
women with
repeated
urinary tract
infections
Turbid,
foul
smellin
Permanent
scarring of
the renal
tissue
Polyuria and
nocturia
develop as
tubular
function is
lost
W ith disease
progression,
there is
hypertension
and altered
renal and
glomerular
flow
Cloudy
Acute interstitial
nephritis
Inflammation
of the renal
interstitium
caused by
drug toxicity
or an
allergic
reaction
Fever,
eosinophilia
Skin rash
Cloudy
SG, specific gravity.
Adapted from Finnegan K: Routine urinalysis. In Lehmann C

Clinical Laboratory Science. Philadelphia, W. B. Saunders,
1. When mucus predominat es, t he shreds f loat on t he surf ace.
2. When epit helial cells predominat e, t he shreds occupy t he middle zone.
3. When pus (WBCs) predominat es, t he shreds are draw n t o t he bot t om of t he
specimen.
4. O t her f indings in urine caused by specimen cont aminat ion include

microscopic yeast , Tri chomonas, spermat ozoa, veget able f ibers, parasit es,
and meat f ibers. These should be report ed because t hey have clinical
signif icance.
a. Yeast may indicat e urinary moniliasis or vaginal moniliasis (Candi da
al bi cans)
b. Parasit esusually f rom f ecal or vaginal cont aminat ion
c. Spermat ozoaseen af t er sexual int ercourse, af t er noct urnal emissions,
or in t he presence of prost at ic disease
An 82-year-old female resident displayed the following

signs and symptoms related to a urinary tract infection:
high fever (101.0F) for 24 hours; lethargy past 2 days;
cloudy, foul-smelling urine; and dysuria. Urinalysis
microscopic exam and culture sensitivity were ordered.
URINALYSIS
Interpretation of test results for routine urinalysis
and urine culture with interventions.
Urinalysis Report:
Macroscopic
Analysis
Norm al
Date: 06/16/03 Tim e:

2130
Color
Pale
yellowamber
Yellow
Clarity
Clear to
slightly
hazy
Cloudy*
Urine chem istries

Specific
gravity
1.005
1.030
1.02.0*
Glucose
Negative
Negative
Ketones
Negative
Negative
pH
5.08.0
8.5 High
Protein
Negative
30*
Blood
Negative
Small*
Bilirubin
Negative
Negative
Urobilinogen
0.21.0
EU/dL
0.2
Nitrite
Negative
Pos*
Leukocyte
ester
Negative
Small
Microscopic exam ination

BACT/hpf
None
4+*
W BC/hpf
02
50100
RBC/hpf
02
25*
SQ EPITH/lpf
02
1020*
Casts/lpf
None
Present*
Hyaline/lpf
Occasional
25*
None
Few *(occurs in alkaline,

neutral, or slightly acid
urine)
Triple Phos
* = abnormal, HPF = high-powered field, LPF = lowpowered field, NEG = negative, BACT = bacteria, W BC
= white blood cells, RBC = red blood cells, SPEC =
specific (as in specific gravity), POS = positive, TRC =
trace, ABN = abnormal, EU = Ehrlich units, MIC =
minimum inhibitory concentration (the lowest
concentration of the antibiotic that inhibits the
organism's growth), S = sensitive or susceptible, R =
resistant, TMP-SMX = trimethoprim sulfamethoxazole
Urine Culture Antibiotic Drug Sensitivity and

Organism Susceptibility
Collected: 06/16/03Time 2130
Received: 06/17/03Time 1006
Final Report6/19/03 of antibiotic drug sensitivity and
organism susceptibility
>100,000 colonies/mL Streptococcus agalactiae, Group
B hemolytic
>100,000 colonies/mL Escherichia coli
Susceptibility TestingE. coli
S = sensitivity or susceptibility; R = resistant; TMPSMX = trimethoprim sulfamethoxazole
Susceptibility
Interpretation
of Organism
Susceptibility
to Antibiotic
Minim um
Inhibitory
Concentration
(MIC) (the lowest
concentration of
antibiotic that
inhibits the
organism 's
growth)
Ampicillin
Piperacillin
< 8
Ampicill/Sulbac
8/4
Cefazolin
< 8
Gentamicin
Tobramycin
Tetracycline
Ciprofloxacin
Levofloxacin
< 2
Nitrofurantoin
< 32
TMP-SMX
Bactrim
5/9.5
Results of the tests were abnormal outcomes and the

following interventions started on 06/19/03 with Bactrim
DS (double strength) BID 7 days; then Bactrim SS
(single strength) every day until further orders; force
fluids as appropriate. Repeat urinalysis and culture and
sensitivity in 2 weeks. The rationale for Bactrim as drug
of choice was because of both sensitivity and MIC (see
legend).
URINE CHEM ISTRY

Urine Pregnancy Test; Human Chorionic Gonadotropin
(hCG) Test From the earliest stage of development, the
placenta produces hormones, either on its own or in
conjunction with the fetus. The very young placental
trophoblast produces appreciable amounts of the
hormone human chorionic gonadotropin (hCG), which
is excreted in the urine. This hormone is not found in
the urine of men or of normal, young, nonpregnant
women.
I ncreased urinary hCG levels f orm t he basis of t he t est s f or pregnancy; hCG is
present in blood and urine w henever t here is living chorionic/ placent al t issue.
hCG is made up of - and -subunit s. The -subunit is t he most sensit ive and
specif ic t est f or early pregnancy. hCG can be det ect ed in t he urine of pregnant
w omen 26 t o 36 days af t er t he f irst day of t he last menst rual period (ie, 5 t o 7
days af t er concept ion). Pregnancy t est s should ret urn t o negat ive 3 t o 4 days
af t er delivery.
Reference Values
Normal
Posit ive: pregnancy exist s
Negat ive: nonpregnant st at e
Procedure
1. Collect an early morning urine specimen. The f irst morning specimen
generally cont ains t he great est concent rat ion of hCG . A random specimen
may be used, but t he SG must be more t han 1. 005.
2. Do not use grossly bloody specimens. I f necessary, a cat het erized specimen
should be used.
1. A posi ti ve result usually indicat es pregnancy.
2. Posi ti ve result s also occur in

a. Choriocarcinoma
b. Hydat idif orm mole
c. Test icular and t rophoblast ic t umors in males
d. Chorioepit helioma
e. Chorioadenoma dest ruens
f. About 65% of ect opic pregnancies
3. Negati ve or decreased result s occur in
a. Fet al demise
b. Abort ion, t hreat ened abort ion (t est remains posit ive f or 1 w eek af t er
procedure)
Interfering Factors
1. False-negat ive t est result s and f alsely low levels of hCG may be caused by
dilut e urine (low SG ) or by using a specimen obt ained t oo early in pregnancy.
2. False-posit ive t est s are associat ed w it h
a. Prot einuria
b. Hemat uria
c. The presence of excess pit uit ary gonadot ropin
d. Cert ain drugs (eg, chlorpromazine, phenot hiazines, met hadone)
Urine Estrogen, Total and Fractions (Estradiol [E2 ] and

Estriol [E3 ]), 24-Hour Urine and Total EstrogenBlood
Estradiol is the most active of the endogenous
estrogens. The test evaluates female menstrual and
fertility problems. In men, estradiol is useful for
evaluating estrogen-producing tumors. Estriol is the
prominent urinary estrogen in pregnancy. Serial
measurements reflect the integrity of the fetal-placental
complex.
Total estrogens evaluat e ovarian est rogen-producing t umors in premenarchal or
post menopausal f emales.
These measurement s, t oget her w it h t he gonadot ropin (f ollicle-st imulat ing

hormone [ FSH] ) level (see Chap. 6), are usef ul in evaluat ing menst rual and
f ert ilit y problems, male f eminizat ion charact erist ics, est rogen-producing t umors,
and pregnancy. Est radiol (E2 ) is t he most act ive of t he endogenous est rogens.
Est riol (E3 ) levels in bot h plasma and urine rise in pregnancy advances;
signif icant amount s are produced in t he t hird t rimest er. E3 is no longer
considered usef ul f or det ect ion of f et al dist ress. Tot al est rogens may be helpf ul
t o est ablish t ime of ovulat ion and t he opt imum t ime f or concept ion.
Reference Values
Normal
Normal values vary w idely bet w een w omen and men and in t he presence or
pregnancy, t he menopausal st at e, or t he f ollicular, ovulat ory, or lut eal st age of
t he menst rual cycle.
Urine Estradiol (E2 )

Men:
06 g/24 hours or 022 nmol/day

Follicular phase, 03 g/24 hours or 011 nmol/day
Ovulatory peak, 414 g/24 hours or 1551 nmol/day
Women:
Luteal phase, 410 g/24 hours or 1537 nmol/day
Postmenopausal, 04 g/24 hours or 015 nmol/day
Urine Estriol (E3 ) (wide range of normal)

Men:

Follicular phase, 014 g/24 hours or
051 nmol/day
Ovulatory phase, 1354 g/24 hours or
48198 nmol/day
Women:
Luteal phase, 860 g/24 hours or 29

220 nmol/day
Postmenopausal, 011 g/24 hours or
040 nmol/day
Pregnancy:
1st trimester, 0800 g/24 hours or 0

2900 nmol/day
2nd trimester, 80012,000 g/24

hours or 290044,000 nmol/day
3rd trimester, 5,00050,000 g/24

hours or 18,000180,000 nmol/day
Urine Total Estrogens

Men:

Menstruating, 1580 g/24 hours or 55
294 nmol/day
W omen:
Postmenopausal, <20 g/24 hours or <73
nmol/day
1st trimester, 0800 ug/24 hours or 0
2,900 nmol/day
Pregnancy:
2nd trimester, 8005,000 g/24 hours or

2,90018,350 nmol/day
3rd trimester, 5,00050,000 g/24 hours
or 2,900183,000 nmol/day
Blood Total Estrogens
Men:
2080 pg/mL or 2080 ng/L

60400 pg/mL or 60400 ng/L
Postmenopausal: <130 pg/mL or <130 ng/L
W omen:
Prepuberty: <25 pg/mL or <25 ng/L
Puberty: 30280 pg/mL or 30280 ng/mL
NOTE
Tot al serum est rogen does not measure est riol (E3 ) and should not be used in
pregnancy or t o assess f et al w ell-being.
Procedure
1. O bt ain a venous blood sample if needed f or t ot al est rogen.
2. Collect a 24-hour urine specimen and use boric acid preservat ive f or all
est rogen t est s. Keep t he cont ainer ref rigerat ed or on ice during collect ion.
3. Follow general collect ion procedures f or a 24-hour urine specimen (see
Long-Term, Timed Urine Specimen, page 171).
4. Record t he age and sex of t he pat ient .
5. Ensure t hat t he number of gest at ion w eeks is communicat ed if pat ient is
pregnant .
6. Document t he number of days int o t he menst rual cycle f or t he nonpregnant
w oman.
1. Increased uri ne E2 is f ound in t he f ollow ing condit ions:
a. Feminizat ion in children (t est icular f eminizat ion syndrome)
b. Est rogen-producing t umors
c. Precocious pubert y relat ed t o adrenal t umors
d. Hepat ic cirrhosis
e. Hypert hyroidism
f. I n w omen, est radiol increases during menst ruat ion, bef ore ovulat ion, and
during t he 23rd t o 41st w eeks of pregnancy.
2. Decreased uri ne E2 occurs in:
a. Primary and secondary hypogonadism
b. Kallmann's syndrome
c. Hypof unct ion or dysf unct ion of t he pit uit ary or adrenal glands
d. Menopause
3. Increased uri ne E3 occurs in pregnancy; t here is a sharp rise w hen delivery

is imminent .
4. Decreased uri ne E3 is f ound in:
a. Cases of placent al insuff iciency or f et al dist ress (abrupt drop of > 40%
on 2 consecut ive days). Serial monit oring of est riol f or 4 consecut ive
days is recommended t o evaluat e f et al dist ress.
b. Congenit al heart disease
c. Dow n syndrome
5. Blood and urine t ot al est rogens are i ncreased in:
a. Malignant neoplasm of adrenal gland
b. Malignant neoplasm of cell t umor of ovary
c. Benign neoplasm of ovary
d. G ranulosa cell t umor of ovary
e. Lut ein cell t umor of ovary
f. Theca cell t umor of ovary
g. Test icular t umors
6. Blood and urine t ot al est rogens are decreased in:
a. O varian hypof unct ion (ovarian agenesis, primary ovarian malf unct ion)
b. I nt raut erine deat h
c. Preeclampsia
d. Hypopit uit arism
e. Hypof unct ion of adrenal cort ex
f. Menopause
g. Anorexia nervosa
Clin ical Alert

Est radiol may be used f or Pergonal (menot ropins, ie, combinat ion of f olliclest imulat ing and lut einizing hormones used t o promot e ovarian f ollicular grow t h)
monit oring. Serial measurement s of E2 during ovulat ion induct ion enable t he
physician t o minimize high E2 levels caused by ovarian overst imulat ion and
t hereby decrease side eff ect s.
Clin ical Alert

Normal values are guidelines and must be int erpret ed in conjunct ion w it h
clinical f indings.
Interfering Factors
1. Tot al est rogens
a. O ral cont racept ives
b. Est rogen t herapy
c. Progest erone t herapy
d. Pregnancy and af t er administ rat ion of acet azolamide during pregnancy
2. Est radiol
a. Radioact ive pharmaceut icals
b. O ral cont racept ives
3. Est riol
a. G lucose and prot ein int erf ere w it h out come.
b. Day-t o-day physiologic variat ion can be as much as 30%; t heref ore,
single det erminat ions are of limit ed use.
c. Renal diseasein w hich case a serum assay w ould be more accurat e.
Interventions
1. Explain t he t est purpose and procedure.
2. St ress t est compliance. The pat ient must be able t o adjust daily act ivit ies t o
accommodat e urine collect ion prot ocols.
3. Do not administ er radioisot opes f or 48 hours bef ore specimen collect ion.
4. Discont inue all medicat ions f or 48 hours bef ore specimen collect ion (w it h
physician's approval). Drugs deemed necessary must be document ed and
communicat ed.

1. Resume medicat ions and act ivit y.
2. I nt erpret t est out comes, monit or, and counsel appropriat ely.
URINE DRUG INVESTIGATION SPECIM ENS

When screening f or unknow n drugs, t he most valuable samples are obt ained f rom
urine, gast ric cont ent s, and blood. Urine drug screening is pref erred f or several
reasons:
1. Specimens are easily procured.
2. I t is not an invasive procedure (unless bladder cat het erizat ion is involved).
3. Drug concent rat ions are more elevat ed in urine or may not be det ect able in
blood.
4. Drug met abolit es are excret ed f or a longer period (days or w eeks) t hrough
urine, indicat ing past drug use.
5. Urine t est procedures are more easily done and are more economical.
Clin ical Alert

Blood is t he pref erred medium f or et hyl alcohol t est ing because t he alcohol
concent rat ion is more elevat ed and t heref ore more reliably measured in a
blood sample (see Chap. 6).
Toxicology screening should be perf ormed:
1. To conf irm clinical or post mort em diagnosis
2. To diff erent iat e drug-induced disease f rom ot her causes, such as t rauma or
met abolic or inf ect ious disease processes
3. To ident if y cont ribut ing diagnoses, such as et hanol abuse, t rauma, presence
of ot her drugs, or underlying psychosis
4. To seek a basis f or high-risk int ervent ions such as hemodialysis
5. To t est f or drug abuse in t he w orkplace, especially w hen public saf et y is at
risk or concern; also t o t est f or doping in at hlet es
6. As part of preemployment screening f or drug use or abuse
7. To t est prisoners and parolees randomly t o det er or det ect drug use (Chart
3. 2)
Ch art 3.2 Common Urine Drug Tests*

Alcohol
Amphet amines
Analgesics
Barbit urat es
Benzodiazepines
Cocaine, crack
Cyanide
Lysergic acid diet hylamide (LSD)
Major t ranquilizers
Marijuana
O piat es
Phencyclidine (PCP)
Sedat ives
St imulant s
Sympat homimet ics
Footn otes
* Many of t hese drugs are det ect able in urine but are not det ect able in blood
serum. How ever, all drugs det ect able in blood serum are also det ect able in
urine, except f or glut et himide.
Because minor t ranquilizers are almost complet ely met abolized, t hey are not
likely t o be det ect ed in urine unless an overdose is t aken.
Clin ical Alert

When report ing drug t est result s f or subst ance abuse, healt h care w orkers
and pat ient s need t o be aw are of t he psychological, social, economic, and
legal implicat ions and t he pot ent ial liabilit ies associat ed w it h mismanaged or
incorrect ly report ed result s. Document ed procedures should be est ablished
and f ollow ed t o ensure t hat bef ore a result is report ed, corroborat ing
evidence exist s t o support t hat result . Conf irmat ion of all posit ive result s must
be done t hrough an equally sensit ive and specif ic met hod t hat uses a diff erent
chemical principle t o cross-check t he init ial result s. Keep in mind t hat
problems associat ed w it h incorrect t est result s are direct ly proport ional t o t he
volume of drug abuse t est ing being done.
Urine screening is not a cure-all f or prevent ing subst ance abuse in t he
w orkplace. When properly implement ed, how ever, it can support a w ell
t hought -out subst ance abuse rehabilit at ion program. Screening can det ect a
problem t hat t he employee may not admit t o having. Sure know ledge t hat an
employee abuses drugs allow s an employer t o move w it h conf idence t ow ard
handling t he problem.
Witnessed Urine Sampling for Suspected Substance

Abuse The following procedure is an example of the
chain of custody. A chain-of-custody document is
originated at the time the sample is collected. The
donor and the individual who witnessed specimen
collection must sign and date the document, as does
every person who handles the sample thereafter. The
sealed chain-of-custody specimen bag remains in the
possession and control of the collector or is kept in a
secured area until shipment to the testing facility.
Sealed collections are placed in large shipping cartons
or specially designated bags.
Af t er init ial and conf irmat ory t est ing, t he sample is resealed in a labeled bag and
securely st ored f or 30 days or longer. All records of t est s done on t he sample
and t he chain-of -cust ody report must be caref ully maint ained.
The t est result s should be released only t o predesignat ed, aut horized persons t o
lessen t he risk f or f alse or speculat ive inf ormat ion being communicat ed t o
inappropriat e persons.
Several f act ors may int erf ere w it h accurat e out comes and could cause incorrect
or f alse-posit ive or f alse-negat ive result s: higher or low er pH t han normal;
presence of blood, sodium chloride, det ergent s, or ot her cont aminant s; or low
specif ic gravit y.
Procedure
1. Ensure t hat t he t est ed pat ient 's signed inf ormed consent f orm and phot o
ident if icat ion are available; t hey are required.
2. I nst ruct pat ient t o remove ext ra out er garment s and leave t hem out side t he
bat hroom. Make provisions f or personal privacy during specimen
procurement .
3. Direct t he donor t o void a random sample of 60 t o 100 mL of urine int o t he
clean specimen cup. The t oilet may not be f lushed at any t ime.
4. Have t he w it ness t ransf er t he cont ent s of t he cup int o t he laborat ory
specimen bot t le on receipt of t he voided specimen f rom t he donor. The donor
is present f or t he ent ire t ransf er procedure (view ing t his and t he f ollow ing
procedure).
5. Check and record any visible signs of cont aminat ion (eg, sediment ,
discolorat ion). The ent ire procedure must be w it nessed by a t rained,
designat ed individual w ho is legally responsible t o ensure t hat t he specimen
has been obt ained f rom t he correct pat ient .
6. Aff ix a t emperat ure-sensing st rip t o t he specimen bot t le, and read and
record t he t emperat ure w it hin 4 minut es of specimen collect ion. Temperat ure
st rips and collect ion cont ainers must be at room t emperat ure (urine
t emperat ure must be bet w een 90 and 98F).
7. Very f irmly screw dow n t he cap ont o t he laborat ory specimen bot t le t o seal
it . The rim of t he specimen bot t le should be dry.
8. Aff ix one end of t he t amper-evident t ape t o t he side of specimen bot t le.
Record t he dat e collect ed, and have t he donor init ial t he evidence t ape.
Wrap t he t amper-evident t ape across t he t op of t he bot t le, and overlap t he
f ree end of t he t ape w it h t he ot her end t o discourage t ampering w it h t he
specimen.
9. Seal t he specimen bot t le in a zip-lock bag w it h absorbent mat erial.
10. Af t er sealing, have t he donor sign and dat e t he Drug Screen Request Form in
t he space provided. The collect or t hen signs, dat es, and provides a
t elephone number on t he Drug Screen Request Form, indicat ing t hat all of
t he above st eps have been f ollow ed. Every person w ho handles t he sample
t hereaf t er must also sign t he f orm (ie, chain-of -cust ody procedure).
11. Put t he original and t he f irst copy of t he Drug Screen Form and t he sealed
laborat ory specimen bot t le int o t he shipping cont ainer, and seal it . Place
t amper-evident t ape across t he seal.
12. Ret ain t he t hird copy of t he f orm f or agency records.
13. G ive t he f ourt h copy of t he f orm t o t he donor, or send it t o t he company or
place of employment , as required.
Clin ical Alert

Nat ional I nst it ut e f or Drug Abuse (NI DA)-approved laborat ory st andards have
st ringent requirement s. At t he collect ion sit e (eg, bat hroom), place t oilet
bluing markers in t he t oilet t ank, and use t amper-proof t ape on w at er f aucet
and soap dispensers t o prevent w at er access f or specimen dilut ion.
Cert ain drugs can be det ect ed in t he urine f or hours t o several days af t er
ingest ion (Table 3. 10). (Check w it h agency laborat ory f or specif ic drugs and
specif ic t ime int ervals. )
Table 3.10 Screening Limits
Drugs Tested
Screening Cutoff Levels
Length of
Detection
Alcohol
Ethanol (all methods)
20 ng/mL
12 h
Am phetam ines
D-Amphetamine
Methamphetamine
1,000 ng/mL
23 d
Barbiturates
Secobarbital
200 ng/mL
Up to 30 d
Benzodiazepines
Nordiazepam
200 ng/mL
Up to 40 d
Marijuana
11-nor-D9-THC-9
COOH
50 ng/mL
3060 d
Cocaine m etabolite
Benzoylecgonine
300 ng/mL
24 d
Methadone
Methadone HCl
300 ng/mL
860 h
Methaqualone
Methaqualone HCl
300 ng/mL
Up to 7 d
Opiates
Morphine
300 ng/mL
24 d
PCP
Phencyclidine HCl
25 ng/mL
23 d
Propoxyphene
D-Propoxyphene HCl
300 ng/mL
13 d
Tricyclic
antidepressants
(T CAs)
Desipramine (triage
plus TCA)
1,000 ng/mL
13 d
Heroin
Acetylmorphine
2,000 ng/mL
12 h
Interfering Factors
Fact ors associat ed w it h incorrect t est result s f or urine drug screens include t he
presence of :
1. Det ergent s
2. Sodium chloride (t able salt ) (NaCl)
3. Low SG (dilut e urine)
4. High pH (acid urine)
5. Low pH (alkaline urine)
6. Blood in t he urine
Interventions
1. Explain t he t est purpose and t he procedure f or specimen collect ion.

1. I nt erpret t est out comes and counsel appropriat ely regarding result s and
possible ret est ing.
Clin ical Alert

Screening t est s w ill be posit ive f or opiat es if poppy seeds are ingest ed (eg,
bagels), if t he screening cut -off level is 300 ng/ mL. Theref ore, many screen
labs have raised t he cut -off level t o 2000 ng/ mL.
TIM ED URINE TESTS

Urine Chloride (Cl), Quantitative (24-Hour) Normally,
the urinary chloride excretion approximates the dietary
intake. The amount of chloride excreted in the urine in
a 24-hour period is an indication of the state of the
electrolyte balance. Chloride is most often associated
with sodium balance and fluid change.
The urine chloride measurement may be used t o diagnose dehydrat ion or as a
guide in adjust ing f luid and elect rolyt e balance in post operat ive pat ient s. I t also
serves as a means of monit oring t he eff ect s of reduced-salt diet s, w hich are of
great t herapeut ic import ance in pat ient s w it h cardiovascular disease,
hypert ension, liver disease, and kidney ailment s.
Urine chloride is of t en ordered along w it h sodium and pot assium as a 24-hour
urine t est . The urinary anion gap (Na + K) - Cl is usef ul f or init ial evaluat ion of
hyperchloremic met abolic acidosis. I t is also used t o det ermine w het her a case
of met abolic alkalosis is salt responsive.
Reference Values
Normal
Adult : 140250 mEq/ 24 hours or 140250 mmol/ day Child <6 years old: 1540
mEq/ 24 hours or 1540 mmol/ day Child 1014 years old: 64176 mEq/ 24 hours
or 64176 mmol/ day Children's values are much low er t han adult values.
Values vary great ly w it h salt int ake and perspirat ion.
Diff erent labs may have diff erent values.
I t is diff icult t o t alk about normal and abnormal ranges because t he t est f indings
have meaning only in relat ion t o salt int ake and out put .
Procedure
1. Collect a 24-hour urine specimen.
2. Record t he exact st art ing and ending t imes on t he specimen cont ainer and in
t he pat ient 's healt h care record.
3. The complet e specimen should be sent t o t he laborat ory f or ref rigerat ion
unt il it can be analyzed.
Clin ical Alert

Because t he elect rolyt es and w at er balance are so closely relat ed, evaluat e
t he pat ient 's st at e of hydrat ion by checking daily w eight , by recording
accurat e int ake and out put , and by observing and recording skin t urgor, t he
appearance of t he t ongue, and t he appearance of t he urine sample.
1. Decreased urine chloride occurs in:
a. Chloride-deplet ed pat ient s (<10 mEq/ L or <10 mmol/ L); t hese pat ient s
have low serum chloride and are chloride responsive (t hey respond t o
chloride t herapy so t hat serum and urine levels ret urn t o normal).
1. Syndrome of inappropriat e ant idiuret ic hormone (SI ADH) secret ion
2. Vomit ing, diarrhea, excessive sw eat ing
3. G ast ric suct ion
4. Addison's disease
5. Met abolic alkalosis
6. Massive diuresis f rom any cause
7. Villous t umors of t he colon
b. Chloride is decreased by endogenous or exogenous cort icost eroids (>20
mEq/ L or >20 mmol/ L); t his condit ion is not responsive t o chloride
administ rat ion. Diagnosis of a chloride-resist ant met abolic alkalosis
helps ident if y a cort icot ropin (ACTH)- or aldost erone-producing
neoplasm, such as:
1. Cushing's syndrome
2. Conn's syndrome
3. Mineralocort icoid t herapy
4. Post operat ive chloride ret ent ion
2. Increased urine chloride occurs in:
a. I ncreased salt int ake
b. Adrenocort ical insuff iciency
c. Pot assium deplet ion
d. Bart t er's syndrome
e. Salt -losing nephrit is
Interfering Factors
1. Decreased chloride is associat ed w it h:
a. Carbenicillin t herapy
b. Reduced diet ary int ake of chloride
c. I ngest ion of large amount s of licorice
d. Alkali ingest ion
e. Dehydrat ion
2. I ncreased chloride is associat ed w it h:
a. Ammonium chloride administ rat ion
b. Excessive inf usion of normal saline
c. I ngest ion of sulf ides, cyanides, halogens, bromides, and sulf hydryl
compounds
Interventions
1. I nst ruct t he pat ient about t he t est purpose and t he met hod f or collect ing a
24-hour specimen.

1. I nt erpret t est out comes and monit or appropriat ely f or f luid imbalances.
Urine Sodium (Na), Quantitative (24-Hour) Sodium is a

primary regulator for retaining or excreting water and
maintaining acid-base balance. The body has a strong
tendency to maintain a total base content; on a relative
scale, only small shifts are found even under
pathologic conditions. As the predominant base

substance in the blood, sodium helps to regulate acidbase balance because of its ability to combine with
chloride and bicarbonate. Sodium also promotes the
normal balance of electrolytes in the intracellular and
extracellular fluids by acting in conjunction with
potassium under the effect of aldosterone. This
hormone promotes the 1:1 exchange of sodium for
potassium or the hydrogen ion.
This t est measures one aspect of elect rolyt e balance by det ermining t he amount
of sodium excret ed in a 24-hour period. I t is done f or diagnosis of renal,
adrenal, w at er, and acid-base imbalances.
Reference Values
Normal
Adult : 40220 mEq/ 24 hours or 40220 mmol/ day Child: 41115 mEq/ 24 hours or
41115 mmol/ day Values are diet dependent .
Procedure
1. Properly label a 24-hour urine cont ainer.
2. The urine cont ainer must be ref rigerat ed or kept on ice.
3. Follow general inst ruct ions f or 24-hour urine collect ions (see Long-Term,
4. Record exact st art ing and ending t imes on t he specimen cont ainer and in t he
pat ient 's healt h care record.
5. Transf er t he specimen t o t he laborat ory f or proper st orage w hen t he t est is
complet ed.
1. Increased urine sodium occurs in:
a. Adrenal f ailure (Addison's disease) (primary and secondary)
b. Salt -losing nephrit is
c. Renal t ubular acidosis
d.
SIADH
e. Diabet ic acidosis
f. Aldost erone def ect (AI DS-relat ed hypoadrenalism)
g. Tubuloint erst it ial disease
h. Bart t er's syndrome
2. Decreased urine sodium occurs in:
a. Excessive sw eat ing, diarrhea
c. Adrenocort ical hyperf unct ion
d. Nephrot ic syndromes w it h acut e oliguria
e. Prerenal azot emia
f. Cushing's disease
g. Primary aldost eronism
Interfering Factors
1. I ncreased sodium levels are associat ed w it h caff eine int ake, diuret ic t herapy,
dehydrat ion, dopamine, post menst rual diuresis, increased sodium int ake, and
vomit ing (see Appendix J).
2. Decreased sodium levels are associat ed w it h int ake of cort icost eroids and
propranolol; low sodium int ake; premenst rual and w at er ret ent ion;
overhydrat ion and st ress diuresis (see Appendix J).
Interventions
1. I nst ruct t he pat ient about t he purpose of t he t est , met hod of collect ion, and
specimen ref rigerat ion or icing. Writ t en inst ruct ions can be helpf ul.
2. Encourage int ake of f ood and f luids.
Clin ical Alert
Because elect rolyt es and w at er balance are so closely relat ed, det ermine t he
pat ient 's st at e of hydrat ion by checking and recording daily w eight s, accurat e
int ake and out put of f luids, and observat ions about skin t urgor, t he
appearance of t he t ongue, and t he appearance of t he urine.

1. I nt erpret t est out comes and monit or as necessary f or f luid and elect rolyt e
st at e.
Urine Potassium (K), Quantitative (24-Hour) and

Random Potassium acts as a part of the body's buffer
system and serves a vital function in the body's overall
electrolyte balance. Because the kidneys cannot
completely conserve potassium, this balance is
regulated by the excretion of potassium through the
urine. It takes the kidney 1 to 3 weeks to conserve
potassium effectively.
This t est provides insight int o elect rolyt e balance by measuring t he amount of
pot assium excret ed in 24 hours. This measurement is usef ul in t he st udy of renal
and adrenal disorders and w at er and acid-base imbalances. An evaluat ion of
urinary pot assium can be helpf ul in det ermining t he origin of abnormal pot assium
levels. Urine pot assium values <20 mEq/ L (or <20 mmol/ L) are associat ed w it h
nonrenal condit ions, w hereas values >20 mEq/ L (or >20 mmol/ L) are associat ed
w it h renal causes.
Reference Values
Normal
Adult : 25125 mEq/ 24 hours or 25125 mmol/ day Child: 1060 mEq/ 24 hours or
1060 mmol/ day Values are diet dependent .
Procedure
1. Label a 24-hour urine cont ainer properly.
2. Ref rigerat e t he urine cont ainer or keep it on ice during t he collect ion.
3. Follow general inst ruct ions f or 24-hour urine collect ion (see Long-Term,
4. Record exact st art ing and ending t imes on t he cont ainer and in t he pat ient 's
healt h care record.
5. Transf er t he specimen t o t he laborat ory f or proper st orage.
6. A random urine pot assium det erminat ion may be done.
1. Increased urine pot assium occurs in:
a. Primary renal diseases
b. Diabet ic and renal t ubule acidosis
c. Albright -t ype renal disease
d. St arvat ion (onset )
e. Primary and secondary aldost eronism
f. Cushing's syndrome
g. O nset of met abolic alkalosis
h. Fanconi's syndrome
i. Bart t er's syndrome
2. Decreased urine pot assium occurs in:
a. Addison's disease
b. Severe renal disease (eg, pyelonephrit is, glomerulonephrit is)
c. I n pat ient s w it h pot assium def iciency, regardless of t he cause, t he urine
pH t ends t o f all.
This occurs because hydrogen ions are released in exchange f or sodium ions,
given t hat bot h pot assium and hydrogen are excret ed by t he same mechanism.
Interfering Factors
1. Increased urinary pot assium is associat ed w it h:
a. Acet azolamide and ot her diuret ics
b. Cort isone
c. Et hylenediaminet et raacet ic acid (EDTA) ant icoagulant
d. Penicillin, carbenicillin
e. Thiazides
f. Licorice
g. Sulf at es (see Appendix J)
2. Decreased urinary pot assium is associat ed w it h:
a. Amiloride
b. Diazoxide
c. I nt ravenous glucose inf usion (see Appendix J)
Clin ical Alert

I n t he presence of excessive vomit ing or gast ric suct ioning, t he result ing
alkalosis maint ains urinary pot assium excret ion at levels inappropriat ely high
f or t he degree of act ual pot assium deplet ion t hat occurs.
Interventions
1. I nst ruct t he pat ient about t he purpose of t he t est , t he collect ion procedure,
and t he need f or ref rigerat ion or icing of t he 24-hour urine specimen. Writ t en
inst ruct ions can be helpf ul.
2. Food and f luids are permit t ed and encouraged.
Clin ical Alert

1. Because elect rolyt es and w at er balance are so closely relat ed, det ermine
t he pat ient 's st at e of hydrat ion by checking and recording daily w eight s,
accurat e int ake and out put of f luids, and observat ions about skin t urgor,
t he appearance of t he t ongue, and t he appearance of t he urine.
2. O bserve f or signs of muscle w eakness, t remors, changes in
elect rocardiographic t racings, and dysrhyt hmias. The degree of
hypokalemia or hyperkalemia at w hich t hese sympt oms occur varies w it h
each person.

1. I nt erpret t est out comes and monit or appropriat ely f or signs and sympt oms of
elect rolyt e imbalances and kidney disorders.
Urine Uric Acid, Quantitative (24-Hour) Uric acid is

formed from the metabolic breakdown of nucleic acids
composed of purines. Excessive uric acid relates to
excessive dietary intake of purines or to endogenous
uric acid production in certain disorders. Normally, one
third of the uric acid formed is degraded by bacteria in
the intestines.
This t est evaluat es uric acid met abolism in gout and renal calculus f ormat ion.
Evaluat ion of excess uric acid excret ion is import ant t o aid in evaluat ing st one
f ormat ion and nephrolit hiasis. I t also ref lect s t he eff ect s of t reat ment w it h
uricosuric agent s by measuring t he t ot al amount of uric acid excret ed w it hin a
24-hour period.
Reference Values
Normal
Wit h normal diet : 250750 mg/ 24 hours or 1. 484. 43 mmol/ day Wit h purine-f ree
diet : <400 mg/ 24 hours or <2. 48 mmol/ day Wit h high-purine diet : <1000 mg/ 24
hours or <5. 90 mmol/ day
Procedure
1. Properly label a 24-hour urine cont ainer t o w hich t he appropriat e
preservat ive has been added.
2. Follow general inst ruct ions f or 24-hour urine collect ion (see Long Term,
4. When collect ion is complet ed, send t he specimen t o t he laborat ory.
1. Increased urine uric acid (uricosuria) occurs in:
a. Nephrolit hiasis (primary gout )
b. Chronic myelogenous leukemia (secondary nephrolit hiasis)
c. Polycyt hemia vera
d. Lesch-Nyhan syndrome
e. Wilson's disease
f. Viral hepat it is
g. Sickle cell anemia
h. High uric acid concent rat ion in urine w it h low urine pH may produce uric
acid st ones in t he urinary t ract . (These pat ient s do not have gout . )
2. Decreased urine uric acid is f ound in:
a. Chronic kidney disease
b. Xant hinuria
c. Folic acid def iciency
d. Lead t oxicit y
Interfering Factors
1. Many drugs increase uric acid levels, including:
a. Salicylat es (aspirin) and ot her ant i-inf lammat ory drugs
b. Diuret ics
c. Vit amin C (ascorbic acid)
d. Warf arin
e. Cyt ot oxic drugs used t o t reat lymphoma and leukemia (see Appendix J)
2. O t her f act ors increasing uric acid urine levels include:
a. X-ray cont rast media
b. St renuous exercise
c. Diet high in purines (eg, kidney, sw eet breads) (see Chap. 6)
3. Allopurinol decreases uric acid levels (see Appendix J)
Interventions
1. I nst ruct t he pat ient about t he t est purpose, int erf ering f act ors, collect ion
process, and ref rigerat ion or icing of t he 24-hour urine specimen. A w rit t en
reminder may be helpf ul.
2. Encourage f ood and f luids. I n some sit uat ions, a diet high or low in purines
may be ordered during and bef ore specimen collect ion.

1. Resume usual diet .
2. I nt erpret t est out comes and counsel appropriat ely regarding prescribed
t reat ment and possible need f or f urt her t est ing.
Urine Calcium (Ca), Quantitative (24-Hour) Calcium

hemostasis is maintained by the parathyroid hormone.
The bulk of calcium excreted is eliminated in the stool.
However, a small quantity of calcium is normally
excreted in the urine. This amount varies with the
quantity of dietary calcium ingested. Increased calcium
in urine results from an increase in intestinal calcium
absorption, a lack of renal tubule reabsorption of
calcium, resorption or loss of calcium from bone, or a
combination of these mechanisms. Values in both
healthy and sick persons have a wide range.
The urine calcium t est is used f or evaluat ion of calcium int ake and/ or t he rat e of
int est inal absorpt ion, bone resorpt ion, and renal loss. Urine calcium is high in
30% t o 80% of cases of primary hyperparat hyroidism but does not reliably
diagnose t his disease. Urine calcium t est does not have much value in a
diff erent ial diagnosis.
Reference Values
Normal
Normal diet : 100300 mg/ 24 hours or 2. 507. 50 mmol/ day Low -calcium diet : 50
150 mg/ 24 hours or 1. 253. 75 mmol/ day
Procedure
1. Label properly a 24-hour urine cont ainer.
2. Procure an acid-w ashed bot t le. See Table 3-3 regarding 24-hour urine
collect ion dat a.
Timed Urine Specimen, page 171). Ref rigerat e during collect ion.
4. Record exact st art ing and ending t imes of t he collect ion on t he specimen
cont ainer and in t he pat ient 's healt h care record.
5. Send t he specimen t o t he laborat ory w hen collect ion is complet ed.
6. Perf orm a random (Sulkow it ch) t est in an emergency. Follow direct ions f or
random urine collect ion in f irst part of t he chapt er.
1. Increased urine calcium is f ound in:
a. Hyperparat hyroidism (30% t o 80% of cases)
b. Sarcoidosis
c. Primary cancers of breast and bladder
d. O st eolyt ic bone met ast ases (carcinoma, sarcoma)
f. Paget 's disease
g. Renal t ubular acidosis
h. Fanconi's syndrome
i. Vit amin D int oxicat ion
j. I diopat hic hypercalcuria
k. O st eoporosis (especially af t er immobilizat ion)
l. O st eit is def orms
m. Thyrot oxicosis
2. I ncreased urinary calcium almost alw ays accompanies increased blood

calcium levels.
3. Calcium excret ion levels great er t han calcium int ake levels are alw ays
excessive; urine excret ion values > 400500 mg/ 24 hours (>1012. 5 mmol/ d)
are reliably abnormal.
4. I ncreased calcium excret ion occurs w henever calcium is mobilized f rom t he
bone, as in met ast at ic cancer or prolonged skelet al immobilizat ion.
5. When calcium is excret ed in increasing amount s, t he sit uat ion creat es t he
pot ent ial f or nephrolit hiasis or nephrocalcinosis, especially w it h high prot ein
int ake.
6. Decreased urine calcium is f ound in:
a. Hypoparat hyroidism
b. Familial hypocalcuria hypercalcemia
c. Vit amin D def iciency
d. Preeclampsia
e. Acut e nephrosis, nephrit is, renal f ailure
f. Renal ost eodyst rophy
g. Vit amin Dresist ant ricket s
h. Met ast at ic carcinoma of prost at e
i. Malabsorpt ion syndromeceliac-spruce disease, st eat orrhea
7. Urine calcium decreases lat e in normal pregnancy.
Interfering Factors
1. Falsely elevat ed levels may be caused by:
a. Some drugs (eg, calcit onin; vit amins A, K, and C; and cort icost eroids)
(see Appendix J)
b. Urine procured immediat ely af t er meals in w hich high calcium int ake has
occurred (eg, milk)
c. I ncreased exposure t o sunlight
d. I mmobilizat ion (especially in children)
2. Falsely decreased levels may be f ound w it h:
a. I ncreased ingest ion of phosphat e, bicarbonat e, ant acids
b. Alkaline urine
c. Thiazide diuret ics (can be used t o low er calcium levels t herapeut ically)
d. O ral cont racept ives, est rogens
e. Lit hium (see Appendix J)
Interventions
1. I nst ruct t he pat ient about t he t est purpose and procedure. Writ t en
inst ruct ions may be helpf ul.
2. Encourage f ood and f luids.
3. I f t he urine calcium t est is done because of a met abolic disorder, t he pat ient
should eat a low -calcium diet , and calcium medicat ions should be rest rict ed
f or 1 t o 3 days bef ore specimen collect ion.
4. For a pat ient w it h a hist ory of renal st one f ormat ion, urinary calcium result s
w ill be more meaningf ul if t he pat ient 's usual diet is f ollow ed f or 3 days
bef ore specimen collect ion. Do not st op medicat ions.

1. I nt erpret t est out comes, monit or and counsel accordingly regarding calcium
imbalances.
2. Follow Chapt er 1 guidelines regarding saf e, eff ect ive, inf ormed posttest
care.
Clin ical Alert

1. O bserve pat ient s w it h very low urine calcium levels f or signs and
sympt oms of t et any (muscle spasms, t w it ching, hyperirrit able nervous
syst em).
2. The f irst sign of calcium imbalance may be pat hologic f ract ure t hat can be
relat ed t o calcium excess.
3. The Sulkow it ch t est (random urine sample) can be used in an emergency,
especially w hen hypercalcemia is suspect ed, because hypercalcemia is
lif e-t hreat ening.
Urine Magnesium (Mg), Quantitative (24-Hour)

Magnesium excretion controls serum magnesium
balance. Urinary magnesium excretion is diet
dependent. With normal dietary intake of 200500
mg/day, urine excretion is normally 75150 mg/24
hours (36 mmol/d). The remainder of the dietary intake
is excreted in the stool.
This t est evaluat es magnesium met abolism, invest igat es elect rolyt e st at us, and
is a component of a w orkup f or nephrolit hiasis. I t is usef ul f or assessing t he
cause of abnormal serum magnesium.
Reference Values
Normal
75150 mg/ 24 hours or 3. 06. 0 mEq/ 24 hours or 3. 006. 00 mmol/ day
Procedure
1. Collect a 24-hour urine specimen in a met al-f ree and acid-rinsed cont ainer.
The pH must be < 2.
2. Record exact st art ing and ending t imes.
3. See Long-Term, Timed Urine Specimen (page 171) f or 24-hour urine
collect ion guidelines.
1. Increased urine magnesium is associat ed w it h:
a. I ncreased blood alcohol
b. Bart t er's syndrome
c. Chronic glomerulonephrit is
2. Decreased urine magnesium is associat ed w it h:
a. Malabsorpt ion
b. Long-t erm chronic alcoholism (poor diet )
c. Long-t erm parent eral t herapy

d. Magnesium def iciency
e. Chronic renal disease
f. Hypoparat hyroidism
g. Hypercalcuria
h. Decreased renal f unct ion (eg, Addison's disease)
Interfering Factors
1. I ncreased magnesium levels are associat ed w it h:
a. Cort icost eroids
b. Cisplat in t herapy
c. Thiazide diuret ics
d. Amphot ericin (see Appendix J)
e. Blood in urine
2. Decreased magnesium levels; many drugs aff ect t est out comes (see
Appendix J)
Interventions
1. Explain purpose of t est and collect ion procedures.
2. I nst ruct t hat t he specimen w ill be unaccept able if it comes in cont act w it h
any t ype of met al.

1. I nt erpret t est out comes and monit or appropriat ely f or abnormal magnesium
excret ion.
Urine Oxalate, Quantitative (24-Hour) Oxalate is an end

product of metabolism. Normal oxalate is derived from
dietary oxalic acid (10%) and from the metabolism of
ascorbic acid (35%50%) and glycine (40%). Patients
who form calcium oxalate kidney stones appear to
absorb and excrete a higher proportion of dietary
oxalate in the urine.
The 24-hour urine collect ion f or oxalat e is indicat ed in pat ient s w it h surgical loss
of dist al small int est ine, especially t hose w it h Crohn's disease. The incidence of
nephrolit hiasis in pat ient s w ho have inf lammat ory bow el disease is 2. 6% t o 10%.
Hyperoxaluria is regularly present af t er jejunoileal bypass f or morbid obesit y;
such pat ient s may develop nephrolit hiasis.
O xaluria is also a charact erist ic of et hylene glycol int oxicat ion. Addit ionally,
vit amin C increases oxalat e excret ion and in some people may be a risk f act or
f or calcium oxalat e nephrolit hiasis. Such ingest ion can usually be det ermined
t hrough t he pat ient 's hist ory. I f oxalat e excret ion becomes normal af t er reduct ion
of vit amin C int ake, addit ional t herapy t o prevent st ones may not be required.
Reference Values
Normal
Men: <55 mg/ 24 hours or <611 mol/ day Women: <50 mg/ 24 hours or <555
mol/ day
Procedure
1. Collect and ref rigerat e or place on ice a 24-hour urine specimen according t o
prot ocols. Do not acidif y.
2. See Long-Term, Timed Urine Specimen (page 171) f or direct ions f or a 24hour urine collect ion.
1. Increased urine oxalat e is associat ed w it h:
a. Et hylene glycol poisoning (>150 mg/ 24 hours or >1700 mol/ day)
b. Primary hyperoxaluria, a rare genet ic disorder (100600 mg/ 24 hours or
11006700 mol/ day [ nephrocalcinosis] )
c. Pancreat ic disorders (diabet es, st eat orrhea)

d. Cirrhosis, biliary diversion
e. Vit amin B6 def iciency (pyridoxine)
f. Sarcoidosis
g. Crohn's disease (inf lammat ory bow el disease)
h. Celiac disease (sprue)
i. Jejunoileal bypass f or t reat ment of morbid obesit y
2. Decreased urine oxalat e occurs in renal f ailure
Interfering Factors
1. Foods cont aining oxalat es, such as rhubarb, st raw berries, beans, beet s,
spinach, t omat oes, gelat in, chocolat e, cocoa, and t ea, cause increased
levels.
2. Et hylene glycol and met hoxyf lurane cause increased levels (see Appendix J).
3. Calcium causes decreased levels (see Appendix J).
4. Ascorbic acid (vit amin C) increases levels.
Interventions
2. Advise t he pat ient t o avoid f oods t hat promot e oxalat e excret ion bef ore t he
t est . A list of such f oods is helpf ul. Normal f luid int ake should be cont inued.
3. Vit amin C should not be t aken w it hin 24 hours bef ore t he beginning of t he
t est nor during t he t est .
4. The pat ient should be ambulat ory and pref erably at home.

1. Resume normal diet and exercise.
2. I nt erpret t est out comes and counsel appropriat ely about abnormal levels.
Urine Pregnanediol (24-Hour) Pregnanediol levels in

normally menstruating women are constant during the
follicular phase. Levels increase sharply during the
luteal phase. During pregnancy, levels gradually
increase, falling sharply before the onset of labor and
delivery.
This t est measures ovarian and placent al f unct ion. Specif ically, it measures a
part of t he hormone progest erone and it s principal excret ed met abolit e,
pregnanediol. Progest erone exert s it s main eff ect on t he endomet rium by causing
t he endomet rium t o ent er t he secret ory phase and t o become ready f or t he
implant at ion of t he blast ocyt e should f ert ilizat ion t ake place.
Pregnanediol excret ion is elevat ed in pregnancy and decreased in lut eal
def iciency or placent al f ailure.
NOTE
A serum progest erone t est is more inf ormat ional and is now used as an index
of progest erone product ion.
Reference Values
Normal
This t est is diff icult t o st andardize; it varies w it h age, sex, and lengt h of exist ing
pregnancy.
Child:
<0.1 mg/24 hours or <0.312 mol/day
Men:
01.9 mg/24 hours or 05.9 mol/day

Follicular phase, 02.6 mg/24 hours or 0
8.1 mol/day
W omen:
Luteal, 2.610.6 mg/24 hours or 8.133.1
mol/day
1st trimester, 1035 mg/24 hours or 31
109 mol/day
Pregnancy:
2nd trimester, 3570 mg/24 hours or 109

218 mol/day
3rd trimester, 70100 mg/24 hours or
218312 mol/day
Procedure

2. Ref rigerat e t he specimen or use a boric acid preservat ive. Check laborat ory
policy. Prot ect t he specimen f rom light .
5. Send t he complet ed specimen t o t he laborat ory.
1. Increased urine pregnanediol is associat ed w it h:
a. Lut eal cyst s of ovary (ovarian cyst )
b. Arrhenoblast oma of t he ovary
c. Congenit al hyperplasia of adrenal gland
d. G ranulosa t heca cell t umor of ovary
2. Decreased urine pregnanediol is associat ed w it h:
a. Amenorrhea (ovarian hypof unct ion)
b. Threat ened abort ion (if <5. 0 mg/ 24 hours or <15. 6 mol/ day, abort ion is
imminent )
c. Fet al deat h, int raut erine deat h, placent al insuff iciency
d. Toxemia, eclampsia
e. O varian f ailure
f. Chronic nephrit is in pregnancy
Interfering Factors
Decreased values occur w it h est rogen or progest erone t herapy and w it h t he
usage of oral cont racept ives.
Interventions
1. I nst ruct t he pat ient about t he t est purpose and t he 24-hour urine specimen
collect ion procedure. A w rit t en reminder may be helpf ul.
2. Allow f ood and f luids.

3. See Chapt er 1 guidelines regarding saf e, eff ect ive, inf ormed pretest care .

1. I nt erpret t est out comes and counsel appropriat ely about abnormal ovarian
and placent al f unct ion.
care.
Urine Pregnanetriol (24-Hour) Pregnanetriol is a

ketogenic steroid reflecting one segment of
adrenocorticol activity. Pregnanetriol should not be
confused with pregnanediol, despite the similarity of
name. This test has been largely replaced with the
serum test 17-hydroxyprogesterone.
This 24-hour urine t est is done t o diagnose congenit al adrenal hyperplasia,
adrenogenit al syndrome, ow ing t o a def ect in 21-hydroxylat ion. The diagnosis of
adrenogenit al syndrome is indicat ed in:
1. Adult w omen w ho show signs and sympt oms of excessive androgen
product ion w it h or w it hout hypert ension.
2. Craving f or salt
3. Sexual precocit y in boys
4. I nf ant s w ho exhibit signs of f ailure t o t hrive
5. Presence of ext ernal genit alia in f emales (pseudohermaphrodit ism). I n
males, diff erent iat ion must be made bet w een a virilizing t umor of t he adrenal
gland, neurogenic and const it ut ional t ypes of sexual precocit y, and int erst it ial
cell t umor of t he t est es.
Reference Values
Normal
Adult f emale: 01. 4 mg/ 24 hours or 04. 2 mol/ day Adult male: 0. 22. 2 mg/ 24
hours or 0. 66. 5 mol/ day Child (<9 years old): <0. 3 mg/ 24 hours or <0. 9
mol/ day Child (1016 years old): 0. 10. 6 mg/ 24 hours or 0. 31. 8 mol/ day
Procedure
2. Ref rigerat e t he specimen if necessary; some laborat ories may require a
boric acid preservat ive in t he collect ion recept acle.
1. El evated urine pregnanet riol occurs in:
a. Congenit al adrenocort ical hyperplasia
b. St ein-Levent hal syndrome
c. O varian and adrenal t umors
2. Decreased urine pregnanet riol occurs in:
a. Hydroxylase def iciency (rare)
b. O varian f ailure
Interventions
1. I nst ruct t he pat ient about t he t est purpose and procedure f or collect ion of a
24-hour urine specimen. A w rit t en reminder may be helpf ul.
2. Allow f ood and f luids.
3. Avoid muscular exercise bef ore and during specimen collect ion.
1. I nt erpret t est out comes and counsel appropriat ely about adrenogenit al
syndrome.
Urine 5-Hydroxyindoleacetic Acid (5-HIAA) (24-Hour)

Serotonin is a vasoconstricting hormone normally
produced by the argentaffin cells of the
gastrointestinal tract. The principal function of the
cells is to regulate smooth muscle contraction and
peristalsis. 5-hydroxyindoleacetic acid (5-HIAA) is the
major urinary metabolite of serotonin. 5-HIAA assays
are more useful than the parent hormone serotonin.
This urine t est is conduct ed t o diagnose t he presence of a f unct ioning carcinoid
t umor, w hich can be show n by signif icant elevat ions of 5-HI AA. Excess amount s
of 5-HI AA are produced by most carcinoid t umors. Carcinoid t umors produce
sympt oms of f lushing, hepat omegaly, diarrhea, bronchospasm, and heart
disease.
Reference Values
Normal
Q ualit at ive: Negat ive
Q uant it at ive: 27 mg/ 24 hours or 1137 mol/ day
Procedure
1. Do not allow t he pat ient t o eat any bananas, pineapple, t omat oes, eggplant s,
plums, or avocados f or 48 hours bef ore or during t he 24-hour t est because
t hese f oods cont ain serot onin.
2. Properly label a 24-hour urine cont ainer t hat cont ains t he preservat ive (acid).
3. Discont inue t he f ollow ing drugs 48 hours bef ore sample collect ion:
acet aminophen, salicylat es, phenacet in, naproxen, imipramine, and
monoamine oxidase inhibit ors.
4. Follow general direct ions f or 24-hour urine collect ion (see Long-Term, Timed
Urine Specimen, page 171).

1. Levels > 25 mg/ 24 hours or > 131 mol/ day indicat e large carcinoid t umors,
especially w hen met ast at ic:
a. I leal t umors
b. Pancreat ic t umors
c. Duodenal t umors
d. Biliary t umors
2. Increased urine 5-HI AA is f ound in:
a. O varian carcinoid t umor
b. Nont ropical sprue
c. Bronchial adenoma (carcinoid t ype)
d. Malabsorpt ion
e. Celiac disease
f. Whipple's disease
g. O at cell cancer of respirat ory syst em
3. Decreased urine 5-HI AA is f ound in:
a. Depressive illness
b. Small int est ine resect ion
c. Phenylket onuria (PKU)
d. Hart nup's disease
e. Mast ocyt osis
Interfering Factors
1. False-posit ive result s occur w it h:
a. I ngest ion of banana, pineapple, plum, w alnut , eggplant , t omat o,
chocolat e, and avocado, because of t heir serot onin cont ent
b. Many drugs (see Appendix J)
c. Af t er surgery (surgical st ress)

2. False-negat ive result s can be caused by specif ic drugs t hat depress 5-HI AA
product ion.
Interventions
1. I nst ruct t he pat ient about t est purpose and procedure f or collect ion of t he
24-hour urine specimen. Writ t en inst ruct ions may be helpf ul.
2. Encourage int ake of f ood and w at er. Foods high in serot onin cont ent must
not be eat en f or 48 hours bef ore or during t he t est .
3. I f possible, no drugs should be t aken f or 72 hours bef ore t he t est nor during
t he t est (especially af orement ioned drugs), including over-t he-count er drugs.

1. Resume normal diet and medicat ions w hen t est is complet ed.
2. I nt erpret t est out come and counsel appropriat ely about abnormal 5-HI AA
levels.
Clin ical Alert

A serum serot onin assay may det ect some carcinoids missed by t he urine 5HI AA assay.
Urine Vanillylmandelic Acid (VMA); Catecholamines

(24-Hour) The principal substances formed by the
adrenal medulla and excreted in urine are VMA,
epinephrine, norepinephrine, metanephrine, and
normetanephrine. These substances contain a catechol
nucleus together with an amine group and therefore are
referred to as catecholamines. Most of these hormones
are changed into metabolites, the principal one being
3-methoxy-4-hydroxymandelic acid, known as

vanillylmandelic acid, or VMA.
VMA is t he primary urinary met abolit e of t he cat echolamine group. I t has a urine
concent rat ion 10 t o 100 t imes great er t han t he concent rat ions of t he ot her
amines. I t is also f airly simple t o det ect ; met hods used f or cat echolamine
det erminat ion are much more complex.
This 24-hour urine t est of adrenomedullary f unct ion is done primarily w hen
pheochromocyt oma, a t umor of t he chromaff in cells of t he adrenal medulla, is
suspect ed in a pat ient w it h hypert ension.
The assay f or pheochromocyt oma is most valuable w hen a urine specimen is
collect ed during a hypert ensive episode. Because a 24-hour urine collect ion
represent s a longer sampling t ime t han a sympt om-direct ed serum sample, t he
24-hour urine t est may det ect a pheochromocyt oma missed by a single blood
level det erminat ion.
Reference Values
Normal
Adult s
VMA: up t o 9 mg/ 24 hours or up t o 45 mol/ day Cat echolamines (t ot al): <100
g/ day or <591 nmol/ day Epinephrine: 020 g/ 24 hours or 0109 nmol/ day
Met anephrine: 74297 g/ 24 hours or 3751506 nmol/ day Norepinephrine: 1580
g/ 24 hours or 89473 nmol/ day Normet anephrine: 105354 g/ 24 hours or 573
1933 nmol/ day Dopamine: 65400 g/ 24 hours or 4202612 nmol/ day Children's
levels are diff erent f rom t hose of adult s. Check w it h your laborat ory f or values in
children.
NOTE
Diff erent laborat ories report values in diff erent unit st his should be kept in
mind w hen analyzing result s.
Procedure
1. Properly label a 24-hour cont ainer w it h acid preservat ive and ref rigerat e t he
cont ainer or keep it on ice.
4. Send t he specimen t o t he laborat ory.
1. Increased uri ne VMA occurs as f ollow s:
a. High levels in pheochromocyt oma
b. Slight t o moderat e elevat ions in
1. Neuroblast oma
2. G anglioneuroma
3. G anglioblast oma
4. Carcinoid t umor (some cases)
2. Increased uri ne catechol ami nes are f ound in:
a. Pheochromocyt oma
1. Norepinephrine, >170 mg/ 24 hours or >170 mg/ day
2. Epinephrine, >35 mg/ 24 hours or >35 mg/ day
b. Neuroblast omas
c. G anglioneuromas
d. Myocardial inf arct ion (acut e)
e. Hypot hyroidism
f. Diabet ic acidosis
g. Long-t erm manic-depressive st at es
3. Decreased uri ne catechol ami nes are f ound in:

a. Diabet ic neuropat hy
b. Parkinson's disease
Interfering Factors
1. I ncreased urine VMA and cat echolamines are caused by:
a. Hypoglycemiaf or t his reason, t he t est should not be scheduled w hile
t he pat ient is receiving not hing by mout h.
b. Many f oods, such as t he f ollow ing:
1. Caff eine-cont aining product s (eg, t ea, coff ee, cocoa, carbonat ed
drinks)
2. Vanilla
3. Fruit , especially bananas
4. Licorice
c. Many drugs cause increased VMA levels, especially reserpine, met hyldopa, levodopa, monoamine oxidase inhibit ors, sinus and cough
medicines, bronchodilat ors, and appet it e suppressant s.
d. Exercise, st ress, smoking, and pain cause physiologic increases of
cat echolamines.
e. Heavy alcohol int ake increases cat echolamine levels.
2. Falsely decreased levels of VMA and cat echolamines are caused by:
a. Alkaline urine
b. Uremia (causes t oxicit y and impaired excret ion of VMA)
c. Radiographic cont rast agent sf or t his reason, an int ravenous pyelogram
should not be scheduled bef ore a VMA t est .
d. Cert ain drugs (see Appendix J)
Interventions
1. I nst ruct t he pat ient about t he t est purpose and t he procedure f or collect ion
of t he 24-hour urine specimen. A w rit t en reminder may be helpf ul, especially
regarding rest rict ed f oods.

2. Explain diet and drug rest rict ions. Diet rest rict ions vary among laborat ories,
but coff ee, t ea, bananas, cocoa product s, vanilla product s, and aspirin are
alw ays excluded f or 3 days (2 days bef ore and 1 day during specimen
collect ion).
3. Many laborat ories require t hat all drugs be discont inued f or 1 w eek bef ore
t est ing.
4. Encourage adequat e rest , f ood, and f luids.
5. St ress, st renuous exercise, and smoking should be avoided during t he t est .

1. The pat ient may resume pret est diet , drugs, and act ivit y w hen t he t est is
complet ed.
Urine Porphyrins and Porphobilinogens (24-Hour and

Random); -Aminolevulinic Acid (ALA, -ALA)
Porphyrins are cyclic compounds formed from aminolevulinic acid (-ALA), which plays a role in the
formation of hemoglobin and other hemoproteins that
function as carriers of oxygen in the blood and tissues.
In health, insignificant amounts of porphyrin are
excreted in the urine. However, in certain conditions,
such as porphyria (disturbance in metabolism of
porphyrin), liver disease, and lead poisoning,
increased levels of porphyrins and -ALA are found in
the urine. Disorders in porphyrin metabolism also
result in increased amounts of porphobilinogen in
urine. The most common signs and symptoms of acute
intermittent porphyria are abdominal pain,
photosensitivity, sensory neuropathy, or psychosis.
Patients with the porphyrias may pass urine that is

pink, port wine, or burgundy colored.
When urine is t est ed f or t he presence of porphyrins, porphobilinogen, and/ or
ALA, it is also given t he black-light screening t est (Wood's light t est ). Porphyrins
are f luorescent w hen exposed t o black or ult raviolet light . See Chapt er 2 f or
ot her t est s f or porphyria.
This t est is used t o diagnose porphyrias and lead poisoning in children. The
f ollow ing is a summary of laborat ory f indings f or various porphyrias.
Congenital Erythropoietic Porphyria. Elevat ions of urine uroporphyrin and
coproporphyrin occur, w it h t he f ormer exceeding t he lat t er. Lesser amount s of
hept a, hexa, and pent a carboxyporphyrins are secret ed. ALA and
porphobilinogen levels are normal.
Acute Intermittent Porphyria. Porphobilinogen and -ALA are elevat ed in acut e
at t acks, and small increases of urine uroporphyrin and coproporphyrin may be
f ound. During periods of lat ency, t he values are normal.
Porphyria Cutanea Tarda. A more common f orm of porphyriaincreased
uroporphyrins, uroporphyrinogen, and hept a carboxylporphyrins.
Protoporphyria. Mild disease, w hich mainly has t he clinical sympt oms of solar
urt icaria and solar eczema (exposure t o sunshine). I ncreased f ecal
prot oporphyrin.
Hereditary Coproporphyria. Urine coproporphyrin and porphobilinogen are
markedly increased during acut e at t acks; increases of urine uroporphyrin may
also be f ound.
Variegate Porphyria. I n acut e at t acks, result s are similar t o t hose seen in acut e
int ermit t ent porphyria. Porphobilinogen and -ALA usually ret urn t o normal
bet w een at t acks. Urine coproporphyrin exceeds uroporphyrin excret ion during
acut e at t acks.
Chemical Porphyrias. (I nt oxicat ion porphyria. ) Porphyrinogenic chemicals
include cert ain halogenat ed hydrocarbons, w hich cause increased uroporphyrin
levels in t he urine. Also increased are ALA, coproporphyrin, and porphobilinogen.
Lead Poisoning. -ALA levels exceed t hose of porphobilinogen, w hich may
remain normal. I n children, ALA secret ion in urine is more sensit ive t han blood
lead levels.
Reference Values
Normal
Porphobi l i nogens Random specimen: 02. 0 mg/ L or negat ive or 08. 8 mol/ L
24-hour specimen: 01. 5 mg/ 24 hours or 06. 6 mg/ day -ALA

Random specimen: 04. 5 mg/ L or 034 mol/ L
24-hour specimen: 1. 57. 5 mg/ 24 hours or 11. 457. 2 mol/ day (Table 3. 11)
Table 3.11 Specimen Values
Male
Porphyrins*
(g/24
h)
Random specimen
(nm ol/d)
Fem ale
(g/24
h)
Negative
(nm
Negative
24-h Specimens:
Uroporphyrin
844
1053
422
102
Coproporphyrin
10
109
15167
356
586
Heptacarboxyporphyrin
012
015
09
011
Pentacarboxyporphyrin
04
06
03
04
Hexacarboxyporphyrin
05
07
05
05
*Total porphyrins: 20
121 g/L or 24146
nmol/L.
Procedure
1. Properly label a 24-hour clean-cat ch urine cont ainer.
2. Provide ref rigerat ion or icing. The specimen must be kept prot ect ed f rom
exposure t o light . Check w it h your laborat ory regarding t he need f or
preservat ives.
6. O bt ain midmorning or midaf t ernoon specimens f or random t est s because it is
more likely t hat t he pat ient w ill excret e porphyrins at t hose t imes. Transport
t he specimen t o t he laborat ory immediat ely. Prot ect t he specimen f rom light .
7. O bserve and record t he urine color. I f porphyrins are present , t he urine may
appear amber-red or burgundy in color, or it may vary f rom pale pink t o
almost black. Some pat ient s excret e urine of normal color t hat t urns dark
af t er st anding in t he light .
1. Increased uri ne porphobi l i nogen occurs in:
a. Porphyria (acut e int ermit t ent t ype)
b. Variegat e porphyria
c. Heredit ary coproporphyria
d. See pages 246247 f or list of ot her porphyrias.
2. Increased f racti onated porphyri ns occur in:
a. Acut e int ermit t ent porphyria
b. Congenit al eryt hropoiet ic porphyria
c. Heredit ary porphyria
d. Variegat e porphyria
e. Chemical porphyria caused by heavy-met al poisoning or carbon
t et rachloride
f. Lead poisoning
g. Viral hepat it is
h. Cirrhosis (alcoholism)
i. New born of mot her w it h porphyria
j. Congenit al hepat ic porphyria
3. Increased uri ne - ALA can occur in:
a. Acut e int ermit t ent porphyria (acut e phase)
b. Variegat e porphyria (during crisis)
c. Heredit ary coproporphyria
d. Lead poisoning does not increase urine -ALA unt il serum lead levels
reach > 40 g/ dL; urine -ALA may remain elevat ed f or several mont hs
af t er cont rol of lead exposure.
e. Congenit al hepat ic porphyria
f. Slight increase in pregnancy, diabet ic acidosis
4. Decreased uri ne - ALA is f ound in alcoholic liver disease
Clin ical Alert

Porphobilinogen is not increased in lead poisoning.
Interfering Factors
1. O ral cont racept ives and diazepam can cause acut e porphyria at t acks in
suscept ible pat ient s.
2. Alcohol ingest ion int erf eres w it h t he t est .
3. Many ot her drugs, especially phenazopyridine, procaine, sulf amet hoxazole,
and t he t et racyclines, int erf ere w it h t he t est (see Appendix J).
Interventions
1. I nst ruct t he pat ient about t he purpose and procedure of collect ion a 24-hour
urine specimen. A w rit t en reminder may be helpf ul.
2. Allow f ood and f luids, but alcohol and excessive f luid int ake should be
avoided during t he 24-hour collect ion.
3. I f possible, discont inue all drugs f or 2 t o 4 w eeks bef ore t he t est so t hat
result s w ill be accurat e.

1. The pat ient may resume normal act ivit ies and medicat ions.
Clin ical Alert

This t est should not be ordered f or pat ient s receiving Donnat al or ot her
barbit urat e preparat ions. How ever, if int ermit t ent porphyria is suspect ed, t he
pat ient should t ake t hose medicat ions according t o prescribed prot ocols
because t hese drugs may provoke an at t ack of porphyria.
Urine Amylase Excretion and Clearance (Random,

Timed Urine, and Blood) Amylase is an enzyme that
changes starch to sugar. It is produced in the salivary
glands, pancreas, liver, and fallopian tubes and is
normally excreted in small amounts in the urine. If the
pancreas or salivary glands are inflamed, much more
of the enzyme enters the blood and, consequently,
more amylase is excreted in the urine.
This t est of blood and urine indicat es pancreat ic f unct ion and is done t o
diff erent iat e acut e pancreat it is f rom ot her causes of abdominal pain, epigast ric
discomf ort , or nausea and vomit ing.
I n pat ient s w it h acut e pancreat it is, t he urine of t en show s a prolonged elevat ion
of amylase, compared w it h a short -lived peak in t he blood. Moreover, urine
amylase may be elevat ed w hen blood amylase is w it hin normal range, and,
conversely, t he blood amylase may be elevat ed w hen t he urine amylase is w it hin
normal range. The advant age of t he amylase-creat inine clearance t est is t hat it
can be done on a single random urine specimen and a single serum sample
inst ead of having t o w ait f or a 2- or 24-hour urine collect ion. The rat io is
increased in cert ain condit ions ot her t han acut e pancreat it is, such as diabet ic
acidosis and renal insuff iciency. Alt hough t he usef ulness of t his t est in pancreat ic
disease has been quest ioned, it can be helpf ul t o screen f or macroamylasia.
Reference Values
Normal
Amylase/ creat inine clearance rat io: 1%4% or 0. 010. 04 clearance f ract ion This
is a rat io calculat ed as f ollow s:
Uri ne Amyl ase 2-hour specimen: 234 U or 16283 nkat / hour 24-hour specimen:
24408 U or 4006800 nkat / day Values vary according t o laborat ory met hods
used. Check w it h your lab.
NOTE
kat = kat al, w hich is a measure of enzyme act ivit y.
Procedure
For t he amylase clearance t est , a venous blood sample of 4 mL must be
collect ed at t he same t ime t he random urine specimen is obt ained.
1. O rder a random, 2-hour, or 24-hour t imed urine specimen. A 2-hour specimen
is usually collect ed.
2. Ref rigerat e t he urine specimen. Amylase is unst able in acidic urine. The pH
must be adjust ed t o pH > 7. 0.
3. Follow general inst ruct ions f or t he appropriat e urine collect ion.
4. Record exact st art ing and ending t imes on t he specimen cont ainer and on t he
healt h care record. This is very import ant f or calculat ion of result s.
1. Amylase/ creat inine clearance is i ncreased in:
a. Pancreat it is, pancreat ic cancer
b. Diabet ic ket oacidosis (some pat ient s)
c. Toxemia of pregnancy, hyperemesis of pregnancy
d. Renal insuff iciency
2. Amylase/ creat inine clearance is decreased in macroamylasia.
3. Urine amylase is i ncreased in:
a. Pancreat it is
b. Parot it is
c. I nt est inal obst ruct ion
d. Diabet ic ket oacidosis
e. St rangulat ed bow el
f. Pancreat ic cyst
g. Perit onit is
h. Biliary t ract disease
i. Some lung and ovarian t umors

4. Urine amylase is decreased in:
a. Pancreat ic insuff iciency
b. Advanced cyst ic f ibrosis
c. Severe liver disease
d. Renal f ailure
e. Macroamylasemia
Interfering Factor
1. Acid pHdecreases urine amylase.
2. Some drugs produce increased amylase and possible pancreat it is.
Interventions
1. I nst ruct t he pat ient about t he t est purpose and procedure f or urine specimen
collect ion. A w rit t en inst ruct ion sheet may be helpf ul.
2. Encourage f luids, if t hey are not rest rict ed.

Clin ical Alert

Follow -up calcium levels should be checked in f ulminat ing pancreat it is because
ext remely low calcium levels can occur.
Phenylketonuria (PKU); Urine Phenylalanine (Random

Urine and Blood) Routine blood and urine tests are
done on newborns to detect phenylketonuria (PKU), an

inherited disease that can lead to mental retardation
and brain damage if untreated. This disease is
characterized by a lack of the enzyme that converts
phenylalanine, an amino acid, to tyrosine, which is
necessary for normal metabolic function. Because
dietary phenylalanine is not converted to tyrosine,
phenylalanine, phenylpyruvic acid, and other
metabolites accumulate in blood and urine. Tyrosine
and the derivative catecholamines are deficient, which
results in mental retardation. Both sexes are affected
equally, with most cases occurring in persons of
northern European ancestry.
This t est is used f or new borns t o det ect t he met abolic disorder
hyperphenylalaninemia. I f unt reat ed, t his disorder can lead t o ment al ret ardat ion.
Diet ary rest rict ions of phenylalanine have show n good result s.
Reference Values
Normal
Blood: <2 mg/ dL (25 days af t er birt h) or <121 mol/ L
Urine: Negat ive dipst ick (det ect s phenylalanine in range of 510 mg/ dL or 302
605 mol/ L) 24-hour urine: 1. 21. 7 mg/ 24 hours (10 days t o 7 w eeks af t er birt h)
or 7. 210. 3 mol/ day Adult s: <16. 5 mg/ 24 hours or <100 mol/ day Children (3
12 years old): 4. 017. 5 mg/ 24 hours or 24106 mol/ day
Procedure
Collecting the Blood Sample
1. Cleanse t he skin w it h an ant isept ic and pierce t he inf ant 's heel w it h a st erile
disposable lancet .
2. Support t he inf ant , if bleeding is slow, so t hat t he blood f low s by means of
gravit y w hile spot t ing t he blood w it h f ilt er paper.
3. Fill t he circles on t he f ilt er paper complet ely. This can best be done by
placing one side of t he f ilt er paper against t he inf ant 's heel and w at ching f or
t he blood t o appear on t he ot her side of t he paper unt il it complet ely f ills t he
circle.
4. Do not t ouch blood circles unt il t hey are complet ely dry. Keep in cool, dry
area.
5. Transport samples t o t est ing sit e w it hin 12 t o 24 hours.
6. Conf irm all posit ive f ilt er paper t est s w it h a quant it at ive blood or urine t est .
Collecting the Urine Sample in Nursery or at Home

1. Dip t he reagent st rip int o a f resh sample of urine or press it against a w et
diaper (phenylalanines and phenylpyruvic acid may not appear in urine unt il
t he inf ant is 2 t o 3 w eeks of age).
2. Af t er exact ly 30 seconds, compare t he st rip w it h a color chart according t o
manuf act urer's direct ions.
3. Salicylat es and phenot hiazine may cause abnormal color react ions.
4. All posit ive t est s must be conf irmed w it h a quant it at ive chemical t est .
Increased phenyl al ani ne is f ound in:
1. Hyperphenylalaninemia. I n a posit ive t est f or PKU, t he blood phenylalanine is
> 15 mg/ dL or > 907 mol/ L. Blood t yrosine is < 5 mg/ dL or < 276 mol/ L; it
is never increased in PKU.
2. O besit y
3. I n low -birt h-w eight or premat ure inf ant s, t ransient hyperphenylalaninemia,
along w it h t ransient hypert yrosinemia, may occur.
Interfering Factors
1. Premat ure inf ant s, t hose w eighing < 2. 3 kg (<5 pounds), may have elevat ed
phenylalanine and t yrosine levels w it hout having t he genet ic disease. This is
a result of delayed development of appropriat e enzyme act ivit y in t he liver
(liver immat urit y).
2. Ant ibiot ics int erf ere w it h t he blood assay.
3. Cord blood cannot be used f or analysis.
4. Tw o days of prot ein f eeding must be done bef ore blood is t aken.
Instructions to M others
1. I nf orm t he mot her about t he purpose of t he t est and t he met hods of
collect ing t he specimens.
2. Most parent s are int erest ed t o know t hat PKU (a genet ic disease in w hich a
def ect ive gene is passed on f rom each parent ) w as f irst recognized by a
young mot her of t w o ment ally ret arded children. She w as aw are t hat t he
urine of t hese children had a peculiar odor and, on t he basis of t his, w as
able t o have a biochemist st udy t he urine and ident if y phenylpyruvic acid. Her
discovery led t o t he f irst successf ul diet ary t reat ment , rest rict ion of
phenylalanine (eg, in milk) f or t hose new born babies ident if ied as having
PKU. This result ed in normal ment al development of t hese children.
3. I nt erpret t est out comes and counsel regarding diet if result s are posit ive.
Clin ical Alert

The est ablished st andard is t hat all new born inf ant s should be t est ed f or PKU
and congenit al hypot hyroidism bef ore discharge.
1. The blood t est must be perf ormed at least 3 days af t er birt h or af t er t he
child has ingest ed prot ein (milk) f or at least 24 t o 48 hours.
2. Urine t est ing is usually done at t he 4- or 6-w eek checkup if a blood t est
w as not done.
3. PKU st udies should be done on all inf ant s w ho w eigh 2. 3 kg (5 pounds)
bef ore t hey leave t he hospit al.
4. Sick or premat ure inf ant s should be t est ed w it hin 7 days af t er birt h
regardless of prot ein int ake, w eight , or ant ibiot ic t herapy.
D-Xylose Absorption (Timed Urine and Blood) The Dxylose test is a diagnostic measure for evaluating
malabsorptive conditions and intestinal absorption of
D-xylose, a pentose not normally present in the blood
in significant amounts.
It is passively absorbed in the proximal small bowel,
passes unchanged in the liver, and is excreted by the
kidneys.
This t est direct ly measures int est inal absorpt ion. When D-xylose (w hich is not
met abolized by t he body) is administ ered orally, blood and urine levels are
checked f or absorpt ion rat es. Absorpt ion is normal in pancreat ic insuff iciency but
is impaired in int est inal malabsorpt ion. I t is a reliable index of t he f unct ional
int egrit y of t he jejunum in pediat ric pat ient s.
Reference Values
Normal
Bl ood
1-hour absorpt ion of 5-g doseinf ant : >15 mg/ dL or >1. 0 mmol/ L
1-hour absorpt ion of 5-g dosechild: >20 mg/ dL or >1. 3 mmol/ L
2-hour absorpt ion of 5-g doseadult : >20 mg/ dL or >1. 3 mmol/ L
2-hour absorpt ion of 25-g doseadult : >25 mg/ dL or >1. 6 mmol/ L
Uri ne Xyl ose 5-Hour Ref erence Range f or 25-g dose Child: 16%33% of 5-g
dose
Adult : >16% of 5-g dose or >4. 0 g of max (0. 5 g/ kg t o a maximum of 25 g) Adult ,
65 years of age and older: >14% of dose or >3. 5 g of maximum
Procedure
1. Have t he pat ient ref rain f rom f oods cont aining pent ose f or 24 hours bef ore
t est .
2. Do not allow f ood or liquids by mout h f or at least 8 hours bef ore t he st art of
t he t est . Pediat ric pat ient s should f ast only 4 hours.
3. Have t he pat ient void at t he beginning of t he t est . Discard t his urine.
4. Administ er t he oral dose of D-xylose af t er it has been dissolved in 100 mL of
w at er. Adult dosage is 25 g; f or children younger t han 12 years of age, a 5-g
oral dose is recommended. For adult s, addit ional w at er up t o 250 mL should
be t aken at t his t ime and anot her 250 mL in 1 hour. Record t hese t imes on
t he pat ient 's healt h care record. G ive no f urt her f luids (except w at er) or f ood
unt il t he t est is complet ed.
5. Draw a 3-mL sample of venous blood w it hin 60 t o 120 minut es lat er.
6. Have t he pat ient rest quiet ly in one place unt il t he t est is complet ed.
7. Have t he pat ient void 5 hours f rom t he st art of t he t est . Save all urine voided
during t he t est .
1. Urine D-xylose is decreased in:
a. I nt est inal malabsorpt ion
b. I mpaired renal f unct ion
c. Small bow el ischemia
d. Whipple's disease
e. Viral gast roent erit is (vomit ing)
f. Bact erial overgrow t h in small int est ine.
2. The D-xylose t est is normal in t he f ollow ing condit ions:
a. Malabsorpt ion due t o pancreat ic insuff iciency
b. Post gast rect omy
c. Malnut rit ion
Interfering Factors
1. Many drugs and ant ibiot ics (see Appendix J)
2. Nonf ast ing st at e, t reat ment w it h hyperaliment at ion
3. Foods rich in pent ose (f ruit s and preserves)
4. Vomit ing of t he xylose t est meal (25-g dose may cause gast roint est inal
dist ress).
5. I mpaired renal f unct ionuse serum t est only
6. I n adult s, t he serum t est has lit t le valueuse 5-hour urine t est .
Interventions
1. Explain purpose and procedure of t he t est and t he urine collect ion process.
The ent ire 5-hour specimen must be collect ed.
2. The pat ient must f ast at least 8 hours bef ore t he st art of t he t est ; children
younger t han 9 years of age should f ast f or only 4 hours.
3. Wat er may be t aken at any t ime.
4. Weigh t he pat ient t o det ermine t he proper dose of D-xylose.

5. The pat ient must not ingest cont raindicat ed drugs f or 1 w eek bef ore t he t est .

1. Normal f ood, f luids, and act ivit ies can be resumed.
Clin ical Alert

Nausea, vomit ing, and diarrhea may result f rom ingest ion of t he D-xylose. I f
vomit ing occurs, t he t est is invalid and must be repeat ed. A 5-gram dose is
more t olerat ed but is less sensit ive.
Urine Creatinine; Creatinine Clearance (Timed Urine

and Blood) Creatinine is a substance that, in health, is
easily excreted by the kidney. It is the byproduct of
muscle energy metabolism and is produced at a
constant rate according to the muscle mass of the
individual. Endogenous creatinine production is
constant as long as the muscle mass remains constant.
Because all creatinine filtered by the kidneys in a given
time interval is excreted into the urine, creatinine
levels are equivalent to the glomerular filtration rate
(GFR). Disorders of kidney function prevent maximum
excretion of creatinine. The creatinine clearance test is
part of most batteries of quantitative urine tests.
Creatinine clearance is measured together with other
urinary components in order to interpret the overall
excretion rate of the various urinary components.
The creat inine clearance t est is a specif ic measurement of kidney f unct ion,
primarily glomerular f ilt rat ion. I t measures t he rat e at w hich t he kidneys clear
creat inine f rom t he blood. I n a broad sense, clearance of a subst ance may be
def ined as t he imaginary volume (in millilit ers) of plasma f rom w hich t he
subst ance w ould have t o be complet ely ext ract ed in order f or t he kidney t o
excret e t hat amount in 1 minut e. I n addit ion t o est imat ing t he G FR, t his t est is
used t o evaluat e renal f unct ion in pat ient s.
Because t he excret ion of creat inine in a given person is relat ively const ant , t he
24-hour urine creat inine level is used as a check on t he complet eness of a 24hour urine collect ion. I t is of no help in t he evaluat ion of renal f unct ion unless it
is done as part of a creat inine clearance t est .
Reference Values
Normal
Urine creat inine, men: 1426 mg/ kg/ 24 hours or 124230 mol/ kg/ day Urine
creat inine, w omen: 1120 mg/ kg/ 24 hours or 97177 mol/ kg/ day Blood
creat inine: 0. 81. 2 mg/ dL or 71106 mol/ L (Table 3. 12)
Table 3.12 Mean Creatinine Clearance (mL/min/1.73

m 2 )*
Age
(y)
Men
Wom en
20
30
90140 or 0.81.3
mL/sec/m 2
72110 or 0.691.06
mL/sec/m 2
30
40
59137 or 0.51.3
mL/sec/m 2
71121 or 0.681.17
mL/sec/m 2
*Values slowly increase to adult levels, then slowly

decrease each decade thereafter (the decrease per
decade is approximately 6.5 mL/min/1.73 m2 or 0.06
mL/sec/m 2 ).
Procedure
1. Properly label a 12-hour or 24-hour urine cont ainer.
2. Ref rigerat e or ice t he specimen.
5. Send t he ent ire specimen t o t he laborat ory.
6. O bt ain a 5-mL venous blood sample f or creat inine w hen t he t est begins.
7. Record t he pat ient 's height and w eight on t he cont ainer and in t he pat ient 's
healt h care record. Creat inine clearance values are based on t he body
surf ace area, and t hese values are needed t o calculat e t he surf ace area.
8. Ensure t hat t he pat ient is adequat ely hydrat ed t hroughout t he t est t o provide
proper urine f low.
1. Decreased creat inine clearance is f ound in any condit ion t hat decreases
renal blood f low :
a. I mpaired kidney f unct ion, int rinsic renal disease, glomerulonephrit is,
pyelonephrit is, nephrot ic syndrome, acut e t ubular dysf unct ion,
amyloidosis, int erst it ial nephrit is
b. Shock, dehydrat ion
c. Hemorrhage
d. Chronic obst ruct ive lung disease
2. Increased creat inine clearance is f ound in:
a. St at e of high cardiac out put
b. Pregnancy
c. Burns
d. Carbon monoxide poisoning
3. Increased urine creat inine is f ound in:

a. Acromegaly
b. G igant ism
c. Diabet es mellit us
d. Hypot hyroidism
4. Decreased urine creat inine is f ound in:
a. Hypert hyroidism
b. Anemia
c. Muscular dyst rophy
d. Polymyosit is, neurogenic at rophy
e. I nf lammat ory muscle disease
f. Advanced renal disease, renal st enosis
g. Leukemia
Interfering Factors
1. Exercise may increase creat inine clearance and urine creat inine.
2. Pregnancy subst ant ially increases creat inine clearance.
3. Many drugs decrease creat inine clearance (see Appendix J).
4. The creat inine clearance overest imat es t he G FR w hen t here is severe renal
impairment . The serum creat inine is more indicat ive of t he G FR in t his
sit uat ion.
5. A diet high in meat may elevat e t he urine creat inine concent rat ion.
6. Prot einuria and advanced renal f ailure make creat inine clearance an
unreliable met hod f or det ermining G FR.
Clin ical Alert

Det erminat ion of urine creat inine is of lit t le value f or evaluat ing renal f unct ion
unless it is done as part of a creat inine clearance t est .
Interventions
1. I nst ruct t he pat ient about t he purpose and procedure of t he t est and urine
specimen collect ion. A w rit t en reminder may be helpf ul.
2. Allow f ood and encourage f luids f or good hydrat ion. Large urine volumes
ensure opt imal t est result s. Avoid t ea and coff ee (diuret ics).
3. Avoid vigorous exercise during t he t est .
4. Drugs aff ect ing t he result s should be st opped bef orehand (especially
adrenocort icot ropic hormone [ ACTH] , cort isone, or t ypoxine). Check w it h
physician.
5. Avoid eat ing large amount s of meat . Check w it h physician.

1. The pat ient may resume normal f ood, f luids, and act ivit y.
Urine Cystine (Random and 24-Hour) Cystinuria is a

condition characterized by increased amounts of the
amino acid cystine in the urine. The presence of
increased urinary cystine is caused not by a defect in
the metabolism of cystine but rather by the inability of
the renal tubules to reabsorb cystine filtered by the
glomeruli. The tubules fail to reabsorb not only cystine
but also lysine, ornithine, and arginine; this rules out
the possibility of an error in metabolism, even though
the condition is inherited.
These urine t est s are usef ul f or t he diff erent ial diagnosis of cyst inuria, an
inherit ed disease charact erized by bladder calculi (cyst ine has low solubilit y).
Pat ient s w it h cyst ine st ones f ace recurrent urolit hiasis and repeat ed urinary
inf ect ions.
Reference Values
Normal
Random specimen: Negat ive
24-hour specimen, adult : <38 mg/ 24 hours or <316 mol/ day 24-hour specimen,
child: 531 mg/ 24 hours or 42258 mol/ day
Procedure
1. O bt ain a random 20-mL urine specimen f or a qualit at ive screening t est .
2. When collect ing a 24-hour urine specimen, t he cont ainer needs a
preservat ive (t oluene). Follow general procedures f or a 24-hour urine
specimen (see Long-Term, Timed Urine Specimen, page 171).
1. Urine cyst ine is i ncreased in cyst inuria (up t o 20 t imes normal).
2. Urine cyst ine is decreased in burn pat ient s.
Clin ical Alert

1. Cyst inosis, a diff erent ent it y f rom cyst inuria, is not det ect ed by cyst ine
st udies. Most pat ient s w it h inf ant ile nephropat hic cyst inosis have
neurologic def ect s t hat become apparent in inf ancy. Failure t o t hrive and
renal dysf unct ion are evidence of t his disease.
2. Pat ient s w it h cyst inosis have a def ect in renal t ubular reabsorpt ion t hat
develops int o Fanconi's syndrome, w hich leads t o a generalized amino
aciduria. Cyst ine is elevat ed in t he urine in t he same proport ion as all
amino acids; t he concent rat ion is not high enough t o f orm cyst ine st ones.
Plasma cyst ine is normal, but cyst ine is elevat ed in kidneys, eyes, spleen,
and bone marrow ; f or purposes of diagnosis, it is usually measured in
WBCs.
Interventions
1. Explain t est purpose and procedure f or t imed urine collect ion.

Urine Hydroxyproline (Timed Urine and Blood)

Hydroxyproline is an amino acid found only in
collagen. It increases during periods of rapid growth,
in bone diseases, and in some endocrine disorders.
Urine hydroxyproline is almost entirely peptide bound,
and only 10% is in the free form.
Tot al hydroxyproline is considered t o be a marker f or bone resorpt ion because
50% of human collagen resides in bone. This t est indicat es t he presence of
reabsorpt ion of bone collagen in various disorders and evaluat es t he degree of
dest ruct ion f rom primary or secondary bone
t umors. Free hydroxyproline is used as an aid t o diagnose hydroxyprolinemia, a
rare genet ic disorder charact erized by ment al ret ardat ion and t hrombocyt openia.
NOTE
During periods of rapid grow t h in early childhood and in pubert y, t ot al
hydroxyproline is great ly increased.
Reference Values
Normal
Uri ne: Tot al hydroxyproline (24-hour): 1545 mg/ 24 hours or 115345 mol/ day
Adult f emales: 0. 42. 9 mg/ 2-hour specimen or 322 mol/ 2 hours Adult males:
0. 45. 0 mg/ 2-hour specimen or 338 mol/ 2 hours Children < 5 years old: 100
400 g/ mg creat inine or 86345 mmol/ day Children 512 years: 100150 g/ mg
creat inine or 86129 mmol/ day Bl ood (Pl asma)Free Hydroxyprol i ne: New born:
0. 52 0. 52 mg/ dL or 40 40 mol/ L
Child (male): <0. 66 mg/ dL or <50 mol/ L
Child (f emale): <0. 58 mg/ dL or <44 mol/ L
Adult (male): <0. 55 mg/ dL or <42 mol/ L
Adult (f emale): <0. 45 mg/ dL or <34 mol/ L
Procedure
1. O bt ain a 2-hour specimen af t er t he pat ient has f ast ed overnight (pref erred
met hod).
2. Not if y t he laborat ory of t he pat ient 's age and sex.
3. I f ordered, collect a 24-hour urine specimen. No preservat ive is required, but
t he specimen must be ref rigerat ed or placed on ice.
4. Follow 24-hour urine collect ion procedures. The laborat ory w ill record t he
t ot al 24-hour volume.
5. Not e t hat t he pref erred met hod of t est ing in t he f irst f ew mont hs of lif e is
blood sampling (f ree hydroxyproline only f or genet ic screening).
1. Free hydroxyprol i ne i s i ncreased in:
a. Hydroxyprolinemia, a heredit ary aut osomal recessive condit ion (very
rare)
b. Familial iminoglycinuria, also inherit ed and rare
2. Total hydroxyprol i ne i s i ncreased in:

a. Hyperparat hyroidism, hypert hyroidism
b. Paget 's diseasemeasures t he severit y and t he response t o t reat ment
c. Marf an's syndrome, acromegaly
d. O st eoporosis
e. Myeloma
f. Severe burns
3. Total hydroxyprol i ne i s i ncreased in:
a. Hypopit uit arism
b. Hypot hyroidism
c. Hypoparat hyroidism
Interfering Factors
1. G elat in may aff ect t est result s (f alse-posit ive t est ). For best result s, t he
pat ient should be on a nonprot ein diet .
2. Bed rest increases values
3. Pregnancy increases values
Interventions
1. Explain t he t est purpose and procedure f or a t imed urine collect ion. Fast ing
and special f luid requirement s bef ore t est ing are of t en required f or a 24-hour
t imed procedure. Check w it h laborat ory.
2. Avoid gelat in f oods f or several days bef ore t he t est .

1. The pat ient may resume normal diet and act ivit y.
Urine Lysozyme (Random, 24-Hour Urine, and Blood)

Lysozyme (muramidase) in blood or urine is a
bacteriolytic enzyme that comes from degradation of
granulocytes and monocytes, but not lymphocytes. It is
increased in leukemia owing to degradation of
granulocytic or monocytic cells.
This blood and urine t est diff erent iat es acut e myelogenous or monocyt ic
leukemia f rom acut e lymphat ic leukemia. I t is usef ul t o monit or t he response t o
t reat ment of acut e myelogenous and act ive monocyt ic leukemia.
Reference Values
Normal
Blood plasma: 0. 41. 3 mg/ dL or 413 mg/ L
Urine, 24-hour specimen: 03 mg/ 24 hours Ref erence values are not est ablished
f or random urine specimens.
Procedure
1. Collect a 5-mL EDTA-ant icoagulat ed blood sample or urine specimen.
2. Follow general inst ruct ions f or 24-hour urine collect ions. Transport the
sampl e to the l aboratory i mmedi atel y af ter col l ecti on.
1. Lysozyme l evel s are i ncreased in:
a. Acut e myelogenous leukemia (granulocyt ic)
b. Acut e monocyt ic leukemia
c. Malignant hist iocyt osis
2. Lysozyme l evel s may be i ncreased in:
a. Renal disorders and t ransplant reject ion
b. Tuberculosis
c. Sarcoidosis (sarcoid lymph nodes)
d. Crohn's disease
e. Polycyt hemia vera
3. Lysozyme l evel s are normal in acut e lymphat ic leukemia.
4. Lysozyme l evel s are decreased in neut ropenia w it h hypoplasia of bone
marrow.
Interventions
1. Explain t he t est purpose and procedure f or urine or blood collect ion.

Urine Amino Acids, Total and Fractions (Random, 24Hour Urine, and Blood) Many abnormalities in amino
acid transport or metabolism can be detected by
physiologic fluid analysis (urine, plasma, or
cerebrospinal fluid). Free amino acids are found in
urine and in acid filtrates of protein-containing fluids.
Urine is used for initial screening of inborn metabolic
errors. Both transport errors and metabolic errors can
be detected by changes in observed amino acid
patterns. In many cases, metabolic errors are detected
when amino acid or metabolite exceeds its renal
threshold.
This t est is usef ul f or t he diagnosis and monit oring of inborn errors of
met abolism and t ransport in cases of suspect ed genet ic abnormalit ies in pat ient s
w it h ment al ret ardat ion, reduced grow t h, or ot her unexplained sympt oms. More
t han 50 aminoacidopat hies are now recognized.
Reference Values
Normal
Urine and blood amino acid values are age dependent .
Procedure
1. O bt ain a f ast ing blood specimen.
2. Collect a random 24-hour t imed urine specimen. Keep t he specimen
ref rigerat ed or on ice.
1. Total pl asma ami no aci ds are i ncreased in:
a. Specif ic aminoacidopat hies (Table 3. 13)
Table 3.13 Aminoacidurias
Am inoacidurias
Am ino Acids
Increased in Urine
and Blood
Presenc
Abnorm
Enzym e
Phenylketonuria
Phenylketonuria
Phenyla
hydroxyl
Tyrosinosis
Tyrosine
pHydroxy
pyruvic
oxidase
Histidinemia
Histidine
Histidas
Maple syrup urine

disease
Valine, leucine, and

isoleucine
Branche
ketoacid
decarbo
Hypervalinemia
Valine
Probably
transam
Hyperglycinemia
Glycine (lysine on
high-protein diet)
Increase
glycine a
propioni
Type I
Type II
Proline
Proline o
pyrroline
carboxyl
dehydro
Hydroxyprolinemia
Hydroxyproline
Hydroxy
oxidase
Homocystinuria
Methionine,
homocystine
Cystathi
syntheta
Lysine
Lysine-
ketoglut
reductas
Hyperprolinemia
Hyperlysinemia
Arginino
Citrullinemia
Citrulline
acid syn
Alkaptonuria
Homogentisic acid
(2,5dihydroxyphenylacetic
acid); no abnormal
amino acid
Homoge
acid oxid
Oasthouse urine
disease
Methionine,
phenylalanine, valine,
leucine, isoleucine,
and tyrosine, and
also -hydroxybutyric
acid in urine
Possibly
methion
malabso
syndrom
b. Secondary causes
1. Diabet es w it h ket osis
2. Malabsorpt ion
3. Heredit ary f ruct ose int olerance
4. Condit ions w it h severe brain damage
5. Reye's syndrome
6. Acut e and chronic renal f ailure
7. Eclampsia
8. Specif ic aminoacidopat hies
2. Total pl asma ami no aci ds are decreased in:
a. Adrenocort ical hyperf unct ion
b. Hunt ingt on's chorea
c. Phl ebotomus f ever
d. Nephrit ic syndrome
e. Rheumat oid art hrit is
f. Hart nup's disease
3. Total uri ne ami no aci ds are i ncreased in specif ic aminoacidurias (see Table
3-13).
4. Absence of ami no aci ds occurs as list ed in Table 3-14.
Table 3.14 Absence of Amino Acids
Disease
Am ino Acids in
Urine
Presence o
Abnorm al
Exzym e
Argininosuccinic
aciduria
Argininosuccinic acid
(also citrulline)
Argininosuc
Cystathionunuria
Cystathionine
Cystathioni
Homocystinuria
Homocystine
Cystathioni
synthetase
Hypophosphatasia
Phosphoethanolamine
Serum alka
phosphate
5. Renal transport ami noaci duri as include t he element s list ed in Table 3-15.
Table 3.15 Renal Transport Aminoacidur
Disease
Am ino Acids in Urine
Abnorm ality
Cystinuria
(cystine
stones)
Cystine; lysine; arginine,

ornithine (basic amino
acids)
Incomplete ab
cystine, lysine
ornithine
Hartnup's
disease
Monoaminomonocarboxylic
(neutral) amino acids
(proline, glycine,
hydroxyproline, and
methionine not increased)
Incomplete ab
monoaminomo
acids
Glycinuria,
renal type
Glycineproline,
hydroxyproline
Membrane tra
Familial iminoglycinuria
6. Secondary ami noaci duri as occur in t he f ollow ing:
a. Viral hepat it is
c. Hyperparat hyroidism
d. Ricket s (vit amin D resist ant )
e. O st eomalacia
f. Heredit ary f ruct ose int olerance
g. G alact osemia
h. Liver disease or necrosis
i. Renal f ailure, renal disease
j. Cyst inosis
k. Muscular dyst rophy (progressive)
Interfering Factors
1. Amino acid concent rat ion displays a marked circadian rhyt hm30%
variat ion, highest in midaf t ernoon and low est in morning.
2. Hyperaliment at ion and int ravenous t herapy aff ect out come.
3. Drugs such as amphet amines, norepinephrine, levodopa, and all ant ibiot ics
aff ect result s.
4. Age is a signif icant f act or, especially in new borns and inf ant s.
5. Pregnancy decreases values.
Interventions
1. G enet ic counseling is recommended bef ore specimen collect ion.
2. I nst ruct t he pat ient regarding t he t est purpose, collect ion procedure, and
need f or ref rigerat ion. A w rit t en reminder may be helpf ul.
3. Allow f oods and moderat e amount s of f luids (do not overhydrat e).
4. I t may be necessary t o consume prot eins or carbohydrat es f or a challenge
load t o produce cert ain amino acid met abolit es.

1. I nt erpret t est out comes and counsel appropriat ely. G enet ic counseling may
be necessary.
care.
BIBLIOGRAPHY
Ali A: Prot einuria: How much evaluat ion is appropriat e? Post grad Med 101:
173, 1997
Belsey R, Baer DM: Specimen collect ion f or diagnosing UTI . Medical
Laborat ory O bserver 28: 29, 1996
Cooper C: What color is t hat urine specimen. Am J Nurs 93(8): 37, 1990
Finnegan K: Correlat ing rout ine urinalysis w it h select ed kidney disorders.
Advances f or Laborat ory Prof essionals 2(12), June 1999
G oroll AH, May LA, Mully AG Jr: Primary Medicine, 4t h ed. Philadelphia,
G raff L: Handbook of Rout ine Urinalysis. Philadelphia, JB Lippincot t , 1983
Klee G G : Maximizing Eff icacy of Endocrine Test s: I mport ance of Decisionf ocused Test ing St rat egies and Appropriat e Pat ient Preparat ion. Clin Chem
45(8): 13231330, Special I ssue 1999, Part 2 of 2, Proceedings of t he
Tw ent y-Second Annual Arnold O . Beckman Conf erence in Clinical Chemist ry
Feb 2122, 1999
Kunin CM: Urinary Tract I nf ect ions: Det ect ion, Prevent ion, and Management ,
5t h ed. Balt imore, Williams & Wilkins, 1996
Leavelle DE: I nt erpret ive Dat a f or Diagnost ic Laborat ory Test s. Rochest er,
MN, Mayo Medical Laborat ories, 2001
Lehmann CA (ed): Saunders Manual of Clinical Laborat ory Science.
Marchiondo K, Credit CE: A new look at urinary t ract inf ect ions. Am J Nurs
98(3): 3439, 1998
McBride LJ: Text book of Urinalysis and Body Fluids. Philadelphia, Lippincot t
New land JA: Cyst it is in w omen. Am J Nurs 98(1): 16AAA, 1998
Q uant imet rix Corporat ion: Urinalysis Made Simple. Redondo Beach, CA,
Aut hor, 2000
St rasinger SK: Urinalysis and Body Fluids, 4t h ed. Philadelphia, FA Davis,
2001
Thompson WG : Things t hat go red in t he urine; and ot hers t hat don't . Lancet
347: 5, 1996
Tiet z N: Clinical G uide t o Laborat ory Test s, 3rd ed. Philadelphia, WB
Saunders, 1995
Toff alet t i J: Renal Funct ion and Failure. Washingt on, DC, AACC Press, 1999
Young DS: Eff ect s of Drugs on Clinical Laborat ory Test s, 5t h ed. Washingt on,
DC, AACC Press, 1999

Wilkins
> Table of C ontents > 4 - S tool S tudies
4
Stool Stu dies
OVERVIEW OF STOOL STUDIES

The eliminat ion of digest ive w ast e product s f rom t he body is essent ial t o healt h.
These excret ed w ast e product s are know n as stool or f eces. St ool examinat ion is
of t en done f or evaluat ion of gast roint est inal (G I ) disorders. These st udies are
helpf ul in det ect ing G I bleeding, G I obst ruct ion, obst ruct ive jaundice, parasit ic
disease, dysent ery, ulcerat ive colit is, and increased f at excret ion. (See St ool
Analysis on p. 266. ) An adult excret es 100 t o 200 g of f ecal mat t er a day, of
w hich as much as 75% may be w at er. The f eces are w hat remain of t he 8 t o 10
L of digest ed f luid-like mat erial t hat ent ers t he int est inal t ract each day, and oral
f ood and f luids, saliva, gast ric secret ions, pancreat ic juice, and bile add t o t he
f ormat ion of f eces.
Feces are composed of t he f ollow ing mat erials:
1. Wast e residue of indigest ible mat erial (eg, cellulose) f rom f ood eat en during
t he previous 4 days
2. Bile (pigment s and salt s): st ool color is normally due t o bile pigment s t hat
have been alt ered by bact erial act ion.
3. I nt est inal secret ions
4. Wat er and elect rolyt es

5. Epit helial cells t hat have been shed
6. Large numbers of bact eria

7. I norganic mat erial (10%20%), chief ly calcium and phosphat es
8. Undigest ed or unabsorbed f ood (normally present in very small quant it ies)
The out put of f eces depends on a complex series of absorpt ive, secret ory, and
f erment at ive processes. Normal f unct ion of t he colon involves t hree physiologic
processes: (1) absorpt ion of f luid and elect rolyt es; (2) cont ract ions t hat churn
and expose t he cont ent s t o t he G I t ract mucosa and t ransport t he cont ent s t o
t he rect um; and (3) def ecat ion.
The small int est ine is approximat ely 23 f eet (7 m) long, and t he large int est ine is
4 t o 5 f eet (1. 21. 5 m) long. The small int est ine degrades ingest ed f at s,
prot eins, and carbohydrat es t o absorbable unit s and t hen absorbs t hem.
Pancreat ic, gast ric, and biliary secret ions exert t heir eff ect s on t he G I cont ent s
t o prepare t his mat erial f or act ive mucosal t ransport . O t her act ive subst ances
absorbed in t he small int est ine include f at -soluble vit amins, iron, and calcium.
Vit amin B12 , af t er combining w it h int rinsic f act ors, is absorbed in t he ileum. The
small int est ine also absorbs as much as 9. 5 L of w at er and elect rolyt es f or
ret urn t o t he bloodst ream. Small int est ine cont ent s (ie, chyme) begin t o ent er t he
rect um as soon as 2 t o 3 hours af t er a meal, but t he process is not complet e
unt il 6 t o 9 hours af t er eat ing.
The large int est ine perf orms less complex f unct ions t han t he small int est ine. The
proximal or right colon absorbs most of t he w at er remaining af t er t he G I
cont ent s have passed t hrough t he small int est ine. Colonic absorpt ion of w at er,
sodium, and chloride is a passive process. Fecal w at er excret ion is only about
100 mL/ day. The colon mainly moves t he luminal cont ent s t o and f ro by
seemingly random cont ract ions of circular smoot h muscle. I ncreased propulsive
act ivit y (ie, perist alsis) occurs af t er eat ing. Perist alt ic w aves are caused by t he
gast rocolic and duodenocolic ref lexes, w hich are init iat ed af t er meals and
st imulat ed by t he empt ying of t he st omach int o t he duodenum. The muscles of
t he colon are innervat ed by t he aut onomic nervous syst em. Addit ionally, t he
parasympat het ic nervous syst em st imulat es movement , and t he sympat het ic
syst em inhibit s movement . Massive perist alsis usually occurs several t imes a
day. Result ant dist ent ion of t he rect um init iat es t he urge t o def ecat e. I n persons
w it h normal mot ilit y and a mixed diet ary int ake, normal colon t ransit t ime is 24 t o
48 hours.
STOOL ANALYSIS
St ool analysis det ermines t he various propert ies of t he st ool f or diagnost ic
purposes. Some of t he more f requent ly ordered t est s on f eces include t est s f or
leukocyt es, blood, f at , ova, parasit es, and pat hogens (Table 4. 1). (St ool cult ure
is explained in Chap. 7, Microbiologic St udies. ) St ool is also examined by
chromatographi c analysis f or t he presence of gallst ones. The recovery of a
gallst one f rom f eces provides t he only proof t hat a common bile duct st one has
been dislodged and excret ed. St ool t est ing also screens f or colon cancer and
asympt omat ic ulcerat ions or ot her masses of t he G I t ract and evaluat es G I
diseases in t he presence of diarrhea and/ or const ipat ion. St ool t est ing is done in
immunocompromised persons f or parasit ic diseases. Fat analysis is used as t he
gold st andard t o diagnose malabsorpt ion syndrome.
Table 4.1 Stool Testing for Infections
Source of Stool
Infection
Com m unity Acquired

from intermediate
hosts, ie:
Homepets, dogs,
contaminated water
Occupational
Fishingsnails and
worms
Meat cuttersfrom
contaminated animals
Clinical
Signs or
Sym ptom s
Laboratory
Test
(Sequence or
Follow-up)
Diarrhea,
bloody,
purulent
Steatorrhea
Cramping,
bloating,
Screen stool
for ova and
parasites
Microscopic
exam of stool
for ova and
Health care workers

from patients
Farm workersanimals
(cows, pigs), garden,
flies, mosquitoes,
insects, fleas, bugs
Recreational
backpacking, poor
sanitation
TravelThird W orld
contaminated water
supply
Contact with fair
animals
Hookworm infection
not fecal or oral; it is
direct penetration of
skin by larva in
contaminated soil or in
animal droppings
Nosocom ial Acquired

from institutions such
as hospitals or nursing
homes
belching
Small bowel
obstruction,
weight loss
Generalized
skin rash
Huge
swelling of
legs, arms,
or scrotum
Huge
lymphatic
swelling
Fever,
chills, night
sweats
Diarrhea
Medication
history of
antibiotic
use
parasites
Stool culture
Clostridium
difficile assay
(some patients
may require
more than one
assay)
Eosinophilia in
blood sample
Exam for
worms in stool
or around anus
Fecal smear
for leukocytes
and yeast
Eosinophilia in
blood sample
Exam for
worms in stool
or around anus
Microscopic
exam of stool
for ova and
parasites
Stool culture
for Clostridium
difficile
Fecal smear
for leukocytes
and yeast
Personal Contact with

an infected host when
patient is compromised
(weakened immune
system, ie, HIV) or
debilitated as in frail
children or elderly
Screen stool
for ova and
parasites
Microscopic
exam of stool
for ova and
parasites
Stool culture
for Clostridium
difficile
Toxin stool
assay
Acid-fast
bacilli (AFB) in
stool for
tuberculosis
Microsporidium
Pat ient s and healt h care personnel may dislike collect ing and examining f ecal
mat erial; how ever, t his nat ural aversion must be overcome in light of t he value of
a st ool examinat ion f or diagnosing dist urbances and diseases of t he G I t ract , t he
liver, and t he pancreas.
Random Collection and Transport of Stool Specimens

1. O bserve st andard/ universal precaut ions (see Appendix A) w hen procuring
and handling specimens t o avoid inf ect ious pat hogens (eg, hepat it is A,
Sal monel l a, and Shi gel l a).
2. Collect f eces in a dry, clean, urine-f ree cont ainer t hat has a properly f it t ing
cover.
3. The specimen should be uncont aminat ed w it h urine or ot her bodily secret ions
such as menst rual blood. St ool can be collect ed f rom t he diaper of an inf ant
or incont inent adult . Samples can be collect ed f rom t emporary ost omy bags.
4. While w earing gloves, collect t he ent ire st ool specimen and t ransf er it t o a
cont ainer using a clean t ongue blade or similar object . A sample 2. 5-cm (1inch) long or 64. 7 mg (1 oz) of liquid st ool may be suff icient f or some t est s.
5. For best result s, cover specimens and deliver t o t he laborat ory immediat ely
af t er collect ion. Depending on t he examinat ion t o be perf ormed, t he
specimen should be eit her ref rigerat ed or kept w arm. I f you are unsure of
how t o handle t he specimen, cont act t he laborat ory f or det ailed inst ruct ions
concerning t he disposit ion of t he f ecal specimen bef ore collect ion is begun.
6. Post signs in bat hrooms t hat say DO NO T DI SCARD STO O L or SAVE
STO O L t o serve as reminders t hat f ecal specimen collect ion is in progress.
Collection and Transport of Specimens for Ova and

Parasites
1. Wear gloves. O bserve st andard precaut ions (see Appendix A). Collect f eces
in a dry, clean, urine-f ree cont ainer. I f unsure of how t o collect specimen,
cont act t he laborat ory bef ore collect ion is begun.
2. Warm st ools are best f or det ect ion of ova and parasit es. Do not ref rigerat e
specimens f or ova and parasit es.
3. Special vials t hat cont ain 10% f ormalin and polyvinyl alcohol (PVA) f ixat ive
may be used f or collect ing st ool samples t o t est f or ova and parasit es. I n
t his case, specimen st orage t emperat ure is not crit ical.
4. Because of t he cyclic lif e cycle of parasit es, t hree separat e random st ool
specimens f or analysis are recommended.
Collection and Transport of Specimens for Enteric

Pathogens
1. While w earing gloves, collect f eces in a dry, clean, urine-f ree cont ainer. I f
unsure of how t o collect t he specimen, cont act t he laborat ory bef ore
collect ion is begun. O bserve st andard precaut ions.
2. Some colif orm bacilli produce ant ibiot ic subst ances t hat dest roy ent eric
pat hogens. Ref rigerat e t he specimen immediat ely t o prevent t his f rom
happening in t he sample.
3. A diarrheal st ool w ill usually give accurat e result s.
4. A f reshly passed st ool is t he specimen of choice.
5. Collect st ool specimens bef ore ant ibiot ic t herapy is init iat ed and as early in
t he course of t he disease as possible.
6. I f mucus or blood is present , it def init ely should be included w it h t he
specimen because pat hogens are more likely t o be f ound in t hese
subst ances. I f only a small amount of st ool is available, a w alnut -sized
specimen is usually adequat e.
7. Accurat ely label all st ool specimens w it h t he pat ient 's name, dat e, and t est s
ordered on t he specimen. Keep t he out side of t he cont ainer f ree f rom
cont aminat ion and immediat ely send t he sealed cont ainer t o t he laborat ory.
8. For best preservat ion and t ransport of pat hogens, a Cary-Blair solut ion vial
w it h indicat or should be used.
Interfering Factors for All Types of Stool Collection

1. St ool specimens f rom pat ient s receiving t et racyclines, ant idiarrheal
medicat ions, barium, bismut h, oil, iron, or magnesium may not yield accurat e
result s.
2. Bismut h f ound in paper t ow els and t oilet t issue int erf eres w it h accurat e
result s.
3. Do not collect or ret rieve st ool f rom t he t oilet bow l or use a specimen t hat
has been cont aminat ed w it h urine, w at er, or t oilet bow l cleaner. A clean, dry
bedpan may be t he best recept acle f or def ecat ion.
4. I naccurat e t est result s may result if t he sample is not representati ve of t he
ent ire st ool evacuat ion.
5. Lif est yle, personal habit s, t ravel, home and w ork environment s, and
bat hroom accessibilit y are some of t he f act ors t hat may int erf ere w it h proper
sample procurement .
6. Specimen not t ransport ed prompt ly. Trophozit es in liquid st ool disint egrat e
rapidly af t er def ecat ion; t heref ore, t he specimen needs t o be examined 30
minut es f rom st art of collect ion of specimen, not 30 minut es f rom end of
collect ion. Semi-f ormed st ool should be examined w it hin 60 minut es af t er
def ecat ion. No t rophozit es are seen in f ormed st ool.
Interventions

1. Explain t he collect ion purpose, procedure, and int erf ering f act ors in language
t he pat ient underst ands. Because t he specimen cannot be obt ained on
demand, it is import ant t o provide det ailed inst ruct ions bef ore t he t est so
t hat t he specimen is collect ed w hen t he opport unit y present s it self . Provide
w rit t en inst ruct ions if necessary.
2. Provide proper cont ainers and ot her collect ion supplies. I nst ruct t he pat ient
t o def ecat e in a large-mout hed plast ic cont ainer, bag, or clean bedpan.
Provide f or and respect t he pat ient 's privacy.
3. I nst ruct t he pat ient not to uri nate int o t he collect ing cont ainer or bedpan.
4. Do not place t oilet paper in t he cont ainer or bedpan because it int erf eres
w it h t est ing.
5. I f t he pat ient has diarrhea, a large plast ic bag at t ached by adhesive t ape t o
t he t oilet seat may be helpf ul in t he collect ion process. Af t er def ecat ion, t he
bag can be placed int o a gallon cont ainer.
6. Specimens f or most t est s can be produced by a w arm saline enema or Fleet
Phospho-Soda enema.
7. Test s f or bot h ova and parasit es and cult ures f or ent eric pat hogens may be
ordered t oget her. I n t his case, t he specimen should be divided int o t w o
samples, w it h one port ion ref rigerat ed f or cult ure t est ing and one port ion
kept at room t emperat ure f or ova and parasit e t est ing. There are commercial
collect ion kit s t hat require t he st ool t o be divided and placed int o separat e
vials f or bet t er recovery of ova and parasit es and ent eric pat hogens. (See
Chap. 7, Microbiologic St udies. )

1. Provide pat ient privacy and t he opport unit y t o cleanse perineal area and
hands. Assist as necessary.
Clin ical Alert

1. Any st ool collect ed may harbor highly inf ect ive pat hogens. Use ext reme
caut ion and proper handling t echniques at all t imes.
2. I nst ruct pat ient s in proper hand-w ashing t echniques af t er each use of t he
bat hroom.
STOOL STUDIES
Stool Consistency, Shape, Form, Amount, and Odor
Inspection of the feces is an important diagnostic tool.
The quantity, form, consistency, and color of the stool
should be noted. When diarrhea is present, the stool is
watery. Large amounts of mushy, frothy, foul-smelling
stool are characteristic of steatorrhea. Constipation is
associated
with firm, spherical masses of stool. Feces have a
characteristic odor that varies with diet and the pH of
the stool.
Normally, evacuat ed f eces ref lect t he shape and caliber of t he colonic lumen as
w ell as t he colonic mot ilit y. The normal consist ency is somew hat plast ic and
neit her f luid, mushy, nor hard. Consist ency can also be described as f ormed,
sof t , mushy, f rot hy, or w at ery. The odor of normal st ool is caused by indole and
skat ole, f ormed by bact erial f erment at ion and put ref act ion.
Reference Values
Normal
1. 100200 g/ d
2. Charact erist ic odor present ; plast ic, sof t , f ormed; sof t and bulky on a highf iber diet ; small and dry on a high-prot ein diet ; seeds and small amount s of
veget able f iber present (as opposed t o muscle f iber) (Table 4. 2)
Table 4.2 Normal Values in Stool Analysis
Macroscopic
Exam ination
Norm al Value
Amount
100200 g/d
Color
Brown
Odor
Varies with pH of stool and

depends on bacterial fermentation
and putrefaction
Consistency
Plastic; not unusual to see fiber,

vegetable skins, and seeds; soft
and bulky in high-vegetable diet;
small and dry in high-meat diet
Size and
shape
Formed
Gross blood
None
Mucus
None
Pus
None
Parasites
None
Microscopic
Exam ination
Norm al Values
Fat
Colorless, neutral fat (18%) and

fatty acid crystals and soaps
Undigested
food, meat
fibers, starch,
trypsin
None to small amount
Eggs and
segments of
parasites
None
Bacteria and
viruses
None
Yeasts
None
Leukocytes
None
Chem ical
Exam ination
Norm al Values
W ater
Up to 75%
pH
Neutral to weakly alkaline (pH 7.0

7.5)
Occult blood
Negative
Urobilinogen
50300 mg/24 h
Porphyrins
Corporphyrins: 4001200 g/24 h

(6111832 nmol/d)
Uroporphyrins: 1040 g/24 h (12
48 nmol/d)
Nitrogen
<2.5 g/24 h (<178 mmol/d)
Apt test for

swallowed
blood
Negative in adults; positive in

newborns
Trypsin
2095 U/g
Osmolality,
used with
stool
Na + K to
calculate
osmotic gap
200250 mOsm
Sodium
5.89.8 mEq/24 h (5.89.8 mmol/d)
Chloride
2.53.9 mEq/24 h (2.53.9 mmol/d)
Potassium
15.720.7 mEq/24 h (15.720.7

mmol/d)
Lipids (fatty
acids)
06 g/24 h (021 mmol/d)
Carbohydrates
(as reducting
substances)
<0.25 g/dL
Note: Reference values for electrolytes differ greatly

from laboratory to laboratory.
Procedure
Collect a random st ool specimen in a plast ic cont ainer.
1. Fecal consist ency alt erat ions

a. Diarrhea due t o t he f ollow ing:
1. I nf ect ionSal monel l a, Shi gel l a, Yersi ni a, human immunodef iciency
virus (HI V) ent eropat hy, Campyl obacter
2. I nf lammat ory disorderCrohn's disease, ulcerat ive colit is
3. St eat orrheasprue, celiac disease
4. Carbohydrat e malabsorpt ionlact ose or sucrose def iciency
5. Endocrine abnormalit iesdiabet es mellit us, hypert hyroid or
hypot hyroid, adrenal insuff iciency
6. Hormone-producing t umorsZollinger-Ellison syndrome, gast rinoma,
medullary t hyroid carcinoma, villous adenoma
7. Colon carcinoma
8. I nf ilt rat ion of lesions due t o lymphoma, scleroderma of bow el
9. Drugs, ant ibiot ics, cardiac medicat ions, chemot herapy
10. O smot ically act ive diet ary it emssorbit ol, psyllium f iber, caff eine,
et hanol
11. G I surgerygast rect omy, st omach st apling, int est inal resect ion
12. Fact it iousself -induced laxat ive abuse associat ed w it h psychiat ric
disorders
b. Past y st ool associat ed w it h high-f at cont ent can be caused by t he
f ollow ing:
1. Common bile duct obst ruct ion

2. Celiac disease (sprue and st eat orrhea); st ool resembles aluminum
paint
3. Cyst ic f ibrosisgreasy but t er st ool appearance due t o pancreat ic
involvement
c. Bulky or f rot hy st ool is usually due t o st eat orrhea and celiac disease.
2. Alt erat ions in st ool size or shape indicat e alt ered mot ilit y or colon w all
abnormalit ies.
a. A narrow, ribbon-like st ool suggest s t he possibilit y of spast ic bow el,
rect al narrow ing or st rict ure, decreased elast icit y, or a part ial
obst ruct ion.
b. Excessively hard st ools are usually due t o increased f luid absorpt ion
because of prolonged cont act of luminal cont ent s w it h colon mucosa
during delayed t ransmit t ime t hrough t he colon.
c. A large-circumf erence st ool indicat es dilat at ion of t he viscus.
d. Small, round, hard st ools (ie, scybala) accompany habit ual, moderat e
const ipat ion.
e. Severe f ecal ret ent ion can produce huge, f irm, impact ed st ool masses
w it h a small amount of liquid st ool as overf low. These must be removed
manually, occasionally under light anest hesia.
3. Fecal odor should be assessed w henever a st ool specimen is collect ed.
a. A f oul odor is caused by dehydrat ion of undigest ed prot ein and is
produced by excessive carbohydrat e ingest ion.
b. A sickly sw eet odor is produced by volat ile f at t y acids and undigest ed
lact ose.
4. Mucus in st ool occurs in const ipat ion, malignancy, and colit is (see p. 278).
Interventions

1. Ensure t hat t he pat ient avoids barium procedures and laxat ive preparat ions
f or 1 w eek bef ore st ool specimen collect ion.
2. Advise t he pat ient of t he purpose of t est and inst ruct him or her in collect ion
t echniques and ref rigerat ion of specimen. Provide collect ion cont ainer.
Assessment of Diarrhea and Constipation

1. When perf orming a w orkup f or t he diff erent ial diagnosis of diarrhea or
const ipat ion, a pat ient hist ory is most import ant . The f ollow ing f act ors should
be chart ed:
a. An est imat e of volume and f requency of f ecal out put
b. St ool consist ency and presence of blood, pus, mucus, oiliness, or bad
odor in specimen; evaluat e t hrough direct observat ion
c. Decrease or increase in f requency of def ecat ion
d. Sensat ions of rect al f ullness w it h incomplet e st ool evacuat ion
e. Painf ul def ecat ion

2. Assess diet ary habit s and f ood allergies.
3. Assess emot ional st at e of pat ient psychological st ress may be major cause
of alt ered bow el habit s.
4. Be alert f or signs of laxat ive abuse.

1. Evaluat e out come; int erpret , report , and record f indings. I f abnormalit ies are
det ect ed, counsel pat ient appropriat ely. I f pat ient has w at ery diarrhea, not e
hist ory of cont act w it h aff ect ed f amily members, t ravel t o a developing
count ry, involvement in vacat ion or resort backpacking, communit y and
municipal w at er supply, or cont act w it h f arm animals. Explain t hat addit ional
t est ing (eg, colonoscopy) may be necessary.
Stool Color
The brow n color of normal f eces is probably due t o st ercobilin (urobilin), a bile
pigment derivat ive, w hich result s f rom t he act ion of reducing bact eria in bilirubin
and ot her undet ermined f act ors.
The f irst indicat ion of G I dist urbances is of t en a change in t he normal brow n
color of t he f eces. A change in color can provide inf ormat ion about pat hologic
condit ions, organic dysf unct ion, or int ake of drugs. Color abnormalit ies may aid
t he clinician in select ion of appropriat e diagnost ic chemical and microbiologic
st ool t est s.
Reference Values
Normal
Brow n
Procedure
Collect a random st ool specimen. O bserve st andard precaut ions.
Clinical Implications The color of feces changes in

some disease states is as follow s:
1. Yellow, yellow -green, or green: severe diarrhea
2. Black, w it h a t arry consist ency: usually t he result of bleeding in t he upper G I
t ract (>100 mL blood)
3. Maroon, red, or pink: possibly t he result of bleeding of t he low er G I t ract
f rom t umors, hemorrhoids, f issures, or an inf lammat ory process
4. Clay-colored (t an-gray-w hit e): biliary obst ruct ion
5. Pale, w it h a greasy consist ency: pancreat ic def iciency causing malabsorpt ion
of f at
Clin ical Alert

G rossly visible blood alw ays indicat es abnormal st at e.
1. Blood st reaked on t he out er surf ace of st ool usually indicat es hemorrhoids
or anal abnormalit ies.
2. Blood present in st ool can also be caused by abnormalit ies higher in t he
colon. I f t ransmit t ime is suff icient ly rapid, blood f rom t he st omach or
duodenum can appear as bright red, dark red, or maroon in st ool.
Interfering Factors
1. St ool darkens on st anding.
2. The color of st ool is inf luenced by diet (cert ain f oods), f ood dyes, and drugs
(see Appendix J).
a. Yellow -rhubarb; yellow t o yellow -green color occurs in t he st ool of
breast -f ed inf ant s w ho lack normal int est inal f lora.
b. Pale yellow, w hit e, or gray st ools are due t o barium int ake.
c. G reen color occurs w it h diet s high in chlorophyll-rich green veget ables
such as spinach or w it h some drugs (see Appendix J).
d. Black color may be due t o f oods such as cherries, an unusually high
proport ion of diet ary meat , art if icially colored f oods such as black jelly
beans, or drugs and supplement s such as charcoal, bismut h, or iron.
e. Light -colored st ool w it h lit t le odor may be due t o diet s high in milk and
low in meat .
f. Clay-like color may be due t o a diet w it h excessive f at int ake or barium
int ake.
g. Red color may be due t o a diet high in beet s or t omat oes, red f ood
coloring, or peridium compound.
h. Cert ain color changes may result f rom specif ic drugs (see Appendix J).
Clin ical Alert

A complet e diet ary and drug hist ory w ill help t o diff erent iat e signif icant
abnormalit ies f rom int erf ering f act ors.
Interventions

1. Advise pat ient of purpose of t est . Ask pat ient t o not if y clinician about st ool
color changes. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed
pretest care .
2. Record diet ary and drug hist ory.
3. Ensure t hat t he pat ient avoids laxat ives and barium procedures f or 1 w eek
bef ore collect ion.

1. I nt erpret and document abnormal appearance and colors of st ool; counsel
pat ient appropriat ely regarding t he meaning of color changes and explain
need f or f urt her t est ing (eg, G I st udies).
Blood in Stool; Occult Blood The most frequently

performed fecal analysis is chemical screening for the
detection of occult (ie, hidden) blood. Bleeding in the
upper GI tract may produce a black, tarry stool.
Bleeding in the lower GI tract may result in an overtly
bloody stool. However, no visible signs of bleeding
may be present with smaller amounts of blood found in
early stages of GI diseases; thus, the chemical
detection of occult blood is necessary to identify and
treat disease early in its course. Occult blood testing
is also controversial owing to many false-positive and
false-negative results. If the patient preparation and
collection of specimen is followed explicitly, the
results are more accurate.
An average, healt hy person passes up t o 2. 0 mL of blood per 150 g of st ool int o
t he G I t ract daily. Passage of more t han 2. 0 mL of blood in t he st ool in 24 hours
is pat hologically signif icant . Det ect ion of occult blood in t he st ool is very usef ul
in det ect ing early disease of t he G I t ract . This t est demonst rat es t he presence
of blood produced by upper G I bleeding, as in t he presence of gast ric ulcer; it
also screens f or colonic carcinomas w hile t hey are st ill in t he localized st ages.
Wit h proper medical f ollow -up, an 84% survival rat e has been demonst rat ed f or
t reat ment of colonic carcinoma.
Reference Values
Normal
Negat ive f or blood
Procedure
1. O bt ain a random st ool specimen. O bserve st andard precaut ions. Test s f or
det ect ing f ecal blood use t he pseudoperoxidase act ivit y of hemoglobin
react ing w it h hydrogen peroxide t o oxidize a colorless compound t o a
colored one (usually blue). Hemoccult I I (Smit h-Kline) is t he most w idely
used commercial t est w it h t he low est percent age of f alse-posit ive result s
(1%12%). This t est syst em uses guaiac-impregnat ed f ilt er paper as t he
chromogen t hat produces t he blue color in a posit ive react ion.
2. Apply a t hin smear of st ool inside t he indicat ed circle using a w ood
applicat or st ick and allow it t o dry. I f st ool is bloody, t he collect or may be at
risk f or hepat it is B, hepat it is C, or HI V inf ect ion.
3. Prot ect t he Hemoccult slide f rom light , heat , and humidit y. Do not
ref rigerat e.
4. Do not allow t he delay bet w een smearing t he st ool and t est ing t o exceed 14
days. Do not ref rigerat e sample bef ore t est ing.
1. St ool t hat appears dark red t o t arry black indicat es a loss of 50. 0 t o 75. 0
mL of blood f rom t he upper G I t ract . Smaller quant it ies of blood in t he G I
t ract can produce similar-appearing st ools or appear as bright red blood.
2. A st ool sample should be considered grossly bloody onl y af t er a chemical
t est ing f or presence of blood. This w ill eliminat e t he possibilit y t hat abnormal
coloring caused by diet or drugs may be mist aken f or bleeding in t he G I
t ract .
3. Posit ive t est ing f or occult blood may be caused by t he f ollow ing condit ions:
a. Carcinoma of colon
b. Ulcerat ive colit is and ot her inf lammat ory lesions
c. Adenoma
d. Diaphragmat ic hernia
e. G ast ric carcinoma
f. Rect al carcinoma
g. Pept ic ulcer
h. G ast rit is
i. Vasculit is
j. Amyloidosis
k. Kaposi's sarcoma
Clin ical Alert

1. To be accurat e, t he t est employed must be repeat ed t hree t o six t imes on
diff erent st ool samples; some bow el lesions may bleed int ermit t ent ly.
2. The pat ient 's diet should be f ree of meat and veget able sources of
peroxidase act ivit y (eg, t urnips, horseradish, red or rare meat ,
caulif low er, broccoli, cant aloupe, parsnips). O nly af t er f ollow ing t his
regimen can a posit ive series of t est s be considered an indicat ion f or
f urt her pat ient evaluat ion and t est ing.
Interfering Factors
1. Drugs such as salicylat es (aspirin), st eroids, indomet hacin, nonst eroidal ant iinf lammat ory drugs (NSAI Ds), ant icoagulant s, colchicine, and ant imet abolit es
are associat ed w it h increased G I blood loss in average, healt hy persons and
w it h more pronounced bleeding w hen disease is present . G I bleeding can
also f ollow parent eral administ rat ion of t he above-ment ioned drugs and
should be avoided 7 days bef ore t est ing.
2. Drugs t hat may cause f alse-posit ive result s f or occult blood t est ing include
t he f ollow ing:
a. Boric acid
b. Bromides
c. Colchicine
d. I odine, povidone-iodine (Bet adine)
e. See Appendix J f or ot her drugs.
3. Foods t hat may cause f alse-posit ive result s f or occult blood t est ing include
t he f ollow ing:
a. Meat s, including processed meat s and liver, w hich in t he diet cont ain
hemoglobin, myoglobin, and cert ain enzymes t hat can give f alse-posit ive
t est result s f or up t o 4 days af t er consumpt ion.
b. Veget ables and f ruit s w it h peroxidase act ivit y (eg, t urnips, horseradish,
mushrooms, broccoli, apples, radishes, bananas, cant aloupe)
4. Subst ances t hat cause f alse-negat ive result s f or occult blood t est ing include
t he f ollow ing:
a. Ascorbic acid (vit amin C) in excess of 250 mg/ day
b. Vit amin Cenriched f oods and juices
c. I ron supplement s t hat cont ain vit amin C in excess of 250 mg
d. See Appendix J f or ot her drugs.
5. O t her f act ors aff ect ing t est result s include t he f ollow ing:
a. Bleeding hemorrhoids may produce erroneous result s; t ake samples f rom
cent er of st ool t o avoid t his error.
b. Collect ion of specimen during menst rual period
c. Hemat uria (ie, blood in urine)
d. Some long-dist ance runners (23%) have posit ive out comes f or occult
blood.
e. Toilet bow l cleansers may int erf ere w it h t he chemical react ion of t he
t est ; remove bow l cleaners and f lush t w ice bef ore proceeding w it h t est .
Interventions

1. Explain t he purpose, procedure, and int erf ering f act ors of t he t est as w ell as
t he need t o f ollow appropriat e st ool collect ion prot ocols f or using special kit
f or f ecal occult blood or a plast ic cont ainer w it h a lid.
2. Recommend t hat t he pat ient consume a high-residue diet , st art ing 72 hours
bef ore and cont inuing t hroughout t he collect ion period. Roughage in diet can
increase t est accuracy by helping t o uncover silent lesions t hat bleed
int ermit t ent ly. The diet may include t he f ollow ing:
a. Meat s: only small amount s of chicken, t urkey, and t una
b. Veget ables: generous amount s of bot h raw and cooked veget ables,
including let t uce, corn, spinach, carrot s, and celery; avoid veget ables
w it h high peroxidase act ivit y (see 3b above)
c. Fruit s: plent y of f ruit s, especially prunes
d. Cereals: bran and bran-cont aining cereals
e. Moderat e amount s of peanut s and popcorn daily. I f any of t he above
f oods are know n t o cause discomf ort , t he pat ient should consult t he
physician.
3. Ensure t hat t he pat ient receives no barium enemas 72 hours bef ore or during
t est ing.
Edu cation Alert

Do not collect samples during or unt il 3 days af t er your menst rual period,
or w hile you have bleeding hemorrhoids or blood in your urine.
Do not consume t he f ollow ing medicat ions, vit amins, and f oods: f or 7 days
bef ore and during t he t est period, avoid aspirin or ot her NSAI Ds; f or 72
hours bef ore and during t he t est period, avoid vit amin C in excess of 250
mg/ d (f rom all sources, diet ary and supplement ary), red meat (eg, beef ,
lamb), including processed meat s and liver, and raw f ruit s and veget ables
(especially melons, radishes, t urnips, and horseradish).
Remove t oilet bow l cleaners f rom t oilet t ank and f lush t w ice bef ore
proceeding t o def ecat e.
Collect samples f rom t hree consecut ive bow el movement s or t hree bow el
movement s closely spaced in t ime and spread a small st ool sample
(minimum, 1 mL) on each of t he t hree slides or card provided.
Prot ect card or slides f rom heat , light , and volat ile chemicals (eg, iodine,
bleach). Keep cover f lap of slides closed w hen not in use.

1. Pat ient may resume normal diet af t er t est ing is complet e.
2. I nt erpret occult blood t est result s and record f indings. Counsel t he pat ient
regarding abnormal f indings and monit or as necessary. Advise t hat f urt her
t est ing (eg, barium enema, def ecography) and f ollow -up may be required.
Clin ical Alert

Blood in t he st ool is abnormal and should be report ed and recorded.
Apt Test for Swallowed Blood Dr. L. Apt developed the

test for identifying the swallowed blood syndrome. The
swallowed blood syndrome refers to bloody stools
usually passed on the second or third day of life. The
blood may be swallowed during delivery or may be
from a fissure of the mother's nipple in breast-fed
infants. This condition must be differentiated from GI
hemorrhage of the newborn. The test is based on the
fact that the infant's blood contains largely fetal
hemoglobin (Hb F), which is alkali resistant. This blood
can be differentiated from the mother's blood using
laboratory methods.
The Apt t est is used t o diff erent iat e sw allow ed blood syndrome f rom inf ant G I
hemorrhage. The t est can be done on f eces or vomit us. I n t he laborat ory, t he
blood is dissolved and t reat ed w it h NaO H f or alkali denat urat ion. Fet al
hemoglobin is alkali resist ant , and t he solut ion of blood remains pink. Sw allow ed
blood of mat ernal origin cont ains adult hemoglobin, w hich is convert ed t o
brow nish hemat in w hen t he alkali is added.
Reference Values
Normal
Test result w ill indicat e w het her blood present in new born f eces or vomit us is of
mat ernal or f et al origin.
Procedure
1. Collect a random st ool specimen f rom a new born inf ant ; observe st andard
precaut ions.
2. The f ollow ing are accept able specimens:
a. Blood-st ained diaper
b. G rossly bloody st ool
c. Bloody vomit us or gast ric aspirat ion

3. Place specimen or specimens in a biohazard bag and deliver t o t he
laborat ory as soon as possible. Ref rigerat e t he specimen or specimens if
t here is any delay.
1. Fet al hemoglobin, w hich is pink in color, is present in gast ric hemorrhage of
t he new born.
2. Adult hemoglobin, w hich is brow nish in color, is present in sw allow ed blood
syndrome in t he inf ant .
Interfering Factors
1. The t est is invalid w it h black, t arry st ools because t he blood has already
been convert ed t o hemat in.
2. The t est is invalid if t here is insuff icient blood present ; grossly visible blood
must be present in t he specimen.
3. Vomit us w it h pH < 3. 9 produces an invalid t est result .
4. The presence of mat ernal t halassemia major produces a f alse-posit ive t est
result because of increased mat ernal hemoglobin F.
Interventions

1. Advise parent or parent s of t he purpose of t he t est .

1. Review t est result s and counsel t he parent or parent s regarding t est
out come, f urt her t est ing, and possible t reat ment f or inf ant G I hemorrhage.
Mucus in Stool
The mucosa of t he colon secret es mucus in response t o parasympat het ic
st imulat ion. Recognizable mucus in a st ool specimen is abnormal and should be
report ed and recorded.
Reference Values
Normal
Negat ive f or mucus
Procedure
Collect a random st ool specimen. O bserve and report f indings of mucus.
1. Translucent gelat inous mucus clinging t o t he surf ace of f ormed st ool occurs
in t he f ollow ing condit ions:
a. Spast ic const ipat ion
b. Mucous colit is
c. Emot ionally dist urbed pat ient s
d. Excessive st raining at st ool

2. Bloody mucus clinging t o t he f eces suggest s t he f ollow ing condit ions:
a. Neoplasm
b. I nf lammat ion of t he rect al canal

3. I n villous adenoma of t he colon, copious quant it ies of mucus may be passed
(up t o 34 L in 24 hours).
4. Mucus and diarrhea w it h w hit e and red blood cells is associat ed w it h t he
f ollow ing condit ions:
a. Ulcerat ive colit is (Shi gel l a)
b. Bacillary dysent ery (Sal monel l a)
c. Ulcerat ing cancer of colon
d. Acut e divert iculit is
e. I nt est inal t uberculosis
f. Regional ent erit is
g. Amebiasis
Interventions

1. Advise pat ient of purpose of observing f or st ool mucus.
3. Ensure t hat t he pat ient avoids laxat ives and barium procedures f or 1 w eek
bef ore t est .

1. Report and record presence, t ype, and amount of mucus.
2. Counsel pat ient appropriat ely. Monit or bow el habit s. Explain t hat f urt her
t est ing and f ollow -up monit oring may be necessary.
Stool pH
St ool pH is diet dependent and is based on bact erial f erment at ion in t he small
int est ine. Carbohydrat e f erment at ion changes t he pH t o acid; prot ein breakdow n
changes t he pH t o alkaline.
St ool pH t est ing is done t o evaluat e carbohydrat e and f at malabsorpt ion and
assess disaccharidase def iciency. Breast -f ed inf ant s have slight ly acid st ool;
bot t le-f ed inf ant s have slight ly alkaline st ools.
Reference Values
Normal
1. Neut ral t o slight ly acid or alkaline: pH 7. 07. 5 depending on diet
2. New borns: pH 5. 07. 5
Procedure
1. Collect a f resh, random st ool specimen in a plast ic cont ainer w it h a t ight f it t ing lid (see p. 266).
2. Ref rigerat e specimen.
1. I ncreased pH (alkaline)
a. Secret ory diarrhea w it hout f ood int ake
b. Colit is
c. Villous adenoma
d. Ant ibiot ic use (impaired colonic f erment at ion)
2. Decreased pH (acid)
a. Carbohydrat e malabsorpt ion
b. Fat malabsorpt ion

c. Disaccharidase def iciency (int est inal)
Interfering Factors
1. Barium procedures and laxat ives aff ect t est out comes. They should be
avoided f or 1 w eek bef ore st ool sample collect ion.
2. Specimens cont aminat ed w it h urine w ill invalidat e t he t est .
Interventions

1. Explain t he purpose and procedure of t he t est , f ollow ing general guidelines in
Chapt er 1 f or saf e, eff ect ive, inf ormed pretest care .
2. Advise pat ient t hat laxat ives and barium procedures should be avoided f or 1
w eek bef ore st ool sampling.

1. I nt erpret pH out come and record f indings. I f abnormal pH is f ound, assess
diet ary pat t erns and ant ibiot ic use.
2. Monit or as appropriat e f or malabsorpt ion syndrome.
3. O rder a st ool reducing subst ance t est if disaccharidase def iciency is
suspect ed (see St ool Reducing Subst ances Test below ).
Stool Reducing Substances Test Normally, sugars are

rapidly absorbed in the upper small intestine. However,
if this is not the case, they remain in the intestine and
cause osmotic diarrhea due to osmotic pressure of the
unabsorbed sugar in the intestine, drawing fluid and
electrolytes into the gut. The unabsorbed sugars are
measured as reducing substances. Reducing
substances that can be detected in the stool include
glucose, fructose, lactose, galactose, and pentose.
Carbohydrate malabsorption is a major cause of watery
diarrhea and electrolyte imbalance seen in patients
with the short bowel syndrome. Idiopathic lactase
deficiency is common, occurring in 70% to 75% of
Southern European Greeks and Italians, 70% of Black
adults, >90% of Asian adults, and 5% to 20% of
Caucasian American adults.
The f inding of elevat ed levels of reducing subst ances in t he st ool is abnormal
and suggest s carbohydrat e malabsorpt ion. A presumpt ive diagnosis of
disaccharide int olerance can be made w it h an elevat ed reducing subst ance level
along w it h an acid (ie, low ) pH.
Reference Values
Normal
1. Normal: <0. 25 g/ dL (or <13. 9 mmol/ L) reducing subst ances in st ool
2. Q uest ionable: 0. 250. 50 g/ dL (or 13. 927. 8 mmol/ L) reducing subst ances in
st ool
Abnormal
>0. 5 g/ dL (or >27. 8 mmol/ L)reducing subst ances in st ool
Procedure
Collect a f resh, random st ool specimen and immediat ely deliver it t o t he
laborat ory (see p. 266).
Clinical Implications Elevated reducing substances in

stool are found in the follow ing conditions:
1. Disaccharidase def iciency (int est inal)
2. Short bow el syndrome

3. I diopat hic lact ase def iciency, primary alact asia (enzyme def iciency leading t o
lact ose int olerance)
4. Carbohydrat e malabsorpt ion abnormalit ies due t o:
a. Sprue
b. Celiac disease
c. Viral gast roent erit is
Interfering Factors
1. Bact erial f erment at ion of sugars may give f alsely low result s if t he st ool is
not t est ed immediat ely.
2. New borns may normally have elevat ed result s.
3. Drug may cause malabsorpt ion (eg, neomycin, kanamycin, met hot rexat e).
Interventions

1. Explain t he purpose of t he t est and int erf ering f act ors.
2. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, inf ormed pretest
care.

1. I nt erpret t est out comes. Follow guidelines in Chapt er 1 f or saf e, eff ect ive,
inf ormed posttest care .
2. I f out come is posit ive, f urt her t est ing (lact ose int olerance) and/ or t reat ment
(diet ary t herapy) may be necessary.
Leukocytes in Stool Microscopic examination of the

feces for the presence of white blood cells (leukocytes)
is performed as a preliminary procedure in determining
the cause of diarrhea. Leukocytes are normally not
present in stools and are a response to infection or
inflammation.
The presence or absence of f ecal leukocyt es can provide diagnost ic inf ormat ion
bef ore t he isolat ion of a bact erial pat hogen. Neut rophils (>3 neut rophils per highpow er f ield) are seen in t he f eces in condit ions t hat aff ect t he int est inal w all (eg,
ulcerat ive colit is, invasive bact erial pat hogen inf ect ion). Viruses and parasit es
usually do not cause neut rophils in t he st ool. The great er t he number of
leukocyt es, t he great er t he likelihood t hat an invasive pat hogen is present .
Reference Values
Normal
Negat ive f or leukocyt es
Procedure
Collect a random st ool specimen (see p. 266). Mucus or a liquid st ool specimen
can be used. A f resh specimen is pref erred, or it may be preserved in PVA.
1. Large amount s of leukocyt es (primarily neut rophils) accompany t he f ollow ing
condit ions:
a. Chronic ulcerat ive colit is
b. Bacillary dysent ery
c. Localized abscesses
d. Fist ulas of t he sigmoid rect um or anus
e. Shigellosis
f. Salmonellosis
g. Yersi ni a inf ect ion
h. I nvasive Escheri chi a col i diarrhea
i. Campyl obacter
2. Primarily mononuclear leukocyt es appear in t yphoid. Few leukocyt es are
somet imes seen in amebiasis.
3. Absence of leukocyt es is associat ed w it h t he f ollow ing condit ions:
a. Cholera
b. Nonspecif ic diarrhea (eg, drug or f ood induced)
c. Viral diarrhea
d. Amebic colit is (many red blood cells)
e. Noninvasive E. col i diarrhea
f. Toxigenic bact eria (eg, Staphyl ococcus, Cl ostri di um)
g. Parasit es (eg, G i ardi a, Entamoeba)
Interfering Factors Fecal leukocytes cannot be

performed on formalin-preserved specimens.
Interventions

1. Explain t he purpose of t he t est and t he collect ion procedure. Follow
guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed pretest care .
2. Ensure t hat t he pat ient avoids barium procedures and laxat ives f or 1 w eek
bef ore t est .
3. Wit hhold ant ibiot ic t herapy unt il af t er collect ion.

1. I nt erpret abnormal t est result s. Monit or f or diarrhea. Counsel pat ient
concerning t he need f or f ollow -up t est s (st ool cult ure) and t reat ment (drugs,
eg, ant ibiot ics).
Collection and Transport of 24-, 48-, 72-, and 96-Hour

Stool Specimens This method is used to test for fat,
porphyrins, urobilinogen, nitrogen, and electrolytes.
Special Instructions for Submitting Individual
Specimens
1. Collect all st ool specimens f or 1 t o 3 days. The ent ire st ool should be
collect ed. Some procedures may require 4 days.
2. Label specimens w it h day of t est (eg, Day 1, Day 2, Day 3, Day 4), t ime of
day collect ed, pat ient 's name, and t est s ordered. I t is import ant f or
calculat ions t o disclose t he number of days collect ed.
3. Submit individual specimens t o t he laborat ory as soon as t hey are collect ed.
Special Instructions for Submitting Total Specimens

1. O bt ain a 1-gallon cont ainer f rom t he laborat ory (a 1-gallon paint t in or
covered plast ic pail is pref erred).
2. Save all st ool and place in t he cont ainer. Keep ref rigerat ed or in a cont ainer
w it h canned ice and replace ice as needed.
3. Transf er t he properly labeled cont ainer t o t he laborat ory at t he end of t he
collect ion period.
4. Record dat es, durat ion of collect ion t ime period, t est s t o be perf ormed,
pat ient 's name, and ot her vit al inf ormat ion on t he collect ion recept acle.
Fat in Stool; Fecal Fat Stain Fecal fat is the gold

standard test for diagnosing steatorrhea
(malabsorption). The three major causes of
steatorrhea, which is a pathologic increase in fecal fat,

are impairment of intestinal absorption, deficiency of
pancreatic digestive enzymes, and deficiency of bile.
Specimens f rom pat ient s suspect ed of having st eat orrhea can be screened
microscopically f or t he presence of excess f ecal f at . This procedure can also be
used t o monit or pat ient s undergoing t reat ment f or malabsorpt ion disorders. I n
general, t here is good correlat ion bet w een t he qualit at ive and quant it at ive f ecal
f at procedures. Lipids included in t he microscopic examinat ion of f eces are
neut ral f at s (t riglycerides), f at t y acid salt s (soaps), f at t y acids, and cholest erol.
The presence of t hese lipids can be observed microscopically by st aining w it h
Sudan I I I , Sudan I V, or oil red O dye. The st aining procedure consist s of t w o
part s: t he neut ral f at st ain and t he split f at st ain f or f at t y acids.
Reference Values
Normal
1. Q ualit at ive
a. Neut ral f at : <50 f at globules per high-pow er f ield
b. Fat t y acids: <100 f at globules per high-pow er f ield
2. Q uant it at ive
a. Adult : 27 g/ 24 h (or 27 g/ d) and <20% of t ot al solids
b. I nf ant : <1. 0 g/ 24 h (or <1. 0 g/ d) and breast f ed 10%40% of t ot al
solids; bot t le f ed 30%50% of t ot al solids
Procedure
1. Collect a 48- t o 96-hour specimen f or t he quant it at ive t est . A random
specimen can be used f or t he qualit at ive t est . Each individual st ool specimen
is collect ed and ident if ied w it h t he name of t he pat ient , t ime and dat e of
collect ion, and t est t o be perf ormed. Also indicat e t he lengt h (act ual t ime
f rame) of t he collect ion period. The specimen should be sent immediat ely t o
t he laborat ory.
2. Follow t he procedure f or t he collect ion of 24-, 48-, or 72-hour specimens.
1. I ncreases in f ecal f at and f at t y acids are associat ed w it h malabsorpt ion
syndrome caused by t he f ollow ing condit ions:
a. Celiac disease
b. Crohn's disease
c. Whipple's disease
d. Cyst ic f ibrosis
e. Regional ent erit is
f. Sprue
g. At rophy of malnut rit ion

2. I ncreases in f ecal f at and f at t y acids are also f ound in t he f ollow ing
condit ions:
a. Ent erit is and pancreat ic diseases in w hich t here is a lack of lipase (eg,
chronic pancreat it is)
b. Surgical removal of a sect ion of t he int est ine
3. Fecal f at t est does not provide a diagnost ic explanat ion f or t he presence of
st eat orrhea. I t is not usef ul f or diff erent iat ing among pancreat ic diseases.
a. D-Xylose absorpt ion t est may be ordered f or t he diff erent ial diagnosis of
malabsorpt ion.
Interfering Factors
1. I ncreased neut ral f at may occur under t he f ollow ing nondisease condit ions:
a. Use of rect al supposit ories and/ or oily creams applied t o t he perineum
b. I ngest ion of cast or oil, mineral oil
c. I ngest ion of diet et ic low -calorie mayonnaise, oily salad dressings
d. I ngest ion of high-f iber diet (>100 g/ 24 h or >100 g/ d)
e. Use of psyllium-based st ool sof t eners (eg, Met amucil)
2. Use of barium and bismut h int erf ere w it h t est result s.
3. Urine cont aminat es t he specimen.
4. A random st ool specimen is not an accept able sample f or t he quant it at ive f at
t est .
Interventions

1. Explain t he purpose of t he t est , int erf ering f act ors, and t he procedure f or t he
collect ion of specimens. Follow guidelines in Chapt er 1 concerning diverse
pat ient needs and saf e, eff ect ive, inf ormed pretest care .
2. For a 72- t o 96-hour st ool collect ion, ensure t he pat ient has a diet cont aining
100150 g of f at , 100 g of prot ein, and 180 g of carbohydrat e f or 6 days
bef ore and during t he t est .
3. Do not allow pat ient t o have laxat ives f or 3 days bef ore t he t est .
4. Follow t he procedure f or t he collect ion of 72-hour st ool specimens.

1. Resume normal diet .
2. Record appearance, color, and odor of all st ools in persons suspect ed of
having st eat orrhea. The t ypical st ool in pat ient s w it h t his condit ion is f oamy,
greasy, sof t , past y, and f oul smelling.
3. Counsel pat ient concerning t est out come and possible need f or f urt her
t est ing (eg, colonoscopy) and t reat ment (eg, eliminat ion of cert ain f oods
f rom t he diet ).
Meat Fibers in Stool; Stool Muscle Fiber The presence

of undigested meat fibers (ie, muscle fibers) in stool
implies impaired intraluminal digestion. There is
positive correlation between the presence of meat or
muscle fibers and the presence of fat excreted in the
stool.
Reference Values
Normal
Negat ive (no undigest ed meat f ibers present in t he normal st ool)
Procedure
1. Ensure t hat t he pat ient eat s 4 t o 6 ounces of red meat f or 24 t o 72 hours
bef ore t est ing.
2. Collect a random specimen (see p. 266). Specimens obt ained w it h w arm
saline enema or Fleet Phospho-Soda are accept able.
3. Record met hod and t ype of st ool procurement .
Clinical Implications Increased amounts of meat fibers

are found in the follow ing conditions:
1. Malabsorpt ion syndromes caused by biliary obst ruct ion
2. Pancreat ic exocrine dysf unct ion (cyst ic f ibrosis)
3. G ast rocolic f ist ula
Interfering Factors
1. Specimens should not be obt ained w it h mineral oil, bismut h, or magnesium
compounds.
2. Barium procedures and laxat ives should be avoided f or 1 w eek bef ore
collect ion.
Interventions

1. Explain t he purpose of t he t est and int erf ering f act ors.
2. Ensure t hat t he pat ient eat s a high-meat diet f or 72 hours bef ore t est .

1. Resume normal diet .
2. I nt erpret t est out comes.
Urobilinogen in Stool Increased destruction of red

blood cells, as in hemolytic anemia, increases the
amount of urobilinogen excreted. Liver disease, in
general, reduces the flow of bilirubin to the intestine
and thereby decreases the fecal excretion of
urobilinogen. In addition, complete obstruction of the
bile duct reduces urobilinogen to very low levels.
This t est invest igat es hemolyt ic diseases and hepat ic obst ruct ive condit ions.
Det erminat ion of st ool urobilinogen is an est imat ion of t he t ot al excret ion of bile
pigment s, w hich are t he breakdow n product s of hemoglobin.
Reference Values
Normal
1. 50300 mg/ 24 h or 100400 Ehrlich unit s/ 100 g
2. New borns6 mont hs: negat ive
Procedure
1. Collect a 48-hour specimen.
2. Prot ect t he specimen f rom light . Send t o t he laborat ory as soon as possible.
1. Increased val ues are associat ed w it h hemolyt ic anemias.
2. Decreased val ues are associat ed w it h t he f ollow ing condit ions:
a. Complet e biliary obst ruct ion (clay-colored f eces result )
b. Severe liver disease (eg, inf ect ious hepat it is)
c. O ral ant ibiot ic t herapy t hat alt ers int est inal bact erial f lora
d. Aplast ic anemia, w hich result s in decreased hemoglobin t urnover
Interfering Factors See Appendix J for drugs that affect

test outcomes.
Interventions

1. Explain purpose of t est .
2. Ensure t hat t he pat ient does not receive oral ant ibiot ic t herapy f or 1 w eek
bef ore t est .
3. Ensure t hat t he pat ient avoids laxat ives and barium procedure 1 w eek bef ore
t est .

1. I nt erpret t est out comes. Counsel pat ient appropriat ely regarding f urt her
t est ing. Monit or pat ient f or liver disease, biliary obst ruct ion, and diarrhea.
Trypsin in Stool: Fecal Chymotrypsin Trypsin is a

proteolytic enzyme formed in the small intestine. In
older children and adults, trypsin is destroyed by
bacteria in the GI tract. Inadequate trypsin secretion
can lead to malabsorption and abdominal discomfort.
Chymotrypsin, an intestinal proteolytic enzyme
secreted by the pancreas, can be used to assess
pancreatic function. Fecal chymotrypsin is a more
reliable measurement of pancreatic function than
trypsin.
Procedu ral Alert T h is test w ill probably be replaced by
immu n oassays. It is an u n reliable test in older ch ildren an d
adu lts.
Reference Values
Normal
Trypsin, 20950 U/ g or 20950 g/ g st ool Chymot rypsin, 741200 g/ g or 74
1200 mg/ kg st ool
Procedure
1. Collect random specimens and send t o t he laborat ory. Three separat e, f resh
st ools are usually collect ed.
2. Ensure t hat t he specimen is t aken t o t he laborat ory and t est ed w it hin 2
hours.
3. G ive a cat hart ic bef ore obt aining a specimen f rom older children (saline or
Fleet only).
Clinical Implications Decreased amounts of trypsin

occur in the follow ing conditions:
1. Pancreat ic def iciency syndromes (033 U/ g or 033 g/ g st ool)
2. Cyst ic f ibrosis (sw eat chloride t est is diagnost ic) (<20 U/ g or <20 g/ g st ool)
Interfering Factors
1. No t rypsin act ivit y is det ect able in const ipat ed st ools ow ing t o prolonged
exposure t o int est inal bact eria, w hich inact ivat es t rypsin.
2. Barium and laxat ives used less t han 1 w eek bef ore t est aff ect result s.
3. I n adult s, t he t est is unreliable ow ing t o t rypsin inact ivat ion by int est inal
f lora.
4. Bact erial prot eases may produce posit ive react ions w hen no t rypsin is
present .
Interventions

1. Explain purpose of t est and int erf ering f act ors.
2. Ensure t hat t he pat ient avoids barium procedures and laxat ives f or 1 w eek
bef ore st ool collect ion.

1. I nt erpret abnormal t est result s and counsel pat ient concerning possible need
f or f ollow -up t est ing (eg, sw eat t est ing) and t reat ment (enzymes).
Clin ical Alert

1. Diagnosis of pancreat ic insuff iciency should not be made unt il t hree
specimens exhibit no t rypsin act ivit y.
2. Bact erial prot ease may produce posit ive react ions w hen no t rypsin is
present ; t heref ore, bot h posit ive and negat ive react ions should be
caref ully int erpret ed.
Stool Electrolytes: Sodium, Chloride, Potassium, and

Osmolality Normal colon function involves absorption
of fluid and electrolytes.
St ool elect rolyt e t est s are used t o assess elect rolyt e imbalance in pat ient s w it h
diarrhea. St ool elect rolyt es must be evaluat ed along w it h t he serum and urine
elect rolyt es as w ell as clinical f indings in t he pat ient . St ool osmolalit y is used in
conjunct ion w it h blood serum osmolalit y t o calculat e t he osmot ic gap and t o
diagnose int est inal disaccharide def iciency.
Reference Values
Normal
1. Sodium: 5. 89. 8 mEq/ 24 h or 5. 89. 8 mmol/ d
2. Chloride: 2. 53. 9 mEq/ 24 h or 2. 53. 9 mmol/ d
3. Pot assium: 15. 720. 7 mEq/ 24 h or 15. 720. 7 mmol/ d
4. O smolalit y: 275295 mO sm/ kg
5. O smot ic gap: measured osmolalit y (2 [ NA + K] )
Ref erence values vary f rom laborat ory t o laborat ory. Check w it h your laborat ory
f or normal values.
Procedure
1. Collect a random or 24-hour liquid st ool specimen.
2. Keep t he specimen covered and ref rigerat ed.
1. Elect rolyt e abnormalit ies occur in t he f ollow ing condit ions:
a. I diopat hic proct ocolit is: i ncreased sodium (Na) and chloride (Cl); normal
pot assium (K)
b. I leost omy: i ncreased sodium (Na) and chloride (Cl), l ow pot assium (K)
c. Cholera: i ncreased sodium (Na) and chloride (Cl)
2. Chloride is great ly increased in st ool in t he f ollow ing condit ions:
a. Congenit al chloride diarrhea

b. Acquired chloride diarrhea or secondary chloride diarrhea
c. I diopat hic proct ocolit is
d. Cholera
3. St ool osmolalit y 500 mg/ dL per day is suspicious f or f act it ious disorders (eg,
laxat ive abuse, ingest ion of rat poison). Higher levels indicat e high amount s
of st ool reducing subst ances. The osmot ic gap is increased in osmot ic
diarrhea caused by t he f ollow ing condit ions:
a. Saline laxat ives
b. Sodium or magnesium cit rat e

c. Carbohydrat es (lact ulose or sorbit ol candy)
Interfering Factors
1. Formed st ools invalidat e t he result s. St ools must be liquid f or elect rolyt e
t est s.
2. The st ool cannot be cont aminat ed w it h urine.
3. Surrept it ious addit ion of w at er t o t he st ool specimen considerably low ers t he
osmolalit y. St ool osmolalit y must be less t han 240 mO sm/ kg (or <240
mmol/ kg H2 O ) t o calculat e t he osmot ic gap.
4. See Appendix J f or drugs t hat cause increased values.
Interventions

1. Explain purpose of t est , procedure f or st ool collect ion, and int erf ering
f act ors.
2. Ensure t he pat ient avoids barium procedures and laxat ives f or 1 w eek bef ore
collect ion of specimen.

1. I nt erpret abnormal t est out comes. Monit or diarrhea episodes and record
f indings. Assess pat ient f or elect rolyt e imbalances and counsel regarding
f urt her t est ing and t reat ment .
BIBLIOGRAPHY
Bakerman S: ABCs of I nt erpret ive Laborat ory Dat a, 3rd ed. G reenville, NC,
I nt erpret ive Laborat ory Dat a I nc. , 1993
Bauer TM, et al: Derivat ion and validat ion of guidelines f or st ool cult ures f or
ent eropat hogenic bact eria ot her t han Cl ostri di um di f f i ci l e in hospit alized
adult s. JAMA, 285: 313319, 2001
Bennet t JC, G oldman L, (eds): Cecil Text book of Medicine, 21st ed.
Henry JB (ed): Clinical Diagnosis and Management by Laborat ory Met hods,
Leaville DE (ed): Medical Laborat ories I nt erpret ive Handbook. Rochest er,
MN, Mayo Medical Laborat ories, 2001
Lehman CA (ed): Saunders Manual of Clinical Laborat ory Science.
Levin B, Hess K, Johnson C: Screening f or colorect al cancer. A comparison of
3 f ecal occult blood t est s. Arch I nt ern Med 157: 970, 1997
Mylonakis E, Ryan ET, Calderw ood SB: Cl ostri di um di f f i ci l e-associat ed
diarrhea. Arch I nt ern Med, 161: 525533, 2001
Novak RW: I dent if ying leukocyt es in f ecal specimens. Lab Med 27: 433, 1996
Sent ongo TA, Rut st ein RM, St et t ler N, St allings VA, Rudy B, Mulberg AE:
Associat ion bet w een st eat orrhea, grow t h, and immunologic st at us in children
w it h perinat ally acquired HI V inf ect ion. Arch Pediat r Adolesc Med, 155: 149
153, 2001
Speicher CE: The Right Test , A Physician's G uide t o Laborat ory Medicine, 3rd
St rasinger S, DiLorenzo MS: Urinalysis and Body Fluids, 4t h ed. Philadelphia,
FA Davis, 2001
Tiet z, N: Clinical G uide t o Laborat ory Test s, 3rd ed. Philadelphia, WB
Saunders, 1995
Wallach J: I nt erpret at ion of Laborat ory Test s, Synopsis of Laborat ory
Medicine, 7t h ed. Bost on, Lit t le, Brow n & Co. , 2000
Young DS: Eff ect s of Drugs in Clinical Laborat ory Test s, 5t h ed. Washingt on,
Young DS, Friedman RB: Eff ect s of Disease on Clinical Laborat ory Test s, 4t h
ed. Washingt on, DC, AACC Press, 2001

Wilkins
> Table of C ontents > 5 - C er ebr os pinal Fluid S tudies
5
Cerebrospin al Flu id Stu dies
OVERVIEW OF CEREBROSPINAL FLUID (CSF)
Description, Formation, and Composition

of CSF
Cerebrospinal f luid (CSF) is a clear, colorless f luid f ormed w it hin t he cavit ies (ie,
vent ricles) of t he brain. The choroid plexus produces about 70% of t he CSF by
ult raf ilt rat ion and secret ion. The ependymal lining of t he vent ricles and cerebral
subarachnoid space produce t he remainder of t he CSF t ot al volume.
Approximat ely 500 mL of CSF f luid is f ormed per day, alt hough only 90 t o 150
mL is present in t he syst em at any one t ime. Reabsorpt ion of CSF occurs at t he
arachnoid villi.
CSF circulat es slow ly f rom t he vent ricular syst em int o t he space surrounding t he
brain and spinal cord and serves as a hydraulic shock absorber, diff using
ext ernal f orces t o t he skull t hat might ot herw ise cause severe injury. The CSF
also helps t o regulat e int racranial pressure (I CP), supply nut rient s t o t he nervous
t issues, and remove w ast e product s. The chemical composit ion of CSF does not
resemble an ult raf ilt rat e of plasma. Cert ain chemicals in t he CSF are regulat ed
by specif ic t ransport syst ems (eg, K+ , Ca2 + , Mg2 + ), w hereas ot her subst ances
(eg, glucose, urea, creat inine) diff use f reely. Prot eins ent er t he CSF by passive
diff usion at a rat e dependent on t he plasma-t o-CSF concent rat ion gradient . The
t erm bl ood-brai n barri er is used t o represent t he cont rol and f ilt rat ion of blood
plasma component s (eg, rest rict ion of prot ein diff usion f rom blood int o brain
t issue) t o t he CSF and t hen t o t he brain capillaries. The rat io of increased
albumin in CSF t o blood serum is alw ays caused by blood-brain barrier
dysf unct ion because albumin is f ound ext ensively in blood. A decreased CSF f low
rat e is due t o decreased product ion or rest rict ion or blockage of f low.
Most CSF const it uent s are present in t he same or low er concent rat ions as in t he
blood plasma, except f or chloride concent rat ions, w hich are usually higher.
Disease, how ever, can cause element s ordinarily rest rained by t he blood-brain
barrier t o ent er t he spinal f luid. Eryt hrocyt es and leukocyt es can ent er t he CSF
f rom t he rupt ure of blood vessels or f rom meningeal react ion t o irrit at ion.
Bilirubin can be f ound in t he spinal f luid af t er int racranial hemorrhage. I n such
cases, t he arachnoid granulat ions and t he nerve root sheat hs w ill reabsorb t he
bloody f luid. Normal CSF pressure w ill consequent ly be maint ained by t he
reabsorpt ion of CSF in amount s equal t o it s product ion. Blockage causes an
increase in t he amount of CSF, result ing in hydrocephalus in inf ant s or increased
I CP in adult s. O f t he many f act ors t hat regulat e t he level of CSF pressure,
venous pressure is t he most import ant because t he reabsorbed f luid ult imat ely
drains int o t he venous syst em.
Despit e t he cont inuous product ion (~0. 3 mL/ min) and reabsorpt ion of CSF and
t he exchange of subst ances bet w een t he CSF and t he blood plasma,
considerable pooling occurs in t he lumbar sac. The lumbar sac, locat ed at L4 t o
L5, is t he usual sit e used f or punct ure t o obt ain CSF specimens because damage
t o t he nervous syst em is less likely t o occur in t his area. I n inf ant s, t he spinal
cord is sit uat ed more caudally t han in adult s (L3L4 unt il 9 mont hs of age, w hen
t he cord ascends t o L1L2); t heref ore; a low lumbar punct ure should be made in
t hese pat ient s (Table 5. 1).
Table 5.1 Normal CSF Values

Volume
Adult: 90150 mL;

child: 60100 mL
Appearance
Crystal clear,
colorless
Pressure
Adults: 90180 mm
H 2 O; child: 10100
mm H2 O
Total cell count
Essentially free
cells
Adults
Newborn
(014 d)
030
W BCs
05 cells
cells
Lymphocytes
40%80%
5%35%
Monocytes
15%45%
50%
90%
Polys
0%6%
0%8%
Differential
RBCs (has limited

diagnostic value)
Specific gravity
1.0061.008
Clinical Tests
Glucose
4070 mg/dL (2.2

3.9 mmol/L)
Protein
Lumbar
Adults: 1545
mg/dL (150450
mg/L)
Neonates: 15100
mg/dL (1501000
mg/L)
Elderly (>60 y):
1560 mg/dL
1525 mg/dL (150
6080
mg/dL
Cisternal
250 mg/L)
Ventricular
515 mg/dL (50

150 mg/L)
Lactic acid (lactate)
1024 mg/dL (1.11

2.66 mmol/L)
Glutamine
520 mg/dL (0.34

1.37 mmol/L)
Albumin
1035 mg/dL
(1.525.32 mol/L)
Urea nitrogen
616 mg/dL (2.14

5.71 mmol/L)
Creatinine
0.51.2 mg/dL (44

106 mol/L)
Uric acid
0.54.5 mg/dL
(29.7268 mol/L)
Bilirubin
0 (none)
Phosphorous
1.22.0 mg/dL
(387646 mol/L)
Ammonia
1035 g/dL (5.87

20.5 mol/L)
Lactate
dehydrogenase
(LDH) (10% of serum
level)
Adult: 040 U/L (0

0.67 kat/L)
Electrolytes and pH
pH
Lumbar
7.287.32
Cisternal
7.327.34
Chloride
115130 mEq/L
(mmol/L)
Sodium
135160 mEq/L
(mmol/L)
Potassium
2.63.0 mEq/L
(mmol/L)
CO 2 content
2025 mEq/L
(mmol/L)
PCO 2
4450 mm Hg (5.8
6.6 kPa)
PO 2
4044 mm Hg (5.3
5.8 kPa)
Calcium
2.02.8 mEq/L
1.01.4
mmol/L
Magnesium
2.43.0 mEq/L
Osmolality
280300 mOsm/kg
(280300 mmol/kg)
1.21.5
mmol/L
Serology and
Microbiology
VDRL
Negative
Bacteria
None present
Viruses
None present
Antibody index
>1.5 indicates
chronic
inflammatory
process
<0.4 probably not
acute inflammatory
process
Be sure to include patient's age because it

is needed to evaluate borderline values.
Explanation of Tests Cerebrospinal fluid, obtained by

lumbar/intrathecal puncture, is the main diagnostic tool
for neurologic disorders. A lumbar/intrathecal puncture
is done for the following reasons:
1. To examine t he spinal f luid f or diagnosis of f our major disease cat egories:
a. Meningit is
b. Subarachnoid hemorrhage
c. CNS malignancy (meningeal carcinoma, t umor met ast asis)
d. Aut oimmune disease and mult iple sclerosis
2. To det ermine level of CSF pressure, t o document impaired CSF f low, or t o

low er pressure by removing volume of f luid. (Fluid removal should be done
w it h caut ion. )
3. To ident if y disease-relat ed immunoglobulin pat t erns (I gG , I gA, and I gM
ref erenced t o albumin) in neurot uberculosis, neuroborreliosis (af t er a t ick
bit e), or opport unist ic inf ect ions.
4. To int roduce anest het ics, drugs, or cont rast media used f or radiographic
st udies and nuclear scans int o t he spinal cord.
5. Conf irm t he ident it y of pat hogens involved in acut e inf lammat ory or chronic
inf lammat ory disorders (eg, mult iple sclerosis and blood-brain barrier
dysf unct ion).
6. I dent if y ext ent of brain inf arct ion/ st roke.
7. Formulat e ant ibody index (AI ) of t he I gG class f or polyspecif ic immune
response in CNS. Examples: measles, rubella, and zost er (MRZ) ant ibodies
t o viruses in mult iple sclerosis (MS); HSV ant ibodies in MS; t oxoplasma
ant ibodies in MS; and aut oant ibodies t o dsDNA (double-st randed
deoxyribonucleic acid).
8. I dent if y brain-derived prot eins, such as neuron-specif ic enolase present af t er
brain t rauma.
See Figure 5. 1 f or an example of a CSF analysis report .
FI G URE 5. 1 Cerebrospinal f luid analysis report . Source: Regenit er A,

St eiger JU, Scholer A, Huber PR, Siede WH: Window s t o t he w ard:
G raphically orient ed report f orms. Present at ion of complex, int errelat ed
laborat ory dat a f or elect rophoresis/ immunof ixat ion, cerebrospinal f luid, and
urinary prot ein prof iles. Clinical Chemist ry, 49: 1, 4150, 2003.
Clin ical Alert

The MRZ react ion occurs in MS, lupus eryt hemat osus, Sjgren syndrome, or
Wegener granulomat osis.
Cert ain observat ions are made each t ime lumbar punct ure is perf ormed:
1. CSF pressure is measured.
2. G eneral appearance, consist ency, and t endency of t he CSF t o clot are
not ed.
3. CSF cell count is perf ormed t o dist inguish t ypes of cells present ; t his must
be done w it hin 2 hours of obt aining t he CSF sample.
4. CSF prot ein and glucose concent rat ions are det ermined.
5. O t her clinical serologic and bact eriologic t est s are done w hen t he pat ient 's
condit ion w arrant s (eg, cult ure f or aerobes and anaerobes or t uberculosis).
6. Tumor markers may be present in CSF; t hese t est s are usef ul as
supplement s t o CSF cyt ology analysis (Table 5. 2).
Table 5.2 Tumor Markers in CSF
Determ ination
Used in
Diagnosis of
Norm al
Values*
Alpha-fetoprotein
(AFP)
CNS
dysgerminomas
and meningeal
carcinomas
<1.5
mg/mL
(<1.5
g/L)
<49 mU/L
BetaGlucuronidase
Carcinoembryonic
antigen (CEA)
Possible meningeal
adenocarcinoma
(<0.82
nKat/L)
normal;
4770
mU/L
(0.78
1.17
nKat/L),
suspicious
Acute myeloblastic
leukemia
>70 mU/L
(>1.17
nKat/L)
abnormal
Meningeal
carcinomatosis;
intradural or
extradural, or brain
parenchymal
metastasis from
adenocarcinoma;
although the assay
appears to be
specific for
adenocarcinoma
and squamous cell
carcinoma,
increased CEA
values in CSF are
not seen in all
such tumors of the
brain
<0.6
mg/mL
(<0.6
g/L)
Human chorionic
gonadotropin
(HCG)
Adjunct in
determining CNS
dysgerminomas
and meningeal
carcinomatosis
<0.21 U/L
(<1.5
IU/L)
Lysozyme
(muramidase)
CNS tumors,
especially
myoclonal and
monocytic
leukemia
413
g/mL
Note: The value of tumor markers in

CSF for routine clinical diagnosis has
not been established.
* Normal values vary greatly; check
with your reference laboratory.
Clin ical Alert

1. Blood levels f or specif ic subst ances should alw ays be measured
simult aneously w it h CSF det erminat ions f or meaningf ul int erpret at ion of
result s.
2. Bef ore lumbar punct ure, check eyegrounds f or evidence of papilledema,
because it s presence may signal pot ent ial problems or complicat ions of
lumbar punct ure.
3. A mass lesion should be precluded by CT scan bef ore lumbar punct ure,
because t his can lead t o brain st em herniat ion.
4. How ever, if increased pressure is f ound w hile perf orming t he lumbar
punct ure, it should not be necessary t o st op t he procedure unless
neurologic signs are present .
CEREBROSPINAL FLUID TESTS

Lumbar Puncture (Spinal Tap)
Procedure
1. Place t he pat ient in a side-lying posit ion w it h t he head f lexed ont o t he chest
and knees draw n up t o, but not compressing, t he abdomen t o bow t he
back. This posit ion helps t o increase t he space bet w een t he low er lumbar
vert ebrae so t hat t he spinal needle can be insert ed more easily bet w een t he
spinal processes. How ever, a sit t ing posit ion w it h t he head f lexed t o t he
chest can be used. The pat ient is helped t o relax and inst ruct ed t o breat he
slow ly and deeply w it h his or her mout h open.
2. Select t he punct ure sit e, usually bet w een L4 and L5 or low er. There is a
small bony landmark at t he L5-S1 int erspace know n as t he surgeon's
delight t hat helps t o locat e t he punct ure sit e. The sit e is t horoughly
cleansed w it h an ant isept ic solut ion, and t he surrounding area is draped w it h
st erile t ow els in such a w ay t hat t he drapes do not obscure import ant
landmarks (Fig. 5. 2).
FI G URE 5. 2 Spinal t ap t echnique. The pat ient lies on his side w it h knees
f lexed and back arched t o separat e t he lumbar vert ebrae. The pat ient is
surgically draped and an area overlying t he lumbar spine is disinf ect ed
(A). The space bet w een lumbar vert ebrae L4 and L5 is palpat ed w it h
st erilely gloved f oref inger (B) and t he spinal needle is caref ully direct ed
bet w een t he spinous processes, t hrough t he inf raspinous ligament s int o
t he spinal canal (C).
3. I nject a local anest het ic slow ly int o t he dermis around t he int ended punct ure
sit e.
4. I nsert a spinal needle w it h st ylet int o t he midline bet w een t he spines of t he
lumbar space and slow ly advance unt il it ent ers t he subarachnoid space. The
pat ient may f eel t he ent ry as
a pop of t he needle t hrough t he dura mat er. O nce t his happens, t he pat ient
can be helped t o st raight en his or her legs slow ly t o relieve abdominal
compression.
5. Remove t he st ylet w it h t he needle remaining in t he subarachnoid space, and
at t ach a pressure manomet er t o t he needle t o record t he opening CSF
pressure.
6. Remove a specimen consist ing of up t o 20 mL CSF. Take up t o f our samples
of 2 t o 3 mL each, place in separat e st erile vials, and label sequent ially.
Tube 1 is used f or chemist ry and serology; t ube 2 is used f or microbiology
st udies; t ube 3 is used f or hemat ology cell count s; and t ube 4 is used f or
special st udies such as crypt ococcal ant igens, syphilis t est ing (Venereal
Disease Research Laborat ory [ VDRL] ), prot ein elect rophoresis, and ot her
immunologic st udies. A closing pressure reading may be t aken bef ore t he
needle is w it hdraw n. I n cases of increased int racranial pressure (I CP), no
more t han 2 mL is w it hdraw n because of t he risk t hat t he brain st em may
shif t .
7. Apply a small st erile dressing t o t he punct ure sit e.
8. Label t ubes correct ly w it h t he proper sequent ial number (1, 2, 3, or 4), t he
pat ient 's name, and t he dat e of collect ion. Specimens of CSF must be
immediat ely delivered t o t he laborat ory, w here t hey should be given t o
laborat ory personnel w it h specif ic inst ruct ions regarding t he t est ing. CSF
samples should never be placed in t he ref rigerat or because ref rigerat ion
alt ers t he result s of bact eriologic and f ungal st udies. Analysis should be
st art ed immediat ely. I f viral st udies are t o be done, a port ion of t he
specimen should be f rozen.
9. Record procedure st art and complet ion t imes, pat ient 's st at us, CSF
appearance, and CSF pressure readings.
Procedural Alert
1. I f t he opening pressure is >200 mm H2 O in a relaxed pat ient , no more t han
2 mL of CSF should be w it hdraw n.
2. I f t he init ial pressure is normal, t he Q ueckenst edt 's t est may be done.
(This t est is not done if a cent ral nervous syst em [ CNS] t umor is
suspect ed. ) I n t his t est , pressure is placed on bot h jugular veins t o
occlude t hem t emporarily and t o produce an acut e rise in CSF pressure.
Normally, pressure rapidly ret urns t o average levels af t er jugular vein
occlusion is removed. Tot al or part ial spinal f luid blockage is diagnosed if
t he lumbar pressure f ails t o rise w hen bot h jugular veins are compressed
or if t he pressure requires >20 seconds t o f all af t er compression is
released.
Interventions

1. Explain t he purpose, benef it s, and risks of lumbar punct ure and explain t est s
t o be perf ormed on t he CSF specimen; present a st ep-by-st ep descript ion of
t he act ual procedure. Emphasize t he need f or pat ient cooperat ion. Assess
f or cont raindicat ions or impediment s such as art hrit is. Sedat ion or analgesia
may be used.
2. Help t he pat ient t o relax by having him or her breat he slow ly and deeply. The
pat ient must ref rain f rom breat h holding, st raining, moving, and t alking during
t he procedure.
care.

1. Have t he pat ient lie prone (f lat or horizont al, or on t he abdomen) f or
approximat ely 4 t o 8 hours. Turning f rom side t o side is permit t ed as long as
t he body is kept in a horizont al posit ion.
2. Women may have diff icult y voiding in t his posit ion. The use of a f ract ure
bedpan may help.
3. Fluids are encouraged t o help prevent or relieve headache, w hich is a
possible result of lumbar punct ure.
4. I nt erpret t est out comes. Assess and monit or f or abnormal out comes and
complicat ions such as paralysis (or progression of paralysis, as w it h spinal
t umor), hemat oma, meningit is, asphyxiat ion of inf ant s due t o t racheal
obst ruct ion f rom pushing t he head f orw ard, and inf ect ion. I nst it ut e inf ect ion
cont rol precaut ions if t est out comes reveal an inf ect ious process.
5. O bserve f or neurologic changes such as alt ered level of consciousness,
change of pupils, change in t emperat ure, increased blood pressure,
irrit abilit y, and numbness and t ingling sensat ions, especially in t he low er
ext remit ies.
6. I f headache occurs, administ er analgesics as ordered and encourage a
longer period of prone bed rest . I f headache persist s, a blood pat ch may
need t o be done, in w hich a small amount of t he pat ient 's ow n blood is
int roduced int o t he spinal canal at t he same level t hat t he canal w as
previously ent ered. For reasons not t ot ally underst ood, t his blood pat ch very
eff ect ively st ops spinal headaches w it hin a very short period.
7. Check t he punct ure sit e f or leakage.
8. Document t he procedure complet ion and any problems encount ered or
complaint s voiced by t he pat ient .
9. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, inf ormed posttest
care.
Clin ical Alert

1. Ext reme caut ion should be used w hen perf orming lumbar punct ure:
a. I f I CP is elevat ed, especially in t he presence of papilledema or split
cranial sut ures. How ever, w it h some cases of increased I CP, such as
w it h a coma, int racranial bleeding, or suspect ed meningit is, t he need
t o est ablish a diagnosis is absolut ely essent ial and out w eighs t he risks
of t he procedure.
b. A relat ive cont raindicat ion w ould be I CP f rom a suspect ed mass
lesion. To reduce t he risk f or brain herniat ion, a less invasive
procedure such as a CT scan or MRI should be done.
2. Cont raindicat ions t o lumbar punct ure include t he f ollow ing condit ions:
a. Suspect ed epidural inf ect ion

b. I nf ect ion or severe dermat ologic disease in t he lumbar area, w hich
may be int roduced int o t he spinal canal
c. Severe psychiat ric or neurot ic problems
d. Chronic back pain

e. Anat omic malf ormat ions, scarring in punct ure sit e areas, or previous
spinal surgery at t he sit e
3. I f t here is CSF leakage at t he punct ure sit e, not if y t he physician
immediat ely and document f indings.
4. Follow st andard precaut ions (see Appendix A) w hen handling CSF
specimens.
CSF Pressure
The CSF pressure is direct ly relat ed t o pressure in t he jugular and vert ebral
veins t hat connect w it h t he int racranial dural sinuses and t he spinal dura. I n
condit ions such as congest ive heart f ailure or obst ruct ion of t he superior vena
cava, CSF pressure is increased, w hereas in circulat ory collapse, CSF pressure
is decreased.
Pressure measurement is done t o det ect impairment of CSF f low or t o low er t he
CSF pressure by removing a small volume of CSF f luid. Provided init ial pressure
is not elevat ed and t here is no marked f all in t he pressure as f luid is removed,
10 t o 20 mL of CSF may be removed w it hout danger t o t he pat ient . Elevat ion of
t he opening CSF pressure may be t he only abnormalit y f ound in pat ient s w it h
crypt ococcal meningit is and pseudot umor cerebri. Repeat ed lumbar punct ures
are perf ormed f or I CP elevat ion in crypt ococcal meningit is t o decrease t he CSF
pressure.
Reference Values
Normal
Adult : 90180 mm H2 O in t he lat eral recumbent posit ion. (This value is posit ion
dependent and w ill change w it h a horizont al or sit t ing posit ion. ) Child (<8 years
of age): 10100 mm H2 O
Procedure
1. Measure t he CSF pressure bef ore any f luid is w it hdraw n.
2. Take up t o f our samples of 2 t o 3 mL each, place in separat e st erile vials,
and label sequent ially. Tube 1 is used f or chemist ry and serology; t ube 2 is
used f or microbiology st udies; t ube 3 is used f or hemat ology cell count s; and
t ube 4 is used f or special st udies.
1. Increases in CSF pressure can be a signif icant f inding in t he f ollow ing
condit ions:
a. I nt racranial t umors; abscess; lesions
b. Meningit is (bact erial, f ungal, viral, or syphilit ic)
c. Hypoosmolalit y as a result of hemodialysis
d. Congest ive heart f ailure
e. Superior vena cava syndrome
f. Subarachnoid hemorrhage
g. Cerebral edema
h. Thrombosis of venous sinuses
i. Condit ions inhibit ing CSF absorpt ion

2. Decreases in pressure can be a signif icant f inding in t he f ollow ing condit ions:
a. Circulat ory collapse
b. Severe dehydrat ion
c. Hyperosmolalit y
d. Leakage of spinal f luid

e. Spinal-subarachnoid block
3. Si gni f i cant vari ati ons bet w een opening and closing CSF pressure can be
f ound in t he f ollow ing condit ions:
a. Tumors or spinal blockage above t he punct ure sit e w hen t here is a large
pressure drop (no f urt her f luid should be w it hdraw n)
b. Hydrocephalus w hen t here is a small pressure drop t hat is indicat ive of a
large CSF pool
Interfering Factors
1. Slight elevat ions of CSF pressure may occur in an anxious pat ient w ho holds
his or her breat h or t enses his or her muscles.
2. I f t he pat ient 's knees are f lexed t oo f irmly against t he abdomen, venous
compression w ill cause an elevat ion in CSF pressure. This can occur in
pat ient s of normal w eight and in t hose w ho are obese.
Interventions

1. See page 296 f or care bef ore lumbar punct ure.
care.

1. I nt erpret abnormal pressure levels and monit or and int ervene appropriat ely
t o prevent complicat ions.
2. See page 296 f or care af t er lumbar punct ure.
care.
CSF Color and Appearance Normal CSF is crystal clear,

with the appearance and viscosity of water. Abnormal
CSF may appear hazy, cloudy, smoky, or bloody.
Clotting of CSF is abnormal and indicates increased
protein or fibrinogen levels.
The init ial appearance of CSF can provide various t ypes of diagnost ic
inf ormat ion. I nf lammat ory diseases, hemorrhage, t umors, and t rauma produce
elevat ed cell count s and corresponding changes in appearance.
Reference Values
Normal
Clear and colorless
Procedure
Compare t he CSF w it h a t est t ube of dist illed w at er held against a w hit e
background. I f t here is no t urbidit y, new sprint can be read t hrough normal CSF in
t he t ube.
1. Abnormal appearance (Table 5. 3)causes and indicat ions:
Table 5.3 Color Changes in CSF Suggestive of

Disease States
Appearance
Condition
Opalescent, slightly
yellow, with delicate
clot
Tuberculous meningitis
Opalescent to
purulent, slightly
yellow, with coarse
clot
Acute pyogenic meningitis
Slightly yellow; may

be clear or
opalescent, with
delicate clot
Acute anterior poliomyelitis
Bloody, purulent, may

be turbid
Primary amebic
meningoencephalitis
Generally clear, but

may be xanthochromic
Tumor of brain or cord
Xanthochromic
Toxoplasmosis
Viscous
Metastatic colon cancer,

severe meningeal infection,
cryptococcus, injury
a. Blood. The blood is evenly mixed in all t hree t ubes in subarachnoid and
cerebral hemorrhage. Table 5. 4 describes diff erent iat ion of bloody spinal
t ap f rom cerebral hemorrhage. Clear CSF f luid does not rule out
int racranial hemorrhage.
Table 5.4 Differentiation of Bloody CSF Caused

by Subarachnoid Hemorrhage Versus Traumatic
Lumbar Puncture
CSF Findings
Subarachnoid
Hem orrhage
Traum atic
Lum bar
Puncture*
CSF Pressure
Often
increased
Normal
Blood in tubes
for collecting
CSF
Mixture with
blood is
uniform in all
tubes
Tubes 1 and
2 more
bloody than
tube 3 or 4
CSF clotting
Does not clot
Often clots
Xanthochromia
Present if >8
12 h since
cerebral
hemorrhage
Absent
unless
patient is
jaundiced
Immediate
repeat of lumbar
puncture at
higher level
CSF same as
initial puncture
CSF clear (if

atraumatic)
* CSF with RBCs >6000 per mm3 appears grossly

bloody
b. Turbidit y is graded f rom 1+ (slight ly cloudy) t o 4+ (very cloudy) and may
be caused by t he f ollow ing condit ions:
1. Leukocyt es (pleocyt osis)
2. Eryt hrocyt es
3. Microorganisms such as f ungi and amebae
4. Prot ein
5. Epidural f at aspirat ed (pale pink t o dark yellow )
6. Cont rast media

c. Xant hochromia (pale pink t o dark yellow ) can be caused by t he f ollow ing
condit ions:
1. O xyhemoglobin f rom lysed red blood cells (RBCs) present in CSF
bef ore lumbar punct ure
2. Met hemoglobin
3. Bilirubin (>6 mg/ dL or >103 mol/ L)
4. I ncreased prot ein (>150 mg/ dL or >1500 mg/ L)
5. Melanin (meningeal melanocarcinoma)
6. Carot ene (syst emic carot enemia)
7. Prior bleeding w it hin 236 hours (eg, t raumat ic punct ure >72 hours
bef ore)
d. Yellow color (bilirubin >10 mg/ dL or >171 mol/ L) due t o a prior
hemorrhage (10 hour t o 4 w eeks bef ore)
Clin ical Alert

1. Spinal f luid should be cult ured f or bact eria, f ungi, and t uberculosis. I n
children, Haemophi l us i nf l uenzae t ype B is t he most common cause of
bact erial meningit is; in adult s, t he most common bact erial pat hogens f or
meningit is are meningococci and pneumococci.
2. Spinal f luid w it h any degree of cloudiness should be t reat ed w it h ext reme
care because t his could be an indicat ion of cont agious disease.
Interfering Factors
1. CSF can look xant hochromic f rom cont aminat ion w it h met hylat e used t o
disinf ect t he skin.
2. I f t he blood in t he specimen is due t o a t raumat ic spinal t ap, t he CSF in t he
t hird t ube should be clearer t han t hat in t ube 1 or 2; a t raumat ic t ap makes
int erpret at ion of result s very diff icult t o impossible.
Interventions

1. O bservat ions of color and appearance of CSF are alw ays not ed.

1. Recognize abnormal color and presence of t urbidit y and monit or pat ient
appropriat ely.
CSF Microscopic Examination of Cells; Total Cell

Count; Differential Cell Count Normal CSF contains a
small number of lymphocytes and monocytes in a ratio
of approximately 70:30 in adults. A higher proportion of
monocytes is present in young children. An increase in
the number of white blood cells (WBCs) in CSF is
termed pleocytosis. Disease processes may lead to
abrupt increases or decreases in numbers of cells.
CSF is examined f or t he presence of RBCs and WBCs. The cells are count ed
and ident if ied by cell t ype; t he percent age of cell t ype is compared w it h t he t ot al
number of WBCs or RBCs present . I n general, inf lammat ory disease,
hemorrhage, neoplasms, and t rauma cause an elevat ed WBC count .
Reference Values
Normal
Normal CSF is essent ially f ree of cells (Table 5. 5 and Table 5. 6).
Table 5.5 Cell Counts
Differential
Adults
Newborn (014 d)
Lymphocytes
40%80%
5%35%
Monocytes
15%45%
50%90%
Polys (Neutrophils)
0%6%
0%8%
Table 5.6 Major Cells Seen in Microscopic

Examination of CSF
Cell Types
Occurrence
Findings
Blast forms
Acute leukemia
Lymphoblasts or
myeloblasts
Ependymal
and
choroidal
cells
Trauma
(diagnostic
procedures)
Clusters with
distinct nuclei and
distinct cell walls
Lymphocytes
Normal
Viral, tubercular,
and fungal
meningitis
Multiple
sclerosis
All stages of
development
possible
Macrophages
Viral, tubercular,
and fungal
meningitis
RBCs in spinal
fluid
Contrast media
May contain
phagocytized RBCs
(appearing as
empty vacuoles or
ghost cells) and
hemosiderin
granules
Malignant
cells
Metastatic
carcinomas
Clusters with fusing

of cell borders and
nuclei
Monocytes
Chronic bacterial
meningitis
Viral and
tubercular
meningitis
Multiple
sclerosis
Mixed with
lymphocytes and
neutrophils
Bacterial
Neutrophils
meningitis
Early cases of
viral, tubercular,
and fungal
meningitis
Granules may be
less prominent than
in blood
Pia
arachnoid
mesothelial
(PAM) cells
Normal, mixed
reactions,
including
lymphocytes,
neutrophils,
monocytes, and
plasma cells
Resemble young
monocytes with a
round, not indented,
nucleus
Plasma cells
Multiple
sclerosis
Tuberculosis
Meningitis
Sarcoidosis
Transitional and
classic forms seen
Adult s: 05 WBCs/ L or 05 106 WBCs/ L

New born: 030 WBCs/ L or 030 106 WBCs/ L
Child: 015 WBCs/ L or 015 106 WBCs/ L
Procedure
Use t ube 3 f or count ing t he cells present in t he CSF sample. The cells are
count ed by a manual count ing chamber or by elect ronic means. A CSF smear is
made, and various t ypes of cells present are count ed t o det ermine diff erent iat ion
of cells.
1. The t ot al CSF cell count (includes neut rophils, lymphocyt es, mixed cells, and
cells af t er hemorrhage) is t he most sensit ive index of acut e inf lammat ion of
t he CNS.
2. WBC count s >500 WBCs/ L or >500 106 WBCs/ L usually arise f rom a
purulent inf ect ion and are preponderant ly granulocyt es (ie, neut rophils).
Neut rophilic react ion classically suggest s meningit is caused by a pyogenic
organism, in w hich case t he WBC count can exceed 1000 WBCs/ L or 1000
106 WBCs/ L and even reach 20, 000 WBCs/ L or 20, 000 106 WBCs/ L.
a. I ncreases in neut rophils are associat ed w it h t he f ollow ing condit ions:
1. Bact erial meningit is (see Table 5. 7)
Table 5.7 Abnormal CSF Findings in Type
Total
W BCs
Differential
Protein
Bacterial
Viral
Tuberc
Increased
Increased
Increas
Lymphocytes
present
Lympho
and
monocy
present
Neutrophils
present
Marked
increase
Moderate
increase
Modera
marked
increas
clots oc
with pro
>150 m
(>1500
mg/L)
Glucose
Markedly
decreased
Normal
Decreas
Lactate
Increased
Normal
Increas
LDH
fractions
LD
isoenzymes
4 and 5
increased
LD
isoenzymes
1, 2, and 3
increased
LD
isoenzy
1, 2, an
increas
Limulus
amebocyte
Lysate:
indicator
of
endotoxin
produced
by gramnegative
bacteria
(Not
affected
by
antibiotic
therapy)
Positive
Pellicle
formatio
when pr
>150 m
(>1500
mg/L)
2. Early viral meningit is
3. Early t ubercular meningit is
4. Fungal mycosit ic meningit is
5. Amebic encephalomyelit is
6. Early st ages of cerebral abscess

b. Noninf ect ious causes of neut rophilia include t he f ollow ing:
1. React ion t o CNS hemorrhage

2. I nject ion of f oreign mat erials int o t he subarachnoid space (eg, x-ray
cont rast medium, ant icancer drugs)
3. CSF inf arct

4. Met ast at ic t umor in cont act w it h CSF
5. React ion t o repeat ed lumbar punct ure

3. WBC count s of 300500/ L or 300500 106 w it h preponderant ly
lymphocyt es are indicat ive of t he f ollow ing condit ions:
a. Viral meningit is
b. Syphilis of CNS (ie, meningoencephalit is)
c. Tuberculous meningit is
d. Parasit ic inf est at ion of t he CNS

e. Bact erial meningit is due t o unusual organisms (eg, Li steri a species)
f. Mult iple sclerosis (MS) (react ive lymph present )
g. Encephalopat hy caused by drug abuse

h. G uillain-Barr syndrome (15%)
i. Acut e disseminat ed encephalomyelit is
j. Sarcoidosis of meninges
k. Human T-lymphot ropic virus t ype I I I (HTLV I I I )
l. Asept ic meningit is due t o pept ic f ocus adjacent t o meninges
m. Fungal meningit is
n. Polyneurit is
4. WBC count s w it h 40% monocyt es occur in t he f ollow ing condit ions:
a. Chronic bact erial meningit is
b. Toxoplasmosis and amebic meningit is
c. MS
d. Rupt ure of brain abscess

5. Malignant cells (lymphocyt es or hist iocyt es) may be present w it h primary and
met ast at ic brain t umors, especially w hen t here is meningeal ext ension.
6. I ncreased numbers of plasma cells occur in t he f ollow ing condit ions:
a. Acut e viral inf ect ions
b. MS
c. Sarcoidosis
d. Syphilit ic meningoencephalit is
e. Subacut e sclerosing panencephalit is
f. Tuberculous meningit is
g. Parasit ic inf est at ions of CSF

h. G uillain-Barr syndrome
i. Lymphocyt ic react ions

7. Plasma cells are responsible f or an increase in immunoglobulin G (I gG ) and
alt ered pat t erns in immunoelect rophoresis.
8. Macrophages are present in t uberculous or viral meningit is and in react ions
t o eryt hrocyt es, f oreign subst ances, or lipids in t he CSF.
9. Ependymal and plexus cells may be present af t er surgical procedures or
t rauma t o t he CNS (not clinically signif icant ).
10. Blast cells appear in CSF w hen acut e leukemia is present (lymphoblast s or
myeloblast s).
11. Eosinophils are present in t he f ollow ing condit ions:
a. Parasit ic inf ect ions
b. Fungal inf ect ions

c. Ricket t sial inf ect ions (Rocky Mount ain spot t ed f ever)
d. I diopat hic hypereosinophilic syndrome

e. React ion t o f oreign mat erials in CSF (eg, drugs, shunt s)
f. Sarcoidosis
Clin ical Alert

Neut rophilic react ion classically suggest s meningit is caused by a pyogenic
organism.
Interventions

care.

1. I nt erpret abnormal cell count s. Monit or, int ervene, and counsel as
appropriat e f or inf ect ion and malignancy.
care.
CSF Glucose
The CSF glucose level varies w it h t he blood glucose levels. I t is usually about
60% of t he blood glucose level. A blood glucose specimen should be obt ained at
least 60 minut es bef ore lumbar punct ure f or comparisons. Any changes in blood
sugar are ref lect ed in t he CSF approximat ely 1 hour lat er because of t he lag in
CSF glucose equilibrium t ime.
This measurement is helpf ul in det ermining impaired t ransport of glucose f rom
plasma t o CSF, increased use of glucose in t he CNS, and glucose ut ilizat ion by
leukocyt es and microorganisms. The f inding of a markedly decreased CSF
glucose level accompanied by an increased WBC count w it h a large percent age
of neut rophils is indicat ive of bact erial meningit is.
Reference Values
Normal
Adult : 4070 mg/ dL or 2. 23. 9 mmol/ L
Child: 6080 mg/ dL or 3. 34. 4 mmol/ L
CSF-t o-plasma glucose rat io: <0. 5
CSF glucose level: 60%70% of blood glucose levels
Procedure
Place 1 mL of CSF in a st erile t ube. The glucose t est should be done on t ube 1
w hen t hree t ubes of CSF are t aken. Accurat e evaluat ion of CSF glucose requires
a plasma glucose measurement . A blood glucose level ideally should be draw n 1
hour bef ore t he lumbar punct ure.
1. Decreased CSF glucose levels are associat ed w it h t he f ollow ing condit ions:
a. Acut e bact erial meningit is

b. Tuberculosis, f ungal, and amebic meningit is
c. Syst emic hypoglycemia
d. Subarachnoid hemorrhage
2. CSF glucose levels are uncommonly decreased in t he f ollow ing condit ions:
a. Malignant t umor w it h meningeal involvement
b. Acut e syphilit ic meningit is
c. Nonbact erial meningoencephalit is

3. I ncreased CSF glucose levels are associat ed w it h diabet es and diabet ic
hyperglycemia. Elevat ed CSF levels are alw ays a result of high plasma
values.
Interfering Factors
1. Falsely decreased levels may be due t o cellular and bact erial met abolism if
t he t est is not perf ormed immediat ely af t er specimen collect ion.
2. A t raumat ic t ap may produce misleading result s ow ing t o glucose present in
blood.
Clin ical Alert

1. All t ypes of organisms consume glucose; t heref ore, decreased glucose
levels ref lect abnormal act ivit y.
2. The panic value f or CSF glucose level is <20 mg/ dL (<1. 1 mmol/ L); below
t his level, damage t o t he CNS w ill occur.
3. The f indings of a markedly decreased CSF glucose and an increased WBC
count w it h a high percent age of neut rophils are indicat ive of bact erial
meningit is.
Interventions

2. Explain t he need f or a blood specimen t est f or glucose t o compare w it h CSF
glucose.
care.

1. I nt erpret abnormal CSF glucose levels and correlat e w it h t he presence of
meningit is, cancer, hemorrhage, and diabet es. Monit or and int ervene
appropriat ely t o prevent complicat ions.
care.
CSF Glutamine
G lut amine is synt hesized in brain t issue f rom ammonia and alpha-ket oglut arat e.
Product ion of glut amine provides a mechanism f or removing t he ammonia, a t oxic
met abolic w ast e product , f rom t he CNS.
The det erminat ion of CSF glut amine level provides an indirect t est f or t he
presence of excess ammonia in t he CSF. As t he concent rat ion of ammonia in t he
CSF increases, t he supply of alpha-ket oglut arat e becomes deplet ed;
consequent ly, glut amine can no longer be produced t o remove t he t oxic ammonia,
and coma ensues. A CSF glut amine t est is t heref ore f requent ly request ed f or
pat ient s w it h coma of unknow n origin. A glut amine value of >35 mg/ dL (>2. 4
mmol/ L) usually result s in loss of consciousness.
Reference Values
Normal
818 mg/ dL or 0. 41. 2 mmol/ L
Procedure
1. Use 1 mL of CSF f or t he glut amine t est . Tube 1 is used f or t his chemist ry
t est .
2. Cent rif uge t he samples if cells are present .
Clinical Implications Increased CSF glutamine levels

are associated w ith the follow ing conditions:
1. Hepat ic encephalopat hy (glut amine values >35 mg/ dL or >2. 4 mmol/ L are
diagnost ic)
2. Reye's syndrome
3. Encephalopat hy secondary t o hypercapnia or sepsis
Interventions

care.

1. I nt erpret abnormal glut amine levels and correlat e w it h clinical sympt oms.
Monit or and int ervene appropriat ely t o prevent complicat ions.
care.
CSF Lactic Acid

The source of CSF lact ic acid is CNS anaerobic met abolism. Lact ic acid in CSF
varies independent ly w it h t he level of lact ic acid in t he blood. Dest ruct ion of
t issue w it hin t he CNS because of oxygen deprivat ion causes t he product ion of
increased CSF lact ic acid levels. Thus, elevat ed CSF lact ic acid levels can result
f rom any condit ion t hat decreases t he f low of oxygen t o brain t issues.
The CSF lact ic acid t est is used t o diff erent iat e bet w een bact erial and
nonbact erial meningit is. Elevat ed CSF lact at e levels are not limit ed t o meningit is
and can result f rom any condit ion t hat decreases t he f low of oxygen t o t he brain.
CSF lact at e levels are f requent ly used t o monit or severe head injuries.
Reference Values
Normal
Adult : 1022 mg/ dL or 1. 12. 4 mmol/ L
New born: 1060 mg/ dL or 1. 16. 7 mmol/ L
Procedure
1. Collect 0. 5 mL of CSF in a st erile t est t ube; t ube 1 should be used.
2. Ref rigerat e t he sample.
Clinical Implications Increased CSF lactic acid levels

are associated w ith the follow ing conditions:
1. Bact erial meningit is (>38 mg/ dL or >4. 2 mmol/ L)
2. Brain abscess or t umor
3. Cerebral ischemia
4. Cerebral t rauma
5. Seizures
6. St roke (cerebral inf arct )
Interfering Factors
Traumat ic t ap causes elevat ed levels: RBCs cont ain large amount s of lact at e.
Hemolyzed or xant hochromic specimens w ill give f alsely elevat ed result s.
Interventions

care.

1. I nt erpret t est out comes; monit or and int ervene appropriat ely t o det ect CNS
disease and prevent complicat ions. Result s must be int erpret ed in light of
clinical sympt oms.
care.
Clin ical Alert

I ncreases in CSF lact ic acid levels must be int erpret ed in light of t he clinical
f indings and in conjunct ion w it h glucose levels, prot ein levels, and cell count s
in t he CSF. Equivocal result s in some inst ances of asept ic meningit is may lead
t o erroneous diagnosis of a bact erial et iology. I ncreased lact at e in CSF
f ollow ing head injury suggest s poor prognosis.
CSF Lactate Dehydrogenase (LD/LDH); CSF Lactate

Dehydrogenase (LDH) Isoenzymes Although many
different enzymes have been measured in CSF, only
lactate dehydrogenase (LDH) appears useful clinically.
Sources of LDH in normal CSF include diffusion across
the blood-CSF barrier, diffusion across the brain-CSF
barrier, and LDH activity in cellular elements of the
CSF, such as leukocytes, bacteria, and tumor cells.
Because brain tissue is rich in LDH, damaged CNS
tissue can cause increased levels of LDH in the CSF.
High levels of LDH occur in about 90% of cases of bact erial meningit is and in
only 10% of cases of viral meningit is. When high levels of LDH do occur in viral
meningit is, t he condit ion is usually associat ed w it h encephalit is and a poor
prognosis. Test s of LDH isoenzymes have been used t o improve t he specif icit y of
LDH measurement s and are usef ul f or making t he diff erent ial diagnosis of viral
versus bact erial meningit is (see Chap. 6 f or a complet e descript ion of
isoenzymes). Elevat ed LDH levels f ollow ing resuscit at ion predict a poor out come
in pat ient s w it h hypoxic brain injury.
Reference Values
Normal
Adult s: <20 U/ L or approximat ely 10% of serum levels
Procedure
1. O bt ain 1 mL of CSF f or t he LDH t est ; use t ube 1 f or LDH examinat ion.
2. Take t he sample t o t he laborat ory as quickly as possible.
1. I ncreased CSF/ LDH levels are associat ed w it h t he f ollow ing condit ions:
a. Bact erial meningit is (90% of cases)
b. Viral meningit is (10% of cases)
c. Massive cerebrovascular accident

d. Leukemia or lymphoma w it h meningeal inf ilt rat ion
e. Met ast at ic carcinoma of t he CNS

2. The presence of CSF/ LDH isoenzymes 1, 2, and 3 ref lect s a CNS
lymphocyt ic react ion, suggest ing viral meningit is.
3. The CSF/ LDH isoenzyme pat t ern ref lect s a granulocyt ic (neut rophilic)
react ion w it h LDH isoenzymes 4 and 5, suggest ing bact erial meningit is.
4. High levels of CSF/ LDH isoenzymes 1 and 2 suggest ext ensive CNS damage
and a poor prognosis (ie, t hey are indicat ive of dest ruct ion of brain t issue).
5. CSF/ LDH isoenzymes 3 and 4 suggest lymphat ic leukemia or lymphoma.
Interfering Factors
For t he LDH t est t o be valid, CSF must not be cont aminat ed w it h blood. A
t raumat ic lumbar t ap w ill make result s diff icult t o int erpret .
Interventions

care.

1. I nt erpret abnormal LDH t est pat t erns and monit or and int ervene
appropriat ely t o det ect and prevent complicat ions.
care.
CSF Total Protein

The CSF normally cont ains very lit t le prot ein because t he prot ein in t he blood
plasma does not cross t he blood-brain barrier easily. Prot ein concent rat ion
normally increases caudally f rom t he vent ricles t o t he cist erns and f inally t o t he
lumbar sac.
The CSF prot ein is a nonspecif ic but reliable indicat ion of CNS pat hology such as
meningit is, brain abscess, MS, and ot her degenerat ive processes causing
neoplast ic disease. Elevat ed CSF prot ein levels may be caused by increased
permeabilit y of t he blood-brain barrier, decreased resorpt ion of t he arachnoid
villi, mechanical obst ruct ion of t he CSF f low, or increased int rat hecal
immunologic synt hesis.
Reference Values
Normal
Result s vary by met hod used; check w it h t he laborat ory f or ref erence values.
Tot al prot ein:
Adult s: 1545 mg/ dL or 150450 mg/ L (lumbar) Adult s: 1525 mg/ dL or 150250
mg/ L (cist ernal) Adult s: 515 mg/ dL or 50150 mg/ L (vent ricular) Neonat es: 15
100 mg/ dL or 1501000 mg/ L (lumbar) Elderly pat ient s (>60 years of age): 15
60 mg/ dL or 150600 mg/ L (lumbar)
Procedure
1. O bt ain 1 mL of CSF f or prot ein analysis. Tube 1 should be used.
2. Measure serum prot ein levels concurrent ly t o int erpret CSF prot ein values.
1. I ncreased CSF prot ein occurs in t he f ollow ing sit uat ions:
a. Traumat ic t ap w it h normal CSF pressure: CSF init ially st reaked w it h
blood, clearing in subsequent t ubes
b. I ncreased permeabilit y of blood-CSF barrier: CSF prot ein 100500
mg/ dL (10005000 mg/ L)
1. I nf ect ious condit ions

i. Bact erial meningit is: G ram st ain usually posit ive; cult ure may be
negat ive if ant ibiot ics have been administ ered
ii. Tuberculosis: CSF prot ein 50300 mg/ dL (5003000 mg/ L);
mixed cellular react ion t ypical
iii. Fungal meningit is: CSF prot ein 50300 mg/ dL (5003000 mg/ L);
special st ains helpf ul
iv. Viral meningit is: CSF prot ein usually <200 mg/ dL (<2000 mg/ L)
2. Noninf ect ious condit ions

i. Subarachnoid hemorrhage: xant hochromia 24 hours af t er onset
ii. I nt racerebral hemorrhage: CSF prot ein 20200 mg/ dL (2002000
mg/ L); marked f all in pressure af t er removing small amount s of
CSF; xant hochromia
iii. Cerebral t hrombosis: slight ly increased CSF prot ein in 40% of
cases (usually, <100 mg/ dL or <1000 mg/ L)
iv. Endocrine disorders, diabet ic neuropat hy, myxedema,
hyperadrenalism, hypoparat hyroidism: CSF prot ein 50150 mg/ dL
(5001500 mg/ L) in ~50% of cases
v. Met abolic disorders, uremia, hypercalcemia, hypercapnia,
dehydrat ion: CSF prot ein slight ly elevat ed (usually, <100 mg/ dL
or <1000 mg/ L)
vi. Drug t oxicit y, et hanol, phenyt oin, phenot hiazines: CSF prot ein
slight ly elevat ed in about 40% of cases (usually, <200 mg/ dL or
<2000 mg/ L)
c. O bst ruct ion t o circulat ion of CSF occurs in t he f ollow ing circumst ances:
1. Mechanical obst ruct ion (eg, t umor, abscess), herniat ed disk: rapid
f all in pressure (yellow CSF, cont ains excess prot ein)
2. Loculat ed eff usion of CSF: repeat ed t aps may show a progressive
increase in CSF prot ein; diagnosis by myelography
d. I ncreased CSF/ I gG synt hesis occurs in t he f ollow ing condit ions:
1. MS: CSF prot ein level slight ly increased
2. Subacut e sclerosing panencephalit is: increased CSF prot ein
3. Neurosyphilis: CSF prot ein normal or slight ly increased (usually,
<100 mg/ dL or <1000 mg/ L)
e. I ncreased CSF/ I gG synt hesis and increased permeabilit y of blood-CSF
barrier occur in t he f ollow ing condit ions:
1. G uillain-Barr syndrome (inf ect ious polyneurit is): CSF prot ein usually
100400 mg/ dL (10004000 mg/ L)
2. Collagen diseases (eg, periart erit is, lupus): CSF prot ein usually <
400 mg/ dL (or <4000 mg/ L)
3. Chronic inf lammat ory demyelinat ing polyradiculopat hy

f. Decreased CSF prot ein occurs in t he f ollow ing condit ions:
1. Leakage of CSF due t o t rauma
2. Removal of a large volume of CSF
3. I nt racranial hypert ension
4. Hypert hyroidism
5. Young children bet w een 6 mont hs and 2 years of age
Clin ical Alert

More t han 1000 mg/ dL (>10, 000 mg/ L) of prot ein in CSF suggest s
subarachnoid block. I n a complet e spinal block, t he low er t he t umor locat ion,
t he higher t he CSF prot ein value.
Interfering Factors
1. Hemolyzed or xant hochromic drugs may f alsely depress result s.
2. Traumat ic t ap w ill invalidat e t he prot ein result s.
Interventions

care.

1. I nt erpret abnormal CSF prot ein levels; monit or f or bot h inf ect ious and
noninf ect ious condit ions and int ervene appropriat ely t o prevent and det ect
complicat ions.
care.
CSF Albumin and Immunoglobulin G (IgG) Albumin

composes the majority of the proteins in CSF. The
albumin and IgG that are present in normal CSF are
derived from the serum. Increased levels of either or
both are indicative of damage to the blood-CNS barrier.
The combined measurement of albumin and I gG is used t o evaluat e t he int egrit y
and permeabilit y of t he blood-CSF barrier and t o measure t he synt hesis of I gG
w it hin t he CNS. The I gG index is t he most sensit ive met hod t o det ermine local
CNS synt hesis of I gG and t o det ect increased permeabilit y of t he blood-CNS
barrier.
The I gG index met hod is superior t o t he I gG -t o-albumin rat io or measurement of

I gG only. Normal persons usually have an index < 0. 60. Wit h MS, t he index is >
0. 77.
Reference Values
Normal
Albumin: 1035 mg/ dL or 1. 55. 3 mol/ L
I gG : <4. 0 mg/ dL or <40 mg/ L
CSF-t o-serum albumin index: <9. 0
I gG index: 0. 30. 60
CSF/ I gG -t o-albumin rat io: 0. 0090. 25
Procedure
1. O bt ain 0. 5 mL of CSF in a st erile t ube.
2. Freeze t he sample if t he det erminat ion is not done immediat ely.
1. I ncreased CSF albumin occurs in most of t he same condit ions as increased
t ot al prot ein, especially:
a. Lesions of t he choroid plexus
b. Blockage of CSF f low
c. Bact erial meningit is

d. G uillain-Barr syndrome
e. Many inf ect ious diseases, such as t yphoid f ever, t ularemia, dipht heria,
and sept icemia
f. Malignant neoplasms of t he CNS

2. I ncreased CSF/ I gG -t o-albumin index (increased I gG , normal albumin) occurs
a. MS
b. Subacut e sclerosing leukoencephalit is
c. Neurosyphilis
d. Chronic phases of CNS inf ect ions (subacut e sclerosing panencephalit is
[ SSPE] )
Interfering Factors
A t raumat ic t ap w ill invalidat e t he result s.
Interventions

care.

1. I nt erpret t est out comes; monit or and int ervene appropriat ely t o prevent and
det ect complicat ions.
care.
CSF Protein Electrophoresis; Oligoclonal Bands;

Multiple Sclerosis Panel Agarose gel electrophoresis of
concentrated CSF is used to detect oligoclonal bands,
defined as two or more discrete bands in the gamma
region that are absent or of less intensity than in the
concurrently tested patient's serum.
Fract ionat ion (ie, elect rophoresis) of CSF is used t o evaluat e bact erial and viral
inf ect ions and t umors of t he CNS. How ever, t he most import ant applicat ion of
CSF prot ein elect rophoresis is t he det ect ion and diagnosis of MS. Abnormalit ies
of CSF in MS include an increase in t ot al prot ein, primarily f rom I gG , w hich is
t he main component of t he gamma-globulin f ract ion. Abnormal immunoglobulins
migrat e as discret e, sharp bands, called oligoclonal bands. This is t he pat t ern
observed in MS: a pat t ern of discret e bands w it hin t he gamma-globulin port ion of
t he elect rophoret ic pat t ern. How ever, oligoclonal bands are f ound in t he CSF of
pat ient s w it h ot her t ypes of nervous syst em disorders of t he immune syst em,
including human immunodef iciency virus (HI V).
Elect rophoresis is also t he met hod of choice t o det ermine w het her a f luid is
act ually CSF. I dent if icat ion can be made based on t he appearance of an ext ra
band of t ransf errin (ref erred t o as TAV), w hich occurs in CSF and not in serum.
Reference Values
Normal
G l obul i ns: O ligoclonal banding: none present ; alpha1 : 2%7%
I gG synt hesis rat e: 0. 08. 0 mg/ day; alpha2 : 4%12%
I gG -t o-albumin rat io: 0. 090. 25; bet a: 8%18%
Prealbumin: 2%7%; gamma: 3%12%
Albumin: 56%76%
Procedure
1. O bt ain 3 mL of CSF f or t his t est . Use t ube 1. The sample must be f rozen if
t he t est is not perf ormed immediat ely.
2. Apply a sample of t he concent rat e t o a t hin-layer agarose gel. Subject t he
agarose gel t o elect rophoresis. CSF is concent rat ed approximat ely 80-f old
by select ive permeabilit y. Serum elect rophoresis must be done concurrent ly
f or int erpret at ion of t he bands.
1. I ncreases in CSF I gG or in t he I gG -t o-albumin index occur in t he f ollow ing
condit ions:
a. MS
b. Subacut e sclerosis panencephalit is

c. Tumors of t he brain and meninges
d. Chronic CNS inf ect ions

e. Some pat ient s w it h meningit is, G uillain-Barr syndrome, lupus
eryt hemat osus involving t he CNS, and ot her neurologic condit ions
2. I ncreases in t he CSF albumin index occur in t he f ollow ing condit ions:
a. O bst ruct ion of CSF circulat ion

b. Damage t o t he CNS blood-brain barrier
d. Syst emic lupus eryt hemat osus of t he CNS
e. G uillain-Barr syndrome
f. Polyneuropat hy
g. Cervical spondylosis
3. I ncreased CSF gamma-globulin and t he presence of oligoclonal bands occur
a. MS
b. Neurosyphilis
c. Subacut e sclerosing panencephalit is
d. Cerebral inf arct ion
e. Viral and bact erial meningit is
f. Progressive rubella panencephalit is
g. Crypt ococcal meningit is
h. I diopat hic polyneurit is

i. Burkit t 's lymphoma
j. HI V-I (acquired immunodef iciency syndrome [ AI DS] )
k. G uillain-Barr syndrome
4. I ncreased CSF synt hesis of I gG occurs in t he f ollow ing condit ions:
a. MS (90% of def init e cases)
b. I nf lammat ory neurologic diseases
c. Post polio syndrome
Clin ical Alert

1. A serum elect rophoresis must be done at t he same t ime as t he CSF
elect rophoresis. An abnormal result is t he f inding of t w o or more bands in
t he CSF t hat are not present in t he serum specimen. (See Figure 5. 3. )
FI G URE 5. 3 Cerebrospinal f luid report pat ient w it h mult iple sclerosis.

Source: Reiber H, Pet er JB: Cerebrospinal f luid analysis: Diseaserelat ed dat a pat t erns and evaluat ion programs. J Neuro Sci, 184: 101
122, 2001.
2. O ligoclonal bands are not specif ic f or mult iple sclerosis; how ever, t he
sensit ivit y is 83% t o 94%.
3. Diagnost ic diff erent iat ion bet w een MS and CSF aut oimmune disease relies
on f urt her t est ing (eg, ant inuclear ant ibodies [ ANAs] in blood [ see Chap.
8)] .
Interfering Factors
1. A t raumat ic t ap invalidat es t he result s.
2. Recent myelography aff ect s t he result s.
Interventions

care.

1. I nt erpret t est out come; monit or f or MS and ot her CNS disorders and
int ervene appropriat ely t o prevent and det ect complicat ions.
care.
CSF Syphilis Serology
Reference Values
Normal
Negat ive (ie, nonreact ive) f or syphilis. Neurosyphilis is charact erized by an
increase in prot ein, an increase in t he number of lymphocyt es, and a posit ive
t est f or syphilis (see Chap. 8). Use CSF VDRL t est , only if serum VDRL t est is
posit ive, t o rule in, not rule out , neurosyphilis. Do not use VDRL t o evaluat e t he
result s of syphilis t herapy.
BIBLIOGRAPHY
Bishop ML, Duben-Engelkirk JL, Fody EP: Clinical Chemist ryPrinciples,
Procedures, Correlat ions, 4t h ed. Philadelphia, Lippincot t Williams & Wilkins,
1999
Burt on CA, Ashw ood ER: Tiet z Text book of Clinical Chemist ry, 3rd ed.
Henry JB (ed): Clinical Diagnosis and Management by Laborat ory Met hods,
Leavelle DE (ed): I nt erpret ive Handbook: I nt erpret ive Dat a f or Diagnost ic
Laborat ory Test s. Rochest er, MN, Mayo Medical Laborat ories, 2001
Lehman CA (ed): Saunders Manual of Clinical Laborat ory Science.
Knight JA: Advances in t he analysis of cerebral spinal f luid. Am Clin Lab Sci
27: 93, 1997
McBride LJ: Text book of Urinalysis and Body Fluids. Philadelphia, Lippincot t Raven, 1998
Regenit er A, St eiger JU, Scholer A, Huber PR, Siede WH: Window s t o t he
w ard; G raphically orient ed report f orms: Present at ion of complex, int errelat ed
laborat ory dat a f or elect rophoresis/ immunof ixat ion, cerebrospinal f luid, and
urinary prot ein prof iles. Clinical Chemist ry, 49: 1, 4150, 2003
Reiber H, Pet er JB: Cerebrospinal f luid analysis: Disease-relat ed pat t erns
and evaluat ion programs. J Neurol Science, 184: 101122, 2001
Ryngsrud MK: Urinalysis and Body Fluids: A Color Text and At las. St . Louis,
Mosby, 1998
Smit h S, Forman D: Laborat ory analysis of cerebrospinal f luid. Clin Lab Sci
7(4): 3238, 1994
St rasinger S, DiLorenzo MS. Urinalysis and Body Fluids, 4t h ed. Philadelphia,
FA Davis, 2001
Tiet z NB (ed): Clinical G uide t o Laborat ory Test s, 3rd ed. Philadelphia, WB
Saunders, 1995
Weiner WJ, Shulman LM (eds): Emergent and Urgent Neurology, 2nd ed.
Philadelphia, Lippincot t -Raven, 1998
Young DS: Eff ect s of Drugs on Clinical Laborat ory Test s, 5t h ed. Washingt on,

Wilkins
> Table of C ontents > 6 - C hem is tr y S tudies
6
Chemistry Studies
OVERVIEW OF CHEM ISTRY STUDIES

Blood chemist ry t est ing ident if ies many chemical blood const it uent s. I t is of t en
necessary t o measure several blood chemicals t o est ablish a pat t ern of
abnormalit ies. A w ide range of t est s can be grouped under t he headings of
enzymes, elect rolyt es, blood sugars, lipids, hormones, prot eins, vit amins,
minerals, and drug invest igat ion. O t her t est s have no common denominat or.
Select ed t est s serve as screening devices t o ident if y t arget organ damage.
When collect ing specimens f or chemist ry st udies, ref er t o St andard/ Universal
Precaut ions in Appendix A, Lat ex and Rubber Allergy Precaut ions in Appendix B,
and G uidelines f or Specimen Transport and St orage in Appendix E, and alw ays
ref er t o Appendix J f or Eff ect s of t he Most ly Commonly Used Drugs on
Frequent ly O rdered Laborat ory Test s.
General Biochemical Profiles Profiles are a group of

select tests that screen for certain conditions. Some of
the more common profiles or panels are listed in Table
6.1.
Table 6.1 Common Screening Profiles
Group Headings
Tests Suggested
Cardiac markers
(MI)
Chem panels, cardiac troponin, CK,

MB, homocysteine
Electrolyte panel
Na, K, Cl, CO2 , pH
Kidney
functions/disease
BUN, phosphorus, LDH, creatinine,

creatinine clearance, total protein,
A/G ratio, albumin, calcium,
glucose, CO2
Lipids (coronary
risk)
Cholesterol, triglycerides, HDL,

lipoprotein electrophoresis (LDL,
VLDL, HDL)
Liver
function/disease
Total bilirubin, alkaline

phosphatase, GGT, total protein,
A/G ratio, albumin, AST, LDH, viral
hepatitis panel, PT
Thyroid function
T 3 uptake, free T4 , Total T4 , T7 ,

FTI, TSH
Basic metabolic
screen
Chloride, sodium, potassium,

carbon dioxide, glucose, BUN,
creatinine
Syndrome X
(metabolic
syndrome)
Blood lipid glucose
A/G ratio, albumin/globulin ratio; AST, aspartate

aminotransferase; BUN, blood urea nitrogen; CK,
creatine kinase; FTI, free thyroxine index; HDL, highdensity lipoproteins; LDH, lactate dehydrogenase; LDL,
low-density lipoproteins; PT, prothrombin time; TSH,
thyroid-stimulating hormone; VLDL, very-low-density
lipoprotein.
Use of the Autoanalyzer

Sophist icat ed aut omat ed inst rument at ion makes it possible t o conduct a w ide
variet y of chemical t est s on a single sample of blood and t o report result s in a

t imely manner. Numerical result s may be report ed w it h low, high, panic, t oxic, or
D (ie, f ails Delt a check) comment s along w it h normal ref erence range.
Comput erized int erf aces allow direct t ransmission of result s bet w een laborat ory
and clinical set t ings. Hard copy print out s can t hen become a permanent part of
t he healt h care record. Not only does t his met hod of record keeping provide a
baseline f or f ut ure
comparisons, but it can also allow unsuspect ed diseases t o be uncovered and
can lead t o early diagnosis w hen sympt oms are vague or absent . Chemist ry
t est s may be t ermed chem panels, SMAC, chem 2 zyme prof iles, and SMAS.
These t erms ref er t o t he company t hat produces t he aut o analyzer. A list of
st andard panels f ollow s in Table 6. 2.
Table 6.2 Standard Panels
Panel Tests
Specim en
Collection
ART HRIT IS PANEL (ART H PN)

Uric acid, ESR, ANA (antinuclear
antibody screen), rheumatoid
factor
Two 7-mL red

topped tubes and
1 lavendertopped tube
BASIC METABOLIC PANEL (BC

MET )
Creatinine, CO2 , chloride, glucose,
potassium, sodium, BUN, calcium
1 mL
unhemolyzed
serum (one SST
tube)
COMPREHENSIVE METABOLIC
PANEL (CM MET )
Albumin, alkaline phosphatase,

ALT, AST, total bilirubin, calcium,
CO 2 , chloride, creatinine, glucose,
potassium, sodium, total protein,
BUN
1 mL
unhemolyzed
serum (one SST
tube)
ELECT ROLYT ES (LYT ES)

CO 2 , chloride, potassium, sodium
1 mL
unhemolyzed
serum (one SST
tube)
HEPAT IC FUNCT ION PANEL

(HEPFUN)
ALT, albumin, alkaline
phosphatase, AST, direct bilirubin
and total bilirubin, total protein
1 mL
unhemolyzed
serum (one SST
tube)
ACUT E HEPAT IT IS PANEL

(ACUT E HEP)
Hepatitis A, AB, IgM, hepatitis B
core antibody, IgM, hepatitis B
surface antigen, IgM, hepatitis C,
AB
One 7-mL redtopped tube
LIPID PANEL (LIPID PN)

Cholesterol, HDL, triglycerides
(LDL and CHO/HDL ratio included,
as calculated values)
2 mL serum (one
SST tube)
OBST ET RIC PANEL (OB PN)
One 7-mL redtopped tube, one

lavender-topped
tube, and one

SST tube
CBC WIT H DIFF
Type and Rh, antibody screen,
RPR, rubella Ab-IgG, hepatitis B
surface antigen
PRENATAL SCREEN (PRESCP)
Type and RH, antibody screening
and studies if indicated, RPR for
syphilis, rubella Ab-IgG, hepatitis
B surface antigen
One lavendertopped tube, one

7-mL redtopped
tube, and one
SST tube
NOTE
Normal or ref erence values f or any chemist ry det erminat ion vary w it h t he
met hod or assay employed. For example, diff erences in subst rat es or
t emperat ure at w hich t he assay is run w ill alt er t he normal range. Thus,
normal ranges vary f rom laborat ory t o laborat ory.
The f ollow ing is a list of rout ine aut omat ed t est s perf ormed commonly in t he
chemist ry depart ment :
1. Alanine aminot ransf erase (ALT)
2. Albumin
3. Alkaline phosphat ase
4. Amylase
5. Aspart at e aminot ransf erase (AST)
6. Bilirubin, direct
7. Bilirubin, t ot al
8. Calcium
9. Carbon dioxide (CO2 )
10. Chloride
11. Cholest erol
12. Cholest erol-HDL
13. Creat ine kinase
14. Creat inine
15. -G lut amyl t ransf erase (G G T)
16. G lucose
17. I ron
18. Lact at e dehydrogenase (LDH)
19. LDL cholest erol (calculat ed)
20. Magnesium
21. Phosphorous, inorganic
22. Pot assium
23. Prot ein, t ot al
24. Sodium
25. Tot al iron binding (calculat ed)

26. Triglycerides
27. Unbound iron binding (UI BC)
28. Urea nit rogen
29. Uric acid
DIABETES TESTING (TYPE 1 AND TYPE 2), BLOOD

GLUCOSE, BLOOD SUGAR, AND RELATED TESTS AND
CRITERIA FOR DIAGNOSING DIABETES
C-Peptide
C-pept ide is f ormed during t he conversion of pro-insulin t o insulin. Pro-insulin is
cleaved (holds and insulin chains t oget her in t he pro-insulin molecule) int o
insulin and biologically inact ive C-pept ide. C-pept ide assay provides dist inct ion
bet w een exogenous and endogenous circulat ing insulin.
The main use of C-pept ide is t o evaluat e hypoglycemia. C-pept ide levels provide
reliable indicat ors f or pancreat ic, B, and secret ory f unct ions and insulin
secret ions. I n a pat ient w it h t ype 1 diabet es mellit us, C-pept ide measurement s
can be an index of insulin product ion and mark endogenous -cell act ivit y. Cpept ide levels can also be used t o conf irm suspect ed surrept it ious insulin
inject ions (ie, f act it ious hypoglycemia). Findings in t hese pat ient s reveal t hat
insulin levels are usually high, insulin ant ibodies may be high, but C-pept ide
levels are low or undet ect able. This t est also monit ors t he pat ient 's recovery
af t er excision of an insulinoma. Rising C-pept ide levels suggest insulinoma t umor
recurrence or met ast ases.
Reference Values
Normal
Fast ing: 0. 512. 72 ng/ mL or 0. 170. 90 mmol/ L
Varies w it h laborat ory.
Procedure
1. Draw a 1-mL venous blood sample f rom a f ast ing pat ient using a red-t opped
chilled t ube. Serum is needed f or t est . Dat e and t ime must be correct .
Cent rif uge blood f or 30 minut es.
2. Separat e t he blood at 4C and f reeze if it w ill not be t est ed unt il lat er.
3. Remember t hat a sample f or glucose t est ing is usually draw n at t he same
t ime.
1. Increased C-pepti de values occur in t he f ollow ing condit ions:
a. Endogenous hyperinsulinism (insulinemia)
b. O ral hypoglycemic drug ingest ion
c. Pancreas or -cell t ransplant at ion
d. I nsulin-secret ing neoplasms (islet cell t umor)
e. Type 2 diabet es mellit us (noninsulin-dependent )
2. Decreased C-pepti de values occur in t he f ollow ing condit ions:
a. Fact it ious hypoglycemia (surrept it ious insulin administ rat ion)
b. Radical pancreat ect omy
c. Type 1 diabet es mellit us
3. C-pept ide st imulat ion t est can det ermine t he f ollow ing:
a. Dist inguishes bet w een t ype 1 and t ype 2 diabet es mellit us.
b. Pat ient s w it h diabet es w hose C-pept ide st imulat ion values are >1. 8
ng/ mL (>0. 59 nmol/ L) can be managed w it hout insulin t reat ment .
Interfering Factors
I ncreased C-pept ide:
1. Renal f ailure
2. I ngest ion of sulf onylurea
Clin ical Alert

To diff erent iat e insulinoma f rom f act it ious hypoglycemia, an insulin/ C-pept ide
rat io can be perf ormed.
<1. 0 Rat io: increased endogenous insulin secret ion >1. 0 Rat io: exogenous
insulin
Interventions
1. Explain t he t est purpose and blood-draw ing procedure. O bt ain hist ory of
signs and sympt oms of hypoglycemia.
2. Ensure t hat t he pat ient f ast s, except f or w at er, f or 8 t o 12 hours bef ore
blood is draw n.
3. Remember t hat radioisot ope t est , if necessary, should t ake place af ter blood
is draw n f or C-pept ide levels.
4. I f t he C-pept ide st imulat ion t est is done, give I V glucagon af t er a baseline
value blood sample is draw n.

2. I nt erpret t est result s and monit or as appropriat e. Explain possible need f or
f urt her t est ing. See Chapt er 8 f or insulin ant ibody t est ing.
Glucagon
G lucagon is a pept ide hormone t hat originat es in t he cells of t he pancreat ic
islet s of Langerhans. This hormone promot es glucose product ion in t he liver.
Normally, glucagon is a count erbalance t o insulin. G lucagon provides a sensit ive,
coordinat ed cont rol mechanism f or glucose product ion and st orage. For example,
low blood glucose levels cause glucagon t o st imulat e glucose release int o t he
bloodst ream, w hereas elevat ed blood glucose levels reduce t he amount of
circulat ing glucagon t o abut 50% of t hat f ound in t he f ast ing st at e. The kidneys
also aff ect glucagon met abolism. Elevat ed f ast ing glucagon levels in t he
presence of renal f ailure ret urn t o normal levels f ollow ing successf ul renal
t ransplant at ion. Abnormally high glucagon levels drop t ow ard normal once insulin
t herapy eff ect ively cont rols diabet es. How ever, w hen compared w it h a healt hy
person, glucagon secret ion in t he person w it h diabet es does not decrease af t er
eat ing carbohydrat es. Moreover, in healt hy persons, arginine inf usion causes
increased glucagon secret ion.
This t est measures glucagon product ion and met abolism. A glucagon def iciency
ref lect s pancreat ic t issue loss. Failure of glucagon levels t o rise during arginine
inf usion conf irms glucagon def iciency. Hyperglucagonemia (ie, elevat ed glucagon
levels) occurs in diabet es, acut e pancreat it is, and sit uat ions in w hich
cat echolamine secret ion is st imulat ed (eg, pheochromocyt oma, inf ect ion).
Reference Values
Normal
Adult s: 20100 pg/ mL or 20100 ng/ L
Children: 0148 pg/ mL or 0148 ng/ L
New borns: 01750 pg/ mL or 01750 ng/ L
Normal ranges vary w it h diff erent laborat ories.
Clin ical Alert

During a glucose t olerance t est (G TT) in healt hy persons, glucagon levels w ill
decline signif icant ly compared w it h baseline f ast ing levels as normal
hyperglycemia t akes place during t he f irst hour of t est ing.
Procedure
1. Draw a 5-mL blood sample f rom a f ast ing person int o a chilled EDTA
Vacut ainer t ube cont aining aprot inin (Trasylol) prot einase inhibit or. Special
handling is required because glucagon is very prone t o enzymat ic
degradat ion. Tubes used t o draw blood must be chilled bef ore t he sample is
collect ed and placed on ice af t erw ard, and plasma must be f rozen as soon
as possible af t er cent rif uging.
2. O bserve st andard precaut ions. Place specimen in a biohazard bag.
1. Increased gl ucagon l evel s are associat ed w it h t he f ollow ing condit ions:
a. Acut e pancreat it is (eg, pancreat ic -cell t umor)
b. Diabet es mellit us: persons w it h severe diabet ic ket oacidosis are
report ed t o have f ast ing glucagon levels f ive t imes normal despit e
marked hyperglycemia.
c. G lucagonoma (f amilial) may be manif est ed by t hree diff erent syndromes:
1. The f irst syndrome exhibit s a charact erist ic skin rash, necrolyt ic
migrat ory eryt hema, diabet es mellit us or impaired glucose t olerance,
w eight loss, anemia, and venous t hrombosis. This f orm usually show s
elevat ed glucagon levels (>1000 pg/ mL or >1000 ng/ L) (diagnost ic).
2. The second syndrome occurs w it h severe diabet es.
3. The t hird f orm is associat ed w it h mult iple endocrine neoplasia
syndrome and can show relat ively low er glucagon levels as compared
w it h t he ot hers.
d. Chronic renal f ailure
e. Hyperlipidemia
f. St ress (t rauma, burns, surgery)
g. Uremia
h. Hepat ic cirrhosis
i. Hyperosmolalit y
j. Acut e pancreat it is
k. Hypoglycemia
2. Reduced l evel s of gl ucagon are associat ed w it h t he f ollow ing condit ions:
a. Loss of pancreat ic t issue
1. Pancreat ic neoplasms
2. Pancreat ect omy
b. Chronic pancreat it is
c. Cyst ic f ibrosis
NOTE
Af t er glucose load, t here is no suppression of glucagon in pat ient s w it h
glucagonoma.
Interventions
1. Explain purpose of t est and blood-draw ing procedure. A minimum 8-hour f ast
(no calorie int ake f or at least 8 hours) is necessary bef ore t he t est .
2. Promot e relaxat ion in a low -st ress environment ; st ress alt ers normal
glucagon levels.
3. Do not administ er radiopharmaceut icals w it hin 1 w eek bef ore t he t est .

1. Have pat ient resume normal act ivit ies.
2. I nt erpret t est out come and monit or f or t he t hree diff erent syndromes of
glucagonoma.
Insulin
I nsulin, a hormone produced by t he pancreat ic cells of t he islet s of
Langerhans, regulat es carbohydrat e met abolism t oget her w it h cont ribut ions f rom
t he liver, adipose t issue, and ot her t arget cells. I nsulin is responsible f or
maint aining blood glucose levels at a const ant level w it hin a def ined range. The
rat e of insulin secret ion is primarily regulat ed by t he level of blood glucose
perf using t he pancreas; how ever, it can also be aff ect ed by hormones, t he
aut onomic nervous syst em, and nut rit ional st at us.
I nsulin levels are valuable f or est ablishing t he process of an insulinoma (ie,
t umor of t he islet s of Langerhans). This t est is also used f or invest igat ing t he
causes of f ast ing hypoglycemic st at es and neoplasm diff erent iat ion. The insulin
st udy can be done in conjunct ion w it h a G TT or f ast ing blood glucose (FBG ) t est
or a f ast ing plasma glucose (FPG ) t est .
Reference Values
Normal
Immunoreacti ve Adult s: 035 I U/ mL or 0243 pmol/ L
Children: 010 I U/ mL or 069 pmol/ L
Free
Adult s: 017 I U/ mL or 0118 pmol/ L
Children (prepubert al): 013 I U/ mL or 090 pmol/ L
Procedure
1. O bt ain a 5-mL blood sample f rom a f ast ing person; serum is pref erred.
O bserve st andard precaut ions. Heparinized blood may be used.
2. I f done in conjunct ion w it h a G TT, draw t he specimens bef ore administ ering
oral glucose and again 30, 60, and 120 minut es af t er glucose ingest ion (t he
same t imes as t he G TT).
1. Increased i nsul i n val ues are associat ed w it h t he f ollow ing condit ions:
a. I nsulinoma (pancreat ic islet t umor). Diagnosis is based on t he f ollow ing
f indings:
1. Hyperinsulinemia w it h hypoglycemia (glucose <30 mg/ dL or <1. 66
mmol/ L)
2. Persist ent hypoglycemia t oget her w it h hyperinsulinemia (>20 I U/ mL
or >139 pmol/ L) af t er t olbut amide inject ion (rapid rise and rapid f all)
3. Failed C-pept ide suppression w it h a plasma glucose level <30 mg/ dL
or <1. 66 mmol/ L and insulin/ glucose rat io >0. 3.
b. Type 2 diabet es mellit us, unt reat ed
c. Acromegaly
d. Cushing's syndrome
e. Endogenous administ rat ion of insulin (f act it ious hypoglycemia)
f. O besit y (most common cause)
g. Pancreat ic islet cell hyperplasia
2. Decreased i nsul i n val ues are f ound in t he f ollow ing condit ions:
a. Type 1 diabet es mellit us, severe
b. Hypopit uit arism
Clin ical Alert

Panic range: >35 I U/ mL or >243 pmol/ L (f ast ing)
Interfering Factors
1. Surrept it ious insulin or oral hypoglycemic agent ingest ion or inject ion causes
elevat ed insulin levels (w it h low C-pept ide values).
2. O ral cont racept ives and ot her drugs cause f alsely elevat ed values.
3. Recent ly administ ered radioisot opes aff ect t est result s.
4. I n t he second t o t hird t rimest er of pregnancy, t here is a relat ive insulin
resist ance w it h a progressive decrease of plasma glucose and
immunoreact ive insulin.
Interventions
2. Ensure t hat t he pat ient f ast s f rom all f ood and f luid, except w at er, unless
ot herw ise direct ed.
3. Be aw are t hat because insulin release f rom an insulinoma may be errat ic and
unpredict able, it may be necessary f or t he pat ient t o f ast f or as long as 72
hours bef ore t he t est .
care.

1. Have pat ient resume normal act ivit y and diet .
2. I nt erpret t est result s and counsel appropriat ely. O bese pat ient s may have
insulin resist ance and unusually high f ast ing and post prandial (af t er eat ing)
insulin levels. Explain possible need f or f urt her t est ing and t reat ment .
care.
Clin ical Alert

A pot ent ially f at al sit uat ion may exist if t he insulinoma secret es unpredict ably
high levels of insulin. I n t his case, t he blood glucose may drop t o such
dangerously low levels as t o render t he person comat ose and unable t o self administ er oral glucose f orms. Pat ient s and t heir f amilies must learn how t o
deal w it h such an emergency and t o be vigilant unt il t he problem is t reat ed.
Fasting Blood Glucose (FBG); Fasting Blood Sugar

(FBS); Fasting Plasma Glucose (FPG); Casual Plasma
Glucose (PG) Glucose is formed from carbohydrate
digestion and conversion of glycogen to glucose by the
liver. The two hormones that directly regulate blood
glucose are glucagon and insulin. Glucagon
accelerates glycogen breakdown in the liver and
causes the blood glucose level to rise. Insulin
increases cell membrane permeability to glucose,
transports glucose into cells (for metabolism),
stimulates glycogen formation, and reduces blood
glucose levels. Driving insulin into the cells requires
insulin and insulin receptors. For example, after a
meal, the pancreas releases insulin for glucose
metabolism, provided there are enough insulin
receptors. Insulin binds to these receptors on the
surface of target cells such as are found in fat and
muscle. This opens the channels so that glucose can
pass into cells, where it can be converted into energy.
As cellular glucose metabolism occurs, blood glucose
levels fall. Adrenocorticotropic hormone (ACTH),
adrenocorticosteroids, epinephrine, and thyroxine also
play key roles in glucose metabolism. See Chapter 11
for genetic causes of type 1 and type 2 diabetes

mellitus.
The American Diabet es Associat ion (ADA) has begun using t he t erm predi abetes, also know n as impaired glucose t olerance or impaired f ast ing glucose.
I ndividuals w it h pre-di abetes demonst rat e higher levels of blood plasma glucose
(PG ) (110125 mg/ dL or 6. 16. 9 nmol/ L) t han normals (<110 mg/ dL or <6. 1
nmol/ L) and, if lef t unt reat ed, go on t o develop t ype 2 diabet es w it hin 10 years.
Fast ing blood plasma glucose (see Fig. 6. 1) is a vit al component of diabet es
management . Abnormal glucose met abolism may be caused by inabilit y of
pancreat ic islet cells t o produce insulin, reduced numbers of insulin recept ors,
f ault y int est inal glucose absorpt ion, inabilit y of t he liver t o met abolize glycogen,
or alt ered levels of hormones (eg, ACTH) t hat play a role in glucose met abolism.
FI G URE 6. 1 The glucose cont inuum. FPG , f ast ing plasma glucose; O G TT,
oral glucose t olerance t est . (Source: The American Associat ion f or Clinical
Chemist ry, I nc. , Washingt on, DC, Clinical Laborat ory New s, 28 [ 6] June
2002. )
I n most cases, signif icant ly elevat ed f ast ing plasma glucose levels (ie, >140
mg/ dL or >7. 77 nmol/ L; hyperglycemia) are, in t hemselves, usually diagnost ic of
diabet es. How ever, mild, borderline cases may present w it h normal f ast ing
glucose values. I f diabet es is suspect ed, a G TT can conf irm t he diagnosis.
O ccasionally, ot her diseases may produce elevat ed plasma glucose levels;
t heref ore, a comprehensive hist ory, physical examinat ion, and w orkup should be
done bef ore a def init ive diagnosis of diabet es is est ablished.
Clin ical Alert
A. New NI H guidelines endorse diabet ic t est ing of all adult s 45 years every
3 years.
The American Diabet es Associat ion recommends t he f ollow ing guidelines
f or t est ing:
1. Test ing should be consi dered if pat ient is >45 years of age.
2. Test ing is strongl y recommended if pat ient is >45 years of age and
overw eight .
3. Test ing should be consi dered if pat ient is <45 years of age and
overw eight w it h anot her risk f act or.
B. Diabet es mellit us, a group of met abolic disorders, is charact erized by
hyperglycemia and abnormal prot ein, f at , and carbohydrat e met abolism
due t o def ect s in insulin secret ions, ie, inadequat e and def icient insulin
act ion on t arget organs, or bot h.
C.
1. Sympt oms of diabet es plus random/ casual plasma glucose concent rat ion
200 mg/ dL (11. 1 mmol/ L). Random/ casual is def ined as any t ime of day
w it hout regard t o t ime since last meal. The classic sympt oms of diabet es
include polyuria, polydipsia, and unexplained w eight loss.
2. or FPG 126 mg/ dL (7. 0 mmol/ L). Fast ing is def ined as no caloric int ake
f or at least 8 h.
3. or 2-h PG 200 mg/ dL (11. 1 mmol/ L) during an O G TT. The t est should be
perf ormed as described by WHO , using a glucose load cont aining t he
equivalent of 75 g anhydrous glucose dissolved in w at er.
Footn ote
I n t he absence of unequivalent hyperglycemia w it h acut e, met abolic
decompensat ion, t hese crit eria should be conf irmed by repeat t est ing on a
diff erent day. O G TT is not recommended f or rout ine clinical use. Source:
Diabet es Care 25: 742749, 2000.
Reference Values
Normal
Fast ing adult s: 110 mg/ dL or 6. 1 nmol/ L
Fast ing children (218 years): 60100 mg/ dL or 3. 35. 6 mmol/ L
Fast ing young children (02 years): 60110 mg/ dL or 3. 36. 1 mmol/ L
Fast ing premat ure inf ant s: 4065 mg/ dL or 2. 23. 6 mmol/ L
Procedure
1. Draw a 5-mL venous blood sample f rom a f ast ing person. I n know n cases of
diabet es, blood draw ing should precede insulin or oral hypoglycemic
administ rat ion. O bserve st andard precaut ions. Serum is accept able if
separat ed f rom red cells w it hin an hour. A gray-t opped t ube, w hich cont ains
sodium chloride, is accept able f or 24 hours w it hout separat ion.
2. Be aw are t hat self -monit oring of blood glucose by t he person w it h diabet es
can be done by f inger-st ick blood drop sampling several t imes per day if
necessary. Several devices are commercially available f or t his procedure;
t hey are relat ively easy t o use and have been est ablished as a major
component in sat isf act ory diabet es cont rol. Calibrat ion of monit oring devices
should be done on a regular basis.
3. Be aw are t hat noninvasive met hods using skin pads t o check blood glucose
level are being developed f or self -monit oring t hat eliminat e t he dreaded
f inger-prick t est , f or example, a G luco-w at ch (Cygnes, Redw ood Cit y, CA),
w orn on t he w rist and pow ered by an AAA bat t ery.
NOTE
When w hole blood glucose values are not equivalent t o plasma values, plasma
values are about 1015% higher t han w hole blood values. How ever, some of
t he new er met ers now convert t he w hole blood values t o plasma, t hus giving a
bet t er comparison bet w een t he lab values and bedside or home t est ing.
Patient Checklist for Self-M onitoring of Blood Glucose

(SM BG) Testing This list is a general outline. Each
brand of meter has its ow n instructions. Read the
instructions on each new meter carefully to get
accurate results. Know w hether your monitor and strips
give w hole blood or plasma results.
1. G eneral inst ruct ions
a. Make sure your hands are clean, dry, and w arm.
b. Prick your f inger w it h t he lancet .
c. Squeeze out a drop of capillary blood.
d. Drop t he blood ont o t he t est st rip or sensor.
e. Wait f or t he t est st rip or sensor t o develop.
f. Compare t he t est st rip t o t he chart or insert it in t he met er.
g. Saf ely dispose of your lancet in an approved sharps cont ainer.
h. Record blood glucose result s w it h dat e and t ime.
2. I f you have t ype 1 diabet es mellit us, you should also monit or your urine f or
ket ones t o alert you t o possibly dangerous complicat ions such as diabet ic
ket oacidosis (eg, during st ress or acut e illness).
3. Test more of t en on days w hen you are ill, w hen your blood glucose is t oo
high, w hen your meal or exercise plan changes, w hen you t ravel, or if you
f eel t hat your blood glucose is low.
4. I f you do not f eel you are get t ing accurat e result s, t alk t o your diabet es
educat or and/ or cont act t he manuf act urer of your met er. Make sure you are
using t he met er properly.
5. Several blood glucose met ers current ly available are approved by t he U. S.
Food and Drug Administ rat ion (FDA), t he agency t hat approves medical
devices, f or w hat 's called alt ernat e sit e t est ing.
6. Alt ernat e sit es (ot her t han f ingert ips) include f orearm, bicep area, palm of
hand, bet w een f ingers, and somet imes t he calf .
7. Tips f or using alt ernat e sit es:
a. Rub t he sit e you w ill use t o check your blood glucose vigorously bef ore
you prick your skin. This increases blood f low t o t he sit e.
b. Use one t ype of met er. Do not alt ernat e bet w een diff erent met ers. This
w ill help you get consist ent result s.
c. Consist ent ly use t he same alt ernat e sit e. For example, alw ays use your
f orearms. This w ill help you get consist ent result s.
FI G URE 6. 2 Port able blood glucose analyzer (Source: HemoCue, Mission

Viejo, Calif ornia, USA. )
1. El evated bl ood gl ucose (hypergl ycemi a) occurs in t he f ollow ing condit ions:
a. Diabet es mellit us: a f ast ing glucose of >126 mg/ dL (>7. 0 mmol/ L) or a 2hour post prandial load plasma glucose >200 mg/ dL (>11. 1 mmol/ L)
during an oral G TT.
b. O t her condit ions t hat produce elevat ed blood plasma glucose levels
include t he f ollow ing:
1. Cushing's disease (increased glucocort icoids cause elevat ed blood

sugar levels)
2. Acut e emot ional or physical st ress sit uat ions (eg, myocardial
inf arct ion [ MI ] , cerebrovascular accident , convulsions)
3. Pheochromocyt oma, acromegaly, gigant ism
4. Pit uit ary adenoma (increased secret ion or grow t h hormone causes
elevat ed blood glucose levels)
5. Hemochromat osis
6. Pancreat it is (acut e and chronic), neoplasms of pancreas
7. G lucagonoma
8. Advanced liver disease
9. Chronic renal disease
10. Vit amin B def iciency: Wernicke's encephalopat hy
11. Pregnancy (may signal pot ent ial f or onset of diabet es lat er in lif e)
2. Decreased bl ood pl asma gl ucose (hypogl ycemi a) occurs in t he f ollow ing
condit ions:
a. Pancreat ic islet cell carcinoma (insulinomas)
b. Ext rapancreat ic st omach t umors (carcinoma)
c. Addison's disease (adrenal insuff iciency), carcinoma of adrenal gland
d. Hypopit uit arism, hypot hyroid, ACTH def iciency
e. St arvat ion, malabsorpt ion (st arvat ion does not cause hypoglycemia in
normal persons)
f. Liver damage (alcoholism, chlorof orm poisoning, arsenic poisoning)
g. Premat ure inf ant ; inf ant delivered t o a mot her w it h diabet es
h. Enzyme-def iciency diseases (eg, galact osemia, inherit ed maple syrup
disease, von G ierke's syndrome)
i. I nsulin overdose (accident al or deliberat e)
j. React ive hypoglycemia, including aliment ary hyperinsulinism, prediabet es, endocrine def iciency
k. Post prandial hypoglycemia may occur af t er G I surgery and is described
w it h heredit ary f ruct ose int olerance, galact osemia, and leucine
sensit ivit y.
3. According t o t he ADA crit eria, t here are t hree def init ive t est s f or diabet es:
a. Sympt oms of diabet es plus a random/ casual plasma glucose >200 mg/ dL
(>11. 1 mmol/ L), or
b. A f ast ing plasma glucose >126 mg/ dL (>6. 99 mmol/ L), or

c. An oral glucose t olerance t est w it h a 2-hour post load (75-g glucose load)
level >200 mg/ dL (>11. 1 mmol/ L)
4. Using any of t he t hree met hods, t he crit erion must be reconf irmed on a
subsequent day.
5. The classif icat ion of diabet es diagnosis ref lect s a shif t t o t he et iology or
pat hology of t he disease f rom a classif icat ion based on pharmacological
t reat ment .
6. I mpaired f ast ing glucose (I FG ) or impaired glucose t olerance (I G T) is
ref erred t o as pre-diabet es. See Figure 6. 1.
Interfering Factors
1. El evated gl ucose:
a. St eroids, diuret ics, ot her drugs (see Appendix J)
b. Pregnancy (a slight blood glucose elevat ion normally occurs)
c. Surgical procedures and anest hesia
d. O besit y or sedent ary lif est yle
e. Parent eral glucose administ rat ion (eg, f rom t ot al parent eral nut rit ion)
f. I V glucose (recent or current )
g. Heavy smoking
2. Decreased gl ucose:
a. Hemat ocrit >55%
b. I nt ense exercise
c. Toxic doses of aspirin, salicylat es, and acet aminophen
d. O t her drugs, including et hanol, quinine, and haloperidol
Interventions
1. Explain t est purpose and blood-draw ing procedure.
2. Tell pat ient t hat t he t est requires at least an overnight f ast ; w at er is
permit t ed. I nst ruct t he pat ient t o def er insulin or oral hypoglycemics unt il
af t er blood is draw n, unless specif ically inst ruct ed t o do ot herw ise.

3. Not e t he last t ime t he pat ient at e in t he record and on t he laborat ory
requisit ion.

1. Tell t he pat ient t hat he or she may eat and drink af t er blood is draw n.
2. I nt erpret t est result s and monit or appropriat ely f or hyperglycemia and
hypoglycemia. Counsel regarding necessary lif est yle changes (eg, diet ,
exercise, glucose monit oring, medicat ion).
3. G ive t he pat ient t he f ollow ing checklist :
a. Take special care of your f eet .
b. Use a lubricant or unscent ed hand cream on dry, scaly skin.
c. Look f or calluses on your soles. Rub t hem gent ly w it h a pumice st one.
d. Make sure new shoes f it properly; w ear f reshly w ashed socks or
st ockings.
e. Never go baref oot .
f. Avoid using hot w at er bot t les, t ubs of hot w at er, or heat ing pads on your
f eet .
g. Trim your t oenails st raight across.
h. Make sure your doct or inspect s your f eet as part of every visit .
i. Use a t eam approach t o help you make decisions about your care. The
t eam may include your doct or, a nurse diabet es educat or, a diet it ian,
your pharmacist , and your f amily.
j. Use ot her healt h prof essionals t o help w it h your care. These may include
an eye doct or (opht halmologist or opt omet rist ), an exercise physiologist ,
a podiat rist (a f oot specialist ), and a psychologist .
k. Follow t he most healt hf ul lif est yle you can.
4. Persons w it h glucose levels >200 mg/ dL (>11. 1 mmol/ L) should be placed on
a st rict int ake and out put program.
Clin ical Alert

1. I f a person w it h know n or suspect ed diabet es experiences headaches,
irrit abilit y, dizziness, w eakness, f aint ing, or impaired cognit ion, a blood
glucose t est or f inger-st ick t est must be done bef ore giving insulin. Similar
sympt oms may be present f or bot h hypoglycemia and hyperglycemia. I f a
blood glucose level cannot be obt ained and one
P.
2.
3.
4.
5.
6.
is uncert ain regarding t he sit uat ion, glucose may be given in t he f orm of
orange juice, sugar-cont aining soda, or candy (eg, Lif e-Savers or jelly
beans). Make cert ain t he person is suff icient ly conscious t o manage eat ing
or sw allow ing. I n t he acut e care set t ing, I V glucose may be given in t he
event of severe hypoglycemia. A glucose gel is also commercially available
and may be rubbed on t he inside of t he mout h by anot her person if t he
person w it h diabet es is unable t o sw allow or t o respond properly. I nst ruct
persons prone t o hypoglycemia t o carry sugar-t ype it ems on t heir person
and t o w ear a necklace or bracelet t hat ident if ies t he person as diabet ic.
Frequent blood glucose monit oring, including self -monit oring, allow s bet t er
cont rol and management of diabet es t han urine glucose monit oring.
When blood glucose values are > 300 mg/ dL (>16. 6 mmol/ L), urine out put
increases, as does t he risk f or dehydrat ion.
Panic values/ crit ical values f or f ast ing blood glucose: <40 mg/ dL (<2. 22
mmol/ L) may cause brain damage (w omen and children), <50 mg/ dL
(<2. 77 mmol/ L) (men); >400 mg/ dL (>22. 2 mmol/ L) may cause coma
Diabet es is a disease of t he moment : persons living w it h diabet es are
cont inually aff ect ed by f luct uat ions in blood glucose levels and must learn
t o manage and adapt t heir lif est yle w it hin t his f ramew ork. For some,
adapt at ion is relat ively st raight f orw ard; f or ot hers, especially t hose
ident if ied as being brit t le, lif est yle changes and management are more
complicat ed, and t hese pat ient s require const ant vigilance, at t ent ion,
encouragement , and support .
Each person w it h diabet es may experience cert ain sympt oms in his or her
ow n unique w ay and in a unique pat t ern.
Clin ical Alert

1. I nf ant s w it h t remor, convulsion, or respirat ory dist ress should have STAT
glucose done, part icularly in t he presence of mat ernal diabet es, or w it h
hemolyt ic disease of t he new born.
2. New borns t hat are t oo small or t oo large f or gest at ional age should have
glucose level measured in t he f irst day of lif e.
3. Diseases relat ed t o neonat al hypoglycemia:
a. G lycogen st orage diseases
b. G alact osemia
c. Heredit ary f ruct ose int olerance

d. Ket ogenic hypoglycemia of inf ancy
e. Carnit ine def iciency (Reye's syndrome)
Gestational Diabetes Mellitus (GDM); O'Sullivan Test

(1-h Gestational Diabetes Mellitus Screen) Glucose
intolerance during pregnancy (gestational diabetes
mellitus [GDM]) is associated with an increase in
perinatal morbidity and mortality, especially in women
who are aged >25 years, overweight, or hypertensive.
Additionally, more than one half of all pregnant
patients with an abnormal GTT do not have any of the
same risk factors. It is therefore recommended that all
pregnant women be screened for gestational diabetes.
The O 'Sullivan t est , based on an O G TT, is done t o det ect gest at ional diabet es
and screen nonsympt omat ic pregnant w omen. During pregnancy, abnormal
carbohydrat e met abolism is evaluat ed by screening all pregnant w omen at f irst
prenat al visit , t hen again at 24 t o 28 w eeks.
O ne-step approach: An oral glucose load of 50 g is administ ered, and blood is
examined f or glucose levels 1 hour af t er administ rat ion. Women w it h a f amily
hist ory of diabet es or previous gest at ional diabet es should undergo t he
O 'Sullivan t est at 15 t o 19 w eeks of gest at ion and again at 24 t o 28 w eeks of
gest at ion.
Two-step approach: Measure plasma or serum glucose 1 hour af t er G TT
(glucose challenge).
Reference Values
Normal
130140 mg/ dL or 7. 27. 9 mmol/ L (1 hour af t er 50 g of glucose)
Procedure
1. Draw a 5-mL venous blood sample (sodium f luoride) af t er 814 hour f ast , at
least 3 days of unrest rict ed diet and act ivit y and af t er glucose load.
1. Abnormal G DM t est result is af t er 100 g glucose load and af t er 75 g glucose
load reveals glucose int olerance.
2. A 3-hour gest at ional G TT must t hen be done.
3. A posit ive result in a pregnant w oman means she is at much great er risk (7
t imes) f or having gest at ional diabet es mellit us (G DM).
4. G DM is any degree of glucose int olerance w it h onset during pregnancy or
f irst recognized pregnancy.
Interventions
1. Explain t est purpose (t o evaluat e abnormal carbohydrat e met abolism and
predict diabet es in lat er lif e) and procedure. No f ast ing is usually required.
O bt ain pert inent hist ory of diabet es and record any signs or sympt oms of
diabet es.
2. I nst ruct t he w oman about obt aining a urine sample f or glucose t est ing t o
check bef ore drinking t he glucose load. Posit ive urine glucose should be
checked w it h t he physician bef ore glucose load. Those w it h glycosuria >250
mg/ dL (>13. 8 mmol/ L) must have a blood glucose t est bef ore O 'Sullivan or
G DM t est ing.
3. G ive t he pat ient 75100 g of glucose beverage (150 mL dissolved in w at er,
or Trut ol or O range DEX).
4. Explain t o t he pat ient t hat no eat ing, drinking, smoking, or gum chew ing is
allow ed during t he t est . The pat ient should not leave t he off ice. She may void
if necessary.
5. Af t er 1 hour, draw one NaFl or EDTA t ube (5-mL venous blood) using
st andard venipunct ure t echnique. I f a 75 g glucose is given, also collect a 2hour specimen. I f a 100 g glucose load is given, obt ain 2- and 3-hour
specimens.

1. Normal act ivit ies, eat ing, and drinking may be resumed.
2. I nt erpret t est result s and explain t o pat ient t hat a normal out come is <140
mg/ dL (<7. 8 mmol/ L).
3. A f ollow -up 3-hour gest at ional G TT or O G TT is indicat ed f or all abnormal
screenings.
4. Six w eeks af t er delivery, t he pat ient should be ret est ed and reclassif ied. I n
most cases, glucose w ill ret urn t o normal.
Glucose Tolerance Test (GTT); Oral Glucose Tolerance

Test (OGTT) In a healthy individual, the insulin
response to a large oral glucose dose is almost
immediate. It peaks in 30 to 60 minutes and returns to
normal levels within 3 hours when sufficient insulin is
present to metabolize the glucose ingested at the
beginning of the test. The test should be performed
according to WHO guidelines using glucose load
containing the equivalent of 75100 g of anhydrous
glucose dissolved in water or other solution.
I f f ast ing and post load glucose t est result s are borderline, t he G TT can support
or rule out a diagnosis of diabet es mellit us; it can also be a part of a w orkup f or
unexplained hypert riglyceridemia, neuropat hy, impot ence, renal diseases, or
ret inopat hy. This t est may be ordered w hen t here is sugar in t he urine or w hen
t he f ast ing blood sugar level is signif icant ly elevat ed. The G TT/ O G TT should not
be used as a screening t est f or nonpregnant adult s or children.
Indications for Test

The G TT/ O G TT should be done on cert ain pat ient s, part icularly t hose w it h t he
f ollow ing indicat ions (f ew indicat ions st ill meet w ide accept ance):
1. Family hist ory of diabet es
2. O besit y
3. Unexplained episodes of hypoglycemia
4. Hist ory of recurrent inf ect ions (boils and abscesses)
5. I n w omen, hist ory of delivery of large inf ant s, st illbirt hs, neonat al deat h,
premat ure labor, and spont aneous abort ions
6. Transit ory glycosuria or hyperglycemia during pregnancy, surgery, t rauma,
st ress, MI , and ACTH administ rat ion
Reference Values
Normal
Fasti ng pl asma gl ucose (PG ): Adult s: 110 mg/ dL or 6. 1 mmol/ L
30-mi nute: Adult s: 110170 mg/ dL or 6. 19. 4 mmol/ L
60-mi nute (1-hour) pl asma gl ucose (PG ) af ter gl ucose l oad: Adult s: <184 mg/ dL
or <10. 2 mmol/ L
120-mi nute (2-hour G TT test) 2-hour pl asma gl ucose (PG ) after gl ucose
l oad: Adults: <138 mg/ dL or <7. 7 mmol/ L
Children: <140 mg/ dL or <7. 8 mmol/ L
3-hour pl asma gl ucose (PG ) af ter gl ucose l oad: Adult s: 70120 mg/ L or 3. 96. 7
mmol/ L
All f our blood values must be w it hin normal limit s t o be considered normal.
Procedure
This is a t imed t est f or glucose t olerance. A 2-hour plasma glucose t est is done
af t er glucose load t o det ect diabet es in individuals ot her t han pregnant w omen;
t he 3-hour t est is done f or pregnant w omen; and t he 4-hour t est evaluat es
possible hypoglycemia.
1. Have pat ient eat a diet of >150 g of carbohydrat es f or 3 days bef ore t he
t est .
2. Ensure t hat t he f ollow ing drugs are discont inued 3 days bef ore t he t est
because t hey may inf luence t est result s:
a. Hormones, oral cont racept ives, st eroids
b. Salicylat es, ant i-inf lammat ory drugs
c. Diuret ic agent s
d. Hypoglycemic agent s
e. Ant ihypert ensive drugs
f. Ant iconvulsant s (see Appendix J)
3. I nsulin and oral hypoglycemics should be w it hheld unt il t he t est is complet ed.
4. Record t he pat ient 's w eight .
a. Pediat ric doses of glucose are based on body w eight , calculat ed as 1. 75
g/ kg not t o exceed a t ot al of 75 g.
b. Pregnant w omen: 100 g glucose
c. Nonpregnant adult s: 75 g glucose
d. Possible gest at ional diabet es: 100 g glucose
5. A 5-mL sample of venous blood is draw n. Serum or gray-t opped t ubes are
used. The pat ient should f ast 12 t o 16 hours bef ore t est ing. Af t er t he blood
is draw n, t he pat ient drinks all of a specially f ormulat ed glucose solut ion
w it hin a 5-minut e t ime f rame.
6. Blood samples are obt ained 30 minut es, 1 hour, 2 hours, and 3 hours af t er
glucose ingest ion.
7. Specimens t aken 4 hours af t er ingest ion are signif icant f or det ect ing
hypoglycemia and may be ordered (5-hour specimens have been
discredit ed).
8. Tolerance t est s can also be perf ormed f or pent ose, lact ose, galact ose, and
d-xylose.
9. The G TT is not indicat ed in t hese sit uat ions:
a. Persist ent f ast ing hyperglycemia >140 mg/ dL or >7. 8 mmol/ L
b. Persist ent f ast ing normal plasma glucose
c. Pat ient s w it h overt diabet es mellit us
d. Persist ent 2-hour plasma glucose >200 mg/ dL or >11. 1 mmol/ L
10. Test has limit ed value in diagnosis of diabet es mellit us in children and is
rarely indicat ed f or t hat purpose.
1. The presence of abnormal G TT values (decreased t olerance t o glucose) is
based on t he I nt ernat ional Classif icat ion f or Diabet es Mellit us and t he
f ollow ing glucose int olerance cat egories:
a. At least t w o G TT values must be abnormal f or a diagnosis of diabet es
mellit us t o be validat ed.
b. I n cases of overt diabet es, no insulin is secret ed; abnormally high
glucose levels persist t hroughout t he t est .
c. G lucose values t hat f all above normal values but below t he diagnost ic
crit eria f or diabet es or impaired glucose t olerance (I G T) should be
considered nondiagnost ic.
2. See Table 6. 3 f or an int erpret at ion of glucose t olerance levels.
Table 6.3 Glucose Tolerance Test (GTT) Levels
Conventional
Units
(m g/dL)
SI Units
(m m ol/L)
Fasting adult
140
>7.8
Adult diabetes mellitus

1-h glucose
>200
>11.1
and 2-h glucose
>200
>11.1
Fasting adult
140
7.8
Adult impaired glucose

tolerance 1-h glucose
>200
>11.1
and 2-h glucose
>140200
>7.8
11.1
Juvenile diabetes
mellitus (fasting
glucose)
>140
>7.8
and 1-h glucose
>200
>11.1
and 2-h glucose
>200
>11.1
>140
>7.8
Impaired glucose
tolerance in children
(fasting glucose)
and 2-h glucose
3. A diagnosis of gest at ional diabet es mellit us (G DM) is based on t he f ollow ing

blood glucose result s (more t han t w o t est s must be met and exceeded):
f ast ing, >95 mg/ dL (>5. 3 mmol/ L); 1-hour, >180 mg/ dL (>10. 8 mmol/ L); 2hour, >155 mg/ dL (>8. 6 mmol/ L); and 3-hour, >140 mg/ dL (>7. 8 mmol/ L).
a. All pregnant w omen should be t est ed f or gest at ional diabet es w it h a 50-g
dose of glucose at 24 t o 28 w eeks of gest at ion. Pregnant w omen w it h
abnormal G TT are at risk f or preeclampsia/ eclampsia and delivery of a
large inf ant .
b. I f abnormal result s occur during pregnancy, repeat G TT at t he f irst
post part um visit .
c. During labor, maint ain mat ernal glucose levels at 80 t o 100 mg/ dL (4. 4
5. 5 mmol/ L); bew are of markedly increased insulin sensit ivit y in t he
immediat e post part um period.
4. Decreased glucose t olerance occurs w it h high glucose values in t he f ollow ing
condit ions:
b. Post gast rect omy
c. Hypert hyroidism
d. Excess glucose ingest ion
e. Hyperlipidemia t ypes I I I , I V, and V
f. Hemochromat osis
g. Cushing's disease (st eroid eff ect )
h. CNS lesions
i. Pheochromocyt oma
5. Decreased glucose t olerance w it h hypoglycemia can be f ound in persons w it h
von G ierke's disease, severe liver damage, or increased epinephrine levels.
6. I ncreased glucose t olerance w it h f lat curve (ie, glucose does not increase,
but may decrease t o hypoglycemic levels) occurs in t he f ollow ing condit ions:
a. Pancreat ic islet cell hyperplasia or t umor
b. Poor int est inal absorpt ion caused by diseases such as sprue, celiac
disease, or Whipple's disease
c. Hypoparat hyroidism
d. Addison's disease
e. Liver disease
f. Hypopit uit arism, hypot hyroidism
Interfering Factors
1. Smoking increases glucose levels.
2. Alt ered diet s (eg, w eight reduct ion) bef ore t est ing can diminish carbohydrat e
t olerance and suggest f alse diabet es.
3. G lucose levels normally t end t o increase w it h aging.
4. Prolonged oral cont racept ive use causes signif icant ly higher glucose levels in
t he second hour or in lat er blood specimens.
5. I nf ect ious diseases, illnesses, and operat ive procedures aff ect glucose
t olerance. Tw o w eeks of recovery should be allow ed bef ore perf orming t he
t est .
6. Cert ain drugs impair glucose t olerance levels (t his list is not all inclusive; see
Appendix J f or ot her drugs):
a. I nsulin
b. O ral hypoglycemics
c. Large doses of salicylat es, ant i-inf lammat ories
d. Thiazide diuret ics
e. O ral cont racept ives
f. Cort icost eroids
g. Est rogens
h. Heparin
i. Nicot inic acid
j. Phenot hiazines
k. Lit hium
l. Met yrapone (Met opirone)
I f possible, t hese drugs should be discont inued f or at least 3 days bef ore
t est ing. Check w it h clinician f or specif ic orders.
7. Prolonged bed rest inf luences glucose t olerance result s. I f possible, t he
pat ient should be ambulat ory. A G TT in a hospit alized pat ient has limit ed
value.
Interventions
1. Explain t est purpose and procedure. A w rit t en reminder may be helpf ul.
a. A diet high in carbohydrat es (150 g) should be eat en f or 3 days
preceding t he t est . I nst ruct t he pat ient t o abst ain f rom alcohol.
b. The pat ient should f ast f or at least 12 hours but not more t han 16 hours
bef ore t he t est . O nly w at er may be ingest ed during f ast ing t ime and t est
t ime. Use of t obacco product s is not permit t ed during t est ing.
c. Pat ient s should rest or w alk quiet ly during t he t est period. They may f eel
w eak, f aint , or nauseat ed during t he t est . Vigorous exercise alt ers
glucose values and should be avoided during t est ing.
2. Collect blood specimens at t he prescribed t imes and record exact t imes
collect ed. Urine glucose t est ing is no longer recommended.

1. Have t he pat ient resume normal diet and act ivit ies at t he end of t he t est .
Encourage eat ing complex carbohydrat es and prot ein if permit t ed.
2. Administ er prescribed insulin or oral hypoglycemics w hen t he t est is done.
Arrange f or t he pat ient t o eat w it hin a short t ime (30 minut es) af t er t hese
medicat ions are t aken.
3. I nt erpret t est result s and counsel appropriat ely. Pat ient s new ly diagnosed
w it h diabet es w ill need diet , medicat ion, and lif est yle modif icat ion
inst ruct ions.
Clin ical Alert

1. G TT is cont raindicat ed in pat ient s w it h a recent hist ory of surgery, MI , or
labor and delivery; t hese condit ions can produce invalid values.
2. I f f ast ing glucose is >140 mg/ dL (>7. 8 mmol/ L) on t w o separat e
occasions, or if t he 2-hour post prandial blood glucose is >200 mg/ dL
(>11. 1 mmol/ L) on t w o separat e occasions, G TT is not necessary f or a
diagnosis of diabet es mellit us t o be est ablished.
3. The G TT is of limit ed diagnost ic value f or children.
P.
4. The G TT should be post poned if t he pat ient becomes ill, even w it h
common illnesses such as t he f lu or a severe cold.
5. Record and report any react ions during t he t est . Weakness, f aint ness, and
sw eat ing may occur bet w een t he second and t hird hours of t he t est . I f t his
occurs, a blood sample f or a glucose level should be draw n immediat ely
and t he G TT abort ed.
6. Should t he pat ient vomit t he glucose solut ion, t he t est is declared invalid;
it can be repeat ed in 3 days (~72 hours).
Glycosylated Hemoglobin (Hb A1c ); Glycohemoglobin

(G-Hb); Glycated Hemoglobin (GhB); Diabetic Control
Index; Glycated Serum Protein (GSP), Fructosamine
Glycohemoglobin is a normal, minor type of
hemoglobin. Glycosylated hemoglobin is formed at a
rate proportional to the average glucose concentration
by a slow, nonenzymatic process within the red blood
cells (RBCs) during their 120-day circulating life span.
Glycohemoglobin is blood glucose bound to
hemoglobin. In the presence of hyperglycemia, an
increase in glycohemoglobin causes an increase in Hb
A 1c . If the glucose concentration increases because of
insulin deficiency, then glycosylation is irreversible.
G lycosylat ed hemoglobin values ref lect average blood sugar levels f or t he 2- t o
3-mont h period bef ore t he t est . This t est provides inf ormat ion f or evaluat ing
diabet ic t reat ment modalit ies (every 3 mont hs), is usef ul in det ermining
t reat ment f or juvenile-onset diabet es w it h acut e ket oacidosis, and t racks cont rol
of blood glucose in milder cases of diabet es. I t can be a valuable adjunct in

det ermining w hich t herapeut ic choices and direct ions (eg, oral ant ihypoglycemic
agent s, insulin, -cell t ransplant at ions) w ill be most eff ect ive. A blood sample
can be draw n at any t ime. The measurement is of part icular value f or specif ic
groups of pat ient s: diabet ic children, diabet ic pat ient s in w hom t he renal
t hreshold f or glucose is abnormal, unst able t ype 1 diabet ic pat ient s (t aking
insulin) in w hom blood sugar levels vary markedly f rom day t o day, t ype 2
diabet ic pat ient s w ho become pregnant , and persons w ho, bef ore t heir
scheduled appoint ment s, change t heir usual habit s, diet ary or ot herw ise, so t hat
t heir met abolic cont rol appears bet t er t han it act ually is.
Reference Values
Normal
Result s are expressed as percent age of t ot al hemoglobin. Values vary slight ly be
met hod and laborat ory.
G -Hb: 4. 0%7. 0%
Hb A 1c : 4. 0%6. 7% of t ot al hemoglobin H
Procedure
1. O bt ain a 5-mL venous blood sample w it h EDTA purple-t opped ant icoagulant
addit ive. Serum may not be used.
1. Values are f requent ly increased in persons w it h poorly cont rolled or new ly
diagnosed diabet es.
2. Wit h opt imal cont rol, t he Hb A 1c moves t ow ard normal levels.
3. A diabet ic pat ient w ho recent ly comes under good cont rol may st ill show
higher concent rat ions of glycosylat ed hemoglobin. This level declines
gradually over several mont hs as nearly normal glycosylat ed hemoglobin
replaces older RBCs w it h higher concent rat ions.
4. I ncreases in glycosylat ed hemoglobin occur in t he f ollow ing condit ions:
a. I ron-def iciency anemia
b. Splenect omy
c. Alcohol t oxicit y
d. Lead t oxicit y
5. Decreases in glycosylat ed hemoglobin occur in t he f ollow ing condit ions:
a. Hemolyt ic anemia
b. Chronic blood loss
c. Pregnancy
Interfering Factors
1. Presence of Hb F and H causes f alsely elevat ed values.
2. Presence of Hb S, C, E, D, G , and Lepore causes f alsely decreased values.
Interventions
1. Explain t est purpose and blood-draw ing procedure. O bserve st andard
precaut ions. Fast ing is not required.
2. Not e t hat t his t est is not meant f or short -t erm diabet es mellit us management ;
inst ead, it assesses t he eff icacy of long-t erm management modalit ies over
several w eeks or mont hs. I t is not usef ul more of t en t han 46 w eeks.

1. I nt erpret t est out come and counsel pat ient appropriat ely f or management of
diabet es. I f t est result s are not consist ent w it h clinical f indings, check t he
pat ient f or Hb F, w hich elevat es Hb A 1c result s.
care.
Clin ical Alert

A number of diff erent t est s can det ermine glycosylat ed hemoglobin levels. The
most specif ic of t hese measures is Hb A 1c . There are diff erent expect ed
values f or each t est . Keep in mind t hat Hb A 1 is alw ays 2% t o 4% higher t han
Hb A 1c . When int erpret ing result s, be cert ain of t he specif ic t est used.
Critical Valu e
1. G HB: >10. 1%
2. A 1c : >8. 1% (corresponds w it h glucose >200 mg/ dL or >11. 1 mmol/ L)
Lactose Tolerance; Breath Hydrogen Test Lactose

intolerance often begins in infancy, with symptoms of
diarrhea, vomiting, failure to thrive, and malabsorption.
The patient becomes asymptomatic when lactose is
removed from the diet. This syndrome is caused by a
deficiency of sugar-splitting enzymes (lactase) in the
intestinal tract.
This t est is act ually a G TT done t o diagnose int est inal disaccharidase (lact ase)
def iciency. G lucose is measured, and it is t he increase or lack of increase over
t he f ast ing specimen t hat is used f or t he int erpret at ion. Breat h samples reveal
increased hydrogen levels, w hich are caused by lact ose buildup in t he int est inal
t ract . Colonic bact eria met abolize t he lact ose and produce hydrogen gas.
Reference Values
Normal
Change in glucose f rom normal value of >30 mg/ dL or >1. 7 mmol/ L
I nconclusive: 2030 mg/ dL or 1. 11. 7 mmol/ L
Abnormal: <20 mg/ dL or <1. 1 mmol/ L
Hydrogen (breat h): <10 ppm increase f rom baseline is abnormal
Procedure
1. Follow inst ruct ion given f or t he G TT.
2. Draw a blood specimen f rom a f ast ing pat ient . The pat ient t hen drinks 50 g
of lact ose mixed w it h 200 mL of w at er (2 g lact ose/ kg body w eight ).
3. Draw blood lact ose samples at 0, 30-, 60-, and 90-minut e int ervals.
4. Take hydrogen breat h samples at t he same t ime int ervals as t he blood
specimens. Cont act your laborat ory f or collect ion procedures.
1. Lact ose int olerance occurs as f ollow s:
a. A f lat lact ose t olerance f inding (ie, no rise in glucose) point s t o a
def iciency of sugar-split t ing enzymes, as in irrit able bow el syndrome.
This t ype of def iciency is more prevalent in American I ndians, Af rican
Americans, Asians, and Jew s.
b. A monosaccharide t olerance t est such as t he glucose/ galact ose
t olerance t est should be done as a f ollow -up.
1. The pat ient ingest s 25 g of bot h glucose and galact ose.
2. A normal increase in glucose indicat es a lact ose def iciency.
c. Secondary lact ose def iciency f ound in:
1. I nf ect ious ent erit is
2. Bact erial overgrow t h in int est ines
3. I nf lammat ory bow el disease, Crohn's disease
4. G i ardi a l ambl i a inf est at ion
5. Cyst ic f ibrosis of pancreas
d. The hydrogen breat h t est is abnormal in t he lact ose def iciency t est
because:
a. Malabsorpt ion causes hydrogen (H2 ) product ion t hrough t he process
of f erment at ion of lact ose in t he colon.
b. The H2 f ormed is direct ly proport ional t o t he amount of t est dose
lact ose not digest ed by lact ase.
e. I n diabet es:
a. Blood glucose values may show increases of >20 mg/ dL (>1. 11
mmol/ L) despit e impaired lact ose absorpt ion.
b. I n diabet es, t here may be an abnormal lact ose t olerance curve due
t o f ault y met abolism, not necessarily f rom lact ose int olerance.
Interventions
1. Explain t est purpose and procedure. The pat ient must f ast f or 812 hours
bef ore t he t est .
2. Do not allow t he pat ient t o eat dark bread, peas, beans, sugars, or highf iber f oods w it hin 24 hours of t he t est .
3. Do not permit smoking during t he t est and f or 8 hours bef ore t est ing; no gum
chew ing.
4. Do not allow ant ibiot ics t o be t aken f or 2 w eeks bef ore t he t est unless
specif ically ordered.

1. Have t he pat ient resume normal diet and act ivit y.
2. I nt erpret t est result s and counsel appropriat ely. Pat ient s w it h irrit able bow el
syndrome w it h gas, bloat ing, abdominal pain, const ipat ion, and diarrhea have
lact ose def iciency. Rest rict ing milk int ake relieves sympt oms.
care.
END PRODUCTS OF M ETABOLISM AND OTHER TESTS

Ammonia (NH3 )
Ammonia, an end product of prot ein met abolism, is f ormed by bact eria act ing on
int est inal prot eins t oget her w it h glut amine hydrolysis in t he kidneys. The liver
normally removes most of t his ammonia via t he port al vein circulat ion and
convert s t he ammonia t o urea. Because any appreciable level of ammonia in t he
blood aff ect s t he body's acid-base balance and brain f unct ion, it s removal f rom
t he body is essent ial. The liver accomplishes t his by synt hesizing urea so t hat it
can be excret ed by t he kidneys.
Blood ammonia levels are used t o diagnose Reye's syndrome, t o evaluat e
met abolism, and t o det ermine t he progress of severe liver disease and it s
response t o t reat ment . Blood ammonia measurement s are usef ul in monit oring
pat ient s on hyperaliment at ion t herapy.
Reference Values
Normal
Adult s: 1556 g/ dL or 933 mol/ L

Children: 3685 g/ dL or 2150 mol/ L
10 days2 years: (<2 w eeks): 95157 g/ dL or 5692 mol/ L
Birt h10 days: 109182 g/ dL or 64107 mol/ L
Values t est somew hat higher in capillary blood samples. Values can vary great ly
w it h t est ing met hod used.
Procedure
1. O bt ain a 5-mL venous plasma sample f rom a f ast ing pat ient . A green-t opped
(heparin) or purple-t opped (EDTA) t ube may be used. O bserve st andard
precaut ions.
2. Place t he sample in an iced cont ainer. The specimen must be cent rif uged at
4C. Prompt ly remove plasma f rom cells. Perf orm t he t est w it hin 20 minut es
or f reeze plasma immediat ely.
3. Not e all ant ibiot ics t he pat ient is receiving; t hese drugs low er ammonia
levels.
Increased ammoni a l evel s occur in t he f ollow ing condit ions:
1. Reye's syndrome
2. Liver disease, cirrhosis
3. Hepat ic coma (does not ref lect degree of coma)
4. G I hemorrhage
5. Renal disease
6. HHH syndrome: hyperornit hinemia, hyperammonemia, homocit rullinuria
7. Transient hyperammonemia of new born
8. Cert ain inborn errors of met abolism or urea except f or
argininosuccinicaciduria
9. G I t ract inf ect ion w it h dist ent ion and st asis
10. Tot al parent eral nut rit ion
11. Uret erosigmoidost omy
Interfering Factors
1. Ammonia levels vary w it h prot ein int ake and many drugs.
2. Exercise may cause an increase in ammonia levels.
3. Ammonia levels may be increased by use of a t ight t ourniquet or by t ight ly
clenching t he f ist w hile samples are draw n.
4. Ammonia levels can rise rapidly in t he blood t ubes.
5. Hemolysed blood gives f alsely elevat ed levels.
Interventions
1. Explain t est purpose and procedure. I nst ruct t he pat ient t o f ast (if possible)
f or 8 hours bef ore t he blood t est . Wat er is permit t ed.
2. Do not allow t he pat ient t o smoke f or several hours bef ore t he t est (raises
levels).
care.

1. I nt erpret t est out comes, monit or appropriat ely, and begin t reat ment .
2. Remember t hat in pat ient s w it h impaired liver f unct ion demonst rat ed by
elevat ed ammonia levels, t he blood ammonia level can be low ered by
reduced prot ein int ake and by use of ant ibiot ics t o reduce int est inal bact eria
count s.
Clin ical Alert

Ammonia should be measured in all cases of unexplained let hargy and
vomit ing, in encephalit is, or in any neonat e w it h unexplained neurologic
det eriorat ion.
Bilirubin
Bilirubin result s f rom t he breakdow n of hemoglobin in t he red blood cells and is a

byproduct of hemolysis (ie, red blood cell dest ruct ion). I t is produced by t he
ret iculoendot helial syst em. Removed f rom t he body by t he liver, w hich excret es it
int o t he bile; it gives t he bile it s major pigment at ion. Usually, a small amount of
bilirubin is f ound in t he serum. A rise in serum bilirubin levels occurs w hen t here
is an excessive dest ruct ion of red blood cells or w hen t he liver is unable t o
excret e t he normal amount s of bilirubin produced.
There are t w o f orms of bilirubin in t he body: indirect or unconjugat ed bilirubin,
w hich is prot ein bound, and direct or conjugat ed bilirubin, w hich circulat es f reely
in t he blood unt il it reaches t he liver, w here it is conjugat ed w it h glucuronide
t ransf erase and t hen excret ed int o t he bile. An increase in prot ein-bound bilirubin
(unconjugat ed bilirubin) is more f requent ly associat ed w it h increased dest ruct ion
of red blood cells (hemolysis); an increase in f ree-f low ing bilirubin is more likely
seen in dysf unct ion or blockage of t he liver. A rout ine examinat ion measures
only t he t ot al bilirubin. A normal level of t ot al bilirubin rules out any signif icant
impairment of t he excret ory f unct ion of t he liver or excessive hemolysis of red
cells. O nly w hen t ot al bilirubin levels are elevat ed w ill t here be a call f or
diff erent iat ion of t he bilirubin levels by conjugat ed and unconjugat ed t ypes.
The measurement of bilirubin allow s evaluat ion of liver f unct ion and hemolyt ic
anemias. This t est is not suit able f or inf ant s younger t han 15 days (see Neonat al
Bilirubin on page 342).
Reference Values
Normal
Adult s
Tot al: 0. 31. 0 mg/ dL or 517 mol/ L
Conjugat ed (direct ): 0. 00. 2 mg/ dL or 0. 03. 4 mol/ L
Procedure
1. O bt ain a 5-mL nonhemolyzed sample f rom a f ast ing pat ient . O bserve
st andard precaut ions. Serum is used.
2. Prot ect t he sample f rom ult raviolet light (sunlight ).
3. Avoid air bubbles and unnecessary shaking of t he sample during blood
collect ion.
4. I f t he specimen cannot be examined immediat ely, st ore it aw ay f rom light and
in a ref rigerat or.
1. Total bi l i rubi n el evati ons accompani ed by jaundi ce may be due t o hepat ic,
obst ruct ive, or hemolyt ic causes.
a. Hepatocel l ul ar jaundi ce result s f rom injury or disease of t he parenchymal
cells of t he liver and can be caused by t he f ollow ing condit ions:
1. Viral hepat it is
2. Cirrhosis
3. I nf ect ious mononucleosis
4. React ions of cert ain drugs such as chlorpromazine
b. O bstructi ve jaundi ce is usually t he result of obst ruct ion of t he common
bile or hepat ic duct s due t o st ones or neoplasms. The obst ruct ion
produces high conjugat ed bilirubin levels due t o bile regurgit at ion.
c. Hemol yti c jaundi ce is due t o overproduct ion of bilirubin result ing f rom
hemolyt ic processes t hat produce high levels of unconjugat ed bilirubin.
Hemolyt ic jaundice can be f ound in t he f ollow ing condit ions:
1. Af t er blood t ransf usions, especially t hose involving many unit s
2. Pernicious anemia
3. Sickle cell anemia
4. Transf usion react ions (ABO or Rh incompat ibilit y)
5. Crigler-Najjar syndrome (a severe disease t hat result s f rom a genet ic
def iciency of a hepat ic enzyme needed f or t he conjugat ion of
bilirubin)
6. Eryt hroblast osis f et alis (see Neonat al Bilirubin, page 342)
d. Miscellaneous diseases
1. Dubin-Johnson syndrome
2. G ilbert 's disease (f amilial hyperbilirubinemia)
3. Nelson's disease (w it h acut e liver f ailure)
4. Pulmonary embolism/ inf arct
2. El evated i ndi rect unconjugated bi l i rubi n l evel s occur in t he f ollow ing
condit ions:
a. Hemolyt ic anemias due t o a large hemat oma
b. Trauma in t he presence of a large hemat oma
c. Hemorrhagic pulmonary inf arct s

d. Crigler-Najjar syndrome (rare)
e. G ilbert 's disease (conjugat ed hyperbilirubinemia; rare)
3. El evated di rect conjugated bi l i rubi n l evel s occur in t he f ollow ing condit ions:
a. Cancer of t he head of t he pancreas
b. Choledocholit hiasis
c. Dubin-Johnson syndrome
Interfering Factors
1. A 1-hour exposure of t he specimen t o sunlight or high-int ensit y art if icial light
at room t emperat ure w ill decrease t he bilirubin cont ent .
2. No cont rast media should be administ ered 24 hours bef ore measurement ; a
high-f at meal may also cause decreased bilirubin levels by int erf ering w it h
t he chemical react ions.
3. Air bubbles and shaking of t he specimen may cause decreased bilirubin
levels.
4. Cert ain f oods (eg, carrot s, yams) and drugs (see Appendix J) increase t he
yellow hue in t he serum and can f alsely increase bilirubin levels w hen t est s
are done using cert ain met hods (eg, spect rophot omet er).
5. Prolonged f ast ing raises t he bilirubin level, as does anorexia.
6. Nicot inic acid increases unconjugat ed bilirubin.
Clin ical Alert

Pan ic Valu e for Biliru bin in Adu lts >12 mg/dL or >200 mol/L
Interventions
1. Explain t est purpose and procedure and relat ion of result s t o jaundice.
2. Ensure t hat t he pat ient is f ast ing, if possible.
NOTE
Excessive amount s of bilirubin event ually seep int o t he t issues, w hich assume
a yellow hue as a result . This yellow color is a clinical sign of jaundice. I n
new borns, signs of jaundice may indicat e hemolyt ic anemia or congenit al
ict erus. Tot al bilirubin must be >2. 5 mg/ dL (>41. 6 mol/ L) t o det ect jaundice in
adult s.

Neonatal Bilirubin, Total and Fractionated (Baby Bili)

In newborns, signs of jaundice may indicate hemolytic
anemia or congenital icterus. If bilirubin levels reach a
critical point in the infant, damage to the CNS may
occur in a condition known as kernicterus. Therefore,
in these infants, the level of bilirubin is the deciding
factor in whether
or not to perform an exchange transfusion. Total
bilirubin must be >5.0 mg/dL to detect jaundice in
newborns.
Jaundice may also be seen in babies w ho are breast f eeding as a result of low
milk int ake and subsequent lack of vit amin Kdependent clot t ing f act ors. This
condit ion usually resolves w it hin 1 w eek.
Neonat al bilirubin is used t o monit or eryt hroblast osis f et alis (hemolyt ic disease
of t he new born), w hich usually causes jaundice in t he f irst 2 days of lif e. All
ot her causes of neonat al jaundice, including physiologic jaundice,
hemat oma/ hemorrhage, liver disease, and biliary disease, should also be
monit ored. Normal, f ull-t erm neonat es experience a normal, neonat al,
physiologic, t ransient hyperbilirubinemia by t he t hird day of lif e, w hich rapidly
f alls by t he f if t h t o t ent h day of lif e. This t est cannot be used af t er t he t ent h day
of lif e ow ing t o t he f ormat ion of endogenous carot enoids.
Reference Values
Normal
Newborns (07 days) Tot al: 1. 010. 0 mg/ dL or 17170 mol/ L
Conjugat ed (direct ): 0. 00. 8 mg/ dL or 0136 mol/ L
Unconjugat ed (indirect ): 0. 010. 0 mg/ dL or 0170 mol/ L
Cord blood t ot al:
Full t erm: <2. 5 mg/ dL or <43 mol/ L
Premat ure: <2. 9 mg/ dL or <50 mol/ L
See Table 6. 4 f or a comparison of premat ure and f ull-t erm inf ant s.
Table 6.4 Neonatal Total Comparison
Prem ature
(m g/dL)
SI Units
(m ol/L)
Full Term
(m g/dL)
SI Units
(m ol/L)
<24
h:
<8.0
<137
<6.0
<103
<48
h:
<12.0
<205
<10.0
<170
35
day:
<15.0
<256
<12.0
<205
7
day:
<15.0
<256
<10.0
<170
Note: Most labs are not doing conjugated and

unconjugated anymore.
Procedure
1. Draw blood f rom heel of new born using a capillary pipet t e and amber
Microt ainer t ube; 0. 5 mL of serum is needed. Cord blood may also be used.
2. Prot ect sample f rom light .
1. El evated total bi l i rubi n (neonat al) is associat ed w it h t he f ollow ing condit ions:
a. Eryt hroblast osis f et alis occurs as a result of blood incompat ibilit y
bet w een mot her and f et us.
1. Rh (D) ant ibodies and ot her Rh f act ors
2. ABO ant ibodies
3. O t her blood groups, including KI DD, KELL, and DUFFY (see Chapt er
8)
b. G alact osemia
c. Sepsis
d. I nf ect ious diseases (eg, syphilis, t oxoplasmosis, cyt omegalovirus)
e. Red blood cell enzyme abnormalit ies
1. G lucose-6-phosphat e dehydrogenase (G 6PD) def iciency
2. Pyruvat e kinase (PK) def iciency
3. Spherocyt osis
f. Subdural hemat oma, hemangiomas
2. El evated unconjugated (i ndi rect) neonatal bi l i rubi n is associat ed w it h t he
a. Eryt hroblast osis f et alis
b. Hypot hyroidism
c. Crigler-Najjar syndrome
d. O bst ruct ive jaundice
e. I nf ant s of diabet ic mot hers
3. El evated conjugated (di rect) neonatal bi l i rubi n is associat ed w it h t he
a. Biliary obst ruct ion
b. Neonat al hepat it is
c. Sepsis
Clin ical Alert

Pan ic Valu e for Neon atal Biliru bin >15 mg/dL or >256 mol/L
(men tal retardation can occu r)
Interventions
1. Explain t est purpose and procedure and it s relat ion t o jaundice t o t he
mot her.
2. See Chapt er 1 guidelines f or saf e, inf ormed, eff ect ive pretest care.

2. Be aw are t hat f or slight elevat ions (ie, <10. 0 mg/ dL or <170 mol/ L),
phot ot herapy may be init iat ed.
3. Monit or neonat al bilirubin levels t o det ermine indicat ion f or exchange
t ransf usion. Test s should be done every 12 hours in jaundiced new borns. See
Table 6. 5 f or exchange t ransf usion indicat ions.
Table 6.5 Indications for Exchange Transfusion
Birth
Weight (g)
Serum Bilirubin
(m g/dL)
Serum Bilirubin
(m ol/L)
<1000
10.0
170
10011250
13.0
222
12511500
15.0
256
15012000
17.0
291
20012500
18.0
309
>2500
20.0
>342
4. Transf use at one st ep earlier in t he presence of t he f ollow ing condit ions:

a. Coombs' t est posit ive
b. Serum prot ein <5 g/ dL
c. Met abolic acidosis (pH < 7. 25)
d. Respirat ory dist ress (w it h O2 <50 mm Hg or 6. 6 kPA)
e. Cert ain clinical f indings (eg, hypot hermia, CNS, or ot her clinical
det eriorat ion; sepsis; hemolysis)
O t her crit eria f or exchange t ransf usion are suddenness and rat e of bilirubin
increase and w hen such an increase occurs; f or example, an increase of 3 mg/ dL
(51 mol/ L) in 12 hours, especially af t er bilirubin has already leveled off , must
be f ollow ed by f requent serial det erminat ions, especially if it occurs on t he f irst
or sevent h day of lif e rat her t han on t he t hird day. Bew are of a rat e
of bilirubin increase of >1 mg/ dL (>17 mol/ L) during t he f irst day of lif e. Serum
bilirubin of 10 mg/ dL (170 mol/ L) af t er 24 hours or 15 mg/ dL (256 mol/ L) af t er
48 hours despit e phot ot herapy usually indicat es t hat serum bilirubin w ill reach 20
mg/ dL (342 mol/ L).
Blood Urea Nitrogen (BUN, Urea Nitrogen) Urea forms

in the liver and, along with CO2 , constitutes the final
product of protein metabolism. The amount of excreted
urea varies directly with dietary protein intake,
increased excretion in fever, diabetes, and increased
adrenal gland activity.
The t est f or BUN, w hich measures t he nit rogen port ion of urea, is used as an
index of glomerular f unct ion in t he product ion and excret ion of urea. Rapid
prot ein cat abolism and impairment of kidney f unct ion w ill result in an elevat ed
BUN level. The rat e at w hich t he BUN level rises is inf luenced by t he degree of
t issue necrosis, prot ein cat abolism, and t he rat e at w hich t he kidneys excret e
t he urea nit rogen. A markedly increased BUN is conclusive evidence of severe
impaired glomerular f unct ion. I n chronic renal disease, t he BUN level correlat es
bet t er w it h sympt oms of uremia t han does t he serum creat inine.
Reference Values
Normal
Adult s: 620 mg/ dL or 2. 17. 1 mmol/ L
Elderly pat ient s (>60 years): 823 mg/ dL or 2. 98. 2 mmol/ L
Children: 518 mg/ dL or 1. 86. 4 mmol/ L
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is pref erred.
1. Increased BUN l evel s (azotemi a) occur in t he f ollow ing condit ions:
a. I mpaired renal f unct ion caused by t he f ollow ing condit ions:
2. Salt and w at er deplet ion
3. Shock
4. St ress
5. Acut e MI
b. Chronic renal disease such as glomerulonephrit is and pyelonephrit is

c. Urinary t ract obst ruct ion
d. Hemorrhage int o G I t ract
e. Diabet es mellit us w it h ket oacidosis
f. Excessive prot ein int ake or prot ein cat abolism as occurs in burns or
cancer
g. Anabolic st eroid use
2. Decreased BUN l evel s are associat ed w it h t he f ollow ing condit ions:
a. Liver f ailure (severe liver disease), such as t hat result ing f rom hepat it is,
drugs, or poisoning
b. Acromegaly
c. Malnut rit ion, low -prot ein diet s
d. I mpaired absorpt ion (celiac disease)
e. Nephrot ic syndrome (occasional)
f. Syndrome of inappropriat e ant idiuret ic hormone (SI ADH)
Interfering Factors
1. A combinat ion of a low -prot ein and high-carbohydrat e diet can cause a
decreased BUN level.
2. The BUN is normally low er in children and w omen because t hey have less
muscle mass t han adult men.
3. Decreased BUN values normally occur in lat e pregnancy because of
increased plasma volume (physiologic hydremia).
4. O lder persons may have an increased BUN w hen t heir kidneys are not able
t o concent rat e urine adequat ely.
5. I V f eedings only may result in overhydrat ion and decreased BUN levels.
6. Many drugs may cause increased or decreased BUN levels.
Clin ical Alert

1. I f a pat ient is conf used, disorient ed, or has convulsions, t he BUN level
should be checked. I f t he level is high, it may help t o explain t hese signs
and sympt oms.
2. Panic value f or BUN is >100 mg/ dL (>35 mmol/ L).
Interventions
1. Explain t est purpose and blood-draw ing procedure. Assess diet ary hist ory.

1. I nt erpret t est out come and monit or as appropriat e f or impaired kidney
f unct ion.
2. Be aw are t hat in pat ient s w it h an elevat ed BUN level, f luid and elect rolyt e
regulat ion may be impaired.
Albumin
Albumin (along w it h t ot al prot ein) is a part of a diverse microenvironment . I t s
primary f unct ion is t he maint enance of colloidal osmot ic pressure (CO P) in t he
vascular and ext ravascular spaces (eg, urine, cerebrospinal f luid, and omniot ic
f luid). Albumin is a source of nut rit ion and also a part of a complex buff er
syst em. I t is a negat ive acut e-phase react ant . I t decreases in response t o
acut e inf lammat ory inf ect ious processes.
Albumin is used t o evaluat e nut rit ional st at us, albumin loss in acut e illness, liver
disease and renal disease w it h prot einuria, hemorrhage, burns, exudat es or
leaks in t he G I t ract , and ot her chronic diseases. Hypoalbuminuria is an
independent risk f act or f or older adult s f or mort alit yadmission serum albumin
in geriat ric pat ient s is a predict or of out come.
Reference Values
Normal
Children: 2. 95. 5 g/ dL or 2955 g/ L
Adult s: 3. 54. 8 g/ dL or 3548 g/ L
Af t er age 40 years and in persons living in subt ropics and t ropics (secondary t o
parasit ic inf ect ions), level slow ly declines.
Procedure
1. O bt ain 5 mL of serum in a light green t ube. Fast ing is not necessary.
2. Cent rif uge w it hin 30 minut es of blood draw. Place specimen in a biohazard
bag.
3. O bserve st andard procedures.
4. Urine specimens may also be collect ed (see Chapt er 3).
1. I ncreased albumin is not associat ed w it h any nat urally occurring condit ion.
When albumin is increased, t he only cause is decreased plasma w at er t hat
increases t he albumin proport ionally: dehydrat ion.
2. Decreased albumin is associat ed w it h t he f ollow ing condit ions:
a. Acut e and chronic inf lammat ion and inf ect ions
b. Cirrhosis, liver disease, alcoholism
c. Nephrot ic syndrome, renal disease (increased loss in urine)
d. Crohn's disease, colit is
e. Congenit al analbuminurea
f. Burns, severe skin disease
g. Heart f ailure
h. St arvat ion, malnut rit ion, malabsorpt ion, anorexia (decreased synt hesis)
i. Thyroid diseases: Cushing's disease, t hyrot oxicosis
Interfering Factors
Albumin is decreased in:
1. Pregnancy (last t rimest er, ow ing t o increased plasma volume)
2. O ral birt h cont rol (est rogens) and ot her drugs (see Appendix J)
3. Prolonged bed rest
4. I V f luids, rapid hydrat ion, overhydrat ion
Clin ical Alert

Panic range: <1. 5 g/ dL or 15 g/ L
Levels at 2. 02. 5 g/ dL or 2025 g/ L may be t he cause of edema.
Low levels occur w it h prolonged hospit al st ay.
Lipemic specimens w it h a high f at cont ent int erf ere.
Interventions
1. Explain t est purpose and specimen collect ion procedure. No f ast ing is
required.

1. I nt erpret t est out come and monit or appropriat ely. Explain possible need f or
t reat ment (replacement t herapy).
2. Low levels are associat ed w it h edema. Assess pat ient f or t hese signs and
sympt oms.
4. Be aw are t hat f urt her t est s may have t o be done:
a. Tot al prot ein
b. Prot ein elect rophoresis
c. 24-hour urine prot ein
Prealbumin (PAB)
I n 1995, t he Joint Commission on Accredit at ion of Healt hcare O rganizat ions
(JCAHO ) f irst issued st andards t hat hospit als assess a pat ient 's nut rit ional
st at us and t hat all pat ient s at risk f or malnut rit ion be ident if ied. Visceral prot eins
most of t en used in nut rit ion assessment include albumin, prealbumin, C-react ive
prot ein, and ret inol-binding prot ein. When used in combinat ion, t hey can very
accurat ely ref lect a subclinical def icit and assess response t o rest orat ive
t herapy.
For years albumin w as t he w idely accept ed marker f or malnut rit ion. How ever,
mount ing evidence point s t o prealbumin (PAB) as t he bet t er choice. Because

albumin has a half -lif e of 21 days, it is slow t o respond t o a pat ient 's recent
increase in nut rient s and, t heref ore, is not a good indicat or of recent changes in
prot ein levels. I n cont rast , prealbumin responds more rapidly and gives a t imelier
pict ure of a change in diet ary st at us. Because of it s short half -lif e (2 days), PAB
responds quickly t o a decrease in nut rit ional int ake and nut rit ional rest orat ion. I t
ref lect s t he current nut rit ional st at us w it hin a pat ient 's body, not t he st at us f rom
3 w eeks ago.
Reference Values
Normal
1938 mg/ dL (190380 mg/ L) by nephelomet ry
Procedure
1. Collect 7-mL blood serum sample in a red-t opped t ube. O bserve st andard
precaut ions.
2. Place specimen in a biohazard bag f or t ransport t o t he laborat ory.
1. Hospit al laborat ories, in conjunct ion w it h diet icians, administ rat ion,
pharmacist s, nurses, and physicians, may develop a clinical pat hw ay t hat
includes running a PAB upon admission of each surgical, I CU, and medicinal
pat ient .
2. Values of 05, 510, and 1015 mg/ dL (050, 50100, and 100150 mg/ L)
indicat e severe, moderat e, and mild prot ein deplet ion, respect ively.
Interventions
1. Explain t est purpose. PAB is usef ul in assessing nut rit ional st at us, especially
in monit oring t he response t o nut rit ional support in t he acut ely ill pat ient .
2. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, inf ormed, pretest
care.

1. I nt erpret t est out comes and det ermine t he need f or possible f ollow -up
t est ing. Hospit al prot ocol may require pat ient s t o be ret est ed t w ice a w eek
unt il discharge if t heir PAB level is less t han 18 mg/ dL (<180 mg/ L). Possible
t reat ment includes replacement / rest orat ive t herapy.
care.
Cholinesterase, Serum (Pseudocholinesterase);

Cholinesterase, Red Blood Cell (Acetylcholinesterase)
The cholinesterase of serum is referred to as
pseudocholinesterase to distinguish it from the true
cholinesterase of the red blood cell (RBC). Both of
these enzymes act on acetylcholine and other
cholinesters. Alkylphosphates are potent inhibitors of
both serum and RBC cholinesterase.
Pat ient s w ho are homozygous f or t he at ypical gene t hat cont rols serum
cholinest erase act ivit y have low levels of cholinest erase t hat are not inhibit ed by
dibucaine. Persons w it h normal serum cholinest erase act ivit y show 70% t o 90%
inhibit ion by dibucaine.
The red cell (t rue cholinest erase) enzyme is specif ic f or t he subst rat e
acet ylcholine.
These are t w o separat e t est s. The primary use of serum cholinest erase
measurement (pseudocholinest erase) is t o monit or t he eff ect of muscle relaxant s
(eg, succinylcholine), w hich are used in surgery. Pat ient s f or w hom
suxamet honium anest hesia is planned should be t est ed using t he dibucaine
inhibit ion t est f or t he presence of at ypical cholinest erase variant s t hat are
incapable of hydrolyzing t his w idely used muscle relaxant .
The RBC cholinest erase t est is used w hen poisoning by pest icides such as
Parat hion or Malat hion is suspect ed. Severe insect icide poisoning causes
headaches, visual dist ort ions, nausea, vomit ing, pulmonary edema, conf usion,
convulsions, reparat ory paralysis, and coma.
Reference Values
Normal
Serum cholinest erase: 4. 911. 9 U/ mL or 4. 911. 9 ( 1. 00) kU/ L

Dibucaine inhibit ion: 79%84%
RBC cholinest erase 3040 U/ g hemoglobin Values vary w it h subst rat e and
met hod. These are t w o diff erent t est s. Values are low at birt h and f or t he f irst 6
mont hs of lif e
Procedures
1. For serum cholinest erase, obt ain a 5-mL blood sample; 3 mL of serum is
needed. This is st able f or 1 w eek at 425C. O bserve st andard
precaut ions.
2. For RBC cholinest erase, draw a blood sample using sodium heparin as an
ant icoagulant ; do not use serum. O bserve st andard precaut ions. This is
st able f or 1 w eek at 425C.
1. Decreased or no serum chol i nesterase occurs in t he f ollow ing condit ions:
a. Congenit al inherit ed recessive disease. These pat ient s are not able t o
hydrolyze drugs such as muscle relaxant s used in surgery. These
pat ient s may have a prolonged period of apnea and may die if t hey are
given succinlycholine.
b. Poisoning f rom organic phosphat e insect icides.
c. Liver diseases, hepat it is, cirrhosis w it h jaundice
d. Condit ions t hat may have decreased blood albumin, such as malnut rit ion,
anemia, inf ect ions, skin diseases, and acut e MI
2. Decreased RBC chol i nesterase l evel s occur in t he f ollow ing condit ions:
a. Congenit al inherit ed recessive disease
b. O rganic phosphat e poisoning
c. Paroxysmal noct urnal hemoglobinemia
d. Megaloblast ic anemia (ret urns t o normal w it h t herapy)
3. Increased serum chol i nesterase is associat ed w it h
a. Type I V hyperlipidemia
b. Nephrosis
c. O besit y
d. Diabet es
4. Increased RBC chol i nesterase is associat ed w it h:
a. Ret iculocyt osis
b. Sickle cell anemia
c. Hemolyt ic anemias
5. Increased RBC chol i nesterase in amniot ic f luid, along w it h elevat ed AFP, is
presumpt ive evidence of open neural t ube def ect (not normally present in
amniot ic f luid)
Interventions
1. Explain t est purpose and procedure
2. Draw blood f or serum cholinest erase 2 days bef ore surgery.
3. Be aw are t hat blood should not be draw n in t he recovery room; prior
administ rat ion of surgical drugs and anest hesia invalidat es t he t est result s.

1. I nt erpret t est out come and counsel appropriat ely.
2. Consider pat ient s exhibit ing <70% inhibit ion as an at ypical cholinest erase
variant , and be aw are t hat t he administ rat ion of succinylcholine or similar
t ype drugs may pose a risk.
Clin ical Alert

1. I n indust rial exposure, w orkers should not ret urn t o w ork unt il
cholinest erase values rise t o at least 75% of normal. Red blood cell
cholinest erase regenerat es at t he rat e of 1% per day. Plasma
cholinest erase regenerat es at t he rat e of 25% in 7 t o 10 days and ret urns
t o baseline in 4 t o 6 w eeks.
2. Cholinest erase act ivit y is complet ely and irreversibly inhibit ed by
organophosphat e pest icides.
Creatinine
Creat inine is a byproduct in t he breakdow n of muscle creat ine phosphat e
result ing f rom energy met abolism. I t is produced at a const ant rat e depending on
t he muscle mass of t he person and is removed f orm t he body by t he kidneys.
Product ion of creat inine is const ant as long as muscle mass remains const ant . A
disorder of kidney f unct ion reduces excret ion of creat inine, result ing in increased
blood creat inine levels. Thus, creat inine levels give an approximat ion of t he
glomerular f ilt rat ion rat e.
This t est diagnoses impaired renal f unct ion. I t is a more specif ic and sensit ive
indicat or of kidney disease t han BUN, alt hough in chronic renal disease, bot h
BUN and creat inine are ordered t o evaluat e renal problems because t he
BUN/ creat inine rat io provides more inf ormat ion.
Reference Values
Normal
Adult men: 0. 91. 3 mg/ dL or 80115 mol/ L
Adult w omen: 0. 61. 1 mg/ dL or 5397 mol/ L
Children (318 years): 0. 51. 0 mg/ dL or 4488 mol/ L
Young children (03 years): 0. 30. 7 mg/ dL or 2762 mol/ L
BUN/ creat inine rat io: 10: 1 t o 20: 1
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is pref erred, but heparinized
blood can be used. Place specimen in a biohazard bag.
1. Increased bl ood creati ni ne l evel s occur in t he f ollow ing condit ions:
a. I mpaired renal f unct ion
b. Chronic nephrit is
c. O bst ruct ion of urinary t ract

d. Muscle disease
1. G igant ism
2. Acromegaly
3. Myast henia gravis
4. Muscular dyst rophy
5. Poliomyelit is
f. Shock
g. Dehydrat ion
h. Rhabdomyolysis
i. Hypert hyroidism
2. Decreased creati ni ne l evel s occur in t he f ollow ing condit ions:
a. Small st at ure
b. Decreased muscle mass
c. Advanced and severe liver disease
d. I nadequat e diet ary prot ein
e. Pregnancy (0. 40. 6 mg/ dL or 3653 mol/ L is normal; >0. 8 mg/ dL or >71
mol/ L is abnormal and should be not ed)
3. Increased rati o (>20: 1) w it h normal creat inine occurs in t he f ollow ing
condit ions:
a. I ncreased BUN (prerenal azot emia), heart f ailure, salt deplet ion,
dehydrat ion
b. Cat abolic st at es w it h t issue breakdow n
c. G I hemorrhage
d. I mpaired renal f unct ion plus excess prot ein int ake, product ion, or t issue
breakdow n
4. Increased rati o (>20: 1) w it h elevat ed creat inine occurs in t he f ollow ing
condit ions:
a. O bst ruct ion of urinary t ract
b. Prerenal azot emia w it h renal disease
5. Decreased rati o (<10: 1) w it h decreased BUN occurs in t he f ollow ing
condit ions:
b. Decreased urea synt hesis as in severe liver disease or st arvat ion

c. Repeat ed dialysis
d.
SIADH
e. Pregnancy
6. Decreased rati o (<10: 1) w it h increased creat inine occurs in t he f ollow ing
condit ions:
a. Phenacemide t herapy (accelerat es conversion of creat ine t o creat inine)
b. Rhabdomyolysis (releases muscle creat inine)
c. Muscular pat ient s w ho develop renal f ailure
Interfering Factors
1. High levels of ascorbic acid and cephalosporin ant ibiot ics can cause a f alsely
increased creat inine level; t hese agent s also int erf ere w it h BUN/ creat inine
rat io.
2. Drugs t hat inf luence kidney f unct ion plus ot her medicat ions can cause a
change in t he blood creat inine level (see Appendix J).
3. A diet high in meat can cause increased creat inine levels.
4. Creat inine is f alsely decreased by bilirubin, glucose, hist idine, and quinidine
compounds.
5. Ket oacidosis may increase serum creat inine subst ant ially.
Clin ical Alert

1. Panic value is 10 mg/ dL or 890 mol/ L in nondialysis pat ient s.
2. Creat inine level should alw ays be checked bef ore administ ering
nephrot oxic chemot herapeut ics such as met hot rexat e, cisplat in,
cyclophosphamide, mit hramycin, and semust ine.
Interventions
2. Assess diet f or meat and prot ein int ake.

1. I nt erpret t est result s and monit or as appropriat e f or impaired renal f unct ion.
Cystatin C
Cyst at in C is a low -molecular-w eight prot ein inhibit or f ound in blood serum and is
an indicat or of glomerular f ilt rat ion in kidney f unct ion.
This t est is done t o assess glomerular f ilt rat ion rat e (G FR) in t he elderly.
Cyst at in C may be a more reliable indicat or of renal f unct ion in t he elderly t han
is t he creat inine level. G FR and kidney size decline w it h age and t hus creat inine
levels may be unreliable as an indicat or of G FR.
Reference Values
Normal
Young adult s: <0. 70 mg/ mL (<2. 9 mol/ mL) Elderly adult s: <0. 85 mg/ mL (<3. 5
mol/ mL)
Procedure
1. No f ast ing is required.
2. O bt ain a venous blood sample.
Cyst at in C levels abnormally increase in associat ion w it h impaired renal f unct ion
and loss of kidney homeost asis, as in acut e renal f ailure, chronic renal f ailure,
diabet ic nephropat hy, and inf ect ions.
Interventions
1. Explain purpose and sampling procedure f or cyst at in C.
2. Assess f or signs of abnormal kidney f unct ion (hypert ension, pain, edema,
uremia, disorders of urinat ion, and urine composit ion). Some condit ions have
no sympt oms of nephrot ic syndrome.
Posttest Patient Care

1. I nt erpret out comes and provide t he pat ient w it h support and counseling.
2. Explain f ollow -up t est ing and possible t reat ment f or kidney disease.
Uric Acid
Uric acid is f ormed f rom t he breakdow n of nucleonic acids and is an end product
of purine met abolism. Uric acid is t ransport ed by t he plasma f rom t he liver t o t he
kidney, w here it is f ilt ered and w here about 70% is excret ed. The remainder of
uric acid is excret ed int o t he G I t ract and degraded. A lack of t he enzyme
uricase allow s t his poorly soluble subst ance t o accumulat e in body f luids.
The basis f or t his t est is t hat an overproduct ion of uric acids occurs w hen t here
is excessive cell breakdow n and cat abolism of nucleonic acids (as in gout ),
excessive product ion and dest ruct ion of cells (as in leukemia), or an inabilit y t o
excret e t he subst ance produced (as in renal f ailure). Measurement of uric acid is
used most commonly in t he evaluat ion of renal f ailure, gout , and leukemia. I n
hospit alized pat ient s, renal f ailure is t he most common cause of elevat ed uric
acid levels, and gout is t he least common cause.
Reference Values
Normal
Men: 3. 47. 0 mg/ dL or 202416 mol/ L
Women: 2. 46. 0 mg/ dL or 143357 mol/ L
Children: 2. 05. 5 mg/ dL or 119327 mol/ L
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is pref erred; heparinized blood
is accept able. Place specimen in a biohazard bag.
1. El evated uri c aci d l evel s (hyperuri cemi a) occur in t he f ollow ing condit ions:
a. G out (t he amount of increase is not direct ly relat ed t o t he severit y of t he
disease)
b. Renal diseases and renal f ailure, prerenal azot emia
c. Alcoholism (et hanol consumpt ion)
d. Dow n syndrome
e. Lead poisoning
f. Leukemia, mult iple myeloma, lymphoma
g. Lesch-Nyhan syndrome (heredit ary gout )
h. St arvat ion, w eight -loss diet s
i. Met abolic acidosis, diabet ic ket oacidosis
j. Toxemia of pregnancy (serial det erminat ion t o f ollow t herapy)
k. Liver disease
l. Hyperlipidemia, obesit y
m. Hypoparat hyroidism, hypot hyroidism
n. Hemolyt ic anemia, sickle cell anemia
o. Follow ing excessive cell dest ruct ion, as in chemot herapy and radiat ion
t reat ment (acut e elevat ion somet imes f ollow s t reat ment )
p. Psoriasis
q. G lycogen st orage disease (G 6PD def iciency)
2. Decreased l evel s of uri c aci d occur in t he f ollow ing condit ions:
a. Fanconi's syndrome
b. Wilson's disease
c.
SIADH
d. Some malignancies (eg, Hodgkin's disease, mult iple myeloma)

e. Xant hinuria (def iciency of xant hine oxidase)
Interfering Factors
1. St ress and st renuous exercise w ill f alsely elevat e uric acid.
2. Many drugs cause increase or decrease of uric acid (see Appendix J).
3. Purine-rich diet (eg, liver, kidney, sw eet breads) increases uric acid levels.
4. High levels of aspirin decrease uric acid levels.
5. Low purine int ake, coff ee, and t ea decrease uric acid levels.
Interventions
1. Advise pat ient of t est purpose and blood-draw ing procedure; f ast ing is
pref erred.
2. Promot e relaxat ion; avoid st renuous exercise.

2. I nt erpret t est result s and monit or appropriat ely f or renal f ailure, gout , or
leukemia. Uric acid level should f all in pat ient s w ho are t reat ed w it h
uricosuric drugs such as allopurinol, probenecid, and sulf inpyrazone.
Clin ical Alert

1. Monit or uric acid levels during t reat ment of leukemia.
2. Acut e, dangerous levels may occur f ollow ing administ rat ion of cyt ot oxic
drugs.
Lead (Pb)
Lead is absorbed int o t he body t hrough bot h t he respirat ory and G I t ract s. I t
also moves t ransplacent ally t o t he f et us. Absorpt ion t hrough t hese diff erent
rout es varies and is aff ect ed by age, nut rit ional st at us, part icle size, and
chemical f orm of t he lead. Absorpt ion is inversely proport ional t o part icle size;
t his f act or makes lead-bearing dust import ant . Adult s absorb 6% t o 10% of
diet ary lead and ret ain very lit t le of it ; how ever, children f rom birt h t o 2 years of
age have been show n t o absorb 40% t o 50% and t o ret ain 20% t o 25% of
diet ary lead. Spont aneous
excret ion of lead in urine by inf ant s and young t oddlers is normally about 1
g/ kg/ 24 hours, w hich may increase somew hat in cases of acut e poisoning.
Diet ary int ake of lead is <1 g/ kg of lead, w hich provides a margin of saf et y in
t he sense t hat a child goes int o posit ive lead balance w hen int ake exceeds 5
g/ kg of body w eight . Early sympt oms of lead poisoning include anorexia, apat hy
or irrit abilit y, f at igue, and anemia. Toxic eff ect s include G I dist ress, joint pain,
colic, headache, st upor, convulsions, and coma. Anot her t est t hat may be used
t o evaluat e lead int oxicat ion is f ree eryt hrocyt e prot oporphyrin. How ever, a blood
lead assay is t he def init ive t est .
The blood lead assay is used t o screen adult s and children f or lead poisoning
(plumbism). I n adult s, high levels are caused mainly by indust rial exposure f rom
lead-based paint s, gasoline, and ceramics. High-risk children usually are aged 3
t o 12 years and live in or visit old or dilapidat ed housing w it h lead-based paint . A
single paint chip can cont ain as much as 10, 000 g of lead.
Reference Values
Normal
010 g/ dL or 00. 48 mol/ L
Procedure
1. O bt ain a sample by f inger st ick using lead-f ree heparinized capillary t ubes or
venous blood draw n in a 3-mL t race element f ree t ube. Place specimen in a
lead-f ree biohazard bag or cont ainer.
2. Do not separat e plasma f rom cells. Ref rigerat e t he sample.
Blood lead levels in adult s:

1. <10 g/ dL or <0. 48 mol/ L: normal w it hout occupat ional exposure
2. <20 g/ dL or <0. 97 mol/ L: accept able w it h occupat ional exposure
3. >40 g/ dL or >1. 9 mol/ L: report t o st at e occupat ional agency
4. >60 g/ dL or >2. 9 mol/ L: remove f rom occupat ional exposure and begin
chelat ion t herapy
Table 6. 6 list s t he U. S. Cent ers f or Disease Cont rol and Prevent ion (CDC)
classif icat ions f or levels of blood lead. See Table 6. 7 f or t he eff ect s of blood
lead in children.
Table 6.6 U.S Centers for Disease Control and

Prevention Classifications of Blood Lead Levels
Class
Blood Lead*
Action
<10 g/dL or
0.48 mol/L
Not lead poisoned
IIA
1014 g/dL or
0.480.68
mol/L
Rescreen frequently and

consider prevention
activities
IIB
1519 g/dL or
0.720.92
mol/L
Institute nutritional and

educational interventions
2044 g/dL or
III
0.972.1
mol/L
Evaluate environment and

consider chelation therapy
IV
4569 g/dL or
2.173.33
mol/L
Institute environmental
intervention and chelation
therapy
>69 g/dL or
3.33 mol/L
Medical emergency
*Owing to possible contamination during collection,

elevated levels should be confirmed with a second
specimen before therapy is instituted.
Table 6.7 Effects of Increased Blood Lead Levels on

Children
Blood Lead Level
Effects in Children
>10 g/dL or >0.48

mol/L
Reduced IQ, hearing, and

growth
>20 g/dL or >0.97

mol/L
Impaired nerve function
>30 g/dL or >1.45
Reduced vitamin D
mol/L
metabolism
>40 g/dL or >1.93

mol/L
Damage to blood-forming
system
>50 g/dL or >2.41

mol/L
Severe stomach cramps
>60 g/dL or >2.90

mol/L
Severe anemia
>80 g/dL or >3.86

mol/L
Severe brain damage
>125 g/dL or >6.04

mol/L
Death
Source: President's Task Force on Environmental

Health Risks and Safety Risks to Children: Federal
strategy to eliminate childhood lead poisoning, March
2002 (Online) Accessible at www.hud.gov/lea
Interfering Factors
1. Failing t o use lead-f ree Vacut ainer t ubes invalidat es result s.
2. An elevat ed level should be conf irmed w it h a new second specimen t o ensure
t hat t he specimen w as not cont aminat ed.
Clin ical Alert

1. Crit ical values:
a. <15 years of age, >20 g/ dL or >0. 97 mol/ L; 15 years of age, >30
g/ dL or >1. 45 mol/ L
b. Pat ient s w it h blood lead concent rat ions >80 g/ dL or >3. 86 mol/ L
(panic value) should be hospit alized immediat ely and t reat ed as
medical emergencies.
c. A single lead det erminat ion cannot dist inguish bet w een chronic and
acut e exposure.
2. Follow ing chelat ion t herapy, lead levels are assessed at varying int ervals,
and it is not unusual t o see a slight increase due t o lead leeching f rom
bones.
3. Pregnant w omen w it h blood lead levels (BLL) > 10 g/ dL or >0. 48 mol/ L
are at risk f or delivering a child w it h a BLL also > 10 g/ dL or >0. 48
mol/ L.
Interventions
2. Explain t he import ance of f ollow -up if lead levels are elevat ed.

2. I nt erpret t est result s, counsel, and monit or appropriat ely f or elevat ed lead
levels. Explain chelat ion t herapy and possible need f or f urt her t est ing, eg,
iron def iciency and blood prot oporphyrins.
a. Parent al compliance is necessary. Parent educat ion about lead poisoning
can be given f ace-t o-f ace, by pamphlet dist ribut ion, or in bot h w ays.
b. The most import ant component of medical management is t o f acilit at e
reduct ion in t he child's exposure t o t he environment al lead. I n providing
int ervent ion f or t he child w it h an elevat ed blood lead level, t he init ial st ep
is t o obt ain a det ailed environment al hist ory. The causes of childhood
lead poisoning are mult iple and must t ake int o account pot ent ial
environment al hazards as w ell as charact erist ics of t he individual child.
O nce a child is f ound t o have lead int oxicat ion, all pot ent ial sources must
be ident if ied and removed f rom t he child's environment .
c. The recommended diet f or a child w it h lead t oxicit y is simply a good diet
w it h adequat e prot ein and mineral int ake and limit at ion of excess f at . I t
is no longer necessary t o exclude canned f oods and beverages w hen t he
cans are manuf act ured in t he Unit ed St at es because t he manuf act ure of
cans w it h lead-soldered seams ended in t he Unit ed St at es in 1991.
d. I ron def iciency can enhance absorpt ion and t oxicit y of lead and of t en
coexist s w it h overexposure t o lead. All children w it h a blood lead
concent rat ion >20 g/ dL or >0. 97 mol/ L w hole blood should have
appropriat e t est ing f or iron def iciency.
e. I n class I V lead int oxicat ion, chelat ion is necessary. Chelat ion t herapy
must be done in conjunct ion w it h eliminat ing t he source of t he lead
poisoning. Chelat ion t herapy, w hen prompt ly administ ered, can be lif esaving and can reduce t he period of morbidit y associat ed w it h lead
t oxicit y.
f. Addit ional f ollow -up t est s may be ordered, including f ree eryt hrocyt e
prot oporphyrin or eryt hrocyt e HNC prot oporphyrin.
Osteocalcin (Bone G1a Protein) Osteocalcin, also

referred to as bone G1a protein, is a protein produced
by the osteoblasts and dentin and has a function in
bone mineralization and calcium ion homeostasis. A
small amount of osteocalcin, an integral part in bone
formation, is released into the blood and therefore can
serve as a marker for recent bone formation.
Osteocalcin levels are influenced by age (rapid
growth), gender (males somewhat higher), and are
increased during menopause. This test is used to
screen for osteoporosis in postmenopausal women,
assess risk for fractures, and determine eligibility for
treatment for osteoporosis. Osteocalcin is a specific
marker for bone formation and is regulated by 1, 25dehydroxy vitamin D.
Reference Values
Normal
O st eocalcin: 8. 1 4. 6 g/ L or 1. 4 0. 8 nmol/ L
Carboxylat ed ost eocalcin: 9. 9 0. 5 g/ L or 1. 7 0. 1 nmol/ L
Undercarboxylat ed ost eocalcin: 3. 7 1. 0 g/ L or 0. 6 0. 2 nmol/ L
Normal Using RIA

Adult male: 3. 013. 0 ng/ mL or 3. 013. 0 g/ L
Premenopausal f emale: 0. 48. 2 ng/ mL or 0. 48. 2 g/ L
Post menopausal f emale: 1. 511. 0 ng/ mL or 1. 511. 0 g/ L
There is a diurnal variat ion, a peak during t he night and a decrease in t he
morning.
Procedure
Collect a venous blood sample of serum on ice, separat e w it hin 1 hour, and
immediat ely f reeze. Avoid a f reezet haw cycle.
Interfering Factors
1. I ncreased during bed rest and no increase in bone f ormat ion.
2. I ncreased w it h impaired renal f unct ion and no increase in bone f ormat ion.
1. Abnormally increased levels indicat e increased bone f ormat ion in persons
w it h hyperparat hyroidism, f ract ures, and acromegaly.
2. Decreased levels are associat ed w it h hypoparat hyroidism, a def iciency of
grow t h hormone, and medicat ions such as glucocort icoids, bisphosphonat es,
and calcit onin.
Interventions
1. Explain purpose and procedure of t est . Record age and menopausal st at e.
Tell pat ient t hat t he risk f or ost eoporosis st eadily increases w it h age. Also
obt ain pert inent personal and f amily hist ory of ost eoporet ic f ract ures, hist ory
of f alls, et c.
2. Follow Chapt er 1 guideline f or saf e, eff ect ive, inf ormed pretest care .

1. I nt erpret t est out comes and counsel regarding f urt her t est s (eg, dual-energy
x-ray absorpt iome [ DXA] [ bone densit y of t he f emoral neck] or quant it at ive
ult rasound) and possible t reat ment (eg, medical: alendronat e, raloxif ene).
Sixt een percent of post menopausal w omen w ill be f ound t o have lumbar
spine ost eoporosis. O t her blood t est markers of bone resorpt ion include
pyridinolines, t elopept ides, acid phosphat ase, and urine t est s of
hydroxyproline and galact osyl hydroxlysine. These markers are know n as
collagen cross-links.
2. See Chapt er 1 f or saf e, eff ect ive, inf ormed posttest care .
HORM ONE TESTS

Androstenedione
Androst enedione is one of t he major androgens produced by t he ovaries in
f emales, and t o a lesser ext ent in t he adrenal in bot h genders. This hormone is
convert ed t o est rogens by hepat ic enzymes. Levels rise sharply af t er pubert y
and peak at age 20 years.
This hormone measurement is helpf ul in t he evaluat ion of condit ions
charact erized by hirsut ism and virilizat ion. I n f emales, t here is poor correlat ion
of plasma levels w it h clinical severit y.
Reference Values
Normal
New borns: 20290 ng/ dL or 0. 710. 1 mmol/ L
Prepubert y: 850 ng/ dL or 0. 31. 7 mmol/ L
Women: 75205 ng/ dL or 2. 67. 2 mmol/ L
Men: 85275 ng/ dL or 3. 09. 6 mmol/ L
Post menopausal w omen: <10 ng/ dL or 0. 35 mmol/ L (abrupt decline at
menopause) Diff erent laborat ories may have variat ion in ref erence values.
Procedure
1. O bt ain a 5-mL venous blood sample in t he morning and place on ice. Serum
or EDTA can be used. O bserve st andard precaut ions. Place specimen in a
biohazard bag.
2. I n w omen, collect t his specimen 1 w eek bef ore or af t er t he menst rual period.
Record dat e of last menst rual period on t he laborat ory f orm.
1. Increased androstenedi one val ues are associat ed w it h t he f ollow ing
condit ions:
a. St ein-Levent hal syndrome
b. Cushing's syndrome
c. Cert ain ovarian t umors (polycyst ic ovarian syndrome)
d. Ect opic ACTH-producing t umor

e. Lat e-onset congenit al adrenal hyperplasia
f. O varian st romal hyperplasia
g. O st eoporosis in f emales
2. Decreased androstenedi one val ues are f ound in t he f ollow ing condit ions:
a. Sickle cell anemia
b. Adrenal and ovarian f ailure
Clin ical Alert

>1000 mg/ dL or >34. 9 mmol/ L (suggest s virilizing t umor)
Interventions
1. Explain purpose of t est and blood-draw ing procedure. O bt ain pert inent
hist ory of signs and sympt oms (eg, excessive hair grow t h and inf ert ilit y).
2. Ensure t hat pat ient is f ast ing and t hat blood is draw n at peak product ion
(7: 00 a. m. ). Low est levels are at 4: 00 p. m.
3. Collect specimen 1 w eek bef ore menst rual period in w omen.

2. I nt erpret t est result s and counsel appropriat ely f or ovarian and adrenal
dysf unct ion.
Aldosterone
Aldost erone is a mineralocort icoid hormone produced in t he adrenal zona
glomerulosa under complex cont rol by t he renin-angiot ensin syst em. I t s act ion is
on t he renal dist al t ubule, w here it increases resorpt ion of sodium and w at er at
t he expense of increased pot assium excret ion.
This t est is usef ul in det ect ing primary or secondary aldost eronism. Pat ient s w it h
primary aldost eronism charact erist ically have hypert ension, muscular pains and
cramps, w eakness, t et any, paralysis, and polyuria. I t is also used t o evaluat e
causes of hypert ension (f ound in 1% of hypert ension cases).
NOTE
A random aldost erone t est is of no diagnost ic value unless a plasma renin
act ivit y is done at t he same t ime.
Reference Values
Normal (In upri ght posi ti on) Adult s: 730 ng/ dL or 0. 190. 83 nmol/ L
Adolescent s: 448 ng/ dL or 0. 111. 33 nmol/ L
Children: 580 mg/ dL or 0. 142. 22 nmol/ L
Low -sodium diet : values 35 t imes higher
Procedure
1. Take plasma w it h t he pat ient in an upright posit ion f or 2 hours and w it h
unrest rict ed salt int ake.
2. O bt ain a 5-mL venous blood specimen in a heparinized or EDTA Vacut ainer
t ube. Serum, EDTA, or heparinized blood may be used. The cells must be
separat ed f rom plasma immediat ely. Blood should be draw n w it h pat ient
sit t ing. O bserve st andard precaut ions.
3. Specif y and record t he t ime of t he venipunct ure. Circadian rhyt hm exist s in
normal subject s, w it h levels of aldost erone peaking in t he morning. Specif y if
t he blood has been draw n f rom t he adrenal vein (values are much higher:
200800 ng/ dL or 5. 522. 6 mmol/ L).
4. Be aw are t hat a 24-hour urine specimen w it h boric acid preservat ive may
also be ordered. Ref rigerat e immediat ely f ollow ing collect ion.
5. Have pat ient f ollow a normal sodium diet 24 w eeks bef ore t est .
6. Ensure t hat low pot assium is t reat ed bef ore t est .
1. El evated l evel s of al dosterone (pri mary al dosteroni sm) occur in t he
a. Aldost erone-producing adenoma (Conn's disease)
b. Adrenocort ical hyperplasia (pseudoprimary aldost eronism)
c. I ndet erminat e hyperaldost eronism
d. G lucocort icoid remediable hyperaldost eronism

2. Secondary al dosteroni sm, in w hich aldost erone out put is elevat ed because
of ext ernal st imuli or great er act ivit y in t he renin-angiot ensin syst em, occurs
a. Salt deplet ion
b. Pot assium loading
c. Laxat ive abuse
d. Cardiac f ailure
e. Cirrhosis of liver w it h ascit es
f. Nephrot ic syndrome
g. Bart t er's syndrome
h. Diuret ic abuse
i. Hypovolemia and hemorrhage
j. Af t er 10 days of st arvat ion
k. Toxemia of pregnancy
3. Decreased al dosterone l evel s are f ound in t he f ollow ing condit ions:
a. Aldost erone def iciency
b. Addison's disease
c. Syndrome of renin def iciency (very rare)
d. Low aldost erone levels associat ed w it h hypert ension are f ound in
Turner's syndrome, diabet es mellit us, and alcohol int oxicat ion
Interfering Factors
1. Values are increased by upright post ure.
2. Recent ly administ ered radioact ive medicat ions aff ect t est out comes.
3. Heparin t herapy causes levels t o f all. See Appendix J f or drugs t hat increase
and decrease levels.
4. Thermal st ress, lat e pregnancy, and st arvat ion cause levels t o rise.
5. Aldost erone levels decrease w it h age.
6. Many drugsdiuret ics, ant ihypert ensives, progest ogens, est rogens, and
licoriceshould be t erminat ed 24 w eeks bef ore t est .
Clin ical Alert

1. The simult aneous measurement of aldost erone and renin is helpf ul in
diff erent iat ing primary f rom secondary hyperaldost eronism. Renin levels
are high in secondary aldost eronism and low in primary aldost eronism.
2. Pot assium def iciencies should be correct ed bef ore t est ing f or aldost erone.
Interventions
1. Explain t est purpose and procedures. Assess f or hist ory of diuret ic or
laxat ive abuse. I f 24-hour urine specimen is required, f ollow prot ocols in
Chapt er 3.
2. Discont inue diuret ic agent s, progest at ional agent s, est rogens, and black
licorice f or 2 w eeks bef ore t he t est .
3. Ensure t hat t he pat ient 's diet f or 2 w eeks bef ore t he t est is normal (ot her
t han t he previously list ed rest rict ions) and should include 3 g/ day (135
mEq/ L/ day) of sodium. Check w it h your laborat ory f or special prot ocols.

1. Have pat ient resume normal act ivit ies and diet .
2. I nt erpret t est result s and monit or appropriat ely f or aldost eronism and
aldost erone def iciency.
Antidiuretic Hormone (ADH); Arginine Vasopressin

Hormone ADH is excreted by the posterior pituitary
gland. When ADH activity is present, small volumes of
concentrated urine are excreted. When ADH is absent,
large amounts of diluted urine are produced. Higher
secretion occurs at night, with erect posture, and with
pain, stress, or exercise. Measurement of the level of
ADH is useful in the differential diagnosis of polyuric

and hyponatremic states. ADH testing aids in diagnosis
of urine concentration disorders, especially diabetes
insipidus, SIADH, psychogenic water intoxication, and
syndromes of ectopic ADH production.
Reference Values
Normal
<2. 5 pg/ mL or <2. 3 pmol/ L
Procedure
1. Draw venous blood samples, 5 mL, int o prechilled t ubes and put on ice.
Plasma w it h EDTA ant icoagulant is needed. O bserve st andard precaut ions.
Place specimen in a biohazard bag.
2. Ensure t hat pat ient is in a sit t ing posit ion and calm during blood collect ion.
1. Increased secreti on of ADH is associat ed w it h t he f ollow ing condit ions:
a. SI ADH (w it h respect t o plasma osmolalit y)
b. Ect opic ADH product ion (syst emic neoplasm)
c. Nephrogenic diabet es insipidus
d. Acut e int ermit t ent porphyria
e. G uillain-Barr syndrome
f. Brain t umor, diseases, injury, neurosurgery
g. Pulmonary diseases (t uberculosis)
2. Decreased secreti on of ADH occurs in t he f ollow ing condit ions:
a. Cent ral diabet es insipidus (hypot halamic or neurogenic)
b. Psychogenic polydipsia (w at er int oxicat ion)
Interfering Factors
1. Recent ly administ ered radioisot opes cause spurious result s.
2. Many drugs aff ect result s (eg, t hiazide diuret ics, oral hypoglycemics, and
narcot ics); see Appendix J.
Interventions
2. Encourage relaxat ion bef ore and during blood-draw ing procedure.

2. I nt erpret t est result s and counsel appropriat ely f or urine concent rat ion
disorders and polyuria.
Clin ical Alert

To dist inguish SI ADH f rom ot her condit ions t hat cause dilut ional hyponat remia,
ot her t est s must be done, such as plasma osmolalit y, plasma sodium, and
w at er-loading t est .
Atrial Natriuretic Factor (ANF), ANP and BNP

At rial nat riuret ic f act or (ANF) is a hormone secret ed by t he cardiac at ria during
acut e and chronic cardiac volume and pressure overload. The discovery of ANF
indicat es t hat t he heart is an endocrine gland and conf irms speculat ion t hat t here
is a mechanism in or near t he heart t hat regulat es body f luid hemost asis. This
hormone enhances salt and w at er excret ion, blocks aldost erone and renal
secret ion, and inhibit s t he act ion of angiot ensin I I and vasopressin.
Recent ly, a hormone produced by t he vent ricles of t he heart , brain nat riuret ic
pept ide or B-t ype nat riuret ic pept ide (BNP), has been show n t o increase in
response t o vent ricular volume expansion and pressure overload. BNP is a
marker of vent ricular syst olic and diast olic dysf unct ion. This t est is usef ul in
diagnosing congest ive heart f ailure. I t is not usef ul f or diagnosing ot her heart
condit ions. Chart 6. 1 describes t ypes of heart f ailures; Chart 6. 2 off ers a scale
f or grading t hem. Figure 6. 3 illust rat es t he relat ionship of BNP t o heart disease.
Ch art 6.1 Heart Failure
Type of Heart
Failure
Signs and
Symptoms
Tests to Diagnose
Shortness
of breath
at rest
and
exercise
Persistent
cough
W eakness
or fatigue
Edema in
feet,
ankles,
legs
W eight
gain
History/physical
exam
Electrocardiogram
Echocardiography
Chest x-ray
Blood tests: brain
natriuretic
peptide, atrial
natriuretic factor
Pulmonary
function tests
Cardiac
ultrasound
Treadmill stress
test
Thallium stress
test
Left heart failure

(congestive heart
failure)
Systolic heart
failure (systolic
ventricular
dysfunction);
inability of the
heart to generate
an adequate
cardiac utput to
perfuse vital
tissues
Diastolic heart
failure (diastolic
ventricular
failure);
pulmonary
congestion
despite a normal
stroke volume
Right heart failure
An increase in left
ventricular filling
pressure that is
reflected back in
the pulmonary
circulation
High-output
failure
Inability of the heart
to supply the body
with blood-borne
nutrients despite
adequate blood
volume and normal
myocardial
contractility
Ch art 6.2 Grading Heart Diseases Class In o limitation of

ph ysical activity; n o fatigu e, sh ortn ess of breath , or h eart
palpitation s w ith ordin ary activities Class IIsligh t limitation in
ph ysical activity; w ith fatigu e, sh ortn ess of breath , or h eart
palpitation s du rin g ordin ary activities Class IIImarked
limitation of ph ysical activity; w ith fatigu e, sh ortn ess of breath ,
or h eart palpitation s w ith less-th an -ordin ary ph ysical activity
Class IVsevere to complete limitation of ph ysical activity w ith
fatigu e, sh ortn ess of breath , or h eart palpitation s w ith an y
exertion ; symptoms occu r even at rest
Footn ote
Source: The New York Heart Associat ion, 2001
FI G URE 6. 3 Relat ionship of BNP t o heart disease (classif icat ion of t he New
York Heart Associat ion) (Source: Biosit e Diagnost ics, San Diego, CA, USA)
Reference Values
Normal
At rial nat riuret ic f act or (ANF): 2077 pg/ mL or 2077 ng/ L
B-t ype nat riuret ic pept ide (BNP): <100 pg/ mL or <100 ng/ L
Procedure
1. O bt ain a plasma sample by venipunct ure f rom a f ast ing pat ient . Use a
lavender-t opped KEDTA t ube. I f a nonf ast ing sample is obt ained, not if y
laborat ory.
2. Prechill t he t ube at 4C bef ore draw ing sample. Af t er draw ing sample, chill
t ube in w et ice f or 10 minut es. Place specimen in a biohazard bag.
I ncreased ANF levels occur in:
2. Cardiovascular disease w it h elevat ed f illing pressure

3. A sympt omat ic cardiac volume overload
4. Paroxysmal at rial t achycardia
Interfering Factors
Interventions
1. Explain t est purpose and need t o f ast . Assess f or signs and sympt oms
indicat ing need f or t est ing (eg, chronic f at igue, cough, heart palpit at ions,
high blood pressure).
2. Wit hhold cardiovascular medicat ions per physician's order (eg, and calcium
ant agonist s, cardiac glycosides, diuret ics, vasodilat ors) bef ore draw ing
specimen.

1. Medicat ions and usual diet may be rest art ed per physician's order.
2. Evaluat e pat ient out comes and monit or appropriat ely f or congest ive heart
f ailure.
3. I n collaborat ion w it h physician, explain need f or possible f ollow -up t est s and
medicat ion t herapy.
Cortisol (Hydrocortisone) Cortisol

(hydrocortisone/compound F) is a glucocorticosteroid
of the adrenal cortex and affects metabolism of
proteins, carbohydrates, and lipids. Cortisol stimulates
glucogenesis by the liver, inhibits the effect of insulin,
and decreases the rate of glucose use by the cells. In
health, the secretion rate of cortisol is higher in the

early morning (6:008:00 a.m.) and lower in the
evening (4:006:00 p.m.). This variation is lost in
patients with Cushing's syndrome and in persons
under stress.
The cort isol t est evaluat es adrenal hormone f unct ion. Cort isol is elevat ed in
adrenal hyperf unct ion and decreased in adrenal hypof unct ion. Suppression and
st imulat ion t est s may also be done. Cort isol (dexamet hasone) suppression t est
screens f or Cushing's syndrome and ident if ies depressed persons w ho are likely
t o respond t o ant idepressant s or elect roshock t herapy. I t is based on t he f act
t hat ACTH product ion is suppressed in healt hy persons af t er a low dose of
dexamet hasone but not in persons w it h Cushing's syndrome or in some
depressed persons.
Reference Values
Normal
Corti sol 8: 00 a. m. : 523 g/ dL or 138635 nmol/ L
4: 00 p. m. : 316 g/ dL or 83441 nmol/ L
Midnight : <50% of 8: 00 a. m. level New borns: 211 g/ dL or 55304 nmol/ L
Mat ernal (at birt h): 51. 257. 4 g/ dL or 14131584 nmol/ L
Af t er f irst w eek of lif e, cort isol levels at t ain adult values.
Suppressi on 8: 00 a. m. f ollow ing administ rat ion of dexamet hasone: <5 g/ dL
(a. m. value) or <138 nmol/ L
Sti mul ati on Baseline: at least 5 g/ dL or 138 nmol/ L
Af t er Cort rosyn administ rat ion: rise of at least 10 g/ dL or 276 nmol/ L
Procedure
1. O bt ain 5-mL venous blood samples at 8: 00 a. m. and at 4: 00 p. m. Serum is
pref erred. Heparin ant icoagulant may be used. Place specimen in a
biohazard bag.
1. Decreased corti sol l evel s are f ound in t he f ollow ing condit ions:
a. Adrenal hyperplasia
b. Addison's disease
c. Ant erior pit uit ary hyposecret ion (pit uit ary dest ruct ion)
d. Hypot hyroidism (hypopit uit arism)
2. Increased corti sol l evel s are f ound in t he f ollow ing condit ions:
a. Hypert hyroidism
b. St ress (t rauma, surgery)
c. Carcinoma (ext reme elevat ion in t he morning and no variat ion lat er in t he
day)
d. Cushing's syndrome (high on rising but no variat ion lat er in t he day)
e. O verproduct ion of ACTH due t o t umors (oat cell cancers)
f. Adrenal adenoma
g. O besit y
Interfering Factors
1. Pregnancy w ill cause an increased value.
2. There is no normal diurnal variat ion in pat ient s under st ress.
3. Drugs such as spironolact one and oral cont racept ives w ill give f alsely
elevat ed values (see Appendix J).
4. Decreased levels occur in persons t aking dexamet hasone, prednisone, or
prednisolone (st eroids) (see Appendix J).
5. Random cort isol t est s are useless and provide no pert inent inf ormat ion.
Interventions
1. Explain t est purpose and blood-draw ing procedure. Blood must be draw n at
8: 00 a. m. and 4: 00 p. m.
2. Encourage relaxat ion.
3. Ensure t hat no radioisot opes are administ ered w it hin 1 day bef ore t he t est .

2. I nt erpret t est result s and counsel appropriat ely f or adrenal dysf unct ion.
Cortisol Suppression (Dexamethasone Suppression;

DST) See foregoing cortisol test for purpose and
indications. The DST test helps to differentiate causes
of elevated cortisol. Cortisol <15 g/dL (<41.4 nmol/L)
is indication of adrenal cortisol insufficiency.
Reference Values
Normal
<5 g/ dL (<138 nmol/ L) or <50% of baseline (8: 00 a. m. specimen)
Procedure
1. O bt ain a 5-mL venous blood t he day f ollow ing administ rat ion of
dexamet hasone. Serum or heparinized plasma is accept able. O bserve
st andard precaut ions. Place specimen in a biohazard bag.
2. Administ er lat e evening or bedt ime; dexamet hasone t ablet s by mout h. There
is a low -dose and high-dose suppression t est in w hich eit her 1. 0 mg or 8. 0
mg of dexamet hasone is given, respect ively, at 11: 00 p. m. The f ollow ing
morning at 8: 00 a. m. , a blood sample is draw n t o measure cort isol. (Some
Cushing's disease pat ient s have f alse-posit ive result s w it h t his low dose. )
1. Suppression occurs in persons w it h:
a. Cushing's syndrome (>10 g/ dL or >276 nmol/ L)
b. Endogenous depression (50% of cases)
2. No suppression occurs in:
a. Adrenal adenoma, carcinoma

b. Ect opic ACTH-producing t umors
Interfering Factors
False suppression can occur in t he f ollow ing condit ions:
1. Pregnancy
2. High doses of est rogens
3. Alcoholism
4. Uncont rolled diabet es
5. Trauma, high st ress, f ever, dehydrat ion
6. Phenyt oin (Dilant in) (see Appendix J f or ot her drugs)
Interventions
1. Explain t est purpose and procedure. Fast ing is required f or t he 8: 00 a. m.
t est .
2. Discont inue all medicat ions f or 24 t o 48 hours bef ore t he st udy. Especially
import ant are spironolact one, est rogens, birt h cont rol pills, cort isol,
t et racycline, st ilbest rol, and phenyt oin. Check w it h t he physician.
3. Weigh t he pat ient and record w eight .
4. Have baseline blood cort isol draw n at 8: 00 a. m. and 4: 00 p. m. G ive 1 mg
dexamet hasone at 11: 00 p. m. t he same day. Draw blood at 8: 00 a. m. t he
next morning.
5. Ensure t hat no radioisot opes are administ ered w it hin 1 w eek bef ore t est .
care.

2. I nt erpret t est result s and counsel appropriat ely f or Cushing's syndrome or
depression.
Cortisone Stimulation (Cosyntropin, Cortrosyn

Stimulation); Adrenocorticotropin Hormone (ACTH)
Stimulation This detects adrenal insufficiency after
Cortrosyn administration. Cortrosyn is a synthetic
subunit of ACTH that exhibits the full corticosteroidstimulating effect of ACTH in healthy persons. Failure
to respond is an indication of adrenal insufficiency.
See foregoing cortisol tests for values. This screening
test is less time consuming and can be done on an
outpatient basis.
Reference Values
Normal
Cort isol: >20 g/ dL (>552 nmol/ L) rise af t er Cort rosyn administ rat ion
Procedure
1. O bt ain a 4-mL f ast ing venous blood sample at 8: 00 a. m. O bserve st andard
precaut ions.
2. Administ er Cort rosyn int ramuscularly or int ravenously as prescribed.
3. O bt ain addit ional 4-mL blood specimens 30 and 60 minut es af t er
administ rat ion of Cort rosyn. Serum or heparinized blood is accept able.
1. Absent or blunt ed response t o cort isol st imulat ion occurs in t he f ollow ing
condit ions:
a. Addison's disease (adrenal insuff iciency)
b. Hypopit uit arism (secondary adrenal insuff iciency)
c. Adrenal carcinoma, adenoma
2. Response t o cort isol st imulat ion: adrenal hyperplasma
Interfering Factors
1. Prolonged st eroid administ rat ion
2. Est rogens (see Appendix J)
Interventions
1. Explain t est purpose and procedure. Fast ing during t est is required. Blood
specimens are obt ained bef ore and af t er I M inject ion of Cort rosyn.

2. I nt erpret t est result s and monit or appropriat ely f or adrenal insuff iciency.
Clin ical Alert

I n adrenal hyperplasia, t here is an increase of cort isol levels of 3 t o 5 t imes
t he normal; in adrenal carcinoma, t here is no increase.
Gastrin
G ast rin, a hormone secret ed by t he ant ral G cells in st omach mucosa, st imulat es
gast ric acid product ion and aff ect s ant ral mot ilit y and secret ion of pepsin and
int rinsic f act or. G ast rin values f ollow a circadian rhyt hm and f luct uat e
physiologically in relat ion t o meals. The low est values are bet w een 3: 00 a. m.
and 7: 00 a. m.
Measurement of serum gast rin is generally used t o diagnose st omach disorders
such as gast rinoma and Zollinger-Ellison syndrome in t he presence of
hyperacidit y. (G ast ric hyperacidit y must be document ed. )
Reference Values
Normal
Adult s: <25100 pg/ mL or <1248 pmol/ L
Children: 10125 pg/ mL or 560 pmol/ L
Post prandial: 95140 pg/ mL or 4667 pmol/ L
Procedure
1. O bt ain a 5-mL venous blood sample f rom a f ast ing pat ient . Serum is
required.
2. Freeze if not t est ed immediat ely. I f not f ast ing, t his must be not ed because
values are diff erent . Place specimen in a biohazard bag.
1. Increased gastri n l evel s are f ound in t he f ollow ing condit ions:
a. St omach carcinoma (reduct ion of gast ric acid secret ion)
b. G ast ric and duodenal ulcers
c. Zollinger-Ellison syndrome (>500 pg/ mL or >240 pmol/ L)
d. Pernicious anemia
e. G ast ric carcinoma
f. End-st age renal disease (gast rin met abolized by t he kidneys)
g. Ant ral G -cell hyperplasia
h. Vagot omy w it hout gast ric resect ion
i. Hyperparat hyroidism
j. Pyloric obst ruct ion
2. Decreased gastri n l evel s occur in t he f ollow ing condit ions:
a. Ant rect omy w it h vagot omy
b. Hypot hyroidism
Interfering Factors
Values w ill be f alsely increased in nonf ast ing pat ient s, elderly pat ient s, and
diabet ic pat ient s t aking insulin, as w ell as in post gast roscopy pat ient s and t hose
t aking H2 secret ion blockers (cimet idine), st eroids, and calcium. A prot ein meal
can elevat e gast rin markedly.
Interventions
2. Remind pat ient t hat f ast ing is required f or 12 hours preceding t he t est .
Wat er is permit t ed; no coff ee. No radioisot opes f or 1 w eek.
3. Not e if specimen is draw n post prandial. (I f af t er eat ing, not e w hat w as
eat en. )

2. I nt erpret t est result s and monit or appropriat ely. Follow -up t est ing using
gast ric st imulat ion or gast rin suppression may be indicat ed.
Growth Hormone (hGH); Somatotropin Human growth

hormone (somatotropin, hGH) is essential to the growth
process and has an important role in the metabolism of
adults. It is secreted by the pituitary gland in response
to exercise, deep sleep, hypoglycemia, glucagon,
insulin, and vasopressin. It also stimulates the
production of RNA, mobilizes fatty acids from fat
deposits, and is intimately connected with insulinism.
If the pituitary gland secretes too little or too much
hGH in the growth phase of life, dwarfism or gigantism
will result, respectively. An excess of growth hormone
during adulthood leads to acromegaly.
This t est conf irms hypopit uit arism or hyperpit uit arism so t hat t herapy can be
init iat ed as soon as possible. Challenge or st imulat ion t est s are generally used
t o det ect hG H def iciency and are more inf ormat ive. Much cont roversy surrounds
t he use of grow t h hormone st imulat ion t est s, and t he diagnosis should be
considered in t he cont ext of t he clinical pict ure.
Reference Values
Normal
Men: <5 ng/ mL or <226 pmol/ L
Women: <10 ng/ mL or <452 pmol/ L
Children: 020 ng/ mL or 0904 pmol/ L
New borns: 540 ng/ mL or 2261808 pmol/ L
Sti mul ati on test (usi ng argi ni ne, gl ucagon or i nsul i n): >5 ng/ mL or >226 pmol/ L
(rise f rom baseline) >10 ng/ mL or >452 pmol/ L peak response f rom baseline
Suppressi on test (usi ng 100 g gl ucose): 02 ng/ mL or 090 pmol/ L or
undet ect able
NOTE
Because of marked f luct uat ions in hG H, a random specimen has limit ed value.
St imulat ion or inhibit or t est s provide more inf ormat ion.
Procedure
1. O bt ain a 5-mL venous blood sample f rom a f ast ing pat ient . Serum is best t o
use. O bserve st andard precaut ions. Place specimen in a biohazard bag.
2. Check w it h your laborat ory f or specif ic challenge prot ocols f or st imulat ion
t est s such as insulin-induced hypoglycemia, arginine t ransf usion, glucagon
inf usion, L-dopa, and propranolol w it h exercise.
1. Increased hG H l evel s are associat ed w it h t he f ollow ing condit ions:
a. Pit uit ary gigant ism
b. Acromegaly
c. Laron's dw arf ism (hG H resist ant )
d. Ect opic G H secret ion
e. Uncont rolled diabet es mellit us
2. Decreased hG H l evel s are associat ed w it h t he f ollow ing condit ions:
a. Pit uit ary dw arf ism
c. Adrenocort ical hyperf unct ion
3. Follow ing st imulat ion t est ing, no response (or an inadequat e response) is
seen in hG H and ACTH def iciencies (hypopit uit arism).
a. Blood glucose must f all t o <40 mg/ dL (<2. 2 mmol/ L)
b. Adrenergic signs must be observed.
4. Follow ing suppression t est s, t here is no or incomplet e suppression in
persons w it h gigant ism or acromegaly.
a. Paradoxical rises in hG H may occur in pat ient s w it h acromegaly.
b. Part ial suppression is somet imes seen in anorexia nervosa.
c. I n children, rebound-st imulat ion eff ect may be seen 2 t o 5 hours
f ollow ing administ rat ion of glucose (suppression t est ).
Interfering Factors
1. Increased l evel s are associat ed w it h t he use of oral cont racept ives,
est rogens, arginine, glucagon, levodopa, low glucose, and insulin.
2. Levels w ill rise t o 15 t imes normal by t he second day of st arvat ion; levels
also rise af t er deep sleep, st ress, exercise, and anorexia.
3. Decreased l evel s are associat ed w it h obesit y and t he use of cort icost eroids.
4. Many drugs int erf ere w it h t est result s (see Appendix J).
5. Recent ly administ ered radioisot opes int erf ere w it h t est result s.
Interventions
2. Remind pat ient t hat f ast ing f rom f ood f or 8 t o 10 hours is required; w at er is
permit t ed. For accurat e levels, t he pat ient should be f ree of st ress and at
complet e rest in a quiet environment f or at least 30 minut es bef ore specimen
collect ion.
3. Not e t he pat ient 's physiologic st at e (eg, f eeding, f ast ing, sleep, and/ or
act ivit y) at t est ing in t he healt h care record.
4. For st imulat ion t est s, collect one t ube bef ore st imulat ion and at t imed
int ervals (eg, 10, 20, 30, 45, and 60 minut es) af t er st imulat ion. For
suppression t est s, collect one t ube bef ore suppression and 30, 60, 90, and
120 minut es af t er suppression.
5. Remember t hat f or init ial t est ing of hG H def iciency, a vigorous exercise t est
is considered t o be a simple, risk-f ree screening t est , especially f or children.

2. I nt erpret t est result s and monit or appropriat ely. A glucose challenge t est
may be indicat ed f or f ollow -up.
Parathyroid Hormone Assay; Parathyrin; Parathormone

(PTH-C-Terminal) Parathormone (PTH), a polypeptide
hormone produced in the parathyroid gland, is one of
the major factors in the regulation of calcium
concentration in extracellular fluid. Three molecular
forms of PTH exist: intact (also called native or
glandular hormone); multiple N-terminal fragments; and
C-terminal fragments.
This t est st udies alt ered calcium met abolism, est ablishes a diagnosis of
hyperparat hyroidism, and dist inguishes nonparat hyroid f rom parat hyroid causes
of hypercalcemia. A decrease in t he level of ionized calcium is t he primary
st imulus f or PTH secret ions, w hereas a rise in calcium inhibit s secret ions. This
normal relat ion is lost in hypert hyroidism, and PTH w ill be inappropriat ely high in
relat ion t o calcium. Acut e changes in secret ory act ivit y are bet t er ref lect ed by
t he PTH, N-t erminal assay. PTH and N-t erminal levels are usually decreased
w hen hypercalcemia is due t o neoplast ic secret ions (prost aglandins). PTH and Nt erminal levels may be a more reliable indicat ion of secondary
hyperparat hyroidism in pat ient s w it h renal f ailure. Creat inine level is det ermined
concurrent ly w it h all PTH assays t o det ermine kidney f unct ion and f or meaningf ul
int erpret at ion of result s.
Reference Values
Normal
N-t erminal: 824 pg/ mL or 824 ng/ L
I nt act molecule: 1065 pg/ mL or 1065 ng/ L
Calcium: 8. 510. 9 mg/ dL (calcium must be t est ed t o properly int erpret result s)
C-t erminal (biomolecule): 50330 pg/ mL or 50330 ng/ L
Procedure
1. O bt ain a 10-mL venous blood sample f rom a pat ient w ho has f ast ed f or 10
hours. Collect t he sample in chilled vials and keep on ice. O bserve st andard
precaut ions. Serum or EDTA is used.
2. I mmediat ely t ake specimen t o t he laborat ory and cent rif uge at 4C af t er
blood has clot t ed.
1. Increased PTH val ues occur w it h:
a. Primary hyperparat hyroidism
b. Pseudohyperparat hyroidism w hen t here is a primary def ect in renal
t ubular responsiveness t o PTH (secondary hyperparat hyroidism)
c. Heredit ary vit amin D dependency
d. Zollinger-Ellison syndrome
e. Spinal cord injury
2. Decreased PTH val ues occur in t he f ollow ing condit ions:
a. Hypoparat hyroidism (G raves' disease)
b. Nonparat hyroid hypercalcemia
c. Secondary hypoparat hyroidism (surgical)
d. Magnesium def iciency
e. Sarcoidosis
f. Hypert hyroidism
g. DiG eorge's syndrome
3. Increased PTHN-termi nal val ues occur in t he f ollow ing condit ions:
a. Primary hyperparat hyroidism
b. Secondary hyperparat hyroidism (more reliable t han PTH-C-t erminal)
4. Decreased PTHN-termi nal val ues occur in t he f ollow ing condit ions:
b. Nonparat hyroidism hypercalcemia
c. Aluminum-associat ed ost eomalacia
d. Severely impaired bone mineralizat ion
5. Increased PTHC-termi nal val ues occur in t he f ollow ing condit ions:
a. Primary hyperparat hyroidism (very specif ic f or)
b. Some neoplasms w it h elevat ed calcium
c. Renal f ailure (even if parat hyroid disease is absent )
6. Decreased PTHC-termi nal val ues occur in t he f ollow ing condit ions:
b. Nonparat hyroid hypercalcemia
Interfering Factors
1. Elevat ed blood lipids and hemolysis int erf ere w it h t est met hods.
2. Milk-alkali syndrome may f alsely low er PTH levels (Burnet t 's syndrome).
3. Recent ly administ ered radioisot opes (see Appendix J) w ill alt er result s.
4. Vit amin D def iciency w ill increase PTH levels.
5. Many drugs alt er result s; phosphat es raise PTH levels up t o 125%, and
vit amin A and D overdoses decrease PTH levels (see Appendix J).
Interventions
2. Remind pat ient t hat f ast ing f or at least 10 hours is required. Draw blood by
8: 00 a. m. because of circadian rhyt hm changes. Concurrent ly, also draw
blood f or t est ing of calcium level.

2. I nt erpret t est result s and monit or appropriat ely f or calcium imbalance and
hypoparat hyroidism or hyperparat hyroidism.
Somatomedin C (SM-C); Insulin-like Growth Hormone

Somatomedin C, a polypeptide hormone produced by
the liver and other tissues, mediates growth hormone
activity and glucose metabolism. It is carried in the
blood and is bound to a protein carrier that prolongs its
half-life.
This t est is used t o monit or t he grow t h of children as w ell as t o diagnose

acromegaly and hypopit uit arism. Normal somat omedin C result s rule out a
def iciency of grow t h hormone. Test ing of somat omedin C is pref erable t o grow t h
hormone t est s because it s levels are more
const ant . Somat omedin C is also a reliable nut rit ion index, having a low value f or
anorexia or malnut rit ion.
Reference Values
Normal
See Table 6. 8.
Table 6.8 Values for Somatomedin C
Male
Fem ale
Age (yr)
(ng/mL)
(nmol/L)
(ng/mL)
(nmol/L)
05
0103
013.5
0112
014.7
68
2118
0.215.4
5128
0.616.8
910
15148
2.019.4
24158
3.120.7
1113
55216
7.228.3
65226
8.529.6
1415
114232
14.930.4
124242
16.231.7
1617
84221
11.028.9
94231
12.330.3
1819
56177
7.323.2
66186
8.624.4
2024
75142
9.818.6
64131
8.417.2
2550
60122
7.916.0
50112
6.614.7
Note: levels slowly decrease as person ages.
Procedure
1. Be aw are t hat it is pref erred t hat t he pat ient be f ast ing. O bt ain a 5-mL
plasma venous blood sample using EDTA ant icoagulant . Serum may also be
used. O bserve st andard precaut ion. Place specimen in a biohazard bag.
2. Chill blood-draw ing t ubes bef ore and place on ice immediat ely af t er obt aining
specimen. Spin t he sample in a ref rigerat ed cent rif uge. Freeze if not t est ing
immediat ely.
1. Increased somatomedi n C l evel s are associat ed w it h t he f ollow ing
condit ions:
a. Acromegaly (some cases), gigant ism
b. Hypoglycemia associat ed w it h nonislet cell t umors
c. Hepat oma
d. Wilms' t umor
e. Precocious pubert y
2. Decreased somatomedi n C l evel s are associat ed w it h t he f ollow ing
condit ions:
a. Dw arf ism (short st at ure)
c. Hypot hyroidism
d. Pubert y delay
e. Laron's dw arf ism
f. Cirrhosis of liver and ot her hepat ocellular diseases
g. Malnut rit ion and anorexia
h. Diabet es mellit us (diabet ic ret inopat hy)
i. Emot ional deprivat ion syndrome (mat ernal deprivat ion)
Interfering Factors
1. Somat omedin C levels are i ncreased 2 t o 3 t imes in pregnancy.
2. Somat omedin C levels are decreased in t he f ollow ing condit ions:
a. Acut e illness
b. Normal aging
Interventions
1. Explain t est purpose and procedure. Fast ing is not required.
2. Do not administ er radioisot opes w it hin 1 w eek of t est ing.

2. I nt erpret t est result s and monit or appropriat ely f or abnormal grow t h and
development .
NOTE
Because SM-C is decreased w it h malnut rit ion, it can be used t o monit or
t herapy f or f ood deprivat ion.
FERTILITY TESTS
Fert ilit y denot es t he abilit y of a man and w oman t o reproduce; conversely,
inf ert ilit y denot es t he lack of f ert ilit yan involunt ary reduct ion in t he abilit y t o
produce children. When a couple has been engaging in regular, unprot ect ed
sexual int ercourse f or at least 1 year w it hout conceiving, t he couple is
considered inf ert ile. I n about one t hird of cases, a male f act or is t he
predominant cause; in anot her one t hird, t he f emale f act or predominat es; and in
anot her one t hird, no cause is f ound in eit her part ner.
The w orkup f or inf ert ilit y st art s w it h a complet e hist ory and physical exam f or
bot h t he w oman and t he man, including t heir sexual hist ory. A rat ional approach
is t o put each part ner t hrough a series of t est s t hat generally uncover a vast
majorit y of t he cont ribut ing f act ors of inf ert ilit y. These t est s usually t ake 2 t o 3
mont hs t o complet e.
St andard pret est and post t est care f or couples undergoing f ert ilit y t est ing
includes t he f ollow ing: Provide inf ormat ion and support . Be sensit ive t o t he
couple's need f or privacy and conf ident ialit y. Maint ain a communicat ion net w ork
about new procedures, t est s, and t reat ment s. Help couples deal w it h f eelings of
sadness and loss. Assist couples t o deal w it h t he eff ect s of st ress and t he
f inancial burden during t he diagnost ic process. Assist couples in arranging w ork
and t est ing schedules w it h t he least amount of disrupt ion f or t he couple. Arrange
f or counseling w it h expert s w ho underst and t he diff erent w ays inf ert ilit y aff ect s
someone's lif e.
Test s include evaluat ion of amenorrhea, anovulat ion, sperm count (angiosperm,
oligospermia), hormone t est ing, hyst erosalpingogram, laparoscopy,
hyst eroscopy, f ert iloscopy, semen analysis, post coit al t est , endomet rial biopsy,
and chromosome karyot ype t o exclude Kallmann's syndrome. Hormone t est ing
rules pregnancy in or out (eg, chorionic gonadot ropin, prolact in, lut einizing
hormone [ LH] , f ollicle-st imulat ing hormone [ FSH] , t hyroid-st imulat ing hormone
[ TSH] , post coit al t est , and ant isperm ant ibodies). Also see est rogen t est ing in
Chapt er 3.
NOTE
A post coit al examinat ion is done t o assess cervical mucus and compet ent
sperm mot ilit y. A specimen is obt ained f rom t he endocervical canal w it hin 2 t o
12 hours of coit us and is examined f or viscosit y (st ret ching t o 6 cm is normal)
and f or f erning eff ect of est rogen. The presence of >50% sperm conf irms
male compet ence.
Chorionic Gonadotropin; Human Chorionic

Gonadotropin (hCG) Subunit; Pregnancy Test The
glycoprotein hormones hCG, luteinizing hormone (LH),
follicle-stimulating hormone (FSH), and thyroidstimulating (TSH) are composed of two different
subunits. The subunit is similar in all of the
glycoprotein hormones, and the subunit is unique to
each hormone. Highly specific assays allow hCG to be
measured in the presence of other glycoprotein
hormones. The increased sensitivity of the -hCG test
detects pregnancy as early as 6 to 10 days after
implantation of the oocyte. A variety of poorly
differentiated or undifferentiated neoplasms may
produce ectopic chorionic gonadotropin. Assay for
total hCG, both and subunits, or -hCG may detect
ectopic tumors (eg, choriocarcinoma, hydatidiform
mole, germinal testicular tumors). In these neoplasms,
hCG is usually the product of syncytiotrophoblastic
cells.
This qualit at ive t est det ect s normal pregnancy. I t is quicker but less sensit ive
(sensit ivit y, 2050 mI U/ mL) t han t he quant it at ive t est . This t est can be expect ed
t o become posit ive w it hin 3 days of implant at ion (ie, just af t er t he f irst missed
menst rual period). Cross-react ivit y w it h LH is low, and f alse-posit ive result s are
rare. O ccasionally, a pat ient w it h very high LH levels w ill give a borderline
react ion. The qualit at ive t est is usually done using urine.
The quant it at ive -hCG t est is used f or nonrout ine det ect ion of hCG . I t is
sensit ive t o 1 t o 3 mI U/ mL. This t est provides t he most sensit ive and specif ic
t est f or t he det ect ion of early pregnancy, est imat ion of gest at ional age, and
diagnosis of ect opic pregnancy or t hreat ened spont aneous abort ion. This t est is
also usef ul in t he w orkup and management of t est icular t umors. High levels may
be f ound in choriocarcinoma, embryonal cell carcinoma, and ect opic pregnancy.
hCG levels are ext remely usef ul in f ollow ing germ cell neoplasms t hat produce
hCG , especially t rophoblast ic neoplasms. There is lit t le cross-react ivit y w it h LH.
Reference Values
Normal
Q ual i tati ve (f or routi ne pregnancy tests): urine or serum negat ive (not pregnant )
Q uanti tati ve (f or nonrouti ne detecti on of hCG ) Men: <5. 0 I U/ L or mI U/ mL
Nonpregnant w omen: <5. 0 I U/ L or mI U/ mL
Pregnant w omen:
1 w eek of gest at ion: 550 mI U/ mL or I U/ L
2 w eeks of gest at ion: 50500 mI U/ mL or I U/ L
3 w eeks of gest at ion: 10010, 000 mI U/ mL or I U/ L
12 w eeks of gest at ion: 12, 000270, 000 mI U/ mL or I U/ L
1316 w eeks of gest at ion: up t o 200, 000 mI U/ mL or I U/ L
1740 w eeks of gest at ion: gradual f all t o 4000 mI U/ mL or I U/ L
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is used f or t he t est .
3. Urine may be used f or t he qualit at ive t est . First morning specimen is
recommended.
1. Increased hCG val ues occur in t he f ollow ing condit ions:
a. Pregnancy
b. Successf ul t herapeut ic inseminat ion and in vit ro f ert ilizat ion
c. Hydat idif orm mole
d. Choriocarcinoma
e. Seminoma
f. O varian and t est icular t erat omas
g. Ect opic pregnancy
h. Cert ain neoplasms of t he lung, st omach, and pancreas
i. Dow n syndrome (t risomy 21), mid-t rimest er elevat ion
2. Decreased hCG val ues occur in:
a. Threat ened spont aneous abort ion
b. Ect opic pregnancy
c. Trisomy 18, decrease at mid-t rimest er
Interfering Factors
1. Lipemia, hemolysis, and radioisot opes administ ered w it hin 1 w eek of t est ing
may aff ect result s.
2. Test result s can be posit ive up t o 1 w eek af t er complet e abort ion.
3. False-negat ive and f alse-posit ive result s can be caused by many drugs (see
Appendix J).
Clin ical Alert

Because t here is great variabilit y in hCG concent rat ion among pregnant
w omen, a single t est det erminat ion cannot be used t o accurat ely dat e t he
gest at ional age. Serial det erminat ions may be helpf ul w hen abnormal
pregnancy is suspect ed. Serial values do not double every 48 hours. I n normal
pregnancy, t he hCG level doubles every 48 hours during t he f irst 6 w eeks of
gest at ion.
Interventions
2. Det ermine and record dat e of last menst rual period in w omen.

2. I nt erpret t est result s and counsel appropriat ely f or pregnancy or gest at ional
problems.
Follicle-Stimulating Hormone (FSH); Luteinizing

Hormone (LH) FSH and LH are glycoprotein pituitary
hormones produced and stored in the anterior pituitary.
They are under complex regulation by hypothalamic
gonadotropin-releasing hormone and by gonadal sex
hormones (estrogen and progesterone in females and
testosterone in males). FSH acts on granulosa cells of
the ovary and Sertoli's cells of the testis, and LH acts
on Leydig's (interstitial) cells of the gonads. Normally,
FSH increases occur at earlier stages of puberty,
2 to 4 years before LH reaches comparable levels. In
males, FSH and LH are necessary for spermatozoa
development and maturation. In females, follicular
formation in the early stages of the menstrual cycle is
stimulated by FSH; then the midcycle surge of LH
causes ovulation of the FSH-ripened ovarian follicles to
occur.
This t est measures t he gonadot ropic hormones FSH and LH and may help
det ermine w het her a gonadal def iciency is of primary origin or is due t o
insuff icient st imulat ion by t he pit uit ary hormones.
Evaluat ion of FSH support s ot her st udies relat ed t o det ermining causes of
hypot hyroidism in w omen and endocrine dysf unct ion in men. I n primary ovarian
f ailure or t est icular f ailure, FSH levels are increased. Measuring t he levels of
FSH and LH is of value in st udying children w it h endocrine problems relat ed t o
precocious pubert y.
I n t he case of anovulat ory f ert ilit y problems, t he presence or absence of t he
midcycle peak can be est ablished t hrough a series of daily blood specimens.
Reference Values
Normal
See Table 6. 9.
Table 6.9 Values for Luteinizing and Follicle-Stimulati

Hormones
Luteinizing
Horm one (LH)
(mIU/L)
or
FollicleStim ulating
Horm one
(FSH)
(IU/L)
(mIU/L)
or
(IU
Female
Follicular
1.37
9.9
1.37
9.9
1.68
15
1.6
15
Ovulatory peak
6.17
17.2
6.17
17.2
21.9
56.6
21
56
Luteal
1.09
9.2
1.09
9.2
0.61
16.3
0.6
16
Postmenopausal
19.3
100.6
19.3
100.6
14.2
52.3
14
52
M ale
1.42
15.4
1.42
15.4
1.24
7.8
1.2
7.8
Note: contact your laboratory for reference values in infants

and children. Normal values may vary with method of testing
and units used.
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is needed f or t he t est . Place
2. I n w omen, record t he dat e of last menst rual period.
3. Remember t hat it is import ant t o measure bot h FSH and LH.
Clin ical Alert

Somet imes mult iple blood specimens are necessary because of episodic
releases of FSH f rom t he pit uit ary gland. An isolat ed sample may not indicat e
t he act ual act ivit y; t heref ore, pooled blood specimens or mult iple single blood
specimens may be required.
1. Decreased FSH l evel s occur in t he f ollow ing condit ions:
a. Feminizing and masculinizing ovarian t umors w hen FSH product ion is
inhibit ed because of increased est rogen secret ion.
b. Failure of hypot halamus t o f unct ion properly (Kallmann's syndrome)
c. Pit uit ary LH or FSH def iciency
d. Neoplasm of t est es or adrenal glands t hat inf luence secret ion of
est rogens or androgens
e. Polycyst ic ovarian disease

f. Hemochromat osis
g. Anorexia
2. Decreased FSH and LH occur in pit uit ary or hypot halamic f ailure.
3. Increased FSH l evel s occur in t he f ollow ing condit ions:
a. Turner's syndrome (ovarian dysgenesis); about 50% of pat ient s w it h
primary amenorrhea have Turner's syndrome.
c. Sheehan's syndrome
d. Precocious pubert y, eit her idiopat hic or secondary t o a CNS lesion
e. Klinef elt er's syndrome
f. Cast rat ion
g. Alcoholism
h. Menopause and menst rual disorders
4. Both FSH and LH are i ncreased in t he f ollow ing condit ions:
a. Hypogonadism
b. Complet e t est icular f eminizat ion syndrome
c. G onadal f ailure
d. Congenit al absence of t est icle or t est icles (anorchia)
e. Menopause
5. Elevat ed basal LH w it h an LH/ FSH rat io >2 and some increase of ovarian
androgen in an essent ially nonovulat ory adult w oman is presumpt ive evidence
of St ein-Levent hal syndrome (polycyst ic ovary syndrome).
Interfering Factors
1. Recent ly administ ered radioisot opes
2. Hemolysis of blood sample
3. Est rogens or oral cont racept ives, t est ost erone
4. Several drugs aff ect t est out comes; see Appendix J.
5. Pregnancy
Interventions

1. I nst ruct t he pat ient regarding t est purpose and procedure.
2. For w omen, record dat e of last menst rual period.

Prolactin (hPRL)
Prolact in is a pit uit ary hormone essent ial f or init iat ing and maint aining lact at ion.
The gender diff erence in prolact in does not occur unt il pubert y, w hen increased
est rogen product ion result s
in higher prolact in levels in f emales. Circadian changes in prolact in concent rat ion
in adult s are marked by episodic f luct uat ion and a sleep-induced peak in t he
early morning hours.
This t est may be helpf ul in t he diagnosis, management , and f ollow -up of a
prolact in-secret ing t umor accompanied by secondary amenorrhea or
galact orrhea, hyperprolact inemia, and inf ert ilit y. I t is also usef ul in t he
management of hypot halamic disease and in monit oring t he eff ect iveness of
surgery, chemot herapy, and radiat ion t reat ment of prolact in-secret ing t umors.
Reference Values
Normal
Nonpregnant w omen: 023 ng/ mL or 023 g/ L
Pregnant w omen: 34386 ng/ mL or 34386 g/ L by t hird t rimest er Men: 020
ng/ mL or 020 g/ L
Children: 3. 220 ng/ mL or 3. 220 g/ L
Procedure
1. Ensure t hat t he pat ient f ast s f or 12 hours bef ore t est ing. O bt ain a 5-mL
venous blood sample. Serum is used.
2. Procure specimens in t he morning, bet w een 8: 00 and 10: 00 a. m. Draw in

chilled t ubes keep specimen on ice.
1. Increased prol acti n val ues are associat ed w it h t he f ollow ing condit ions:
a. G alact orrhea or amenorrhea
b. Diseases of t he hypot halamus and pit uit ary (acromegaly)
c. Prolact in-secret ing pit uit ary t umors
d. Chiari-Frommel syndrome
e. Ect opic product ion of prolact in f rom t umors, carcinoma, and leukemia
f. Hypot hyroidism (primary)
g. Polycyst ic ovary syndrome
h. Anorexia nervosa
i. I nsulin-induced hypoglycemia
j. Adrenal insuff iciency
2. Decreased prol acti n val ues are f ound in t he f ollow ing condit ions:
a. Sheehan's syndrome (pit uit ary apoplexy)
b. I diopat hic hypogonadot ropic hypogonadism
NOTE
The only result of prolact in def iciency in pregnancy is t he absence of
post part um lact at ion.
Interfering Factors
1. I ncreased values are associat ed w it h new borns, pregnancy, post part um
period, st ress, exercise, sleep, nipple st imulat ion, and lact at ion (breast
f eeding).
2. Drugs (eg, est rogens, met hyldopa, phenot hiazines, opiat es) may increase
values. See Appendix J f or ot her drugs.
3. Dopaminergic drugs inhibit prolact in secret ion. Administ rat ion of L-dopa can
normalize prolact in levels in galact orrhea, hyperprolact inemia, and pit uit ary
t umor. See Appendix J f or ot her drugs.
4. I ncreased levels are f ound in cocaine abuse, even af t er w it hdraw al f rom
cocaine.
Clin ical Alert

Levels >200 ng/ mL or >200 g/ L in a nonlact at ing f emale indicat e a prolact insecret ing t umor; how ever, a normal prolact in level does not rule out pit uit ary
t umor.
Interventions
1. Explain t est purpose. Fast ing is required. O bt ain blood specimen bet w een
8: 00 and 10: 00 a. m. (34 hours af t er pat ient has aw akened). O bt ain hist ory
of leakage f rom t he breast in nonpregnant f emales.
2. Have pat ient avoid st ress, excit ement , or st imulat ion; venipunct ure it self can
somet imes elevat e prolact in levels.
3. I f possible, discont inue all prescribed medicat ions f or 2 w eeks bef ore t est .

2. I nt erpret t est out come and counsel regarding repeat t est ing t o monit or
t reat ment . Magnet ic resonance imaging may be indicat ed.
Progesterone
Progest erone, a f emale sex hormone, is primarily involved in t he preparat ion of
t he ut erus f or pregnancy and it s maint enance during pregnancy. The placent a
begins producing progest erone at 12 w eeks of gest at ion. Progest erone level
peaks in t he midlut eal phase of t he menst rual cycle. I n nonpregnant w omen,
progest erone is produced by t he corpus lut eum. Progest erone is t he single best
t est t o det ermine w het her ovulat ion has occurred.
This t est is part of a f ert ilit y st udy t o conf irm ovulat ion, evaluat e corpus lut eum
f unct ion, and assess risk f or early spont aneous abort ion. Test ing of several
samples during t he cycle is necessary. O varian product ion of progest erone is
low during t he f ollicular (f irst ) phase of t he menst rual cycle. Af t er ovulat ion,
progest erone levels rise f or 4 t o 5 days and t hen f all. During pregnancy, t here is
a gradual increase f rom w eek 9 t o w eek 32 of gest at ion, of t en t o 100 t imes t he
level in t he nonpregnant w oman. Levels of progest erone in t w in pregnancy are
higher t han in a single pregnancy. Serum progest erone levels used w it h -hCG
assist in diff erent iat ing normal ut erine pregnancy f rom abnormal ut erine or
ect opic pregnancy.
Reference Values
Normal
Men: <1. 0 ng/ mL or <3. 2 nmol/ L
Women:
Prepubert al: 0. 10. 3 ng/ mL or 0. 31. 0 nmol/ L
Follicular: 0. 10. 7 ng/ mL or 0. 52. 3 nmol/ L
Lut eal: 225 ng/ mL or 6. 479. 5 nmol/ L
First t rimest er: 1044 ng/ mL or 32. 6140 nmol/ L
Second t rimest er: 19. 582. 5 ng/ mL or 62. 0262 nmol/ L
Third t rimest er: 65290 ng/ mL or 206. 7728 nmol/ L
Procedure
1. O bt ain a venous blood sample. Serum is needed f or t est . O bserve st andard

precaut ions. Place specimen in a biohazard bag.
2. Remember t hat t he t est request should include gender, day of last menst rual
period, and lengt h of gest at ion in w omen.
3. Be aw are t hat a -hCG may be ordered at t he same t ime.
4. Remember t hat urine levels may be done, but serum is pref erred.
1. Increased progesterone l evel s are associat ed w it h t he f ollow ing condit ions:
a. Congenit al adrenal hyperplasia
b. Lipid ovarian t umor
c. Molar pregnancy
d. Chorionepit helioma of ovary
2. Decreased progesterone l evel s are associat ed w it h t he f ollow ing condit ions:
a. Threat ened spont aneous abort ion
b. G alact orrhea-amenorrhea syndrome (primary or secondary
hypogonadism)
c. Short lut eal phase syndrome
Interfering Factors
2. Crit ical value: levels <10 ng/ mL or <32 nmol/ L are associat ed w it h abnormal
pregnancy out come.
3. 510 ng/ mL or 1632 nmol/ L: pat hologic pregnancy
4. Progest erone <5 ng/ mL or <16 nmol/ L: nonviable
Interventions
1. Explain t est purpose and procedure. Not e dat e of last menst rual
period/ lengt h of gest at ion.
2. Do not administ er radioisot opes w it hin 1 w eek bef ore t he t est .

2. I nt erpret t est result s, and counsel and monit or appropriat ely regarding
f ert ilit y and pregnancy out come.
Testosterone, Total and Free Testosterone is

responsible for the development of male secondary
sexual characteristics. It is secreted by the adrenal
glands and testes in men and by the adrenal glands
and ovaries in women. Excessive production induces
premature puberty in men and masculinity in women.
Testosterone exists in serum as both unbound (free)
fractions and bound fractions to albumin: sex
hormonebinding globulin (SHBG) and testosteronebinding globulin. Unbound (free) testosterone is the
active portion. Testosterone levels undergo large and
rapid fluctuations; levels peak in early morning in
males. Females show a cyclic elevation 1 to 2 days
midcycle.
Test ost erone measurement s in men assess hypogonadism, pit uit ary gonadot ropin
f unct ion, impot ency, and crypt orchidism; t hese measurement s are also usef ul in
t he det ect ion of ovarian t umors and hirsut ism in w omen. I n prepubert al boys,
t hey can assess special precocit y. This
t est may be part of a f ert ilit y w orkup in associat ion w it h chronic anovulat ion
caused by polycyst ic ovary syndrome.
Reference Values
Normal
Total testosterone Men: 2701070 ng/ dL or 938 nmol/ L (values in elderly men
diminish moderat ely) Women: 1570 ng/ dL or 0. 522. 4 nmol/ L

Pregnant w omen: 34 t imes normal Post menopausal w omen: 835 ng/ dL or 0. 3
1. 2 nmol/ L (half of normal) Children: 220 ng/ dL or 0. 070. 7 nmol/ L (depends on
age, sex, and onset of pubert y) Free testosterone Men: 50210 pg/ mL or 174
729 pmol/ L
Women: 1. 08. 5 pg/ mL or 3. 529. 5 pmol/ L
Children:
Boys: 0. 13. 2 pg/ mL or 0. 311. 1 pmol/ L
G irls: 0. 10. 9 pg/ mL or 0. 33. 1 pmol/ L
Pubert y:
Boys: 1. 4156 pg/ mL or 4. 9541 pmol/ L
G irls: 1. 05. 2 pg/ mL or 3. 518. 0 pmol/ L
Procedure
1. O bt ain a 5-mL venous blood sample; serum is pref erred. O bserve st andard
2. I ndicat e age and gender on laborat ory requisit ion.
1. Males: decreased total testosterone l evel s occur in t he f ollow ing condit ions:
a. Hypogonadism (pit uit ary f ailure)
b. Klinef elt er's syndrome
c. Hypopit uit arism (primary and secondary)
d. O rchidect omy
e. Hepat ic cirrhosis
f. Dow n syndrome
g. Delayed pubert y
2. Males: decreased f ree testosterone l evel s occur in hypogonadism and
elderly men.
3. Males: i ncreased total testosterone l evel s occur in t he f ollow ing condit ions:
a. Hypert hyroidism
b. Syndromes of androgen resist ance
c. Adrenal t umors
d. Precocious pubert y and adrenal hyperplasia in boys
4. Females: i ncreased total testosterone l evel s are associat ed w it h t he
a. Adrenal neoplasms
b. O varian t umors, benign or malignant (virilizing)
c. Trophoblast ic disease during pregnancy
d. I diopat hic hirsut ism
e. Hilar cell t umor
5. Females: i ncreased f ree testosterone l evel s are associat ed w it h t he
a. Female hirsut ism
b. Polycyst ic ovaries
c. Virilizat ion
Clin ical Alert

1. Test ost erone levels are normal in crypt orchidism, azoospermia, and
oligospermia.
2. I n general, t here appears t o be lit t le advant age in doing urine t est ost erone
measurement s compared w it h (or in addit ion t o) serum measurement s; t he
serum t est is recommended.
3. Panic value: t ot al t est ost erone >200 ng/ dL or >694 pmol/ L in f emales
indicat es androgenic t umors of t he adrenal or ovaries, especially w it h
severe hirsut ism.
Interfering Factors
1. Alcoholism in males decreases t est ost erone levels.
2. Est rogen t herapy increases t est ost erone levels (see Appendix J).
3. Many drugs, including androgens and st eroids, decrease t est ost erone levels
(see Appendix J).
Interventions

1. Explain t est purpose and procedure. Draw blood at 7: 00 a. m. f or highest
levels.
2. Draw mult iple pooled samples at diff erent t imes t hroughout t he day if
necessary f or more reliable result s.
3. Do not administ er radioisot opes w it hin 1 w eek bef ore t est .
care.

2. I nt erpret t est result s and counsel appropriat ely regarding hormone
dysf unct ion.
ENZYM E TESTS
Acid Phosphatase; Prostatic Acid Phosphatase (PAP)
Acid phosphatases are enzymes that are widely
distributed in tissues, including the bone, liver, spleen,
kidney, red blood cells, and platelets. However, their
greatest diagnostic importance involves the prostate
gland, where acid phosphatase activity is 100 times
higher than in other tissues. Immunochemical methods
are highly specific for determining the prostatic
fraction; however, because PAP is not elevated in early
prostatic disease, this test is not recommended for
screening.
This t est monit ors t he eff ect iveness of t reat ment of cancer of t he prost at e.
Elevat ed levels of acid phosphat ase are seen w hen prost at e cancer has
met ast asized beyond t he capsule t o t he ot her part s of t he body, especially t he
bone. O nce t he carcinoma has spread, t he prost at e st art s t o release acid
phosphat ase, result ing in an increased blood level. The prost at ic f ract ion
procedure specif ically measures t he concent rat ion of prost at ic acid phosphat ase
secret ed by cells of t he prost at e gland. Acid phosphat ase is also present in high
concent rat ion in seminal f luid. Test s f or presence of t his enzyme on vaginal
sw abs may be used t o invest igat e rape.
Reference Values
Normal
2. 53. 7 ng/ mL or 2. 53. 7 g/ L
Procedure
1. O bt ain a 5-mL venous blood sample. Serum may be used, if t est is done
w it hin 1 hour. EDTA plasma is pref erred t o st abilize acid phosphat ase.
2. Remember t hat morning is recommended because diurnal variat ion exist s.
3. Place specimen in a biohazard bag, t ransport t o lab immediat ely, and place
on ice.
1. A signif icant ly elevat ed acid phosphat ase value is almost alw ays indicat ive of
met ast at ic cancer of t he prost at e. I f t he t umor is successf ully t reat ed, t his
enzyme level w ill drop w it hin 3 t o 4 days af t er surgery or 3 t o 4 w eeks af t er
est rogen administ rat ion.
2. Moderat ely elevat ed values also occur in t he absence of prost at e carcinoma
a. Niemann-Pick disease
b. G aucher's disease
c. Prost at it is (benign prost at ic hypert rophy)
d. Urinary ret ent ion
e. Any cancer t hat has met ast asized t o t he bone
f. Myelocyt ic leukemia
Interfering Factors
1. Various drugs may cause increased and decreased PAP levels.
2. Palpat ion of t he prost at e gland and prost at e biopsy bef ore t est ing causes
increases in PAP levels.
3. Transuret hral resect ion of t he prost at e (TURP) and bladder cat het erizat ion
cause increased levels.
Interventions
2. No palpat ion of or procedures on t he prost at e gland and no rect al
examinat ions should be perf ormed 2 t o 3 days bef ore t est .

2. I nt erpret t est result s and counsel appropriat ely regarding repeat t est ing.
When elevat ed values are present , ret est ing and biopsy are considered.
Prostate-Specific Antigen (PSA) Prostate-specific

antigen (PSA) is functionally and immunologically
distinct from prostatic acid phosphatase. PSA is
localized in both normal prostatic epithelial cells and
prostatic carcinoma cells. PSA has proved to be the
most prognostically reliable marker for monitoring
recurrence of prostatic carcinoma; however, this test
does not have the sensitivity or specificity to be
considered an ideal tumor marker. PSA detects
incidental as well as aggressive carcinomas.
The most usef ul approach t o dat e may be age-specif ic PSA ref erence ranges,
w hich are based on t he concept t hat blood PSA concent rat ion is dependent on
pat ient age. The increase in PSA w it h advancing age is at t ribut ed t o f our major
f act ors: prost at e enlargement , increasing
inf lammat ion, presence of microscopic but clinically insignif icant cancer, and
leakage of PSA int o t he serum (Table 6. 10).
Table 6.10 Suggested Age-Specific PSA Reference

Ranges
PSA Range
Age (yr)
(ng/m L)
(g/L)
4049
0.02.5
0.02.5
5059
0.03.5
0.03.5
6069
0.04.5
0.04.5
7079
0.06.5
0.06.5
From Oesterling JE, Jacobson SJ, Chute CG, et al.:

Serum prostate-specific antigen in a community-based
population of healthy men: establishment of agespecific reference ranges. JAMA 270(7): 860864, 1993
Test ing f or bot h PSA and PAP increases det ect ion of early prost at e cancer. PSA
t est ing det ermines t he eff ect iveness of t herapy f or prost at e cancer and is used
as an early indicat or of prost at e cancer recurrence. The great est value of PSA is
as a marker in t he f ollow -up of pat ient s at high risk f or disease progression.
PSA lacks sensit ivit y and specif icit y t o be used alone as a screening t est f or
prost at ic carcinoma, but in conjunct ion w it h a digit al rect al exam, t he det ect ion
rat e of prost at ic carcinoma is great ly increased.
Reference Values
Normal
Men: 04. 0 ng/ mL or 04. 0 g/ L
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is needed.
3. Record pat ient 's age.
1. PSA i ncreases occur in prost at e cancer (80% of pat ient s).

2. Pat ient s w it h benign prost at ic hypert rophy of t en demonst rat e values bet w een
4. 0 and 8. 0 ng/ mL (4. 08. 0 g/ L). Result s bet w een 4. 0 and 8. 0 ng/ mL (4. 0
8. 0 g/ L) may represent benign prost at ic hypert rophy or possible cancer of
t he prost at e. Result s >8. 0 ng/ mL or >8. 0 g/ L are highly suggest ive of
prost at ic cancer.
3. I ncreases t o >4. 0 ng/ mL or >4. 0 g/ L have been report ed in about 8% of
pat ient s w it h no prost at ic malignancies and no benign diseases.
4. I f a prost at e t umor is complet ely and successf ully removed, no ant igen w ill
be det ect ed.
Interfering Factors
1. Transient increases in PSA occur f ollow ing prost at e palpat ion or rect al
examinat ion.
2. I ncreased w it h urinary ret ent ion.
3. Recent exposure t o radioisot opes causes t est int erf erence.
Interventions
2. Do not schedule any prost at ic examinat ions, including rect al examinat ion,
prost at e biopsy, or TURP, f or 1 w eek bef ore t he blood t est is perf ormed.

2. I nt erpret t est result s, and monit or and counsel as appropriat e f or response
t o t reat ment and progression or remission of prost at e cancer.
Clin ical Alert
1. PSA is not a def init ive diagnost ic marker t o screen f or carcinoma of t he

prost at e because it is also f ound in men w it h benign prost at ic hypert rophy.
2. Digit al rect al examinat ion (DRE) is recommended by t he American Cancer
Societ y as t he primary t est f or det ect ion of prost at ic t umor. Recent
st udies indicat e t hat serum PSA may off er addit ional inf ormat ion. PSA
should be used in conjunct ion w it h DRE.
3. The value of prost at ic cancer screening remains cont roversial in t erms of
pat ient morbidit y and longevit y out comes.
Alanine Aminotransferase (Aminotransferase, ALT);

Serum Glutamic-Pyruvic Transaminase (SGPT) ALT is
an enzyme. High concentrations occur in the liver, and
relatively low concentrations are found in the heart,
muscle, and kidney.
This t est is primarily used t o diagnose liver disease and t o monit or t he course of
t reat ment f or hepat it is, act ive post necrot ic cirrhosis, and t he eff ect s of lat er
drug t herapy. ALT is more sensit ive in t he det ect ion of liver disease t han in
biliary obst ruct ion. ALT also diff erent iat es bet w een hemolyt ic jaundice and
jaundice due t o liver disease.
Reference Values
Normal
Adult s (adult levels are reached by 6 mont hs): 1035 U/ L or 0. 170. 60 kat / L
(males slight ly higher) Males: 1040 U/ L or 0. 170. 68 kat / L
Females: 735 U/ L or 0. 120. 60 kat / L
New borns: 1345 U/ L or 0. 220. 77 kat / L
ALT values are slight ly higher in males and black persons. Normal values vary
w it h t est ing met hod. Check w it h your laborat ory f or ref erence values.
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is needed f or t he t est . O bserve
st andard precaut ions. Place specimen in a biohazard bag.
2. Avoid hemolysis during collect ion of t he specimen. (ALT act ivit y is 6 t imes
higher in RBCs. )
1. Increased ALT l evel s are f ound in t he f ollow ing condit ions:
a. Hepat ocellular disease (moderat e t o high increase)
b. Alcoholic cirrhosis (mild increase)
c. Met ast at ic liver t umor (mild increase)
d. O bst ruct ive jaundice or biliary obst ruct ion (mild increase)
e. Viral, inf ect ious, or t oxic hepat it is (3050 t imes normal)
f. I nf ect ious mononucleosis
g. Pancreat it is (mild increase)
h. Myocardial inf arct ion, heart f ailure
i. Polymyosit is
j. Severe burns
k. Trauma t o st riat ed muscle
l. Severe shock
2. Aspart at e t ransaminase (AST)/ ALT comparison:
a. Alt hough t he AST level is alw ays increased in acut e MI , t he ALT level
does not alw ays increase unless t here is also liver damage.
b. The ALT is usually increased more t han t he AST in acut e ext rahepat ic
biliary obst ruct ion.
c. The AST/ ALT rat io is high in alcoholic liver disease; t he ALT is more
specif ic t han AST f or liver disease, but t he AST is more sensit ive t o
alcoholic liver disease.
Clin ical Alert

Critical Valu e
Alcohol-acet aminophen syndrome: ext remely abnormal ALT/ AST values are
f ound >9000 U/ L (>153 kat / L): t his ext reme level can dist inguish t his
syndrome f rom alcoholic or viral hepat it is.
Interfering Factors
1. Many drugs may cause f alsely increased and decreased ALT levels (see
Appendix J).
2. Salicylat es may cause decreased or increased ALT levels.

3. Therapeut ic heparin causes increased ALT.
4. Hemolysed blood causes increases in ALT.
5. O besit y causes increases in ALT.
Clin ical Alert

There is a correlat ion bet w een t he presence of elevat ed serum ALT and
abnormal ant ibodies t o t he hepat it is B virus core ant igen and hepat it is C
ant igen. Persons w it h elevat ed ALT levels should not donat e blood.
Interventions

2. I nt erpret t est result s and monit or as appropriat e f or liver disease.
Alkaline Phosphatase (ALP), Total; 5-Nucleotidase

Alkaline phosphatase is an enzyme originating mainly
in the bone, liver, and placenta, with some activity in
the kidney and intestines. It is called alkaline because
it functions best at a pH of 9. ALP levels are age and
gender dependent. Post puberty ALP is mainly of liver
origin.
Alkaline phosphat ase is used as an index of liver and bone disease w hen
correlat ed w it h ot her clinical f indings. I n bone disease, t he enzyme level rises in
proport ion t o new bone cell product ion result ing f rom ost eoblast ic act ivit y and
t he deposit of calcium in t he bones. I n liver disease, t he blood level rises w hen
excret ion of t his enzyme is impaired as a result of obst ruct ion in t he biliary t ract .
Used alone, alkaline phosphat ase may be misleading.
Reference Values
Normal
Femal es: 112 years: <350 U/ L
>15 years: 25100 U/ L
Mal es:
112 years: <350 U/ L
1214 yrs: <500 U/ L
>20 yrs: 25100 U/ L
Normal values are higher in pediat ric pat ient s and in pregnancy. Values increase
up t o 3 t imes in pubert y. Check w it h your laborat ory f or ref erence values. Values
may vary w it h met hod of t est ing.
Procedure
1. O bt ain a 5-mL f ast ing venous blood sample. Serum is used f or t his t est .
Ant icoagulant s may not be used. O bserve st andard precaut ions. Place
2. Ref rigerat e sample as soon as possible.
3. Not e age and gender on t est requisit ion.
1. El evated l evel s of ALP i n l i ver di sease (correlat ed w it h abnormal liver
f unct ion t est s) occur in t he f ollow ing condit ions:
a. O bst ruct ive jaundice (gallst ones obst ruct ing major biliary duct s;
accompanying elevat ed bilirubin)
b. Space-occupying lesions of t he liver such as cancer (hepat ic carcinoma)
and malignancy w it h liver met ast asis
c. Hepat ocellular cirrhosis
d. Biliary cirrhosis
e. I nt rahepat ic and ext rahepat ic cholest asis
f. Hepat it is, inf ect ious mononucleosis, cyt omegalovirus
g. Diabet es mellit us (causes increased synt hesis), diabet ic hepat ic lipidosis

h. Chronic alcohol ingest ion
i. G ilbert 's syndrome
2. Bone di sease and el evated ALP l evel s occur in t he f ollow ing condit ions:
a. Paget 's disease (ost eit is def ormans; levels 10 t o 25 t imes normal)
b. Met ast at ic bone t umor
c. O st eogenic sarcoma
d. O st eomalacia (elevat ed levels help diff erent iat e bet w een ost eomalacia
and ost eoporosis, in w hich w here is no elevat ion), ricket s
e. Healing f act ors (ost eogenesis imperf ect a)
3. O t her diseases involving el evated ALP l evel s include t he f ollow ing:
a. Hyperparat hyroidism (accompanied by hypercalcemia), hypert hyroidism
b. Pulmonary and myocardial inf arct ions
c. Hodgkin's disease
d. Cancer of lung or pancreas
e. Ulcerat ive colit is, pept ic ulcer
f. Sarcoidosis
g. Perf orat ion of bow el (acut e inf arct ion)
h. Amyloidosis
i. Chronic renal f ailure
j. Congest ive heart f ailure
k. Hyperphosphat asia (primary and secondary)
4. Decreased l evel s of ALP occur in t he f ollow ing condit ions:
a. Hypophosphat asia (congenit al)
b. Malnut rit ion, scurvy
c. Hypot hyroidism, cret inism
d. Pernicious anemia and severe anemias
e. Magnesium def iciency
f. Milk alkali (Burnet t 's syndrome)
g. Celiac sprue
h. Magnesium and zinc def iciency (nut rit ional)
Clin ical Alert

1. This t est should not be done if t he t ot al alkaline phosphat ase level is
normal.
2. For evaluat ion of t he biliary t ract , alt ernat ive t est s such as G G T, leucine
aminopept idase (LAP), and 5-nucleot idase st udies are recommended over
t he ALP I SO t est .
3. Alkaline phosphat ase isoenzymes have lit t le value in children and
adolescent s because bone and liver f ract ions are normally elevat ed.
4. I n pregnancy, marked decline of t he placent al isoenzyme is seen w it h
placent al insuff iciency and imminent f et al demise.
Interfering Factors
1. A variet y of drugs produce mild t o moderat e increases or decreases in ALP
levels. See Appendix J f or drugs t hat aff ect out comes.
2. Young children, t hose experiencing rapid grow t h, pregnant w omen, and
post menopausal w omen have physiologically high levels of ALP; t his level is
slight ly increased in older persons.
3. Af t er I V administ rat ion of albumin, t here is somet imes a marked increase in
ALP f or several days.
4. ALP levels increase at room t emperat ure and in ref rigerat ed st orage. Test ing
should be done t he same day.
5. ALP levels decrease if blood is ant icoagulat ed.
6. ALP levels increase af t er f at t y meals.
Interventions
1. Explain t est purpose and blood-draw ing procedure. Fast ing is required.

2. I nt erpret t est result s and monit or appropriat ely f or liver or bone disease and
evidence of t umor. Test ing f or 5-nucleot idase provides support ive evidence
in t he diagnosis of liver disease.
When ALP and 5-nucleot idase t est result s are evaluat ed, t hey provide
def init ive diagnosis of Paget 's disease and ricket s, in w hich high levels of
ALP accompany normal (05 U/ L) or marginally increased 5-nucleot idase
act ivit y. 5-Nucleot idase is increased in liver disease (eg, hepat ic carcinoma,
biliary cirrhosis, ext rahepat ic obst ruct ion, met ast at ic neoplasia of liver). 5Nucleot idase level usually does not increase in skelet al disease.
3. Remember t hat t o conf irm biliary abnormalit y, a usef ul t est is gamma
glut amylt ransf erase (G G T). The G G T t est is elevat ed in hepat obiliary
disease, but not in uncomplicat ed bone disease.
Alkaline Phosphatase Isoenzymes (ISO) The

isoenzymes of ALP are produced in various tissues.
AP-1, 2 is produced in the liver and by proliferating
blood vessels. AP-2, 1 is produced by bone and
placental tissue. The intestinal isoenzyme AP-3, 2 is
present in small quantities in group O and B
individuals who are Lewis-positive secretors. Placental
ALP is present in the last trimester of pregnancy.
Any pat ient w it h an elevat ion of serum t ot al alkaline phosphat ase is a candidat e
f or ALP isoenzyme st udy. The ALP I SO is mainly used t o dist inguish bet w een
bone and liver elevat ions of alkaline phosphat ase.
Reference Values
Normal
AP-1, 2 : values (liver) report ed as w eak, moderat e, or st rong or 24158 U/ L
(0. 402. 64 kat / L) AP-2, 1 : values (bone) report ed as w eak, moderat e, or
st rong or 24146 U/ L (0. 402. 44 kat / L) AP-3, 2 : values (int est ines) report ed
as w eak, moderat e, or st rong or 022 U/ L (00. 36 kat / L) AP-4: values
(placent al) report ed as w eak, moderat e, or st rong. Placent al AP-4 is f ound only
in pregnant w omen.
Procedure
1. O bt ain a 5-mL f ast ing venous blood sample in a plain red-t opped t ube or
SST t ube. Serum is needed. Cent rif uge blood prompt ly, w it h 30 minut es af t er
draw.
3. Ref rigerat e if not t est ed immediat ely.
1. Liver (AP-1, 2 ) isoenzymes are elevat ed in hepat ic and biliary diseases
such as t he f ollow ing condit ions:
a. Cirrhosis (hepat ic)
b. Hepat ic carcinoma
c. Biliary obst ruct ion, primary biliary cirrhosis
2. Bone (AP-2, 1 ) isoenzymes are elevat ed in t he f ollow ing condit ions:
a. Paget 's disease
b. Hyperparat hyroidism
c. Bone cancer, ricket s (all t ypes)
d. O st eomalacia, ost eoporosis
e. Malabsorpt ion syndrome
f. Cert ain renal disorders (uremia bone disease or renal ricket s)
3. I nt est inal (AP-3, 2 ) isoenzymes are elevat ed in t he f ollow ing condit ions:
a. I nt est inal inf arct ion
b. Ulcerat ive lesions of st omach, small int est ine, and colon
c. I ndividuals w it h blood t ype O or B secret e int est inal isoenzymes 2 hours
af t er a meal.
4. Placent al (AP-4) isoenzymes are increased in t he f ollow ing condit ions:
a. Pregnancy (lat e in t hird t rimest er t o onset of labor)
b. Complicat ions of pregnancy such as hypert ension and preeclampsia
5. Placent al-like isoenzymes occur in some cancers (unident if ied isoenzymes):
a. Regan's isoenzyme
b. Nagao's isoenzyme
Interfering Factors
Same as f or alkaline phosphat ase.
Interventions
1. See t ot al alkaline phosphat ase pat ient pret est care on page 389.
2. Remember t hat t he same guidelines apply t o alkaline phosphat ase isoenzyme
t est ing.

1. See t ot al alkaline phosphat ase pat ient post t est af t ercare on page 389.
2. Remember t hat t he same guidelines apply t o alkaline phosphat ase isoenzyme
t est ing.
Angiotensin-Converting Enzyme (ACE) Angiotensin I is

produced by the action of renin on angiotensinogen.
Angiotensin Iconverting enzyme (ACE) catalyzes the
conversion of angiotensin I to the vasoactive peptide
angiotensin II. Angiotensin I is concentrated in the
proximal tubules.
This t est is used primarily t o evaluat e t he severit y and act ivit y of sarcoidosis.
Serial det erminat ions may be helpf ul in f ollow ing t he clinical course of t he
disease w it h st eroid t reat ment . I t is also used in t he invest igat ion of G aucher's
disease.
Reference Values
Normal
853 U/ L or 0. 140. 88 kat / L
Check w it h your laborat ory f or ref erence values f or inf ant s and childrent hey
are generally higher.
Procedure
1. O bt ain a 5-mL venous blood sample. Serum or heparinized plasma is used.

3. Freeze specimen if t est is not perf ormed immediat ely.
1. Increased ACE l evel s are associat ed w it h t he f ollow ing condit ions:
a. Sarcoidosis (ACE levels ref lect t he severit y of t he disease, w it h 68%
posit ivit y in st age 1 disease, 86% in st age 2, and 92% in st age 3)
b. G aucher's disease
c. Leprosy
d. Acut e and chronic bronchit is
e. Connect ive t issue diseases
f. Amyloidosis
g. Pulmonary f ibrosis
h. Fungal diseases and hist oplasmosis
i. Unt reat ed hypert hyroidism
j. Diabet es mellit us
k. Psoriasis
2. Decreased ACE l evel s occur in t he f ollow ing condit ions:
a. Follow ing prednisone t reat ment f or sarcoidosis (st eroid t herapy)
b. Advanced lung neoplasms
c. St arvat ion
Interfering Factors
1. This t est should not be done in persons <20 years of age because t hey
normally have a very high level of ACE.
2. About 5% of t he normal adult populat ion have elevat ed ACE levels.
3. ACE is inhibit ed by EDTA ant icoagulant .
4. Some ant ihypert ensives may cause low ACE values.
Interventions

1. I nt erpret t est result s and monit or as appropriat e f or sarcoidosis and amyloid
disease.
Amylase and Lipase

Amylase, an enzyme t hat changes st arch t o sugar, is produced in t he salivary
(parot id) glands and pancreas; much low er act ivit ies are present in t he ovaries,
int est ines, and skelet al muscle. I f t here is an inf lammat ion of t he pancreas or
salivary glands, much amylase ent ers t he blood. Amylase levels in t he urine
ref lect blood changes by a t ime lag of 6 t o 10 hours. (See Amylase
Excret ion/ Clearance, Chapt er 3). Lipase is a glycoprot ein t hat , in t he presence
of bile salt s and colipase, changes f at s t o f at t y acids and glycerol. The pancreas
is t he major source of t his enzyme. Lipase appears in t he blood f ollow ing
pancreat ic damage at t he same t ime amylase appears (or slight ly lat er) but
remains elevat ed much longer t han amylase (7 t o 10 days).
Amylase and lipase t est s are used t o diagnose and monit or t reat ment of acut e
pancreat it is and t o diff erent iat e pancreat it is f rom ot her acut e abdominal
disorders (80% of pat ient s w it h acut e pancreat it is w ill have elevat ed amylase
and lipase levels; lipase st ays elevat ed longer). Lipase assay provides bet t er
sensit ivit y and specif icit y and is best used w it h amylase det erminat ion.
Reference Values
Normal
Amyl ase New borns: 665 U/ L or 0. 11. 1 kat / L
Adult s: 25125 U/ L or 0. 42. 1 kat / L
Elderly persons (>60 years): 24151 U/ L or 0. 42. 5 kat / L
Li pase
Adult s: 10140 U/ L or 0. 172. 3 kat / L
Elderly persons (>60 years): 18180 U/ L or 0. 303. 0 kat / L
Normal values vary w idely according t o met hod of t est ing; check w it h your
laborat ory f or ref erence ranges. Amylase levels are low f or t he f irst 2 mont hs of
lif e. Most of t he act ivit y is of salivary origin. Children up t o 2 years of age have
virt ually no pancreat ic amylase.
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is used. (EDTA, cit rat e, and
oxalat e ant icoagulant int erf ere w it h lipase t est ing. )
1. G reatl y i ncreased amyl ase l evel s occur in acut e pancreat it is early in t he
course of t he disease. The increase begins in 3 t o 6 hours af t er t he onset of
pain.
2. Increased amyl ase l evel s also occur in t he f ollow ing condit ions:
a. Chronic pancreat it is, pancreat ic t rauma, pancreat ic carcinoma,
obst ruct ion of pancreat ic duct
b. Part ial gast rect omy
c. Acut e appendicit is, perit onit is
d. Perf orat ed pept ic ulcer
e. Cerebral t rauma, shock
f. O bst ruct ion or inf lammat ion of salivary duct or gland and mumps
g. Acut e cholecyst it is (common duct st one)
h. I nt est inal obst ruct ion w it h st rangulat ion
i. Rupt ured t ubal pregnancy and ect opic pregnancy
j. Rupt ured aort ic aneurysm
k. Macroamylasia
3. Decreased amyl ase l evel s occur in t he f ollow ing condit ions:
a. Pancreat ic insuff iciency
b. Hepat it is, severe liver disease
c. Advanced cyst ic f ibrosis

d. Pancreat ect omy
4. El evated l i pase l evel s occur in pancreat ic disorders (eg, pancreat it is,
alcoholic and nonalcoholic; pancreat ic carcinoma).
5. Increased l i pase val ues also are associat ed w it h t he f ollow ing condit ions:
a. Cholecyst it is
b. Hemodialysis
c. St rangulat ed or inf arct ed bow el
d. Perit onit is
e. Primary biliary cirrhosis
f. Chronic renal f ailure
6. Serum lipase levels are normal in pat ient s w it h elevat ed amylase w ho have
pept ic ulcer, salivary adenit is, inf lammat ory bow el disease, int est inal
obst ruct ion, and macroamylasemia. Coexist ence of increased serum amylase
and normal lipase levels may be a helpf ul clue t o t he presence of
macroamylasemia.
Clin ical Alert

Pan ic Level for Lipase
>600 I U/ L or >10 kat / L
Interfering Factors
1. Amylase
a. Ant icoagulat ed blood gives low er result s. Do not use EDTA, cit rat e
oxalat e.
b. Lipemic serum int erf eres w it h t est .
c. I ncreased levels are f ound in alcoholic pat ient s and pregnant w omen and
in diabet ic ket oacidosis.
d. Many drugs can int erf ere w it h t his t est (see Appendix J).
2. Lipase
a. EDTA ant icoagulant int erf eres w it h t est .
b. Lipase is increased in about 50% of pat ient s w it h chronic renal f ailure.
c. Lipase increases in pat ient s undergoing hemodialysis.
d. Many drugs can aff ect out comes. See Appendix J.
Interventions
1. Explain t est purpose and procedure. Amylase and lipase t est ing are done
t oget her in t he presence of abdominal pain, epigast ric t enderness, nausea,
and vomit ing. These f indings charact erize acut e pancreat it is as w ell as ot her
acut e surgical emergencies.
2. I f amylase/ creat inine clearance t est ing is also being done, collect a single,
random urine sample at t he same t ime blood is draw n.
care.

2. I nt erpret t est result s and monit or as appropriat e f or pancreat it is or ot her
acut e abdominal condit ions.
Aspartate Transaminase (Aminotransferase, AST);

Serum Glutamic-Oxaloacetic Transaminase (SGOT)
Aspartate transaminase (AST) is an enzyme present in
tissues of high metabolic activity; decreasing
concentrations of AST are found in the heart, liver,
skeletal muscle, kidney, brain, pancreas, spleen, and
lungs. The enzyme is released into the circulation
following the injury or death of cells. Any disease that
causes change in these highly metabolic tissues will
result in a rise in AST levels. The amount of AST in the
blood is directly related to the number of damaged
cells and the amount of time that passes between
injury to the tissue and the test. Following severe cell
damage, the blood AST level will rise in 12 hours and

remain elevated for about 5 days.
This t est is used t o evaluat e liver and heart disease. The ALT is usually ordered
along w it h t he AST.
Reference Values
Normal
Men: 1420 U/ L or 0. 230. 33 kat / L
Women: 1036 U/ L or 0. 170. 60 kat / L
New borns: 47150 U/ L or 0. 782. 5 kat / L
Children: 980 U/ L or 0. 151. 3 kat / L
Check w it h your laborat ory. Diff erent met hods have diff erent ref erence values.
Procedure
1. O bt ain a 5-mL venous sample. Serum is used. O bserve st andard
2. Avoid hemolysis.
1. Increased AST l evel s occur in MI .
a. I n MI , t he AST level may be increase t o 4 t o 10 t imes t he normal values.
b. The AST level reaches a peak in 24 hours and ret urns t o normal by post MI day 3 t o 7. Secondary rises in AST levels suggest ext ension or
recurrence of MI .
c. The AST curve in MI parallels t hat of creat inine phosphokinase (CPK).
2. Increased AST l evel s occur in liver diseases (10100 t imes normal).
a. Acut e hepat it is and chronic hepat it is (ALT > AST)
b. Act ive cirrhosis (drug induced; alcohol induced: AST > ALT)
c. I nf ect ious mononucleosis
d. Hepat ic necrosis and met ast asis
e. Primary or met ast at ic carcinoma
f. Alcoholic hepat it is
g. Reye's syndrome
3. O t her diseases associat e w it h el evated AST l evel s include t he f ollow ing:
a. Hypot hyroidism
b. Trauma and irradiat ion of skelet al muscle
c. Dermat omyosit is
d. Polymyosit is
e. Toxic shock syndrome
f. Cardiac cat het erizat ion
g. Recent brain t rauma w it h brain necrosis, cerebral inf arct ion
h. Crushing and t raumat ic injuries, head t rauma, surgery
i. Progressive muscular dyst rophy (Duchenne's)
j. Pulmonary emboli, lung inf arct ion
k. G angrene
l. Malignant hypert hermia, heat angiography
m. Mushroom poisoning
n. Shock
o. Hemolyt ic anemia, exhaust ion, heat st roke
4. Decreased AST l evel s occur in t he f ollow ing condit ions:
a. Azot emia
b. Chronic renal dialysis
c. Vit amin B6 def iciency
Interfering Factors
1. Slight decreases occur during pregnancy, w hen t here is abnormal met abolism
of pyridoxine.
2. Many drugs can cause elevat ed or decreased levels (see Appendix J).
Alcohol ingest ion aff ect s result s.
3. Exercise and I M inject ions do not aff ect result s.
4. False decreases occur in diabet ic ket oacidosis, severe liver disease, and
uremia.
5. G ross hemolysis causes f alsely high levels.
Clin ical Alert

Critical Valu e
AST is ext remely high (>20, 000 U/ L; >333 kat / L) in alcohol-acet aminophen
syndrome. AST > ALT, prot hrombin t ime: 100 seconds. Creat inine: >34 mg/ L
or >0. 30 mmol/ L. m
Interventions
1. Explain t est purpose and blood-draw ing procedure. For diagnosis of MI , AST
t est ing should be done on 3 consecut ive days because t he peak is reached in
24 hours and levels ret urn t o normal in 3 t o 4 days.

1. I nt erpret t est result s and monit or appropriat ely f or heart and liver diseases.
2. Ensure t hat unexplained AST elevat ions are f urt her invest igat ed w it h ALT and
G G T t est s.
Cardiac Troponin T (cTnT): Troponin I (cTnI) Cardiac

troponin is unique to the heart muscle and is highly
concentrated in cardiomyocytes. These isoforms show
a high degree of cardiac specificity. This protein is
released with very small areas of myocardial damage
as early as 1 to 3 hours after injury, and levels return
to normal within 5 to 7 days. Troponin I remains
increased longer than CK-MB and is more cardiac
specific. Troponin T is more sensitive but less specific,
being positive with angina at rest. These tests are
becoming the most important addition to the clinical
assessment of cardiac injury.

This t est is used in t he early diagnosis of small myocardial inf arct s t hat are
undet ect able by convent ional diagnost ic met hods. Cardiac t roponin levels are
also used lat er in t he course of MI because t hey remain elevat ed f or 5 t o 7 days
af t er injury. A single sample may be misleading; t heref ore, serial sampling 0, 4,
8, and 12 hours af t er chest pains may be ordered t o rule out acut e MI . See
Table 6. 11 f or a list of cardiac markers.
Table 6.11 Cardiac Markers
Markers
Tim e of
Initial
Evaluation
Tim e of
Peak
Evaluation
Tim e to
Return to
Norm al
CK-MB
48 h
1224 h
7296 h
LDH
25 days
Myoglobin
24 h
810 h
24 h
Troponin I
(cTnI)
46 h
12 h
310 days
Troponin
T (cTnT)
48 h
1248 h
710 days
Reference Values
10 days
Normal
Negat ive (Q ualit at ive)
Troponin I : <0. 35 ng/ mL or <0. 35 g/ L
Troponin T: <0. 2 ng/ mL or <0. 2 g/ L
Tot al CK: 0120 ng/ mL or 0120 g/ L
CK-MB: 03 ng/ mL or 03 g/ L
CK index: 03
LDH: 140280 U/ L or 2. 344. 68 kat / L
Myoglobin: <55 ng/ mL or <55 g/ L
Troponin: <0. 4 ng/ mL or <0. 4 g/ L
Values may vary depending on t he t est ing met hod used. Check w it h your
laborat ory f or ref erence values.
Procedure
1. O bt ain a 5-mL venous blood sample in a red-t opped t ube w it hin hours af t er
onset of chest pain. O bserve st andard precaut ions. Place specimen in a
biohazard bag.
2. Be aw are t hat serial samples may be ordered. Record dat e and t ime of
sampling.
1. Posit ive or elevat ed cardiac t roponin I levels indicat e:
a. Small inf arct s; increases remain f or 5 t o 7 days.
b. Myocardial injury during surgery
2. Posit ive or elevat ed cardiac t roponin T
a. Acut e MI
b. Perisurgical MI
c. Unst able angina
d. Myocardit is
e. Some noncardiac event s
1. Chronic renal f ailure
2. Acut e t rauma involving muscle

3. Rhabdomyolysis, polymyosit is, dermat omyosis
Interfering Factors
1. Cardiac t roponin T levels may be increased in chronic muscle or renal
disease and t rauma.
2. Levels are not aff ect ed by ort hopedic or lung surgery.
Clin ical Alert

Critical Valu e
Troponin I : >1. 5 ng/ mL or >1. 5 g/ L
Interventions
1. Explain t hat t he t est is a sensit ive marker f or minor myocardial injury in
unst able angina.

1. I nt erpret t est result s, and counsel and monit or appropriat ely. Addit ional
t est ing may be necessary (eg, cardiac myosin light classes, glycogen
phosphorylcholine BB [ G PBB] ).
Creatine Phosphokinase (CPK); Creatine Kinase (CK);

CPK and CK Isoenzymes Creatine kinase (CPK/CK) is
an enzyme found in higher concentrations in the heart
and skeletal muscles and in much smaller
concentrations in brain tissue. Because CK exists in
relatively few organs, this test is used as a specific
index of injury to myocardium and muscle. CPK can be

divided into three isoenzymes: MM or CK3 , BB or CK1 ,
and MB or CK2 . CK-MM is the isoenzyme that
constitutes almost all the circulatory enzymes in
healthy persons. Skeletal muscle contains primarily
MM; cardiac muscle contains primarily MM and MB;
and brain tissue, GI system, and genitourinary tract
contain primarily BB. Normal CK levels are virtually
100% MM isoenzyme. A slight increase in total CPK is
reflected from elevated BB from CNS injury. CPK
isoenzyme studies help distinguish whether the CPK
originated from the heart (MB) or the skeletal muscle
(MM).
The CK (CPK) t est is used in t he diagnosis of MI and as a reliable measure of
skelet al and inf lammat ory muscle diseases. CK levels can prove helpf ul in
recognizing muscular dyst rophy bef ore clinical signs appear. CK levels may rise
signif icant ly w it h CNS disorders such as Reye's syndrome. The det erminat ion of
CK isoenzymes may be helpf ul in making a diff erent ial diagnosis. Elevat ion of
MB, t he cardiac isoenzyme, provides a more def init ive indicat ion of myocardial
cell damage t han t ot al CK alone. MM isoenzyme is an indicat or of skelet al
muscle damage. New er t est s, such as CK isof orms, allow f or earlier det ect ion of
MI t han is possible w it h CK-MB.
Reference Values
Normal
Men: 38174 U/ L (0. 632. 90 kat / L) Women: 26140 U/ L (0. 462. 38 kat / L)
I nf ant s: 23 t imes adult values Isoenzymes: MM (CK3 ): 96%100%
MB (CK2 ): 0%6%
BB (CK1 ): 0%
NOTE
Normal values may vary w it h met hod of t est ing and react ion t emperat ure.
Check w it h your laborat ory.
NOTE
Healt hy Af rican Americans have higher CK levels t han do Caucasian and
Hispanic persons.
Procedure
1. O bt ain a 5-mL venous blood sample. Serum must be used.
3. I f a pat ient has been receiving mult iple I M inject ions, not e t his f act on t he
laborat ory requisit ion.
4. Avoid hemolysis.
1. Tot al CK Levels
a. Increased CK/ CPK l evel s occur in t he f ollow ing condit ions:
1. Acut e MI
a. Wit h MI , t he rise st art s soon af t er an at t ack (about 46 hours)
and reaches a peak of at least several t imes normal w it hin 24
hours. CK ret urns t o normal in 48 t o 72 hours.
b. CK and CK-MB (CK2 ) peaks about 1 day af t er onset , as does
AST.
c. Lact at e dehydrogenase (LD) usually peaks 2 days af t er onset ,
w hen t he LD1 LD 2 inversion (f lip) is f ound.
d. CK-MB, LD1 , LD1 : LD 2 rat io, t ot al CK, and t ot al LD classically
increase w it h acut e MI . CK-MB and LD1 increase bot h in
percent age and absolut ely (each isoenzyme percent age t imes t he
respect ive t ot al enzyme), peak, and t hen decrease.
e. AST t est ing w it h LD and LD isoenzymes is advocat ed w hen t he
pat ient reaches medical at t ent ion 48 t o 72 hours af t er onset of a
possible acut e MI .
2. Severe myocardit is
3. Af t er open heart surgery
4. Cardioversion (cardiac def ibrillat ion)
5. Myocardit is
b. O t her diseases and procedures t hat cause increased CK/ CPK levels
1. Acut e cerebrovascular disease
2. Progressive muscular dyst rophy (levels may reach 20200 t imes
normal), Duchenne's muscular dyst rophy, f emale carriers of muscular
dyst rophy
3. Dermat omyosit is and polymyosit is
4. Delirium t remens and chronic alcoholism
5. Elect ric shock, elect romyography
6. Malignant hypert hermia
7. Reye's syndrome
8. Convulsions, ischemia, or subarachnoid hemorrhage
9. Last w eeks of pregnancy and during childbirt h
10. Hypot hyroidism
11. Acut e psychosis
12. CNS t rauma, ext ensive brain inf arct ion
13. Neoplasms of prost at e, bladder, or G I t ract
14. Rhabdomyolysis w it h cocaine int oxicat ion
15. Eosinophilia-myalgia syndrome
c. Normal values are f ound in myast henia gravis and mult iple sclerosis.
d. Decreased values have no diagnost ic meaning and may be caused by low
muscle mass and bed rest (overnight values can drop 20%).
2. CK I soenzymes
a. El evated MB (CK2 ) i soenzyme l evel s occur in t he f ollow ing condit ions:
1. Myocardial inf arct (rises 46 hours af t er MI ; not demonst rable af t er
2436 hours; ie, peak w it h rapid f all)
2. Myocardial ischemia, angina pect oris
3. Duchenne's muscular dyst rophy
4. Subarachnoid hemorrhage
5. Reye's syndrome
6. Muscle t rauma, surgery (post operat ive)
7. Circulat ory f ailure and shock

8. I nf ect ions of heart myocardit is
10. Malignant hypert hermia, hypot hermia
11. CO poisoning
12. Polymyosis
13. Myoglobulinemia
14. Rocky Mount ain spot t ed f ever
b. BB (CK1 ) elevat ions occur in t he f ollow ing condit ions:
1. Reye's syndrome
2. Some breast , bladder, lung, ut erus, t est es, and prost at e cancers
3. Severe shock syndrome
4. Brain injury, neurosurgery
5. Hypot hermia
6. Follow ing coronary bypass surgery
7. New borns
c. MM (CK1 ) is elevat ed in most condit ions in w hich t ot al CK is elevat ed.
d. MB (CK2 ) is not elevat ed:
1. Exercise (t ot al elevat ed)
2. I M inject ions (t ot al elevat ed)
3. St rokes, cerebrovascular accident , and ot her brain disorders in w hich
t ot al CK is elevat ed
4. Pericardit is
5. Pneumonia, ot her lung diseases; pulmonary embolism
6. Seizures (CK t ot al may be very high)
Clin ical Alert

1. Af t er an MI , MB appears in t he serum in 6 t o 12 hours and remains f or
about 18 t o 32 hours. The f inding of MB in a pat ient w it h chest pain is
diagnost ic of MI . I n addit ion, if t here is a negat ive CK-MB f or 48 hours
f ollow ing a clearly def ined episode, it is clear t hat t he pat ient has not had
an MI .
2. CK-MB, LD1, LD1/ LD-2 rat io, t ot al CK, and t ot al LD classically increase
w it h acut e MI . CK-MB and LD1 increase bot h in percent age and absolut ely
(each isoenzyme percent t imes t he respect ive t ot al enzyme), peak, t hen
decrease.
Interfering Factors
1. St renuous exercise, w eight lif t ing, and surgical procedures t hat damage
skelet al muscle may cause increased levels of CK.
2. Alcohol and ot her drugs of abuse increase CK levels.
3. At hlet es have a higher CK value because of great er muscle mass.
4. Mult iple I M inject ions may cause increased or decreased CK levels (see
Appendix J).
5. Many drugs may cause increased CK levels.
6. Childbirt h may cause increased CK levels.
7. Hemolysis of blood sample causes increased CK levels.
Interventions
1. Explain t est purpose and need f or at least t hree consecut ive blood draw s
f ollow ing episode.
2. Not e on requisit ion w hen suspect ed cardiac episode occurred, and dat es and
t imes of blood draw s.
3. Do not allow exercise bef ore t est .

2. I nt erpret t est result s and monit or as appropriat e f or MI , muscular dyst rophy,
and ot her causes of abnormal t est out comes.
3. Remember t hat high levels of CK/ CK-MB may suggest ot her t est s should be
done t o support diagnosis of acut e MI :
a. Tot al leukocyt e count and diff erent ial

b. Cardiac t roponin T
c. Myoglobin
Galactose-1-Phosphate Uridyltransferase (GPT);

Galactokinase; Galactose-1-Phosphate The enzyme
galactose-1-phosphate uridyltransferase is needed in
the use of galactose-1-phosphate so that is does not
accumulate in the body. A very rare genetic disorder
resulting from an inborn (inherited or acquired during
intrauterine development) error of galactose
metabolism may occur.
This measurement is used t o ident if y galact ose def ect s, w hich can result in
w idespread t issue damage and abnormalit ies such as cat aract s, liver disease,
and renal disease. I t also causes f ailure t o t hrive and ment al ret ardat ion. The
screening t est should be done immediat ely t o enable diet t reat ment if t est is
posit ive.
Reference Values
Normal
G alact ose-1-phosphat e uridylt ransf erase: 18. 528. 5 U/ g of hemoglobin (Hb) or
1. 191. 84 mU/ mol Hb G alact ose-1-phosphat e (dried blood spot -screening):
<0. 74 mmol/ L
G al actoki nase Children 02 years: 11150 mU/ g Hb or 1832500 pkat / g Hb
Children 218 years: 1154 mU/ g Hb or 183900 pkat / g Hb Adult s: 1240 mU/ g
Hb or 200667 pkat / g Hb
Procedure
1. O bt ain a 5-mL venous blood sample.
2. Ant icoagulat e w it h heparin.
Decreased values are associat ed w it h galact osemia, a rare genet ic disorder
t ransmit t ed in an aut osomal recessive f ashion. The result ing accumulat ion of
galact it ol and/ or galact ose-1-phosphat e can result in juvenile cat aract s, liver
f ailure, f ailure t o t hrive, and ment al ret ardat ion in persons w it h galact ose-1phosphat e uridylt ransf erase def iciency.
Interventions
1. Explain t est purpose and procedure. G enet ic counseling may be necessary.

1. I nt erpret t est result s and counsel appropriat ely. See new born screening in
Chapt er 11.
2. I nst ruct parent s of inf ant s and children w it h posit ive t est result s t hat t he
disease can eff ect ively t reat ed by removing galact ose-cont aining f oods,
especially milk, f rom t he diet . Wit h diet ary galact ose rest rict ion, liver and
lens changes are reversible.
Hexosaminidase, Total and Isoenzyme A Three

isoenzymes of hexosaminidase have been identified in
serum: A (acid form), B (base form), and S.
Hexosaminidase A is a lysosomal isoenzyme,
deficiency of which characterizes patients with TaySachs disease. Homozygotes have no hexosaminidase
A and a large increase in hexosaminidase B and S.
Heterozygotes have a moderate decrease in
hexosaminidase A and a slight increase of
hexosaminidase B and S.
Hexosaminidase A is used as a diagnost ic t est f or Tay-Sachs disease and can be
of help in ident if ying carriers among persons w it h no f amily hist ory of Tay-Sachs.
This condit ion is due t o an aut osomal recessive t rait f ound predominant ly, but not
exclusively, in Ashkenazi Jew s and is charact erized by t he appearance during
inf ancy of psychomot or det eriorat ion, blindness, cherry-red spot on t he macula,
and an exaggerat ed ext ension response t o sound. I n t he brains of aff ect ed
children, t he level of ganglioside is increased 100 t imes ow ing t o t he def iciency
of t his enzyme.
Reference Values
Normal
Percentage of normal total hexosami ni dase A 56%80% noncarrier: 7. 29. 88
U/ L or 120165 nkat / L
<50% het erozygous: 3. 305. 39 U/ L or 5590 nkat / L
0% Tay-Sachs: 0 U/ L
Total hexosami ni dase Noncarrier: 9. 8315. 95 U/ L or 164266 nkat / L
Het erozygous: 3. 305. 39 U/ L or 5590 nkat / L (carrier) Homozygous Tay-Sachs:
17. 1 U/ L or 285 nkat / L
Leukocyt e hexosaminidase t ot al: 16. 436. 2 U/ g cellular prot ein or 273603
nkat / g cellular prot ein Leukocyt e hexosaminidase A: 63%75% of t ot al (normal)
Normal values vary w it h met hod of t est ing used. Check w it h your laborat ory f or
ref erence values.
Procedure
1. O bt ain a 5-mL venous blood sample. Allow blood t o clot at +3C and
cent rif uge at 3C. The t est uses serum. I f t he t est is not perf ormed
immediat ely, serum must be f rozen.
2. Be aw are t hat if leukocyt e hexosaminidase A is ordered also, a heparinized
sample is needed. Place in ice immediat ely. Place specimens in biohazard
bags.
1. Decreased hexosami ni dase A. An almost t ot al def iciency of t he A component
is diagnost ic of Tay-Sachs disease or G M2 gangliosidosis. The t ot al
hexosaminidase is of no value in Tay-Sachs.
2. Decreased hexosami ni dase A and B. I n a variant of Tay-Sachs disease
know n as Sandhoff 's disease, bot h A and B isoenzymes are def ect ive,
causing an absence of t his enzyme. The t ot al hexosaminidase level is also

decreased in Sandhoff 's disease.
3. Increased total hexosami ni dase occurs in t he f ollow ing condit ions:
a. Hepat ic disease (biliary obst ruct ion)
b. G ast ric cancer
c. Myeloma
d.
MI
e. Vascular complicat ions of diabet es mellit us
Clin ical Alert

Pregnancy result s in increased serum levels of t ot al hexosaminidase and
decreased hexosaminidase A, w hich gives a f alse appearance of being a
carrier. Theref ore, during pregnancy, t he serum t est should never be done.
How ever, t he leukocyt e t est is valid in pregnancy and should be used.
Interfering Factors
1. Tot al values are increased in pregnancy (5 t imes normal).
2. O ral cont racept ives f alsely increase values.
Clin ical Alert

Critical Valu es for Hexosamin idase A Less th an 50% of total
activity in dicates Tay-Sach s carrier. If th e seru m Hex A test
levels are ambigu ou s th e leu kocyte test sh ou ld be don e.
Interventions
1. Explain t est purpose and procedure. G enet ic counseling may occur bef ore
t est ing.
2. Be aw are t hat pregnancy and/ or oral cont racept ives are cont raindicat ions f or
t est ing.

1. I nt erpret t est result s and be prepared t o perf orm genet ic counseling of
pat ient and f amily. The physician should be inf ormed as soon as possible.
2. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed, posttest care .
Lactate Dehydrogenase (LD, LDH) Lactate

dehydrogenase is an intracellular enzyme that is
widely distributed in the tissues of the body,
particularly in the kidney, heart, skeletal muscle, brain,
liver, and lungs. Increases in the reported value
usually indicate cellular death and leakage of the
enzyme from the cell.
Alt hough elevat ed levels of LDH are nonspecif ic, t his t est is usef ul in conf irming
myocardial or pulmonary inf arct ion w hen view ed in relat ion t o ot her t est f indings.
For example, LD remains elevat ed longer t han CK in MI . LDK level is also helpf ul
in t he diff erent ial diagnosis of muscular dyst rophy and pernicious anemia. More
specif ic f indings may be f ound by breaking dow n t he LDH int o it s f ive
isoenzymes. (When LD values are report ed or quot ed, total LDH is meant . )
Reference Values
Normal
New born: 160450 U/ L
Children: 60170 U/ L
Adult s: 140280 U/ L
Normal values vary w it h met hod of t est ing used. Check w it h your laborat ory f or
ref erence values.
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is used. O bserve st andard
precaut ions.
2. Avoid hemolysis in obt aining blood sample. Place specimen in a biohazard
bag.
1. Increased LDH (LD) occurs in t he f ollow ing condit ions:
a. High levels occur w it hin 36 t o 55 hours af t er MI and cont inue longer t han
elevat ions of SG O T or CPK (310 days). Diff erent ial diagnosis of acut e
MI may be accomplished w it h LDH isoenzymes.
b. I n pulmonary inf arct ion, increased LDH occurs w it hin 24 hours of pain
onset . The pat t ern of normal SG O T and elevat ed LDH t hat levels off 1 t o
2 days af t er an episode of chest pain is indicat ive of pulmonary
inf arct ion.
c. El evated l evel s of LDH are also observed in various ot her condit ions:
2. Liver diseases (eg, cirrhosis, alcoholism, acut e viral hepat it is)
3. Malignant neoplasms, cancer, leukemias, lymphoma
4. Hypot hyroidism
5. Lung diseases
6. Skelet al muscle diseases (muscular dyst rophy), muscular damage
7. Megaloblast ic and pernicious anemias, hemolyt ic anemia, sickle cell
disease
8. Delirium t remens, seizures
9. Shock, hypoxia, hypot ension
10. Hypert hermia
11. Renal inf arct
12. CNS diseases
13. Acut e pancreat it is
14. Fract ures, ot her t rauma including head
15. I nt est inal obst ruct ion
d. Angina and pericardit is do not produce LDH elevat ions.
2. Decreased LDH l evel s are associat ed w it h a good response t o cancer
t herapy.
Interfering Factors
1. St renuous exercise and t he muscular exert ion involved in childbirt h cause
increased LDH levels.
2. Skin diseases can cause f alsely increased LDH levels.
3. Hemolysis of red blood cells due t o f reezing, heat ing, or shaking t he blood
sample w ill cause f alsely increased LDH levels.
4. Various drugs may cause increased or decreased LDH levels (see Appendix
J).
Clin ical Alert

LDH is f ound in nearly every t issue of t he body; t heref ore, elevat ed levels are
of limit ed diagnost ic value by t hemselves. Diff erent ial diagnoses may be
accomplished w it h LD isoenzyme det erminat ion.
Interventions
1. Explain t est purpose and blood-draw ing procedure. O bt ain recent hist ory of
MI or pulmonary inf arct ion.

2. I nt erpret t est result s and monit or f or myocardial and pulmonary inf arct ion
and ot her diseases relat ed t o abnormal result s. LD isoenzymes may be
ordered.
Lactate Dehydrogenase (LDH, LD) Isoenzymes

(Electrophoresis) Electrophoresis, or separation, of
LDH identifies the five isoenzymes of fractions of LDH,
each with its own physical characteristics and
electrophoretic properties. Fractioning the LDH activity
sharpens its diagnostic value because LDH is found in
many organs. LD isoenzymes are released into the
bloodstream when tissue necrosis occurs. The
isoenzymes are elevated in the terms of patterns
established, not on the basis of the value of a single
isoenzyme. The origins of the LDH isoenzymes are as
follow: LD1 and LD2 are present in cardiac tissue and
erythrocytes; LD3 originates mainly from lung, spleen,

pancreas, and placenta; and LD4 and LD5 originate from
skeletal muscle and liver.
The f ive isoenzyme f ract ions of LDH show diff erent pat t erns in various disorders.
Abnormalit ies in t he pat t ern suggest w hich t issues have been damaged. This t est
is usef ul in t he diff erent ial diagnosis of acut e MI , megaloblast ic anemia (eg,
f olat e def iciency, pernicious anemia), hemolyt ic anemia, and very occasionally,
renal inf arct . These ent it ies are charact erized by LD1 increases, of t en w it h
LD 1 : LD 2 inversion (f lip).
Reference Values
Normal
LDH1 : 17%27% of t ot al or 0. 170. 27
LDH2 : 29%39% of t ot al or 0. 290. 39
LDH3 : 19%27% of t ot al or 0. 190. 27
LDH4 : 8%16% of t ot al or 0. 080. 16
LDH5 : 6%16% of t ot al or 0. 060. 16
Procedure
2. Avoid hemolysis.
3. O bserve st andard precaut ions. Place specimen in a biohazard bag. Be aw are
t hat serial det erminat ions may be ordered (3 consecut ive days).
1. Abnormal LD1 and LD2 pat t erns ref lect damaged t issues (see Table 6. 12).
Table 6.12 Abnormal LD Isoenzyme Patterns
Disease
LD 1
LD 2
Myocardial infarction
LD 3
LD 4
LD 5
Pulmonary infarction
Congestive heart
failure
Viral hepatitis
Toxic hepatitis
Leukemia,
granulocytic
Pancreatitis
Carcinomatosis
(extensive)
Megaloblastic
anemia
Hemolytic anemia
Muscular dystrophy
a. The appearance of an LD f lip (ie, w hen LD1 level is higher t han LD2 level)
is ext remely helpf ul in t he diagnosis of MI . The presence of an LD f lip 1
day f ollow ing incident or w it h t he det ect ion of CK-MB is essent ially
diagnost ic of MI if baseline cardiac enzymes/ isoenzymes are normal and
if rises and f alls are as ant icipat ed f or t he diagnosis of acut e MI .
b. Persist ent LD1 LD 2 f lip f ollow ing acut e MI may represent reinf arct ion.
When acut e MI is complicat ed by shock, a normal pat t ern may be f ound.
LD 1 LD 2 inversion commonly appears subsequent t o t he isomorphic
pat t ern in inst ances of acut e MI .
c. The LDH pat t ern in hemolyt ic, megaloblast ic, and sickle cell anemia is
essent ially t he same as in MI and ot her anemias. This is because red
blood cells have an isoenzyme pat t ern similar t o t hat of heart muscle.
The t ime elapsed t o peak values may help t o diff erent iat e t hese
condit ions.
2. LD 3 increases occur in advanced cancer and malignant lymphoma; t his level
should decrease f ollow ing eff ect ive t herapy. LD3 is occasionally elevat ed in
pulmonary inf arct ion or pneumonia.
3. LD 5 is i ncreased in t he f ollow ing condit ions:
a. Liver disease, hepat it is
b. Congest ive heart f ailure, pulmonary edema
c. St riat ed muscle t rauma, burns
4. LD 5 increase is more signif icant w hen LD5 / LD 4 rat io is increased.
5. I n most cancers, one t o t hree of t he bands (LD2 , LD3 and LD4 ) are f requent ly
increased. A not able except ion is in seminomas and dysgerminomas, in w hich
LD 1 is increased. Frequent ly, an increase in LD3 may be t he f irst indicat ion of
t he presence of cancer.
6. All LD isoenzymes are increased in syst emic diseases (eg, carcinomat ous
collagen vascular, disseminat ed int ravascular coagulat ion, sepsis) (see Table
6. 12).
7. I ncreased t ot al LD w it h normal dist ribut ion of isoenzymes may be seen in
coronary art ery disease (CAD) w it h chronic heart f ailure, hypot hyroidism,
inf ect ious mononucleosis and ot her inf lammat ory st at es, uremia, and
necrosis.
Clin ical Alert

1. LD isoenzyme t est ing should be reserved f or diagnosis of complex cases.
I n 5% t o 20% of pat ient s w it h acut e MI , t he expect ed reversal of LD-1/ LD2 does not occur; in t hese pat ient s, t here is of t en simply an increase in
LD-1.
2. LDH isoenzymes should be int erpret ed in light of clinical f indings.
Interventions
1. Explain t est purpose and procedure. Repeat t est ing on 3 consecut ive days is
likely. O bt ain pert inent clinical signs and sympt oms.

2. I nt erpret t est result s and monit or appropriat ely f or abnormal LD pat t erns,
MI , and pulmonary inf arct ions.
Renin (Angiotensin); Plasma Renin Angiotensin (PRA)

Renin is an enzyme that converts angiotensinogen to
angiotensin I. Derived from the liver, angiotensinogen
is an 2 -globulin in the serum. Angiotensin I is then
converted in the lung to angiotensin II. Angiotensin II is
a potent vasopressor agent responsible for
hypertension of renal origin and is a powerful releaser
of aldosterone from the adrenal cortex. Both
angiotensin II and aldosterone increase blood
pressure. Renin levels increase when there is
decreased renal perfusion pressure. The reninaldosterone axis regulates sodium and potassium
balance and blood volume and pressure. Renal
reabsorption of sodium affects plasma volume. Low
plasma volume, low blood pressure, low sodium, and
increased potassium induce renin release, causing

increased aldosterone through stimulation of
angiotensin. Potassium loss, acute blood pressure
increases, and increased blood volumes suppress
renin release.
This t est is most usef ul in t he diff erent ial diagnosis of hypert ension, w het her
essent ial, renal, or renovascular. I n primary hyperaldost eronism, t he f indings w ill
demonst rat e t hat aldost erone secret ion is exaggerat ed and secret ion of renin is
suppressed. I n renal vascular disease, renin is elevat ed.
Reference Values
Normal
Renin act ivit yplasma (PRA)
Adult (normal-sodium diet ):
Supine: 0. 21. 6 ng angiot ensin I (AI )/ mL/ h or 0. 21. 6 g AI / h/ L
St anding: 0. 73. 3 ng AI / mL/ h or 0. 73. 3 g AI / h/ L
Adult (low -sodium diet ):
Supine: renin levels increase 2 t imes normal.
St anding: renin levels increase 6 t imes normal.
Renin direct :
Adult supine: 1279 mU/ L
Adult st anding: 13114 mU/ L
Procedure
1. O bt ain a 5-mL venous blood sample. Fast ing is required. Collect specimen
w it h scrupulous at t ent ion t o det ail. Use EDTA as t he ant icoagulant t o aid in
preservat ion of any angiot ensin f ormed bef ore examinat ion. O bserve
st andard precaut ions.
2. Draw blood in chilled t ubes and place samples on ice. Transport samples t o
laborat ory immediat ely in a biohazard bag. Must be cent rif uged in
ref rigerat ed cent rif uge.
3. Record post ure and diet ary st at us of pat ient at t ime of blood draw ing.
4. A 24-hour urine sodium should be done concurrent ly t o aid in diagnosis.
1. Increased reni n l evel s occur in t he f ollow ing condit ions:
a. Secondary aldost eronism w it h malignant hypert ension
b. Renovascular hypert ension
c. Reduced plasma volume due t o low -sodium diet , diuret ics, Addison's
disease, or hemorrhage.
e. Salt -losing st at us ow ing t o G I disease (Na and K w ast age)
f. Renin-producing t umors of kidney
g. Few pat ient s (15%) w it h essent ial hypert ension
h. Bart t er's syndrome (high in renin hypert ension)
i. Pheochromocyt oma
2. Decreased reni n l evel s are f ound in t he f ollow ing condit ions:
a. Primary aldost eronism (98% of cases)
b. Unilat eral renal art ery st enosis
c. Administ rat ion of salt -ret aining st eroids
d. Congenit al adrenal hyperplasia w it h 17-hydroxylase def iciency
e. Liddle's syndrome
Interfering Factors
1. Levels vary in healt hy persons and increase under inf luences t hat t ent t o
shrink t he int ravascular f luid volume.
2. Random specimens may be diff icult t o int erpret unless diet ary and salt int ake
of pat ient is regulat ed.
3. Values are higher w hen t he pat ient is in an upright posit ion, w hen t he t est is
perf ormed early in t he day, w hen t he pat ient is on a low -sodium diet , during
pregnancy, and w it h drugs such as diuret ics and ant ihypert ensives and f oods
such as licorice. See Appendix J f or ot her drugs t hat aff ect out comes.
4. Recent ly administ ered radioisot opes int erf ere w it h t est result s.
5. I ndomet hacin and salicylat es decrease renin levels.
Interventions
2. Remember t hat a regular diet t hat cont ains 180 mEq (180 mmol/ L) of sodium
and 100 mEq (100 mmol/ L) of pot assium must be maint ained f or 3 days
bef ore t he specimen is obt ained. A 24-hour urine sodium and pot assium
should also be done t o evaluat e salt balance. The blood t est should be
draw n at t he end of t he 24 hour urine t est .
3. I nst ruct t he pat ient t hat it is necessary t o be in a supine posit ion f or at least
2 hours bef ore obt aining t he specimen. The specimen is draw n w it h pat ient in
t he supine posit ion.
4. Ensure t hat ant ihypert ensive drugs, cyclic progest ogens, est rogens,
diuret ics, and licorice are t erminat ed at least 2 w eeks and pref erably 4
w eeks bef ore a renin-aldost erone w orkup.
5. Remember t hat if a st anding specimen is ordered, t he pat ient must be
st anding f or 2 hours bef ore t est ing, and blood should be draw n w it h t he
pat ient in t he sit t ing posit ion.
6. Do not allow caff eine ingest ion t he morning bef ore or during t he t est .

1. I nt erpret t est result s and counsel appropriat ely regarding hypert ension,
f urt her t est ing and possible t reat ment .
Renin Stimulation/Challenge Test
Challenge Test A challenge test

distinguishes primary from secondary
hyperaldosteronism on the basis of renin
levels. The test is performed with the
patient in both the recumbent and upright

positions and after the patient has been
maintained on a low-salt diet. In normal
persons and in those with essential
hypertension, renin concentration is
increased by the reduction in volume due
to sodium restriction and the upright
position. In primary aldosteronism, volume
depletion does not occur, and renin
concentration remains low.
Reference Values
Normal
See challenge t est above.
Procedure
1. Admit t he pat ient t o t he hospit al f or t his t est . O n admission, obt ain and
record t he pat ient 's w eight .
2. Ensure t he pat ient f ollow s a reduced-sodium diet supplement ed w it h
pot assium f or 3 days, along w it h diuret ics (eg, f urosemide, chlorot hiazide),
as ordered.
3. Weigh pat ient again on t he t hird day, record dat a, and ensure t hat t he
pat ient remains upright f or 4 hours and part icipat es in normal act ivit ies.
4. O bt ain a venous heparinized blood sample f or renin at 11: 00 a. m. , w hen
renin is usually at it s maximum level. Place specimen on ice, and send it
immediat ely t o t he laborat ory in a biohazard bag.
Interpretation of Renin Stimulation Test In healthy

persons and most hypertensive patients, the
stimulation of a low-salt diet, a diuretic, and upright

posture will raise renin activity to very high levels and
result in weight loss. However, in primary
aldosteronism, the plasma level is expanded and
remains so. In these patients, there is little if any
weight loss, and the renin level is very low or
undetectable. A response within the normal range can
occur in the presence of aldosterone.
Interventions
1. Explain t est purpose and procedure. The purpose of t he preparat ion is t o
deplet e t he pat ient of sodium.
2. Check w it h individual laborat ory f or specif ic pract ices.

2. I nt erpret t est result s and counsel appropriat ely regarding hypert ension.
-Glutamyltransferase (-Glutamyl Transpeptidase,

GGT, GT) The enzyme -glutamyl transpeptidase is
present mainly in the liver, kidney, and pancreas.
Despite the fact that the kidney has the highest level of
this enzyme, the liver is considered the source of
normal serum activity. GT has no origin in bone or
placenta.
This t est is used t o det ermine liver cell dysf unct ion and t o det ect alcohol-induced
liver disease. Because t he G G T is very sensit ive t o t he amount of alcohol
consumed by chronic drinkers, it can be used t o monit or t he cessat ion or
reduct ion of alcohol consumpt ion in chronic alcoholic pat ient s and early-risk
drinkers. G T act ivit y is elevat ed in all f orms of liver disease. This t est is much
more sensit ive t han eit her t he alkaline phosphat ase t est or t he t ransaminase t est
(ie, SG O T, SG PT) in det ect ing obst ruct ive jaundice, cholangit is, and
cholecyst it is. I t is also indicat ed in t he diff erent ial diagnosis of liver disease in
children and pregnant w omen w ho have elevat ed levels of LDH and alkaline
phosphat ase. G T is also usef ul as a marker f or prost at ic cancer and hepat ic
met ast asis f rom breast and colon.
Reference Values
Normal
Men: 747 U/ L (0. 121. 80 kat / L) Women: 525 U/ L (0. 080. 42 kat / L) Values
higher in new borns and in t he f irst 36 mont hs. Values in adult males are 25%
higher t han in f emales. Values vary w it h met hod (check w it h your laborat ory).
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is used.
1. Increased G T l evel s are associat ed w it h t he f ollow ing condit ions:
a. Liver diseases
1. Hepat it is (acut e and chronic)
2. Cirrhosis (obst ruct ive and f amilial)
3. Liver met ast asis and carcinoma
4. Cholest asis (especially during or f ollow ing pregnancy)
5. Chronic alcoholic liver disease, alcoholism
6. I nf ect ious mononucleosis
b. G T levels are also increased in t he f ollow ing condit ions:
1. Pancreat it is
2. Carcinoma of prost at e
3. Carcinoma of breast and lung
4. Syst emic lupus eryt hemat osus
5. G lycogen st orage disease

c. I n MI , G T is usually normal. How ever, if t here is an increase, it occurs
about 4 days af t er MI and probably implies liver damage secondary t o
cardiac insuff iciency.
d. Hypert hyroidism
2. Decreased G T l evel s are f ound in hypot hyroidism.
3. G T values are normal in bone disorders, bone grow t h, pregnancy, skelet al
muscle disease, st renuous exercise, and renal f ailure. Children and
adolescent s are normal.
Interfering Factors
1. Various drugs, (eg, phenot hiazines and barbit urat es) aff ect t est out comes
(see Appendix J).
2. Alcohol (et hanol)
Interventions
1. Explain t est purpose and blood-draw ing procedure. No alcohol is allow ed

2. I nt erpret t est result s and monit or as appropriat e f or liver, pancreat ic, or
t hyroid disease and/ or cancer recurrence.
Homocysteine (tHcy)
Homocyst eine (t Hcy) is an amino acid result ing f rom t he synt hesis of cyst eine
f rom met hionine and enzyme react ion of cobalamin and f olat e. Large quant it ies
of homocyst eine are excret ed and assimilat ed in t he blood plasma of pat ient s
w it h homocyst inemia associat ed w it h:
1. I ncreased risk f or vascular disease

2. I ncreased risk f or venous t hrombosis
3. Elevat ed homocyst eine w it h a direct t oxic eff ect on endot helium
4. Elevat ed in f olic acid def iciency and B12 def iciency. Folic acid def iciency is
charact erized by elevat ed plasma homocyst eine; f olic acid supplement at ion
reduces plasma homocyst eine. Elevat ed plasma homocyst eine levels due t o
aberrant vit amin B12 respond f avorably t o vit amin B12 supplement at ion.
5. I ncreased risk f or pregnancy complicat ions and neural t ube def ect s
This t est measures t he blood plasma level of homocyst eine. I t is usef ul f or
diagnosing individuals w it h pot ent ial increased risk f act ors f or coronary art ery
disease and t hromboses, f or providing a f unct ional assay f or f olic acid
def iciency, and f or diagnosing homocyst inemia. Homocyst eine is ret ained by
persons w it h reduced renal f unct ion. See Chart 6. 3 f or t est ing guidelines.
Ch art 6.3 Homocysteine Testing

Reason s to Test for Homocystein e Un explain ed an emia
Peripheral neuropat hy or myelopat hy Recurrent spont aneous abort ions or
inf ert ilit y Delayed development or f ailure t o t hrive in inf ant s
Wh o to Test
Elderly people (>75 years of age) Veget arians w ho are not t aking vit amin B12
supplement Pat ient s using drugs t hat int erf ere w it h f olat e st at us (eg,
ant iepilept ics, met hot rexat e)
How Often to Test

Measured every 35 years
I n new borns at 35 days
tHcy in Coron ary Vascu lar Disease In patien ts <40 years of age
w h o h ave CVD to exclu de h omocystin u ria In patien ts w h o are at
h igh risk for CVD every 35 years
Footn ote
Source: Clinical Laborat ory New s, 2002
Reference Values
Normal
417 mol/ L or 0. 542. 30 mg/ L f or f ast ing specimens
Procedure
1. O bt ain a venous blood sample. Serum or heparinized plasma is needed.
Fast ing is necessary.
3. Place on ice immediat ely af t er draw ing. Cent rif uge immediat ely and f reeze
w it hin 1 hour of collect ion.
I ncreased or elevat ed homocyst eine levels occur in t he f ollow ing condit ions:
1. Folic acid def iciency
2. Abnormal vit amin B12 met abolism and def iciency
3. Homocyst inuria
Clin ical Alert

Homocyst eine values and t heir relat ion t o CAD are st ill being invest igat ed. The
met hionine load t est is also current ly invest igat ive and has not yet been
approved as a rout ine t est .
Interfering Factors
1. Penicillamine reduces plasma levels of homocyst eine.
2. Nit rous oxide, met hot rexat e def iciency, and azauridine increase plasma
levels of homocyst eine.
Interventions
2. Remember t hat t he t est requires f ast ing.
3. Evaluat e renal f unct ion in pat ient s w it h homocyst inuria.

1. Allow t he pat ient t o eat and drink af t er blood is draw n.
2. I nt erpret t est result s and counsel appropriat ely.
3. Evaluat e f or ot her cardiovascular risk f act ors, compare t est result s, and
monit or appropriat ely. Promot e lif est yle changes accordingly.
4. Monit or f or f olic acid or vit amin B12 def iciency and provide supplement s as
needed.
1 -Antitrypsin (AAT) 1 -Antitrypsin is a protein

produced by the liver that inhibits the protease
released into body fluids by dying cells. This protein
deficiency is associated with pulmonary emphysema
and liver disease, both at an early age. Human serum
contains at least three inhibitors of protease. Two of
the best known are 1 -antitrypsin and 2 -macroglobulin.
Total antitrypsin levels in blood are composed of about
90% AAT and 10% 2 -macroglobulins.
This is a nonspecif ic met hod t o diagnose inf lammat ion, severe inf ect ion, and
necrosis. AAT measurement is import ant f or diagnosing respirat ory disease and
cirrhosis of t he liver because of it s direct relat ion t o pulmonary and ot her
met abolic disorders. Pulmonary problems such as emphysema occur w hen
ant it rypsin-def icient persons are unable t o w ard off t he act ion of endoprot eases.
Those w ho are def icient in AAT develop emphysema at a much earlier age t han
do ot her emphysema pat ient s.
Reference Values
Normal (by rate nephel ometry) 110200 mg/ dL or 1. 12. 0 g/ L
I f result is <125 mg/ dL (<1. 25 g/ L), phenot ype should be det ermined t o conf irm
homozygous and het erozygous def iciencies.
Procedure
1. O bt ain a 7-mL serum sample. Use a red-t opped t ube.
1. I nt erpret at ion of AAT levels is based on t he f ollow ing:
a. High levels are generally f ound in normal persons.
b. I nt ermediat e levels are f ound in persons w it h a predisposit ion t o
pulmonary emphysema.
c. Low levels are f ound in persons w it h obst ruct ive pulmonary disease and
in children w it h cirrhosis of t he liver.
2. Increased AAT l evel s occur in t he f ollow ing condit ions:
a. Acut e and chronic inf lammat ory disorders
b. Af t er inject ions of t yphoid vaccine
c. Cancer
d. Thyroid inf ect ions
e. O ral cont racept ive use
f. St ress syndrome
g. Hemat ologic abnormalit ies
3. Decreased AAT l evel s are associat ed w it h t hese progressive diseases:
a. Adult , early-onset , chronic pulmonary emphysema
b. Liver cirrhosis in inf ant s (neonat al hepat it is)
c. Pulmonary disease
d. Severe hepat ic damage
e. Nephrot ic syndrome
f. Malnut rit ion
Clin ical Alert

Pat ient s w it h serum levels <70 mg/ dL (<0. 70 g/ L) are likely t o have a
homozygous def iciency and are at risk f or early lung disease.
Interfering Factors
1 -Ant it rypsin in an acut e-phase react ant , and any inf lammat ory process w ill
elevat e serum levels.
Interventions
1. Explain t est purpose and procedure. Fast ing is required if t he pat ient 's
hist ory show s elevat ed cholest erol and/ or t riglyceride levels.

1. I nt erpret t est result s and counsel appropriat ely. Advise pat ient s w it h
decreased levels t o avoid smoking and, if possible, occupat ional hazards
such as dust , f umes, and ot her respirat ory pollut ant s.
2. Be aw are t hat because AAT def iciencies are inherit ed, genet ic counseling
may be indicat ed. Follow -up AAT phenot ype t est ing can be perf ormed on
f amily members t o det ermine t he homozygous or het erozygous nat ure of t he
def iciency.
DRUG M ONITORING
Drug monit oring is used f or t herapeut ic management and t oxicology. Blood,
urine, and gast ric cont ent s are t he most common specimens used f or measuring
drug levels. When a combinat ion of drugs has been used, t he levels of all drugs
should be obt ained. Toxic drug levels are necessary t o evaluat e subst ance abuse
and int ent ional or accident al overdose so immediat e int ervent ions
can be init iat ed (eg, enhanced diuresis, hemodialysis, adding soybean oil t o
bat hw at er) t o avoid deat h or disabling condit ions. Sit uat ions in w hich t oxic drug
levels may be measured include accident al overdose of opiat es; suspect ed
poisoning as in homicide or suicide; medical emergencies w here person arrives
at ED in coma or alt ered st at e of consciousness; suspect ed dat e rape sit uat ions
w here a drug may have been used; accident al poisoning in children; child abuse
cases w here result s may be used t o det ermine parent al cust ody; illicit drug use
such as heroine, cocaine, or opiat es; suspect ed solvent vapor abuse such as
sniff ing of paint s; exposure t o ant icoagulant s as in rodent poisons; exposure t o
iron and heavy met als; int ent ional ingest ion as in chronic overdose secondary t o
chronic pain; and in vehicle accident cases w here alcohol is t he most commonly
abused. See Appendix L f or discussion of t hese drug invest igat ion st udies.
Therapeutic Drug Management Therapeutic drug

management (formerly called therapeutic drug
monitoring) is a reliable and practical approach to
improving drug therapy in both instruction and
maintenance in individual patients. Determination of
drug levels is especially important when the potential
for drug toxicity is significant or when an inadequate or
undesirable response follows the use of a standard
dose. Therapeutic drug management provides an easier
and more rapid estimation of appropriate drug-dosage
requirements than does observation of the drug effects
themselves. For some drugs, monitoring is routinely
useful (eg, digoxin); for others, it can be helpful in
certain situations (eg, antibiotics). The plasma level of
drugs needed to control the patient's symptoms is
called the therapeutic concentration; at a steady state,
the rate of drug administration is equal to the rate of
drug elimination, and the concentration of the drug

remains constant. Monitoring at intervals minimizes the
possibility of the development of dose-related side
effects. If single-drug therapy is not effective,
therapeutic monitoring allows the clinician to select
supplementary medication and monitor its effect on the
primary drug. It should be noted that for many
medications, therapeutic serum levels have not been
established. Therapy is guided by clinical response
and adverse reactions of the medications. Appropriate
therapy may be monitored or managed by other
methods, including outcome of liver function tests,
CBC with differential, platelet counts, serum
electrolytes, serum albumin, and renal function tests.
Indications for Testing
1. Verif y correct drug dosage and level; drug source, dose, or regimen is
changed
2. When noncompliance (nonadherence) is suspect ed, and pat ient mot ivat ion t o
maint ain medicat ion is poor
Reference Values
Normal
See Table 6. 13 f or t herapeut ic maint enance and t oxic levels.
Table 6.13 Blood Concentrations of Commonly Monitore

Drugs
Nam e of Drug
T herapeutic
Toxic Level
Level
Acetaminophen
1020 g/mL,
based on relief
of symptoms
Should be >200 g/mL

at 4 hours after
ingestion or
>50 g/mL at 12 hours

after ingestion
Amikacin
Infections: 20
30 g/mL (34
52 mol/L)
Peak: >35 g/mL (>60

mol/L)
Serious
infections: 20
25 g/mL
Trough: >10 g/mL

(>17 mol/L)
UTI: 1520
g/mL
Trough
Serious
infection: 14
g/mL (27
mol/L)
Lifethreatening
infections: 48
g/mL (714
mol/L)
Amiodarone
(see Fig. 6.4)
0.52.5 mg/L
(0.83.9
mol/L)
>3.5 mg/L
Chloramphenicol
Meningitis:
Peak: 1525
g/mL
>40 g/mL
Trough: 515
g/mL
Other
infections:
Peak: 1020
g/mL
Trough: 510
g/mL
Desipramine
50300 ng/mL
Possibly toxic: >300

ng/mL
Toxic: >1000 ng/mL
Digoxin
CHF: 0.82
ng/mL (1.02.6
nmol/L)
Arrhythmias:
1.52.5 ng/mL
(2.03.2
>2.0 ng/mL (>2.6

nmol/L)
nmol/L)
Adverse
reactions:
nausea,
vomiting,
anorexia,
green/yellow
visual
distortion
(commonly
reported
symptoms in
patients
requiring
hospitalization)
Digitoxin (see
Fig. 6.5)
1835 ng/mL
(2446 nmol/L)
>35 ng/mL (>46

nmol/L)
Disopyramide
(Norpace)
Atrial
arrhythmias:
2.83.2 g/mL
(8.39.4
mol/L)
>7 g/mL (>2.1

mol/L)
Ventricular:
3.37.5 g/mL
(>9.722.2
mol/L)
Epinephrine*
3195 pg/mL
A toxic level has not

been established
Ethasuximide
(Zarontin)
40100 g/mL
(284710
mol/L)
Panic value: >150

g/mL (>1062 mol/L)
Ethchlorvynol
29 g/mL or
1455 mol/L
A toxic level has not

been established
Flecainide
0.21 g/mL
>1.0 g/mL
Flucytosine
(Ancobon)
25100 g/mL
100120 g/mL
Fluoxetine
100800
ng/mL (289
2312 nmol/L)
Fluoxetine +
norfluoxetine
Norfluoxetine
100600
ng/mL (289
1735 nmol/L
>2000 ng/mL (>5780

nmol/L)
Flurazepam*
04 ng/mL (0
9 nmol/L)
>200 ng/mL (>578

nmol/L)
Fosphenytoin
1020 g/mL
3050 g/mL
Lethal: >100 g/mL
Gabapentin*
Minimum
effective serum
>25 g/mL
level: 2 g/mL
Gentamicin
(Garamycin)
Peak:
Serious
infections: 68
g/mL (1217
mol/L)
Lifethreatening: 8
10 g/mL (17
21 mol/L)
UTI: 46
g/mL (812
mol/L)
Trough
Serious
infections:
0.51 g/mL
(12 mol/L)
Lifethreatening:
12 g/mL (2
4 mol/L)
Toxic level is based on

panic or lifethreatening values.
Ibuprofen
2070 g/mL,
based on
symptom relief
>500 g/mL
Lidocaine
1.55.0 g/mL
(6.1421.4
mol/L)
Potentially toxic: >6

g/mL (>25 mol/L)
Toxic: >8.0 g/mL (>34

mol/L). Seizures at
this level,
fatal at >15 g/mL
(>64.5 mol/L)
Lithium
Acute mania:
0.61.2 mEq/L
(0.61.2
mmol/L)
>2 mEq/L (>2 mmol/L)
Protection
against future
episodes in
patients with
Adverse effect levels:
bipolar
disorder:
GI complaints/tremor:
1.52 mEq/L (1.52.0
mmol/L)
0.81 mEq/L
(0.81.0
mmol/L)
Contusion/somnolence
22.5 mEq/L (2.02.5
mmol/L)
Depression:
0.51.5
mmol/L
Seizure/death: >2.5
mEq/L (>2.5 mmol/L)
Lorazepam
50240 ng/mL
Toxic levels not

established
Methotrexate
Depends on
low or high
dose therapy
Low dose toxic

therapy: >9.1 ng/mL
High dose toxic
therapy: >450+ ng/mL
Mexiletine
0.5 g/mL
Potentially toxic: >9.1

ng/mL (>20 mmol/L)
Oxcarbazepine*
(Trileptal)
Active
metabolite (10hydroxcarbazepine)
>2 g/mL (>9 mol/L)
For trigeminal
neuralgia
50110
mol/L;
therapeutic
serum levels
have not
Toxic levels not

established
been
established for
treatment of
epilepsy.
Procainamide
410 g/mL
(1742 mol/L)
>14 g/mL (>60

mol/L)
NAPA: 1030
g/mL (42127
mol/L)
Combined: >30
g/mL (>127
mol/L)
Phenytoin
Children and
adults:
Total
phenytoin: 10
20 g/mL (40
70 mol/L)
2550 g/mL (120200

mol/L)
Neonates
Lethal: >100 g/mL

(>400 mol/L)
815 g/mL
Free
phenytoin: 1
2.0 g/mL (48
mol/L)
Salicylates
Combined: >30 g/mL

(>127 mol/L)
Antiplatelet,
antipyresis,
analgesia: 100
g/mL
Antiinflammatory:
150300
g/mL
Temazepam
26 ng/mL after
24 hours
Information not
available
Theophylline
Asthma: 1020
g/mL (56111
mol/L)
>20 g/mL (>111

mol/L)
Neonatal
apnea: 613
g/mL (3372
mol/L)
>10 g/mL (>56

mol/L)
Pregnancy: 3
12 g/mL (17
67 mol/L)
>30 g/mL (>168

mol/L)
Hypnotic: 15
g/mL
>10 g/mL
Anesthesia: 7
130 g/mL
Coma: 30100 g/mL
50120 g/mL
(wide
therapeutic
range)
>200 g/mL
Thiopental
Valproic acid
Vancomycin
Peak: 2540
g/mL (1727
mol/L)
>80 g/mL (>54

mol/L)
Trough: 510
g/mL (3.46.8
mol/L)
*Therapeutic serum levels have not been established for
epilepsy.
FI G URE 6. 4 Maint enance and t herapeut ic range f or amiodarone

(ant iarrhyt hmic). (Source: Therapeut ic Drug Monit oringClinical G uide, 2nd
edit ion. Abbot t Laborat ories, Abbot t Park, I L, USA. )
FI G URE 6. 5 Maint enance and t herapeut ic range f or digit oxin (cardiac

glycoside). (Source: Therapeut ic Drug Monit oringClinical G uide, 2nd
edit ion. Abbot t Laborat ories, Abbot t Park, I L, USA. )
Blood, Saliva, and Breath Alcohol Content (BAC;

Ethanol [Ethyl Alcohol, ETOH]) Ethanol is absorbed
rapidly from the GI tract, with peak blood levels usually
occurring within 40 to 70 minutes of ingestion on an
empty stomach. Food in the stomach decreases alcohol
absorption. Ethanol is metabolized by the liver to
acetaldehyde. Once peak blood ethanol levels are
reached, disappearance is linear; a 70-kg man
metabolizes 7 to 10 g/h of alcohol (15 + 5 mg/dL/h).
Symptoms of intoxication in the presence of low
alcohol levels could indicate a serious acute medical
problem requiring immediate attention.
Q uant it at ion of alcohol level may be perf ormed f or medical or legal purposes, t o
diagnose alcohol int oxicat ion, and t o det ermine appropriat e t herapy. Alcohol level
must be t est ed as a possible cause of unknow n coma because alcohol
int oxicat ion mimics diabet ic coma, cerebral t rauma, and drug overdose. This t est
is also used t o screen f or alcoholism and t o monit or et hanol t reat ment f or
met hanol int oxicat ion.
Reference Values
Normal
Negat ive: no alcohol det ect ed <10 mg/ dL or <2 mmol/ L is considered negat ive
<20 mg/ dL or <4. 34 mmol/ L is considered negat ive f or t he U. S. Depart ment of
Transport at ion (DO T) >40 mg/ dL or >8. 68 mmol/ L is considered posit ive f or t he
U. S. DO T
>80 mg/ dL or >17. 4 mmol/ L is posit ive under most st at e drunk driving law s
Procedure
1. O bt ain a 5-mL venous blood sample f rom t he arm in living persons. From
dead persons, t ake samples f rom t he aort a. O bserve st andard precaut ions.
a. Use a nonalcohol-based solut ion (eg, povidone-iodine) f or cleansing t he
venipunct ure sit e.
b. Sodium f luoride or oxalat e ant icoagulant is recommended. Serum can
also be used.
c. Keep blood sample t ight ly st oppered. Do not open.
2. A 20-mL sample of urine or gast ric cont ent s can also be used. Place
3. A breat h analyzer measures et hanol cont ent at t he end of expirat ion f ollow ing
a deep inspirat ion. (See Appendix K f or inf ormat ion on breat h alcohol
analyzers. )
1. At levels of 50 t o 100 mg/ dL (10. 821. 7 mmol/ L), cert ain signs and
sympt oms are report ed (eg, f lushing, slow ing of ref lexes, impaired visual
acuit y).
2. At levels >100 mg/ dL (>21. 7 mmol/ L), CNS depression is report ed. I n many
st at es, t his is t he cut off level f or driving under t he inf luence of alcohol.
3. Blood levels >300 mg/ dL (>64. 8 mmol/ L) are associat ed w it h coma.
4. Deat h has been report ed at levels >400 mg/ dL (>86. 4 mmol/ L).
5. Properly collect ed urine samples w ill have an alcohol cont ent similar t o t hat
of blood. Saliva samples w ill have an alcohol cont ent 1. 2 t imes t hat of blood.
Interfering Factors
1. I ncreased blood ket ones, as in diabet ic ket oacidosis, can f alsely elevat e
blood or breat h t est result s.
2. I ngest ion of ot her alcohols, such as isopropanol or met hanol, may aff ect
result s.
Clin ical Alert

1. Panic value is >300 mg/ dL (>64. 8 mmol/ L). Report and init iat e overdose
t reat ment at once.
2. Sympt oms of int oxicat ion in t he presence of low blood alcohol could
indicat e a serious medical problem requiring immediat e medical at t ent ion.
Interventions
1. Explain t est purpose and procedure. Proper collect ion, handling, and st orage
of t he blood alcohol specimen is essent ial w hen t he quest ion of sobriet y is
raised.
2. Advise pat ient of legal right s in cases involving quest ion of sobriet y.
3. A w it nessed, signed consent f orm may have t o be obt ained.

1. I nt erpret t est result s and monit or as appropriat e f or t oxic levels.
2. I f alcohol levels are high, init iat e t reat ment at once.

LIPOPROTEIN TESTS/LIPOPROTEIN PROFILES

Lipoprot ein measurement s are diagnost ic indicat ors f or hyperlipidemia and
hypolipidemia. Hyperlipidemia is classif ied as t ypes I , I ia, I ib, I I I , I V, and V.
Lipids are f at t y subst ances made up of cholest erol, cholest erol est ers (liquid
compounds), t riglycerides, nonest erized f at t y acids, and phospholipids.
Lipoprot eins are unique plasma prot eins t hat t ransport ot herw ise insoluble lipids.
They are cat egorized as chylomicrons, -lipoprot eins (low -densit y lipoprot eins
[ LDLs] ), pre- -lipoprot eins (very-low -densit y lipoprot eins [ VLDLs] ), and lipoprot eins (high-densit y lipoprot eins [ HDLs] ). Apolipoprot ein A is mainly
composed of HDL, chylomicrons, and VLDL. Apolipoprot ein B is t he main
component of LDL. Lipids provide energy f or met abolism, serve as precursors of
st eroid hormones (adrenals, ovaries, t est es) and bile acids, and play an
import ant role in cell membrane development . A lipid prof ile usually includes
cholest erol, t riglycerides, LDL, and HDL levels.
Cholesterol
Cholest erol t est ing evaluat es t he risk f or art hrosclerosis, myocardial occlusion,
and coronary art erial occlusion. Cholest erol relat e t o coronary heart disease
(CHD) and is an import ant screening t est f or heart disease. I t is part of t he lipid
prof iles. Elevat ed cholest erol levels are a major component in t he heredit ary
hyperlipoprot einemias. Cholest erol det erminat ions are also f requent ly a part of
t hyroid f unct ion, liver f unct ion, renal f unct ion, and diabet es mellit us st udies. I t is
also used t o monit or eff ect iveness of diet , medicat ions, lif est yle changes (eg,
exercise), and st ress management .
Reference Values
Normal
Normal values vary w it h age, diet , sex, and geographic or cult ural region.
Adult s, f ast ing:
Desirable level: 140199 mg/ dL or 3. 635. 15 mmol/ L
Borderline high: 200239 mg/ dL or 5. 186. 19 mmol/ L
High: >240 mg/ dL or >6. 20 mmol/ L
Children and adolescent s (1218 years): Desirable level: <170 mg/ dL or <4. 39
mmol/ L

High: >200 mg/ dL or >5. 18 mmol/ L
Procedure
1. O bt ain a 5-mL venous blood sample. Fast ing is required. Serum is needed.
1. Tot al blood cholest erol levels are t he basis f or classif ying CHD risk.
a. Levels >240 mg/ dL or >6. 20 mmol/ L are considered high and should
include f ollow -up lipoprot ein analysis. Borderline high levels (200239
mg/ dL or 5. 186. 19 mmol/ L) in t he presence of CHD or t w o ot her CHD
risk f act ors should also include lipoprot ein analysis/ prof iles.
b. CHD risk f act ors include male gender, f amily hist ory, and premat ure CHD
(MI or sudden deat h bef ore age 55 years in a parent or sibling), smoking
(>10 cigaret t es per day), hypert ension, low HDL cholest erol levels (<35
mg/ dL or <0. 91 mmol/ L conf irmed by repeat measurement ), diabet es
mellit us, hist ory of def init e cerebrovascular or occlusive peripheral
vascular disease, and severe obesit y (>30% overw eight ).
c. I n public screening programs, all pat ient s w it h cholest erol levels >200
mg/ dL or >5. 18 mmol/ L should be ref erred t o t heir physicians f or f urt her
evaluat ion. Bef ore init iat ing any t herapy, t he level should be ret est ed.
2. El evated chol esterol l evel s (hyperchol esterol emi a) occur in t he f ollow ing
condit ions:
a. Type I I f amilial hypercholest erolemia
b. Hyperlipoprot einemia t ypes I , I V, and V
c. Cholest asis
d. Hepat ocellular disease, biliary cirrhosis
e. Nephrot ic syndrome glomerulonephrit is
f. Chronic renal f ailure
g. Pancreat ic and prost at ic malignant neoplasms
h. Hypot hyroidism
i. Poorly cont rolled diabet es mellit us
j. Alcoholism
k. G lycogen st orage disease (von G ierke's disease)

l. Werner's syndrome
m. Diet high in cholest erol and f at s (diet ary aff luence)
n. O besit y
3. Decreased chol esterol l evel s (hypochol esterol emi a) occur in t he f ollow ing
condit ions:
a. Hypo- -lipoprot einemia
b. Severe hepat ocellular disease
c. Myeloprolif erat ive diseases
d. Hypert hyroidism
e. Malabsorpt ion syndrome, malnut rit ion
f. Megaloblast ic or sideroblast ic anemia (chronic anemias)
g. Severe burns, inf lammat ion
h. Condit ions of acut e illness, inf ect ion
i. Chorionic obst ruct ive lung disease
j. Ment al ret ardat ion
Interfering Factors
1. Est rogens decrease plasma cholest erol levels; pregnancy increases t hese
levels.
2. Cert ain drugs increase or decrease cholest erol levels.
3. Seasonal variat ions in cholest erol levels have been observed; levels are
higher in f all and w int er and low er in spring and summer.
4. Posit ional variat ions occur; levels are low er w hen sit t ing versus st anding and
low er w hen recumbent versus sit t ing.
5. Plasma (EDTA) values are 10% low er t han serum.
Interventions
1. Explain t est purpose and procedure. An overnight f ast bef ore t est ing is
recommended, alt hough nonf ast ing specimens may be t aken. Pret est , a
normal diet should be consumed f or 7 days. The pat ient should abst ain f rom
alcohol f or 48 hours bef ore t est ing. Prolonged f ast ing w it h ket osis increases
values.
2. Document drugs t he pat ient is t aking.
3. Encourage t he pat ient t o relax.

1. I nt erpret t est result s and counsel appropriat ely. Cholest erol levels are
inf luenced by heredit y, diet , body w eight , and physical act ivit y. Some
lif est yle changes may be necessary t o reduce elevat ed levels.
2. Remember t hat cholest erol levels >200 mg/ dL (or >5. 18 mmol/ L) should be
ret est ed and t he result s averaged. I f t he t w o result s diff er by >10%, a t hird
t est should be done.
3. Be aw are t hat once hyperlipidemia has been est ablished, t he diet should be
low er in animal f at s and should replace sat urat ed f at s w it h polyunsat urat ed
f at s. Fruit s, veget ables (especially greens), and w hole-grain product s should
be increased. Pat ient s w it h diabet es, as w ell as ot hers, should seek counsel
f rom a diet it ian regarding diet management if necessary. Therapy f or
hyperlipidemia should alw ays begin w it h diet modif icat ion.
4. Remember t hat t he American Heart Associat ion and Nat ional Cholest erol
Educat ion Programs have excellent resources f or providing diet and lif est yle
management inf ormat ion.
5. Be aw are t hat at least 6 mont hs of diet ary t herapy should be t ried bef ore
init iat ing cholest erol-reducing drug t herapy.
6. Perf orm a comprehensive lipoprot ein analysis if cholest erol levels are not
low ered w it hin 6 mont hs af t er st art of t herapy.
Clin ical Alert

1. Cholest erol measurement should not be done immediat ely af t er MI . A 3mont h w ait is suggest ed.
2. >300 mg/ dL or >7. 8 mmol/ L: t here is a st rong relat ionship t o coronary
heart disease, but only a f ract ion of t hose w it h CAD have cholest erol
increased.
High-Density Lipoprotein Cholesterol (HDL-C) HDL-C is

a class of lipoproteins produced by the liver and
intestines. HDL is composed of phospholipids and one
or two apolipoproteins. It plays a role in the
metabolism of the other
lipoproteins and in cholesterol transport from
peripheral tissues to the liver. LDL and HDL may
combine to maintain cellular cholesterol balance
through the mechanism of LDL moving cholesterol into
the arteries and HDL removing it from the arteries.
Decreased HDL levels are atherogenic, whereas
elevated HDL levels protect against arthrosclerosis by
removing cholesterol from vessel walls and
transporting it to the liver where it is removed from the
body. There is a strong relationship of HDL cholesterol
and CAD.
HDL-C, t he good cholest erol, is used t o asses CAD risk and monit or persons
w it h know n low HDL levels. HDL-C levels are inversely proport ional t o CHD risk
and are a primary independent risk f act or. When a slight ly increased cholest erol
is due t o high HDL, t herapy is not indicat ed.
Reference Values
Normal
Men: 3565 mg/ dL or 0. 911. 68 mmol/ L
Women: 3580 mg/ dL or 0. 912. 07 mmol/ L
<25 mg/ dL or <0. 65 mmol/ L of HDL: CHD risk at dangerous level 2 t imes t he risk
2635 mg/ dL or 0. 670. 91 mmol/ L of HDL: high CHD risk: 1. 5 t imes t he risk 36
44 mg/ dL or 0. 931. 14 mmol/ L of HDL: moderat e CHD risk: 1. 2 t imes t he risk
4559 mg/ dL or 1. 161. 53 mmol/ L of HDL: average CHD risk 6074 mg/ dL or
1. 551. 92 mmol/ L of HDL: below -average CHD risk >75 mg/ dL or >1. 94 mmol/ L
of HDL: no risk (associat ed w it h longevit y)
Procedure
1. O bt ain a 5-mL venous blood sample. Fast ing is necessary. The HDL is
precipit at ed out f rom t he t ot al cholest erol f or analysis.
2. Calculat e a cholest erol/ HDL-C rat ion f rom t hese values.
1. Increased HDL-C val ues occur in t he f ollow ing condit ions:
a. Familial hyper- -lipoprot einemia (HDL excess)
b. Chronic liver disease (cirrhosis, alcoholism, hepat it is)
c. Long-t erm aerobic or vigorous exercise
2. Decreased HDL-C val ues are associat ed w it h increased risk f or CHD and
premat ure CHD and occur in t he f ollow ing condit ions:
a. Familial hypo- -lipoprot einemia (Tangier disease), Apo C-I I I def iciency
b. - -Lipoprot einemia
c. Hypert riglyceridemia (f amilial)
d. Poorly cont rolled diabet es mellit us
e. Hepat ocellular diseases
f. Cholest asis
g. Chronic renal f ailure, uremia, nephrot ic syndrome
h. I n t he Unit ed St at es, 3% of men have low HDL levels f or unknow n
reasons, even t hough cholest erol and t riglyceride values are normal, and
t hey are at risk f or premat ure CAD.
Interfering Factors
1. I ncreased HDL level is associat ed w it h est rogen t herapy, moderat e int ake of
alcohol and ot her drugs (especially androgenic and relat ed st eroids), and
insulin t herapy.
2. Decreased HDL levels are associat ed w it h t he f ollow ing:
a. Cert ain drugs such as st eroids, ant ihypert ensive agent s, diuret ics, bet a
blockers, t riglycerides, and t hiazides
b. St ress and recent illness
c. St arvat ion and anorexia
d. O besit y, lack of exercise
e. Smoking
f. Hypert riglyceridemia (>400 mg/ dL or >10. 36 mmol/ L) (ret est making sure
t he pat ient is properly f ast ing)
Interventions
1. Explain t est purpose. A 912 hour f ast is recommended. Alcohol should not
be consumed f or at least 24 hours bef ore t est .
2. Ensure t hat pat ient is on a st able diet f or 3 w eeks.
3. I f possible, w it hhold all medicat ion f or at least 24 hours bef ore t est ing.
Check w it h physician.

1. I nt erpret t est result s and counsel appropriat ely (see cholest erol pat ient
af t ercare, page 423).
2. Remember t hat low HDL levels can be raised by diet management , exercise,
w eight loss, and smoking cessat ion. Many resources are available t hrough
t he American Heart Associat ion and ot her organizat ions.
3. Drug t herapy may be necessary if ot her met hods f ail t o raise HDL levels.
Clin ical Alert

Cholest erol and HDL-C levels should not be done immediat ely af t er MI . A 3mont h w ait is suggest ed.
Clin ical Alert

The cholest erol/ HDL rat io provides more inf ormat ion t han does eit her value
alone. The higher t he cholest erol/ HDL rat io, t he great er t he risk f or developing
at herosclerosis. This rat io should be report ed w it h t ot al cholest erol values,
along w it h t he % HDL-C.
Very-Low-Density Lipoprotein (VLDL); Low-Density

Lipoprotein (LDL) Sixty to 70% of the total serum
cholesterol is present in the LDL. LDLs are the
cholesterol-rich remnants of the VLDL lipid transport
vehicle. Because LDL has a longer half-life (34 days)
than its precursor VLDL, LDL is more prevalent in the
blood. It is mainly catabolized in the liver and possibly
in nonhepatic cells as well. The VLDLs are major
carriers of triglycerides. Degradation of VLDL is a
major source of LDL. Circulating fatty acids form
triglycerides in the liver, and these are packaged with
apoprotein and cholesterol to be exported into the
blood as VLDLs.
This t est is specif ically done t o det ermine CHD risk. LDL, t he bad cholest erol,
is closely associat ed w it h increased incidence of at herosclerosis and CHD. The
t est of choice is LDL because it has a longer half -lif e and it is easier t o
measure.
Reference Values
Normal
Adult s:
Desirable: <130 mg/ dL or <3. 4 mmol/ L
Borderline high-risk: 140159 mg/ dL or 3. 44. 1 mmol/ L
High-risk: >160 mg/ dL or >4. 1 mmol/ L
Children and adolescent s:
Borderline high-risk: 110129 mg/ dL or 2. 83. 4 mmol/ L
High-risk: >130 mg/ dL or >3. 4 mmol/ L
Procedure
1. Use t he f ollow ing equat ion f or VLDL calculat ed (est imat ion): t riglycerides
divided by 5.
2. Calculat e LDL cholest erol levels by using t he Friedw ald's f ormula:
Remember t hat t he f ormula is valid only if t he cholest erol and t riglyceride

values are f rom a f ast ing specimen and t he t riglyceride value is >400 mg/ dL or
>10. 4 mmol/ L.
Lipoprot ein analysis measures f ast ing levels of t ot al cholest erol, t ot al
t riglycerides, and HDL cholest erol. Calculat e LDL cholest erol f rom t hese values.
Remember t hat t here is a nondirect t est f or LDH t hat may be ordered if
t riglycerides are >400 mg/ dL or >10. 4 mmol/ L.
1. Increased LDL l evel s are caused by t he f ollow ing condit ions:
a. Familial t ype 2 hyperlipidemia, f amilial hypercholest erolemia
b. Secondary causes include t he f ollow ing:
1. Diet high in cholest erol and sat urat ed f at
2. Hyperlipidemia secondary t o hypot hyroidism
4. Mult iple myeloma and ot her dysglobulinemias
5. Hepat ic obst ruct ion or disease
6. Anorexia nervosa
7. Diabet es mellit us
9. Porphyria
10. Premat ure CHD
2. Decreased LDL l evel s occur in t he f ollow ing condit ions:
a. Hypolipoprot einemia
b. Tangier disease
c. Type I hyperlipidemia
d. Apo C-I I def iciency
e. Hypert hyroidism
f. Chronic anemias
g. Severe hepat ocellular disease
h. Reye's syndrome
i. Acut e st ress (burns, illness)
j. I nf lammat ory joint disease
k. Chronic pulmonary disease
Interfering Factors
1. I ncreased LDLs are associat ed w it h pregnancy and cert ain drugs such as
st eroids, progest ins, and androgens (see Appendix J).
2. Not f ast ing may cause f alse elevat ion.
3. Decreased LDLs are f ound in w omen t aking oral est rogen t herapy.
Interventions
1. Explain t est purpose. A 912 hour f ast is recommended. Alcohol should not
be consumed f or at least 24 hours bef ore t est .
2. Remember t hat pat ient should ideally be on a st able diet f or 3 w eeks.
3. I f possible, w it hhold all medicat ion f or at least 24 hours bef ore t est ing.
Check w it h physician.

1. I nt erpret t est result s and counsel appropriat ely about result s and need f or
f urt her t est ing.
2. I f pat ient has high LDH levels, repeat t he t est in 2 t o 8 w eeks and average
t he values t o est ablish an accurat e baseline f rom w hich t o devise a
t reat ment plan (Table 6. 14).
Table 6.14 Stages of Treatment for High LDH
Levels
Initiation
Level
Minim al Goal
>160 mg/dL
(>4.1 mmol/L)
<160 mg/dL
(<4.1 mmol/L)
>130 mg/dL
(>3.4 mmol/L)
<130 mg/dL
(<3.4 mmol/L)
>190 mg/dL
(>4.9 mmol/L)
<160 mg/dL
(<4.1 mmol/L)
>160 mg/dL
(>4.1 mmol/L)
<130 mg/dL
(<3.4 mmol/L)
DIETARY
TREATMENT
Without CHD
or two other
risk factors
With CHD or
two other
risk factors
DRUG
TREATMENT
Without CHD
or two other
risk factors
With CHD or
two other
risk factors
3. A comprehensive hist ory and physical exam, t oget her w it h analysis of t est
result s, det ermines w het her high LDL cholest erol is secondary t o anot her
disease or drug or is t he result of a f amilial lipid disorder. The pat ient 's t ot al
coronary risk prof ile, clinical st at us, age, and gender are considered w hen
prescribing a cholest erol-low ering t reat ment program (see Table 6. 15 f or
LDL-C/ HDL-C rat ios).
Table 6.15 LDL-C/HDL-C Ratio
Risk Level
Men
Wom en
Low
1.00
1.47
Average
3.55
3.22
Moderate
6.25
5.03
High
7.99
6.14
Clin ical Alert

Anot her met hod f or assessing CAD/ CHD risk is by calculat ing t he LDH/ HDL
rat io (LDL-CHDL-C).
NOTE
Pat ient s need a low er init iat ion level and goal if t hey are at high risk because
of exist ing CHD or any t w o of t he f ollow ing risk f act ors: male gender, f amily
hist ory of premat ure CHD, smoking, hypert ension, low HDL cholest erol,
diabet es mellit us, cerebrovascular or peripheral vascular disease, or severe
obesit y.
Apolipoprotein A and B (Apo A-I, Apo B)

Hypolipoproteins/apolipoproteins are surface proteins
of lipoprotein particles and are important in the study
of atherosclerosis. Apolipoprotein A is the main (90%)
component of HDL. Apolipoprotein B is the main
component of LDL and VLDL and is important in
regulating cholesterol synthesis and metabolism This
test is used to evaluate the risk for CAD. APO A-I
deficiencies are often associated with premature
cardiovascular disease. Apo B plays an important role
in LDL catabolism. The ratio of Apo A to Apo B
correlates more closely with increased risk for CAD
than do cholesterol levels or the LDL/HDL ratio. The
lower the ratio, the higher the risk.
Reference Values
Normal
Apo A-I: Men: 90155 mg/ dL (0. 901. 55 g/ L) Women: 94172 mg/ dL (0. 941. 72
g/ L) Apo B:
Men: 55100 mg/ dL (0. 551. 00 g/ L) Women: 45110 mg/ dL (0. 451. 10 g/ L) Apo
A-I/ Apo B rati o: Men: 0. 801. 33
Women: 0. 942. 63
Procedure
2. Do not f reeze t he specimen. Place specimen in a biohazard bag.
3. Fast ing f or 12 hours is needed.
1. Increased Apo A-I is associat ed w it h f amilial (inherit ed) hyperlipoprot einemia.
2. Decreased Apo A-I is associat ed w it h t he f ollow ing condit ions:
a. Tangier disease (ext remely low ) hypo- -lipoprot einemia
b. -Lipoprot einemia
c. Apo C-I I def iciency
d. Apo A-I Melano disease
e. Apo A-I C-I I I def iciency
f. Hypert riglyceridemia (f amilial)
g. Poorly cont rolled diabet es
h. Premat ure CHD
i. Hepat ocellular disease
j. Nephrot ic syndrome and renal f ailure
3. Increased Apo B is associat ed w it h t he f ollow ing condit ions:
a. Hyperlipoprot einemia t ypes I I a, I I b, and V
b. Premat ure CHD Fredrickson t ype I I a
d. Hypot hyroidism
e. Nephrot ic syndrome, renal f ailure
f. Hepat ic disease and obst ruct ion
g. Dysglobulinemia
h. Porphyria
i. Cushing's syndrome
j. Werner's syndrome
4. Decreased Apo B occurs w it h t he f ollow ing condit ions:
a. - -Lipoprot einemia
b. Hypo- -lipoprot einuria (Tangier disease)
c. Hypo- -lipoprot einemia
d. Type I hyperlipidemia
e. Apo C-I I def iciency
f. Hypot hyroidism
g. Malnut rit ion/ malabsorpt ion
h. Reye's syndrome
Interfering Factors
1. Decreased Apo A-I is associat ed w it h a diet high in polyunsat urat ed f at s,
smoking, and some drugs (see Appendix J).
2. Decreased Apo B is associat ed w it h a diet high in polyunsat urat ed f at s and
low -cholest erol diet s, and many drugs.
3. Increased apol i poprotei n l evel s can be caused by various drugs.
4. Apolipoprot eins are acut e-phase react ant s and should not be measured in ill
pat ient s (eg, acut e st ress, burns, major illness, inf lammat ory diseases)
Clin ical Alert

An adverse Apo A-I / Apo B rat io in early lif e is a pot ent ial marker f or CHD risk.
Apo A-I values less t han 90 mg/ dL or 0. 90 g/ L indicat e increased CAD risk.
Apo B values above 110 mg/ dL or 1. 10 g/ L indicat e increased CAD risk.
Interventions
1. Explain t est purpose and procedure. A 12-hour f ast is required, but w at er
may be t aken. Smoking is prohibit ed. Alcohol is prohibit ed.

2. I nt erpret t est result s and counsel appropriat ely regarding CAD risk and
pot ent ial lif est yle changes.

Triglycerides
Triglycerides account f or >90% of diet ary int ake and comprise 95% of f at st ored
t issues. Because t hey are insoluble in w at er, t hey are t he main plasma glycerol
est er. Normally st ored in adipose t issue as glycerol, f at t y acids, and
monoglycerides, t he liver reconvert s t hese t o t riglycerides. O f t he t ot al, 80% of
t riglycerides are in VLDL, and 15% are in LDL.
This t est evaluat es suspect ed at herosclerosis and measures t he body's abilit y t o
met abolize f at . Elevat ed t riglycerides, t oget her w it h elevat ed cholest erol, are
at herosclerot ic disease risk f act ors. Because cholest erol and t riglycerides can
vary independent of each ot her, measurement of bot h values is more meaningf ul.
Triglyceride level is needed t o calculat e t he LDL-C and is also used t o evaluat e
t urbid samples of blood and plasma.
Reference Values
Normal
High: 200499 mg/ dL or 2. 265. 64 mmol/ L
Very high: 500 mg/ dL or 5. 65 mmol/ L
See Table 6. 16 f or values.
Table 6.16 Values for Triglycerides
Age
(y)
Males
Fem ales
09
30100 mg/dL (0.34

1.13 mmol/L)
35110 mg/dL (0.40

1.24 mmol/L)
10
14
32125 mg/dL (0.36

1.41 mmol/L)
37131 mg/dL (0.42

1.48 mmol/L)
15
20
37148 mg/dL (0.42

1.67 mmol/L)
39124 mg/dL (0.44

1.40 mmol/L)
20
24
34137 mg/dL (0.38

1.55 mmol/L)
32100 mg/dL (0.36

1.13 mmol/L)
Adults: <250 mg/dL or <2.82 mmol/L

Values are related to age, diet, sex, and race.
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is used, but now many labs use
EDTA ant icoagulant plasma levels, w hich are slight ly low er. Fast ing f or 12 t o
14 hours is required.
2. O bserve st andard precaut ions. Do not use glycerinat ed t ubes. Place
1. Increased tri gl yceri des occur w it h t he f ollow ing condit ions:
a. Hyperlipoprot einemia t ype I , I ib, I I I , I V, and B
b. Liver disease, alcoholism (can be ext remely high w it h alcoholism)
c. Nephrot ic syndrome, renal disease
d. Hypot hyroidism
e. Poorly cont rolled diabet es mellit us
f. Pancreat it is
g. G lycogen st orage disease (von G ierke's disease)

h. Myocardial inf arct ion (elevat ed levels may persist f or several mont hs)
i. G out
j. Werner's syndrome
k. Dow n syndrome
l. Anorexia nervosa
2. Decreased tri gl yceri de levels occur w it h t he f ollow ing condit ions:
a. Congenit al - -lipoprot einemia
b. Malnut rit ion, malabsorpt ion syndromes
c. Hypert hyroidism, hyperparat hyroidism
d. Brain inf arct ion
e. Chronic obst ruct ive lung disease
NOTE
Cert ain levels of t riglycerides are associat ed w it h cert ain disorders:
1. Desirable: <150 mg/ dL (<1. 70 mmol/ L)not associat ed w it h a disease st at e
2. Borderline: 150500 mg/ dL (1. 705. 65 mmol/ L)associat ed w it h peripheral
vascular disease and may be a marker f or genet ic f orms of
hyperlipoprot einemias t hat need specif ic t herapy
3. Hypert riglyceridemia: >500 mg/ dL (>5. 6 mmol/ L)associat ed w it h risk f or
pancreat it is
4. >1000 mg/ dL (>11. 3 mmol/ L)associat ed w it h t ype I or V hyperlipidemia
and subst ant ial risk f or pancreat it is
5. >5000 mg/ dL (>56. 5 mmol/ L)associat ed w it h erupt ive xant homa, corneal
arcus, lipemia ret inalis, and enlarged liver and spleen
Interfering Factors
1. A t ransient increase occurs f ollow ing a heavy meal or alcohol ingest ion.
2. Transient decrease occurs af t er st renuous exercise, permanent decrease
w it h w eight loss.
3. I ncreased values are associat ed w it h pregnancy and oral cont racept ive use.
4. Values may be increased in acut e illness, colds, or f lu.
5. Many drugs cause increases and decreases (see Appendix J).
6. Values are increased w it h obesit y, physical inact ivit y, and smoking.
Interventions
1. Explain t est purpose and procedure. Fast ing f or at least 12 hours overnight
is required, but w at er may be ingest ed.
2. Ask t he pat ient t o f ollow a normal diet f or 1 w eek pret est . No alcohol is
permit t ed f or at least 24 t o 48 hours bef ore t est ing.

1. I nt erpret t est result s (Chart 6. 4) and counsel appropriat ely. Weight
reduct ion, a low -f at diet , and an exercise program can reduce high
t riglyceride levels.
2. Advise t hat t riglycerides are not a st rong predict or of CHD and, as such, are
not an independent risk f act or if <250 mg/ dL (<2. 8 mmol/ L). How ever,
increased levels may increase cardiovascular disease risk.
Ch art 6.4 Example of Lipid Test Outcomes, Interpretation, and

Intervention A 63-year-old w oman , on an n u al exam, h ad th e
follow in g fin din gs: moderately overw eigh t, h eigh t 56 (167 cm),
w eigh t 170 pou n ds (77 kg), BP 126/72, pu lse 72 regu lar,
moderately active lifestyle, an d family (fath er an d moth er)
h istory of coron ary artery an d vascu lar diseases. Fastin g lipid
pan el w as ordered an d don e in th e clin ic Ju ly 10, 2002. Resu lts
w ere:
Results of First Testing*

Cholesterol (C)
320 mg/dL (8.3 mmol/L)
Triglycerides
414 H mg/dL (4.68

mmol/L)
HDL (good) cholesterol

(C)
LDL (bad) cholesterol (C)
Unable to calculate
Cholesterol/HDL ratio
8.4 H
*For reference ranges, see table below.
Because t he t riglycerides w ere high, glucose Hb A 1C w as ordered, and t he

result s w ere w it hin normal limit s. A screening TSH w as t hen done, w it h result s
of 6. 4 MI U/ L (normal, 0. 405. 50), and t reat ment w it h oral levot hyroxine
(Levoxyl), 50 mg (synt het ic t hyroid) every day f or 2 mont hs.
O n Sept ember 10, 2002, a f ast ing lipid panel and TSH t est s w ere repeat ed.
Result s are report ed in t he f ollow ing t able:
Chemistry
ABN/CRIT
Units
Ref. Range
Cholesterol
333 H
mg/dL
< 200
Triglycerides
496 H
mg/dL
35160
HDL (good) C
44
mg/dL
>40
mg/dL
70130
LDL (bad) C*
Chol/HDL ratio
7.6 H
3.06.0
*Unable to calculate owing to triglycerides greater

than 400 mg/dL.
Elevat ed t riglycerides w ere t reat ed by administ ering gemf ibrozil, 600 mg bid
f or 3 mont hs and a low -cholest erol diet . Levot hyroxine w as cont inued t o
maint ain TSH levels WNL.
Repeat lipid panels w ere done at a communit y t est ing at a local drugst ore on
December 15, 2003, w it h t he f ollow ing result s given t o t he physician at t he
next f ollow -up off ice visit . G emf ibrozil w as discont inued and at orvast at in
(Lipit or), 200 mg 1 t ablet daily at 8 p. m. w as begun f or 2 mont hs and t hen
f ollow -up lipid panel w as ordered.
Results of Second Testing
Total blood cholesterol
HDL (good) cholesterol

(C)
Total C to HDL ratio
9.6
LDL (bad) cholesterol (C)
Triglycerides
100 mg/dL (1.13

mmol/L)
Excellent
Protection
Lipids
Total
Cholest.
(mg/dL)
LDL (bad)
Moderate
Risk
High
Age
(yr)
20
39
179
176
180
202
177
197
203
225
40
59
209
209
210
233
210
236
234
257
60+
213
227
214
240
228
252
241
262
20
39
117
108
118
137
109
127
138
159
Cholest.
(mg/dL)
HDL (good)
Cholest.
(mg/dL)
Triglyc.
(mg/dL)
Total
Cholest./HDL
ratio
40
59
140
128
141
162
129
155
163
183
60+
143
149
144
165
150
175
166
190
20
39
>51
>63
51
37
63
45
<37
40
59
>52
>69
52
37
69
49
<37
<60+
>60
>74
60
40
74
50
<40
20
39
93
77
94
133
78
106
134
195
40
59
121
98
122
170
99
140
171
231
60+
110
110
111
154
111
146
155
206
20
39
3.6
2.8
3.7
5.1
2.9
3.8
5.2
6.1
40
59
4.2
3.0
4.3
6.0
3.1
4.0
6.1
7.4
60+
4.0
3.2
4.1
6.0
3.3
4.6
6.1
6.9
These t est result s w ere given t o physician at t he next f ollow -up off ice visit .
O n February 20, 2003, t he lipid panel result s w ere:
Total cholesterol
Triglycerides
207 mg/dL (2.34 mmol/L)
HDL
LDL
Because t he pat ient had art hrit is, she w as t reat ed w it h rof ecoxib (Vioxx), 25
mg every day, and ranit idine, 150 mg t w ice daily. Liver st udies w ere indicat ed.
Result s of t he ALT w ere 28 (normal, 1060 U/ L or 0. 171. 02 kat / L). As a
result of t hese t est ings, Lipit or and art hrit is medicat ions w ere cont inued unt il
t he next physician visit in 6 mont hs.
Clin ical Alert

Test normal or ref erence values may vary somew hat f rom diff erent
laborat ories ow ing t o t est ing met hods used. I t is import ant t o compare t est
result s/ out comes w it h t he normal ref erence values f or t he specif ic
laborat ory.
Clin ical Alert

1. Panic values of >500 mg/ dL (>5. 6 mmol/ L) indicat e hypert riglyceridemia in
t he presence of diagnosed pancreat it is.
2. Values of >1000 mg/ dL (>11. 3 mmol/ L) present a subst ant ial risk f or
pancreat it is.
3. Chylomicronemia, alt hough associat ed w it h pancreat it is, is not
accompanied by increased at herogenesis. Chylomicrons are not seen in
normal f ast ing serum but inst ead are f ound as exogenous t riglycerides in
healt hy persons af t er a f at t y meal has been eat en. Af t er ref rigerat ion,
chylomicrons f loat t o t he surf ace of a blood sample.
Lipoprotein Electrophoresis Lipoproteins are
composed of hydrophobic lipids bound to protein,

which produces a liquid-soluble complex.
Chylomicrons primarily transport dietary triglycerides
from the intestines. They are proteins derived from
dietary sources, and if significantly increased, they
can extend into the pre- area. In
hyperchylomicronemia, chylomicrons represent dietary
fat in transport. The standing plasma contains a cream
layer over a clear layer in type I hyperlipidemia (where
chylomicrons are elevated), but not in type IV (where
both chylomicrons and triglycerides are elevated).
VLDLs transport cholesterol and triglycerides that have
been synthesized in the liver. LDLs are the major
cholesterol-transporting lipoproteins. Atherosclerotic
plaque cholesterol is derived from LDLs, and LDL
elevations are associated with an increased CAD risk.
Conversely, HDLs provide protection against
atherosclerosis by reversing cholesterol transport
mechanisms. Levels of plasma HDL cholesterol are
inversely proportional to the risk for heart disease.
Lipoprot ein elect rophoresis evaluat es hyperlipidemia and det ermines abnormal
serum lipoprot ein dist ribut ion and concent rat ion. Q uant it at ion is not available
w it h t his procedure. Visual est imat es of st ain densit y in comparison t o normal
pat t erns are usually done. Serum cholest erol and t riglyceride levels should also
be done at t he same t ime.
Reference Values
Normal
For 12- t o 14-hour f ast ing specimen: Chylomicrons: 0%2% about 90%
t riglycerides or LDL: 33%52% (mass f ract ion of t ot al lipoprot ein)
cholest erol, t riglyceride phospholipid Pre- or VLDL: 7%28% (mass f ract ion of
t ot al lipoprot ein)t riglyceride, phospholipid cholest erol
or HDL: 10%30% (mass f ract ion of t ot al lipoprot ein)prot ein, phospholipid,
cholest erol Plasma appearance: clear
Procedure
1. O bt ain a 5-mL sample of serum or plasma. Fast ing 1214 hours is required.
Do not f reeze.
2. O bserve st andard precaut ions. Place specimen in a biohazard bag. To aid in
t he classif icat ion, t he blood sample is ref rigerat ed overnight , and t he serum
or plasma is observed f or any creamy layers, t urbidit y, or color change.
1. Pat ient s may be phenot yped (ie, physical appearance or classif icat ion
makeup) using Frederickson's classif icat ion syst em. Triglyceride,
cholest erol, and lipoprot ein levels are considered in t his syst em.
2. Lipoprot eins are decreased in t he f ollow ing condit ions:
a. -Lipoprot einemia
b. Tangier disease
c. Hypo- -lipoprot einemia
3. Lipoprot eins are increased in t he f ollow ing condit ions:
a. Hyper- -lipoprot einemia
b. Hypercholest erolemia
c. Hyper- -lipoprot einemia
d. Hyper pre- -lipoprot einemia
Interfering Factors
1. Lipid phenot ypes are aff ect ed by st ress or diet ary changes.
2. Phenot yping is invalid in t he presence of secondary disorders, such as
diabet es mellit us, renal f ailure, or nephrit is.
3. Cert ain drugs may alt er elect rophoret ic mobilizing of lipoprot eins.
4. Heparinized blood is not accept able; t est result s are not reliable during
heparin t herapy.
NOTE
A clear dist inct ion must be made bet w een primary (inherit ed) and secondary
(liver disease, alcoholism, met abolic diseases) causes.
Interventions
1. Explain t est purpose and blood-draw ing procedure. A 12-hour f ast is required
bef ore blood is draw n.
2. Ask t he pat ient t o f ollow a normal diet f or 2 w eeks bef ore t est .

1. I nt erpret t est result s and counsel appropriat ely regarding diet ary and drug
t herapy. The Nat ional Cholest erol Educat ion Program and ot her organizat ions
have many resources available. (Nat ional Cholest erol Educat ion Program,
Nat ional I nst it ut es of Healt h, 9000 Rockville Pike, Bet hesda, MD 20184).
NOTE
This t est has been largely replaced w it h t he lipid prof ile panel.
Free Fatty Acids; Fatty Acid Profile Free fatty acids are
formed by lipoprotein and triglyceride breakdown. The
amount of free fatty acids and triglycerides present in
blood comes from dietary sources or fat deposits or is
synthesized by the body. Carbohydrates can be
converted to fatty acids and then stored in fat cells as
triglycerides. Fatty acid and carbohydrate metabolism
is altered in the fat breakdown process (eg, when
fasting). Unusually high levels are associated with
untreated diabetes.
Specif ic f at t y acid measurement can be usef ul f or monit oring nut rit ional st at us in
t he presence of malabsorpt ion, st arvat ion, and long-t erm parent eral nut rit ion. I t
is also valuable f or t he
diff erent ial diagnosis of polyneuropat hy w hen Ref sum's disease is suspect ed. I n
t his disease, t he enzyme t hat degrades phyt anic acid is lacking. Free f at t y acids
are also usef ul in det ect ing pheochromocyt oma and glucagon t hyrot ropin and
adrenocort icot ropin-secret ing t umors.
Reference Values
Normal
Adult s: 825 mg/ dL or 0. 280. 89 mmol/ L
Children: <31 mg/ dL or obese adult s: <31 mg/ dL or <1. 0 mmol/ L
Fatty aci d prof i l e Linoleat e: >25% of t ot al f at t y acids Arachnidat e: 0%6%
O leic: 26%35%
Linoleic: 8%16%
St eric: 10%14%
Phytani c aci d Normal: 0. 3%
Borderline: 0. 3%0. 5%
Procedure
1. O bt ain a 5-mL blood sample and place on ice. Serum or EDTA plasma may
be used.
2. Fast ing is required.
3. The blood serum should be separat ed f rom blood cells w it hin 45 minut es of
collect ion and should be placed on ice. O bserve st andard precaut ions. Place
1. Increased f ree f atty aci d val ues are associat ed w it h t he f ollow ing condit ions:
a. Poorly cont rolled diabet es mellit us
b. Pheochromocyt oma
c. Hypert hyroidism
d. Hunt ingt on's chorea
e. von G ierke's disease
f. Alcoholism
g. Acut e myocardial inf arct ion
h. Reye's syndrome
2. Increased phytani c aci d occurs in t he f ollow ing condit ions:
a. Ref sum's disease (>50%; repeat t he t est t o conf irm)
b. -Lipoprot einemia
3. Decreased f atty aci ds are f ound in:
a. Cyst ic f ibrosis
b. Malabsorpt ion (acrodermat it is ent eropat hica)
c. Zinc def iciency (linoleat e and arachnidat e low )
Interfering Factors
1. Values are elevat ed by st renuous exercise, anxiet y, hypot hermia, cert ain
drugs (see Appendix J), and long-t erm f ast ing.
2. Values are decreased by long-t erm I V or parent eral nut rit ion t herapy and
cert ain drugs (see Appendix J).
3. Prolonged f ast ing or st arvat ion (rise as much as 3 t imes normal) aff ect s
levels.
Interventions
1. Explain t est purpose and blood-draw ing procedure. Fast ing is required, but
w at er may be t aken.
2. Do not t est pat ient s receiving heparin t herapy. For f ree f at t y acids, no
alcohol may be t aken w it hin 24 hours.
3. Discont inue st renuous exercise bef ore t he t est . Encourage relaxat ion.

2. I nt erpret t est result s and monit or appropriat ely.
3. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed post t est care.
See Figure 6. 6 f or a complet e laborat ory t est .
FI G URE 6. 6 Example of Laborat ory Test Result s (54 year old f emale, annual
physical examinat ion). I ncludes lipid panel, liver panel, and basic met abolic
panel.
THYROID FUNCTION TESTS

Laborat ory det erminat ions of t hyroid f unct ion are usef ul in dist inguishing pat ient s
w it h eut hyroidism (normal t hyroid gland f unct ion) f rom t hose w it h hypert hyroidism
(increased f unct ion) or hypot hyroidism (decreased f unct ion).
Patient Care for Thyroid Testing

1. Explain t est purpose and blood specimen collect ion procedure. To underst and
t he t hyroid f unct ion t est s, it is necessary t o underst and t he f ollow ing basic
concept s. The t hyroid gland t akes iodine f rom t he circulat ing blood,
combines it w it h t he amino acid t yrosine, and convert s it t o t he t hyroid
hormones t hyroxine (T4 ) and t riiodot hyronine (T3 ). I odine composes about
t w o t hirds of t he w eight of t he t hyroid hormones. The t hyroid gland st ores T3
and T4 unt il t hey are released int o t he bloodst ream under t he inf luence of
TSH f rom t he pit uit ary gland. O nly a small amount of t he hormones is not
bound t o prot ein. How ever, it is t he f ree port ion of t he t hyroid hormones t hat
is t he t rue det erminant of t he t hyroid st at us of t he pat ient .
2. Assess f or signs and sympt oms of t hyroid disease and not e t hyroid and
iodine medicat ions. Fast ing is required f or some t est s.
3. Be aw are t hat a t ypical t hyroid panel includes t he f ollow ing t est s:
a. T 3 upt ake (T3 U)
b. Free T4
c. Tot al T4
d. T 3 t ot al
e. Free t hyroxine index (FTI , T7 )
f.
TSH
4. Remember t hat t he most usef ul laborat ory t est s t o conf irm or exclude
hypert hyroidism are t ot al T4 , f ree t hyroxine index (FTI ), t ot al T3 , and t he
ult rasensit ive TSH. The most usef ul t est s t o det ect hypot hyroidism are t ot al
T 4 , FTI , and TSH (t hyrot ropin). A t hyrot ropin-releasing hormone (TRH)
st imulat ion t est can be valuable in est ablishing t he t hyroid st at us in some
pat ient s w it h equivocal signs of t hyroid dysf unct ion and borderline laborat ory
values. I t
should be kept in mind t hat values obt ained f or t he assessment of t hyroid

f unct ion can be inf luenced by f act ors ot her t han disease, such as age,
current illness, binding capacit y of serum prot eins, and some drugs.

1. I nt erpret t est result s, counsel and monit or appropriat ely f or abnormal t hyroid
f unct ion and disease. Follow -up t est ing may be required.
2. Remember t hat t hyroid ant ibody t est ing can also be done f or diagnosis of
aut oimmune t hyroid t est ing.
Calcitonin
Calcit onin, a hormone secret ed by t he C cells (paraf ollicular) of t he t hyroid
gland, inhibit s bone resorpt ion by regulat ing t he number and act ivit y of
ost eoblast s. Calcit onin is secret ed in direct response t o high blood calcium
levels and helps t o prevent abrupt changes in calcium levels and t he excessive
loss of calcium.
Measurement of calcit onin is used t o diagnose f amiliar medullary t hyroid
carcinoma (MTC) and post operat ively t o det ect recurrence or met ast asis of
t hyroid carcinoma. This t est is done t o measure increases in immunoreact ive
calcit onin af t er st imulat ion w it h calcium and/ or pent agast rin. Early det ect ion of
elevat ed calcit onin leads t o diagnosis of t umor or abnormally secret ing C cells
bef ore cancer spreads. (Doubling of serum levels correlat es w it h recurrence. )
Calcit onin levels are also used in t he invest igat ion of f amilies (of a pat ient w it h
MTC) t o det ect early subclinical cases of MTC t hat may exist as C-cell
hyperplasia or microscopic MTC.
Reference Values
Normal
Men: <19 pg/ mL or <19 ng/ L
Women: <14 pg/ mL or <14 ng/ L
Cal ci um i nf usi on (2. 4 mg/ kg): Men: <190 pg/ mL or <190 ng/ L
Pentagastri n i njecti on (0. 5 g/ kg): Men: <110 pg/ mL or <110 ng/ L
Procedure
1. O bt ain a 5-mL venous blood specimen in green-t opped t ube. Fast ing is
necessary.
2. Heparinize and chill t he blood immediat ely. I f t est ing is not perf ormed
immediat ely, blood should be f rozen. Place specimen in a biohazard bag.
1. Increased l evel s of cal ci toni n are associat ed w it h t he f ollow ing condit ions:
a. Medullary t hyroid cancer (MTC)
b. C-cell hyperplasia
c. Chronic renal f ailure
e. Zollinger-Ellison syndrome
f. Cancer of lung (oat cell lung marker), breast , or pancreas (ect opic
calcit onin)
g. Carcinoid syndrome
h. Alcoholic cirrhosis
i. Pat ient s w it h pancreat it is and t hyroidit is
j. Hypercalcemia of any et iology
2. I n a small proport ion of pat ient s w ho do have medullary cancer, t he f ast ing
level of calcit onin is normal. I n t hese inst ances, a provocat ive t est using
calcium or pent agast rin should be done.
a. Very high levels (ie, 5- t o 30-f old increase over basal levels) are
evidence of MTC but are not diagnost ic.
b. These st imulat ion t est s are not needed if t he basal calcit onin t est is
diagnost ically high.
c. I n pat ient s w it h elevat ed calcit onin levels w ho do not have MTC, t he
response is not as vigorous.
Interfering Factors
1. Levels are normally increased in pregnancy at t erm and in new borns.
2. G ross lipemia and hemolysis int erf ere w it h t est .
Clin ical Alert

1. Screening f amilies of pat ient s w it h proven medullary cancer of t he t hyroid
w it h t he calcit onin t est is recommended because t he t umor has bot h
sporadic and f amilial incidence.
2. I f t he calcit onin t est is normal in f amily members, it is advisable t o repeat
t he calcium provocat ive t est periodically (over a period of mont hs or
years).
3. Some pat ient s do not respond t o t he st imulat ion t est w ho have medullary
t hyroid carcinoma.
Interventions
2. Remind pat ient t hat f ast ing f rom f ood overnight is required. Wat er is
permit t ed.
3. Be aw are t hat if t he provocat ive t est s using calcium and pent agast rin are t o
be done, t he pat ient is t o be f ast ing, also.
a. I nject pentagastri n 0. 5 g/ kg I V push. Draw blood samples bef ore t he
inject ion t o det ermine baseline value of calcit onin. Draw a blood sample
1. 5, 2, and 5 minut es af t er t he inject ion.
b. I nject cal ci um, 2. 0 mg/ kg, af t er baseline sample is draw n. Draw a blood
sample 5 and 10 minut es af t er inject ion.

NOTE
A combined calcium and pent agast rin t est may be more eff ect ive and reliable
t han eit her t est by it self .

1. I nt erpret t est out come and monit or side eff ect s of inject ion.
2. Be aw are t hat t he pat ient may experience t ransient nausea or f at igue af t er
inject ion and may experience chest pain f or a short t ime.
3. Resume normal act ivit ies w hen sympt oms abat e.
Free Thyroxine (FT4 ) Free thyroxine (FT4 ) comprises a

small fraction of total thyroxine. The FT4 is unbound to
protein and available to the tissues, and it is the
metabolically active form of this hormone. This fraction
constitutes about 5% of the circulatory T4 .
FT 4 has diagnost ic value in sit uat ions in w hich t ot al hormone levels do not
correlat e w it h t he t hyromet abolic st at e, and t here is suspect ed abnormalit y in
t hyroxine-binding globulin (TBG ) levels. I t provides a more accurat e pict ure of
t he t hyroid st at us in persons w it h abnormal TBG levels in pregnancy and in t hose
w ho are receiving est rogens, hydrogen, phenyt oin, or salicylat es.
Reference Values
Normal
0. 72. 0 ng/ dL or 1026 pmol/ L
For pat ient s t aking levot hyroxine (Synt hroid), up t o 5. 0 ng/ dL or 64 pmol/ L
Procedures
1. O bt ain a 5-mL venous blood sample. Accurat e result s can be obt ained w it h
as lit t le as 0. 5 mL of blood in pediat ric cases. Serum is needed f or t his t est .
1. Increased FT4 l evel s are associat ed w it h t he f ollow ing condit ions:
a. G raves' disease (hypert hyroidism)
b. Hypot hyroidism t reat ed w it h t hyroxine
c. Eut hyroid sick syndrome
2. Decreased FT4 l evel s are associat ed w it h t he f ollow ing condit ions:
a. Primary hypot hyroidism
b. Secondary hypot hyroidism (pit uit ary)
c. Tert iary hypot hyroidism (hypot halamic)
d. Hypot hyroidism t reat ed w it h t riiodot hyronine
Interfering Factors
1. Values are increased in inf ant s at birt h and rise even higher af t er 2 t o 3 days
of lif e.
2. Many drugs aff ect t est out comes (see Appendix J).
3. Heparin causes f alsely elevat ed FT4 values.
4. Levels can f luct uat e in pat ient s w it h severe or chronic illness.
5. Levels f luct uat e in pregnancy (low in lat e pregnancy)
Interventions
1. See pat ient care f or t hyroid t est ing. The same prot ocols prevail in FT4
t est ing.
2. Follow Chapt er 1 guidelines f or saf e, eff ect ive inf ormed pretest care.

t est ing.
Free Triiodothyronine (FT3 ) This is one of the

determinations used to evaluate thyroid function and
measure that fraction of the circulatory T3 that exists in
the free state in the blood, unbound to protein. FT3 is
done to rule out T3 toxicosis, to evaluate thyroid
replacement therapy, and to clarify protein-binding
abnormalities.
Reference Values
Normal
Adult s: 260480 pg/ dL or 4. 07. 4 pmol/ L
Procedure
1. Increased FT3 val ues are associat ed w it h t he f ollow ing condit ions:
a. Hypert hyroidism
b. T 3 t oxicosis
c. Peripheral resist ance syndrome
2. Decreased FT3 val ues are associat ed w it h t he f ollow ing condit ions:
a. Hypot hyroidism (primary and secondary)
b. Third t rimest er of pregnancy
NOTE
I n nont hyroidal illness, a low FT3 level is a nonspecif ic f inding.
Interfering Factors
1. Recent ly administ ered radioisot opes and some drugs (see Appendix J)
2. High alt it ude: FT3 levels are higher
Interventions
1. See pat ient care f or t hyroid t est ing. The same prot ocols prevail f or FT3 .

t est ing.
Free Thyroxine Index (FTI, T7 ) The free thyroxine index

(FTI) is a mathematical calculation used to correct the
estimated total T4 for the amount of TBG present. To
perform this calculation, two results are needed: the T4
value and the T3 uptake ratio. The product of these two
values is the FTI. The FTI is useful in the diagnosis of
hyperthyroidism and hypothyroidism, especially in
patients with known or suspected abnormalities in
thyroxine-binding protein levels. In such cases, blood
levels and clinical signs may seem contradictory
unless both T4 and TBG are considered as interrelated

parameters of thyroid status. Measurement of FT4 also
gives a more accurate picture of the thyroid status
when the TBG is abnormal in pregnant women or
persons being treated with estrogen, androgens,
phenytoin, or salicylates.
Reference Values
Normal
Adult s: 1. 54. 5 index (t hese are arbit rary unit s) Check w it h your laborat ory f or
t heir normal values.
Procedure
1. Make a calculat ion based on result s of T3 upt ake and T4 t ot al, as f ollow s:
Remember t hat t he FTI permit s meaningf ul int erpret at ion by balancing out most
nont hyroidal f act ors. I n recent years, t his paramet er has lost popularit y and is of
dubious value.
Applicat ion of t he equat ion of t he FTI includes t he inf ormat ion present ed in Table
6. 17. This is a mat hemat ical calculat ion t hat does not involve t he pat ient .
Table 6.17 Application of Equation to Determine

Thyroxine Uptake
Status
T BG
T 3 Uptake
T4
FT I
Euthyroid
Normal
35%
9.0
3.1
Euthyroid
Low
52%
4.0
2.1
Euthyroid
High
13%
16.0
2.8
Hypothyroid
High
24%
4.0
0.9
Hyperthyroid
Low
46%
13.0
6.0
Interfering Factors
1. Levels f luct uat e in pregnancy.
Interventions
1. I nf orm t he pat ient about t he t est purpose and met hod of calculat ion.

1. Be prepared t o counsel parent if t reat ment required.
Neonatal Thyroid-Stimulating Hormone (TSH) Signs of

congenital hypothyroidism are minimal at birth.
Congenital hypothyroidism has an incidence of 1:3600
to 1:5000 in the United States.
This measurement is used as a conf irmat ory t est or in conjunct ion w it h neonat al
T 4 , f or inf ant s w it h posit ive T4 screens or low blood serum T4 levels, and f or
screening in all U. S. st at es. See new born screening in Chapt er 11 f or more
inf ormat ion.
Reference Values
Normal
New born screen: <20 U/ mL or <20 mU/ L by t hird day of lif e TSH surges at
birt h, peaking at 30 minut es of lif e at a level of 25160 U/ mL or 25160 mU/ L.
I t declines and reaches adult levels by t he f irst w eek t o 10 days of lif e.
Procedure
1. Cleanse t he inf ant 's heel w it h an ant isept ic and punct ure w it h a st erile
disposable lancet . Collect t his w hole blood specimen 3 t o 7 days af t er birt h.
2. Be aw are t hat if bleeding is slow, it helps t o hold t he leg dependent f or a
short t ime bef ore blot t ing t he blood on t he f ilt er paper. Do not use pipet t es
or capillary t ubes t o collect blood.
3. Complet ely f ill in t he circles on t he f ilt er paper. This can best be done by
t he blood t o appear on t he f ront side of t he paper and t o f ill t he circle
complet ely. The f ilt er paper is a special f ilt er paper card obt ained f rom t he
laborat ory.
4. Air dry t he f ilt er paper f or 1 hour, f ill in all inf ormat ion, and send t o t he
laborat ory immediat ely. Do not expose samples t o ext reme heat or light .
An elevat ed neonat al TSH t est is associat ed w it h neonat al hypot hyroidism, a
conf irmat ory t est .
Interventions
1. I nf orm t he parent s about t he t est purpose and met hod of specimen
collect ion.
2. See pat ient care f or t hyroid t est ing on page 437.

1. Be prepared t o counsel parent or parent s regarding st eps t o t ake if t he TRH
t est is abnormal and t ype of t reat ment required. See new born screening in
Chapt er 11.
Neonatal Thyroxine (T4 ); Neonatal Screen for

Hypothyroidism Normal brain growth and development
cannot take place without adequate thyroid hormone.
Congenital hypothyroidism (cretinism) is characterized
by low levels of T4 and elevated levels of TSH.
Screening for congenital hypothyroidism is now done
in all 50 states. If hypothyroidism is undetected,
growth and mental retardation occur, and in some
cases, death occurs.
This is a screening t est of T4 act ivit y t o det ect neonat al hypot hyroidism.
Specimens should be obt ained af t er t he f irst 24 hours of prot ein f eeding or
w it hin t he f irst w eek of lif e. Thyroxine is obt ained f rom w hole blood blot t ed on
f ilt er paper using a radioimmunoassay t echnique.
Reference Values
Normal
Peaks in 24 hours t hen decreases.
Neonat es (13 days): 1222 g/ dL or 152292 nmol/ L
Neonat es (12 w eeks): 1017 g/ dL or 126214 nmol/ L
Procedure
1. Cleanse t he inf ant 's heel w it h an ant isept ic and punct ure t he skin w it h a
st erile disposable lancet . To help blood f low, w arm t he f oot or massage t he
leg.
2. Be aw are t hat if bleeding is slow, it helps t o hold t he leg dependent f or a
short t ime bef ore blot t ing t he blood on t he f ilt er paper. Wipe aw ay t he f irst
drop of blood.
3. Complet ely f ill in t he circles on t he f ilt er paper. This can best be done by
t he blood t o appear on t he f ront side of t he paper and t o f ill t he circle
complet ely. Do not damage f ilt er paper. Apply a st erile dressing t o t he
w ound.
4. Air dry f or 1 hour, f ill in all request ed inf ormat ion, and send t o t he laborat ory
immediat ely. Prot ect specimen f rom ext reme heat and light .
1. Low values are associat ed w it h hypot hyroidism.
2. A number of nont hyroid condit ions can result in depressed T4 levels (eg, low
birt h w eight , premat urit y, t w inning, f et al dist ress, def icient TBG levels).
Interventions
1. Ref er t o neonat al TSH t est ing f or care. The same prot ocols prevail f or
neonat al T4 .
2. Be aw are t hat T4 is usually collect ed at t he same t imes as t he
phenylket onuria (PKU) specimen.
3. Remember t hat t he opt imal collect ion t ime is 37 days af t er birt h; t he baby
must be on prot ein f eeding f or at least 24 hours. For low -w eight or
premat ure babies, t he recommended t ime is 410 days old.

1. Ref er t o neonat al TSH t est ing f or care. The same prot ocols prevail f or
neonat al T4 . Also, see new born screening in Chapt er 11.
2. Remember t hat if baby is released early, t he baby must be brought back f or
t est ing.
Clin ical Alert
Pan ic Valu e
7 days or younger T4 : <6. 5 g/ dL or <84 nmol/ L
8 days and older T4 : <5. 0 g/ dL or <64 nmol/ L
Clin ical Alert

1. Do not int erpret t his t est in t erms of t he adult serum T4 values. This is an
ent irely diff erent procedure using a diff erent t ype of specimen.
2. Not if y at t ending physician and t he inf ant 's parent or parent s of posit ive
result s w it hin 24 hours.
3. I f T4 result s are abnormal, a TSH t est should be done.
4. Normal T4 , and, in some cases, normal TSH screening result s do not
ensure against f ailure of normal development because of presence of
hypot hyroidism. O f all cases of inf ant ile hypot hyroidism, 6% t o 12% have
normal screening hormone levels.
Thyroglobulin (Tg)
Thyroglobulin is composed of glycoprot ein and t he iodinat ed secret ions of
epit helial cells of t he t hyroid. These iodinat ed secret ions cont ain bot h t he
precursors of T3 and T4 and t he hormones t hemselves.
This t est is helpf ul in t he diff erent ial diagnosis of hypert hyroidism and in
monit oring t he course of diff erent iat ed or met ast at ic t hyroid cancer. I t is not
usef ul in t he diagnosis of t hyroid cancer. Levels decrease f ollow ing successf ul
init ial t reat ment , and in recurrence of met ast ases, t he level w ill again rise. Lack
of sensit ivit y and specif icit y limit s t he value of t his t est .
Reference Values
Normal
Adult s: 342 ng/ mL or 342 g/ L
New borns (48 hours): 3648 ng/ mL or 3648 g/ L
NOTE
87% of normal adult s have serum values of Tg <10 ng/ mL or <10 g/ L.
At hyrot ic pat ient s have values <5 ng/ mL or <5 g/ L
Procedure
1. Increased thyrogl obul i n l evel s are associat ed w it h t he f ollow ing condit ions:
a. Unt reat ed and met ast at ic diff erent iat ed t hyroid cancers (not MTC)
b. Hypert hyroidism (not good correlat ion w it h elevat ed T4 )
c. Subacut e t hyroidit is, t hyrot oxicosis
d. Benign adenoma (some cases)
e. O ccurrence of met ast ases af t er init ial t reat ment (t hyroid carcinoma)
2. Decreased thyrogl obul i n l evel s are associat ed w it h t he f ollow ing condit ions:
a. Thyrot oxicosis f act it ia
b. I nf ant s w it h goit rous hypot hyroidism
Interfering Factors
1. New borns have high Tg levels t hat drop t o adult levels by 2 years of age
2. Aut oant ibodies t o Tg cause decreased values. Thyroglobulin ant ibody t est
may have t o be done t o conf irm decreased levels.
Interventions
2. Ensure t hat pat ient is off t hyroid medicat ion f or 6 w eeks bef ore specimen
collect ion. The TSH should be elevat ed bef ore t est ing f or t hyroglobulin.
3. Det erminat ion of Tg levels may be subst it ut ed f or 131 I scans in pat ient s at
low risk f or t hyroid cancer.

1. Resume t hyroid medicat ion and normal act ivit ies.
2. Monit or as appropriat e f or met ast at ic t hyroid cancer.
3. Ref er t o pat ient af t ercare inst ruct ions f or t hyroid t est ing on page 439. The
same prot ocols prevail f or Tg t est ing.
Thyroid-Stimulating Hormone (Thyrotropin; TSH) The

thyroid is unique among the endocrine glands because
it has a large store of hormone and a slow rate of
normal turnover. Stimulation of the thyroid gland by the
TSH, which is produced by the anterior pituitary gland,
causes the release and distribution of stored thyroid
hormones. TSH stimulates secretion of T4 and T3 . TSH
secretion is physiologically regulated by T3 and T4
(feedback inhibition) and is stimulated by thyrotropinreleasing hormone (TRH) from the hypothalamus. TSH
is the single most sensitive test for primary
hypothyroidism. If there is clear evidence of
hypothyroidism and the TSH is not elevated, then an
implication of possible hypopituitarism exists.
This measurement is used in t he diagnosis of primary hypot hyroidism w hen t here
is t hyroid gland f ailure ow ing t o int rinsic disease, and it is used t o diff erent iat e
primary f rom secondary hypot hyroidism by det ermining t he act ual circulat ory
level of TSH. TSH levels are high in primary hypot hyroidism. Low TSH levels
occur in hypert hyroidism.
TSH measurement s w it h suff icient sensit ivit y t o dist inguish low levels f rom
normal levels have become t he pref erred t est f or hypert hyroidism. The highsensit ivit y TSH t est is usef ul f or diagnosing sick eut hyroid pat ient s and in
diff erent iat ing mild hypert hyroidism f rom G raves' disease. Wit h t he new,
sensit ive assays, a TRH st imulat ion t est is no longer necessary.
Reference Values
Normal
Adult s: 0. 44. 2 mI U/ L (SI unit s are t he same) Neonat es: 320 I U/ L by day 3 of
lif e
Procedure
1. Increased TSH l evel s are seen in t he f ollow ing condit ions:
a. Adult s and neonat es w it h primary hypot hyroidism
b. Thyrot ropin-producing t umor (eg, ect opic TSH secret ion f rom lung,
breast t umors)
c. Hashimot o's t hyroidit is
d. Thyrot oxicosis due t o pit uit ary t umor
e. TSH ant ibodies (rare)
f. Hypot hyroid pat ient s receiving insuff icient t hyroid replacement hormone
or t hyroid hormone resist ance
2. Decreased TSH l evel s are associat ed w it h t he f ollow ing condit ions:
a. Primary hypert hyroidism
b. Secondary and t ert iary hypot hyroidism
c. Treat ed G raves' disease
d. Eut hyroid sick disease
e. O verreplacement of t hyroid hormone in t reat ment of hypot hyroidism
Clin ical Alert

Critical Valu es
<0. 1 mI U/ L is an indicat ion of primary hypert hyroidism or exogenous
t hyrot oxicosis.
Risk exist s f or at rial f ibrillat ion at TSH levels <0. 1 mI U/ L (major risk f act or f or
st roke).
Interfering Factors
1. Values are normally high in neonat al cord blood. There is hypersecret ion of
TSH in new borns up t o 2 t o 3 t imes normal. The TSH level approaches
normal by t he f irst w eek of lif e.
2. Values are suppressed during t reat ment w it h t hyroxine and cort icost eroids.
See Appendix J f or ot her drugs.
3. Values are abnormally increased w it h lit hium, pot assium iodide, amphet amine
abuse, and iodine-cont aining drugs.
4. Radioisot opes administ ered w it hin 1 w eek bef ore t est invalidat e t he result .
5. Values may be decreased in t he f irst t rimest er of pregnancy.
6. Values are increased in elderly pat ient s (>80 years old); upper limit f or t hese
pat ient s is 10. 0 mI U/ L.
Interventions

2. I nt erpret t est result s and counsel as appropriat e f or hypot hyroidism or
hypert hyroidism.
Thyroxine-Binding Globulin (TBG) Almost all of the

thyroid hormones in the blood are protein bound:
albumin, thyroid-binding prealbumin, and most
important, thyroxine-binding globulin (TBG). Variations

in TBG levels have a major effect on bound and free
(metabolically active) forms of T4 and T3 . Before
considering this test, TSH, FTI, and total T4 should be
measured.
The TBG measurement is usef ul t o dist inguish bet w een hypert hyroidism causing
high T4 levels and eut hyroidism w it h increased binding by TBG , increased T4 , and
normal levels of f ree hormones; t o ident if y heredit ary def iciency or increase of
TBG ; and t o w ork up t hyroid disease in hypot hyroid populat ions, w hen t he mean
TBG concent rat ion is signif icant ly higher t han t he mean level in normal t hyroid
populat ions. I n hypert hyroid populat ions, t he mean TBG level concent rat ion is
low er t han t he mean level in normal t hyroid populat ions.
Reference Values
Normal
I nf ant s: 36 mg/ dL or 3060 mg/ L
Men: 1. 22. 5 mg/ dL or 1225 mg/ L
Women: 1. 43. 0 mg/ dL or 1430 mg/ L
O n oral cont racept ives: 1. 55. 5 mg/ dL or 1555 mg/ L
Third t rimest er of pregnancy: 4. 75. 9 mg/ dL or 4759 mg/ L
Procedure
1. O bt ain a 5-mL venous blood specimen. Serum is needed.
1. The TBG test i s i ncreased in t he f ollow ing condit ions:
a. G enet ically det ermined high TBG
b. Hypot hyroidism (some cases)
c. I nf ect ious hepat it is
d. Acut e int ermit t ent porphyria
e. Est rogen-producing t umors (endogenous or exogenous)
f. Lat e-st age HI V inf ect ions

2. The TBG test i s decreased in t he f ollow ing condit ions:
a. G enet ic def iciency of TBG
b. Nephrot ic syndrome
c. Major illness, surgical st ress
d. O varian hypof unct ion
e. Acromegaly
f. Chronic liver disease
g. Marked hypoprot einemia, malnut rit ion
Interfering Factors
1. Many drugs increase (eg, est rogens, oral cont racept ives) or decrease (eg,
nicot inic acid, phenyt oin, and st eroids) values (see Appendix J).
2. Neonat es have higher values.
3. Recent ly administ ered radioisot opes aff ect result s.
4. Pregnancy increases levels.
5. Prolonged heroin use or met hadone increases levels.
Interventions
1. See pat ient care f or t hyroid t est ing (see page 437).

Thyroxine (T4 ), Total Thyroxine is the thyroid hormone
with four atoms of iodine; hence, it is called T4 . The

combination of the serum T4 and T3 uptake as an
assessment of TBG helps to determine whether an
abnormal T4 value is due to alterations in serum TBG or
to changes in thyroid hormone levels. Deviations of
both tests in the same direction usually indicate that
an abnormal T4 level is due to abnormalities in thyroid
hormone. Deviations of the two tests in opposite
directions provide evidence that an abnormal T4 may
relate to alterations in TBG.
Thyroxine, one of t he t hyroid f unct ion panel t est s, is a direct measurement of t he
concent rat ion of T4 in t he blood serum. Tot al T4 level is a good index of t hyroid
f unct ion w hen t he TBG is normal. The increase in TBG levels normally seen in
pregnancy and w it h est rogen t herapy increases t ot al T4 levels. The decrease of
TBG levels in persons receiving anabolic st eroids, in chronic liver disease, and in
nephroses decreases t he t ot al T4 value. This t est is commonly done t o rule out
hypert hyroidism and hypot hyroidism. The T4 t est also can be used as a guide in
est ablishing maint enance doses of t hyroid in t he t reat ment of hypot hyroidism. I n
addit ion, it can be used in hypert hyroidism t o f ollow t he result s achieved w it h
ant it hyroid drug administ rat ion.
Reference Values
Normal
Adult s: 5. 411. 5 g/ dL or 57148 nmol/ L
Children: 6. 413. 3 g/ dL or 83172 nmol/ L
Neonat es: 11. 822. 6 g/ dL or 152292 nmol/ L
I f t est ing is done by radioimmunoassay, it is report ed as T4 RI A.
Procedure
1. O bt ain a 5-mL venous blood sample. Serum is used. I f t he pat ient is already
receiving t hyroid t reat ment , it must be discont inued 1 mont h bef ore t he t est .
1. Increased T4 val ues are f ound in t he f ollow ing condit ions:
a. Hypert hyroidism (G raves' disease, goit er)
b. Clinical st at us t hat increases TBG
c. Thyrot oxicosis f act it ia
d. Acut e t hyroidit is
e. Hepat it is, liver disease
f. Lymphoma
2. Decreased T4 val ues are f ound in t he f ollow ing condit ions:
a. Hypot hyroidism
b. Disorders of decreased TBG
c. Hypoprot einemia
d. Treat ment w it h t riiodot hyronine
e. Nephrot ic syndrome
Interfering Factors
1. Tot al t hyroxine levels increase during t he second or t hird mont h of pregnancy
as a result of increased est rogen product ion. Normal range: 5. 516. 0 g/ dL
or 71206 nmol/ L.
2. Tot al t hyroxine levels increase w it h t he use of drugs such as est rogens,
heroin, and met hadone and excess iodine (see Appendix J).
3. Cont rast agent s used f or x-rays and ot her diagnost ic procedures aff ect
result s.
4. Values are decreased w it h salicylat es and ant iconvulsant s, st eroids.
Clin ical Alert

Pan ic Ran ge
>20 g/ dL or >258 nmol/ L: Thyroid st orm is possible.
<2. 0 g/ dL or <26 nmol/ L: Myxedema coma is possible.
Interventions
1. Explain t est purpose and procedure. T4 is usually t he f irst t est used in t he
diagnosis of hypot hyroidism or hypert hyroidism, along w it h t he TSH.
2. Have pat ient avoid st renuous exercise.
3. Do not administ er radiopaque cont rast f or 1 w eek bef ore t est ing.
4. I f pat ient is on t hyroid t herapy, discont inue t reat ment f or 1 mont h bef ore
t est ing t o det ermine baseline values.

Clin ical Alert

T 4 values are higher in neonat es due t o elevat ed TBG .
Values rise abrupt ly in t he f irst f ew hours af t er birt h and decline gradually unt il
t he age of 5 years.
Triiodothyronine (T3 ), Total T3 has three atoms of

iodine, compared with four atoms in T4 . T3 is more
active metabolically than T4 , but its effect is shorter.
There is much less T3 than T4 in the serum, and it is
bound less firmly to TBG.
This measurement is a quant it at ive det erminat ion of t he t ot al T3 concent rat ion in
t he blood and is t he t est of choice in t he diagnosis of T3 t hyrot oxicosis. It i s not
the same as the T3 uptake test
that measures the unsaturated TBG i n serum. I t can also be very usef ul in t he
diagnosis of hypert hyroidism. T3 t hyrot oxicosis ref ers t o a variant of
hypert hyroidism in w hich a t hyrot oxic pat ient has elevat ed T3 values and normal
T 4 values. This t est is not reliable in diagnosing hypot hyroidism.
Reference Values
Normal
Adult s: 80200 ng/ dL or 1. 23. 1 nmol/ L
Adolescent s (1223 years): 82213 ng/ dL or 1. 33. 28 nmol/ L
Children (114 years): 105245 ng/ dL or 1. 63. 8 nmol/ L
Pregnancy: 116247 ng/ dL or 1. 83. 8 nmol/ L
I f radioimmunoassay is used, t he result is report ed as T3 RI A.
Procedure
1. Increased T3 val ues are associat ed w it h t he f ollow ing condit ions:
a. Hypert hyroidism
b. T 3 t hyrot oxicosis (G raves' disease)
c. Daily dosage of >25 g of T3 (Cyt omel)
d. Acut e t hyroidit is
e. TBG elevat ion f rom any cause
f. Daily dosage of >300 g of T4
g. Early t hyroid f ailure
h. Thyrot oxicosis f act it ia
i. I odine def iciency goit er
2. Decreased T3 val ues are associat ed w it h t he f ollow ing condit ions:
3. Hypot hyroidism; how ever, some clinically hypot hyroid pat ient s w ill have
normal levels.
4. St arvat ion and st at e of nut rit ion subacut e nont hyroid illness
5. TBG decrease f rom any cause
Interfering Factors
1. Values are increased in pregnancy and w it h t he use of drugs such as
est rogens, met hadone, and heroin (see Appendix J).
2. Values are decreased w it h t he use of drugs such as anabolic st eroids,
androgens, large doses of salicylat es, and phenyt oin, nicot inic acid (see
Appendix J).
3. Fast ing causes T3 level t o decrease.
Clin ical Alert

Panic values of <50 ng/ dL (<0. 77 nmol/ L) or >300 ng/ dL (>4. 62 nmol/ L)
Interventions
1. Care is t he same as f or T4 t est ing (see page 451).

1. Care is t he same as f or T4 t est ing (see page 451).
Triiodothyronine Uptake (T3 U) This test is an indirect

measurement of unsaturated thyroxine-binding globulin
(TBG) in blood. This determination, expressed in
arbitrary terms, is inversely proportional to the TBG.
For this reason, low T3 U levels are indicative of
situations that result in elevated levels of TBG uptake.
For example, in hypothyroidism, when insufficient T4 is
available to produce saturation of TBG, unbound TBG

(UTBG) is elevated, and T3 U values are low. Similarly,
in pregnant patients or those receiving estrogen, TBG
levels are increased proportionately more than are T4
levels, resulting in high levels of UTBG, which are
reflected in low T3 U results. This test should not be
ordered alone; it is useful only when T4 is done. It is
also used to calculate the T7 or FTI.
Reference Values
Normal
0. 91. 10 (rat io bet w een pat ient specimen and t he st andard cont rol) 25%35%
upt ake (t hese are arbit rary unit s)
Procedure
See Table 6. 18 f or implicat ions of clinical condit ions on t est result s.
Table 6.18 Implications of Conditions for T3 (T 3 U)

Testing
Clinical
Condition
T4
T 3 U
FT 4 I
Normal
Normal
Normal
Normal
Hyperthyroid
Increased
Increased
Increased
Hypothyroid
Decreased
Decreased
Decreased
Increased TBG,
as in pregnancy
Increased
Decreased
Normal
Decreased
TBG, as in
nephrotic
syndrome
Decreased
Increased
Normal
Interfering Factors
1. Decreased T3 U l evel s occur in normal pregnancy, and w it h drugs such as
est rogens, ant iovulat ory drugs, met hadone, and heparin.
2. Increased T3 U l evel s occur w it h drugs such as dicumarol, heparin,
androgens, anabolic st eroids, phenyt oin, and large doses of salicylat es.
Interventions
2. Pretest care is t he same as f or T4 t est ing (see page 451).

2. Posttest care is t he same as f or T4 t est ing (see page 451).
Clin ical Alert

1. This t est has not hing t o do w it h t he act ual T3 blood level despit e it s name,
w hich is somet imes conf usingly abbreviat ed t o t he T3 t est . I t is
emphasized t hat t he T3 U and t he t rue T3 are ent irely diff erent t est s. The
T 3 U gives only an indirect measurement of overall binding.
2. This t est should be used only in conjunct ion w it h t he T4 t est t o calculat e
t he f ree t hyroxine index (FTI ).
3. Some met hods of det ermining T3 U have a direct relat ion w it h T4 . Check
t he ref erence values of your laborat ory.
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Wat t s NB: Clinical ut ilit y of biochemical markers of bone remodeling. Clin
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Tw ent y-Second Annual Arnold O . Beckman Conf erence in Clinical Chemist ry,
February 2122, 1999
Wint er W, Schat z D, Kennedy L, Venecor F: The new ADA diabet es
guidelines: I mplicat ions f or t he clinical laborat ory. AACC, 1999 (I nt ernet
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Test s, 6t h ed. Washingt on, DC, AACC Press 2001

Wilkins
> Table of C ontents > 7 - Mic r obiologic S tudies
7
Microbiologic Studies
OVERVIEW OF M ICROBIOLOGIC STUDIES

Diagnostic Testing and Microbes Microorganisms that
cause infectious disease are defined as pathogens.
Organisms that are pathogenic under one set of
conditions may, under other conditions, reside within
or on the surface of the body without causing disease.
When organisms are present but do not cause harm to
the host, they are considered commensals. When
organisms multiply and cause tissue damage, they are
considered pathogens, with the potential for causing or
increasing a pathogenic process (Table 7.1). Many
newly discovered organisms are clinically relevant.
Some of these organisms, formerly considered
insignificant contaminants or commensals, have taken
on roles as causative agents for opportunistic diseases
in patients with human immunodeficiency virus (HIV)
infection or other immunodeficiency syndromes or
diseases associated with a compromised health state.
Consequently, virtually any organism recovered in pure
culture from a body site must be considered a potential
pathogen.
Table 7.1 Some Common Pathogens Detectable in Bod

Tissues and Fluids by Diagnostic Methods
Nasopharynx and
Oropharynx
Sputum
Feces
-Hemolytic
streptococci
Bordetella
pertussis
Mycoplasma spp.
Moraxella
catarrhalis
Herpes simplex
virus
Pseudomonas spp.
Candida albicans
Corynebacterium
diphtheriae
Haemophilus
influenzae
Neisseria
meningitidis
Streptococcus
pneumoniae
Staphylococcus
aureus
Enterobacteriaceae
Cryptococcus
neoformans
Respiratory
syncytial virus
Influenza viruses
Parainfluenza
viruses
Urine
Blastomyces
dermatitidis
Bordetella
pertussis
Candida albicans
Coccidioides
immitis
Influenza viruses
Streptococcus
pneumoniae
Pseudomonas spp.
Haemophilus
influenzae
-Hemolytic
streptococci
Histoplasma
capsulatum
Klebsiella spp.
Mycobacterium
spp.
Yersinia pestis
Francisella
tularensis
Staphylococcus
aureus
Mycoplasma spp.
Legionella spp.
Candida albica
Campylobacter
jejuni
Clostridium
botulinum
Entamoeba
histolytica
Escherichia col
Pseudomonas
spp.
Salmonella spp
Shigella spp.
Staphylococci
Vibrio cholerae
Vibrio comma
Vibrio
parahaemolytic
Yersinia
enterocolitica
Clostridium
difficile
Rotavirus
Hepatitis A, B,
and C
Giardia lamblia
Cryptosporidium
spp.
Streptococcus
agalactiae
Escherichia coli,
other
Enterobacteriaceae
Enterococcus spp.
Neisseria
gonorrhoeae
Mycobacterium
tuberculosis
Pseudomonas
aeruginosa
Staphylococcus
aureus
Staphylococcus
saprophyticus
Salmonella and
Shigella spp.
Trichomonas
vaginalis
Candida albicans
and other yeasts
Staphylococcus
epidermidis
Skin
Ear
Bacteroides spp.
Clostridium spp.
Enterobacteriaceae
Fungi
Pseudomonas spp.
Aspergillus
fumigatus
Candida albicans
and other yeast
Enterobacteriaceae
-Hemolytic
streptococci
Proteus spp.
Streptococcus
pneumoniae
Pseudomonas
aeruginosa
Staphylococcus
Staphylococcus
aureus
Streptococcus
pyogenes
Varicella zoster
virus
aureus
Moraxella
catarrhalis
Mycoplasma
pneumoniae
Peptostreptococcus
spp.
Bacteroides fragilis
Fusobacterium
nucleatum
Influenza virus
Respiratory
syncytial virus
(RSV)
Cerebrospinal
Fluid
Vaginal Discharge
Urethral
Discharge
Bacteroides spp.
Cryptococcus
neoformans
Haemophilus
influenzae
Mycobacterium
tuberculosis
Neisseria
meningitidis
Streptococcus
pneumoniae
Enteroviruses
-Hemolytic
streptococci
Candida albicans
Gardnerella
vaginalis
Listeria
monocytogenes
Mycoplasma spp.
Human papilloma
virus
Neisseria
gonorrhoeae
Treponema
Chlamydia
trachomatis
Coliform bacilli
Haemophilus
ducreyi
Herpes simplex
virus
Neisseria
gonorrhoeae
Treponema
pallidum
Trichomonas
vaginalis
Listeria
monocytogenes
Streptococcus
agalactiae (Group
B)
Staphylococcus
spp.
pallidum
Haemophilus
ducreyi
Herpes simplex
virus
Trichomonas
vaginalis
Mycoplasma sp
Ureaplasma
urealyticum
Human papillom
virus
Mobiluncus spp
and other
anaerobes
Basic Concepts of Infectious Disease Infectious

processes demonstrate observable physiologic
responses to the invasion and multiplication of the
offending microorganisms. Once an infectious disease
is suspected, appropriate cultures should be done or
nonculture techniques should be used, such as
serologic testing for antigens and antibodies,
monoclonal antibodies, and DNA probes. Proper
specimen collection and appropriate blood and skin
tests are necessary to detect and diagnose the
presence of the microorganism.
O pport unit y f or inf ect ion depends on host resist ance, organism volumes, and t he
abilit y of t he organism t o f ind a port al of ent ry and t o overcome host def enses,
invade t issues, and produce t oxins. O rganisms may become seat ed in
suscept ible persons t hrough inhalat ion, ingest ion, direct cont act , inoculat ion,
breaks in nat ural skin or mucous membrane barriers, changes in organism
volumes, alt erat ions in normal f lora balances, or changes in ot her host def ense
mechanisms.
Host Factors
The development of an inf ect ious disease is inf luenced by t he pat ient 's general
healt h, normal def ense mechanisms, previous cont act w it h t he off ending
organism, past clinical hist ory, and t ype and locat ion of inf ect ed t issue.
Mechanisms of host resist ance are det ailed in t he f ollow ing list s:
1. Primary host def enses
a. Anat omic barriers

1. I nt act skin surf aces
2. Nose hairs
3. Respirat ory t ract cilia
4. Coughing and f low of respirat ory t ract f luids and mucus
5. Sw allow ing and gast roint est inal (G I ) t ract perist alsis
b. Physiologic barriers
1. High or low pH and oxygen t ension (prevent s prolif erat ion of
organisms)
2. Chemical inhibit ors t o bact erial grow t h (eg, prot eases)
3. Bile acids
4. Act ive lysozymes in saliva and t ears
5. Fat t y acids on skin surf aces
2. Secondary host def enses (physiologic barriers)

a. Responses of complement , lysozymes, opsonins, and secret ions
b. Phagocyt osis
c. I mmunoglobulin A (I gA), I gG , and I gM ant ibody f ormat ion
d. Cell-mediat ed immune responses
3. Fact ors decreasing host resist ance
a. Age: t he very young and t he very old are more suscept ible
b. Presence of chronic disease (eg, cancer, cardiovascular disease,
diabet es)
c. Use or hist ory of cert ain t herapeut ic modalit ies, such as radiat ion,
chemot herapy, cort icost eroids, ant ibiot ics, or immunosuppressant s
d. Toxins, including alcohol, st reet drugs, legit imat e t herapeut ic drugs,
venom or t oxic secret ions f rom a rept ile or insect , or ot her nonhuman
bit es or punct ures
e. O t hers, including excessive physical or emot ional st ress st at es,
nut rit ional st at e, and presence of f oreign mat erial at t he sit e
COLLECTION AND TRANSPORT OF SPECIM ENS

General Principles
The healt h care prof essional is responsible f or collect ing specimens f or
diagnost ic examinat ions. Because procedures vary, check inst it ut ional prot ocols
f or specimen ret rieval, t ransport , preservat ion, and report ing of t est result s.
Specimens f or bact erial cult ure should be represent at ive of t he disease process.
Also, suff icient mat erial must be collect ed t o ensure an accurat e examinat ion. As
an example, serous drainage f rom a diabet ic f oot ulcer w it h possible
ost eomyelit is may yield inaccurat e result s. I n t his case, a bone biopsy or
purulent drainage of inf ect ed t issue w ould be a bet t er specimen. Likew ise, if
t here is a lesion of t he skin and subcut aneous t issue, mat erial f rom t he margin of
t he lesion rat her t han t he cent ral part of t he lesion w ould be more desirable. I f a
purulent sput um sample cannot be obt ained t o aid in t he diagnosis of pneumonia,
blood cult ures, pleural f luid examinat ion, and bronchoalveolar lavage (BAL)
specimens are also accept able.
I t is imperat ive t hat mat erial be collect ed w here t he suspect ed organism is most
likely t o be f ound, w it h as lit t le cont aminat ion f rom normal f lora as possible. For
t his reason, cert ain precaut ions must be f ollow ed rout inely:
1. O bserve st andard precaut ions. Clean t he skin st art ing cent rally and going
out in larger circles. Repeat several t imes, using a clean sw ab or w ipe each
t ime. I f 70% alcohol is used, it should be applied f or 2 minut es. Tinct ure of
iodine requires only 1 minut e of cleansing.
2. Bypass areas of normal f lora; cult ure only f or a specif ic pat hogen.
3. Collect f luids, t issues, skin scrapings, and urine in st erile cont ainers w it h
t ight -f it t ing lids. Polyest er-t ipped sw abs in a collect ion syst em cont aining an
ampule of St uart 's t ransport medium ensure adequacy of t he specimen f or 72
hours at room t emperat ure.
Clin ical Alert

1. Wit hout rout ine precaut ions f or collect ing and handling specimens, t he
pat ient 's condit ion may be incorrect ly diagnosed, laborat ory t ime may be
w ast ed, eff ect ive t reat ment may be delayed, or pat hogenic organisms may
be t ransmit t ed t o healt h care w orkers and ot her pat ient s.
2. I t is import ant t o report all ident if ied diseases, condit ions, and out breaks
according t o st at e and f ederal guidelines.
3. Tradit ional surveillance requires t hat a disease be diagnosed bef ore it is

report ed. The new er report ing syst em f rom t he CDC requires no w ait ing
f or a def init e diagnosis, but relies on collect ing syndrome inf ormat ion of
signs and sympt oms report ed t o physicians and clinics. The syndrome
syst em compares early report s of f ever, headaches, diarrhea, vomit ing,
rashes, and normal seasonal, daily, and required f luct uat ions in know n
illness. The comput erized net w ork is designat ed t o provide early w arning
of inf ect ious disease t errorism at t ack by monit oring visit s t o physician's
off ices, emergency rooms, and drugst ores (f or remedies). Bot h syst ems
are used. The collaborat ive t eam approach relies on asking pat ient w hat
signs or sympt oms are present bef ore doing t est ing f or inf ect ious and
report able diseases.
4. I n addit ion, t he Environment al Prot ect ion Agency (EPA) monit ors air qualit y
in major cit ies. This surveillance syst em is designed t o provide 24-hour
not ice of release int o t he air of deadly pat hogens (eg, smallpox, ant hrax).
Footn ote
Source: M. Toner CO X New s Service, January 29, 2003.
Sources of Specimens
Microbiologic specimens may be collect ed f rom many sources, such as blood,
pus or w ound exudat es or drainage, urine, sput um, f eces, genit al discharges or
secret ions, cerebrospinal f luid (CSF), and eye or ear drainage. During specimen
collect ion, t hese general procedures should be f ollow ed:
1. Label specimens properly w it h t he f ollow ing inf ormat ion (inst it ut ional
requirement s may vary):
a. Pat ient 's name, age, sex, address, hospit al ident if icat ion number, and
physician's f ull name
b. Specimen source (eg, t hroat , conjunct iva)
c. Time of collect ion
d. Specif ic st udies ordered
e. Clinical diagnosis; suspect ed microorganisms
f. Pat ient 's hist ory
g. Pat ient 's immune st at e
h. Previous and current inf ect ions
i. Previous or current ant ibiot ic t herapy
j. I solat ion st at usst at e t ype of isolat ion (eg, cont act s, respirat ory,
w ound)
k. O t her request ed inf ormat ion pert inent t o t est ing
2. Avoid cont aminat ing t he specimen; maint ain asept ic or st erile t echnique as
required:
a. Special supplies may be required:
1. For anaerobes, st erile syringe aspirat ion of pus or ot her body f luid
2. Anaerobic t ransport cont ainers f or t issue specimens
b. St erile specimen cont ainers
c. Precaut ions t o t ake during specimen collect ion include:
a. Care t o maint ain clean out side cont ainer surf aces
b. Use of appropriat ely f it t ing covers or plugs f or specimen t ubes and
bot t les
c. Replacement of st erile plugs and caps t hat have become
cont aminat ed
d. O bservat ion of st andard precaut ions
3. Ensure t he preservat ion of specimens by delivering t hem prompt ly t o t he
laborat ory. Many specimens may be ref rigerat ed (not f rozen) f or a f ew hours
w it hout any adverse eff ect s. Not e t he f ollow ing except ions:
a. Urine cult ure samples must be ref ri gerated.
b. CSF specimens should be t ransport ed t o t he laborat ory as soon as
possible. I f t his is problemat ic, t he cult ure should be i ncubated
(meningococci do not w it hst and ref rigerat ion).
4. Transport specimens quickly t o t he laborat ory t o prevent desiccat ion of t he
specimen and deat h of t he microorganisms.
a. For anaerobic cult ures, no more t han 10 minut es should elapse bet w een
t ime of collect ion and cult ure. Anaerobic specimens should be placed int o
an anaerobic t ransport cont ainer.
b. Feces suspect ed of harboring Sal monel l a or Shi gel l a organisms should
be placed in a special t ransport medium, such as Cary-Blair, if cult uring
of t he specimen w ill be delayed great er t han 30 minut es.
5. Ensure t hat specimen quant it y is adequat e. Wit h f ew except ions, t he quant it y
of t he specimen should be as large as possible. When only a small quant it y
is available, sw abs should be moist ened w it h st erile saline just bef ore
collect ion, especially f or nasopharyngeal cult ures.
6. Handle specimen collect ion in t he f ollow ing w ay:
a. Submit ent ire f luid specimen collect ed. Do not submit f luids on sw abs.
b. Whenever possible, specimens should be collect ed bef ore ant ibiot ic

regimens are inst it ut ed; f or example, complet e all blood cult ure sampling
bef ore st art ing ant ibiot ic t herapy.
c. Collect ion must be geared t o t he rise in sympt oms such as f ever. (The
pract it ioner should be f amiliar w it h t he clinical course of t he suspect ed
disease. )
Transport of Specimens by Mail Several kits containing

transport media are available for use when there is a
significant delay between collection and culturing.
Culture swabs (containing transport medium) are
available for bacterial, viral, and anaerobic collection
of specimens. Some laboratories provide Cary-Blair
and polyvinyl alcohol (PVA) fixative transport vials for
stool collection for culture and ova and
parasite examination. Depending on the request, some
specimens may have to be shipped in a Styrofoam box
with refrigerant packs. This is especially true for
specimens to be tested for viral examination. It is
prudent to consult the reference laboratory to which
specimens will be sent for information on proper
collection and shipment.
According t o t he Code of Federal Regulat ions (49 CFR), a viable organism or it s
t oxin or a diagnost ic specimen (volume < 50 mL) must be placed in a secure,
closed, w at ert ight cont ainer t hat is t hen enclosed in a second secure, w at ert ight
cont ainer. Biohazard labels should be placed on t he out side of t he cont ainer.
Specimens t hat are t o be t ransport ed w it hin an inst it ut ion should be placed in a
sealed biohazard bag. I deally, t he requisit ion should accompany t he specimen
but not be sealed inside t he bag.
Diagnosis of Bacterial Disease Bacteriologic studies

attempt to identify the specific organism causing an
infection (Table 7.2). This organism may be specific to
one disease, such as Mycobacterium tuberculosis for
tuberculosis (TB), or it may cause a variety of

infections, such as those associated with
Staphylococcus aureus. Antibiotic susceptibility
studies then determine the responses of the specific
organism to various classes and types of antibiotics.
An antibiotic that inhibits bacterial growth is the
logical choice for treating the infection.
Table 7.2 Bacterial Diseases and Their Laborator
Disease
Causative
Organism
Source of
Specim en
Anthrax
Bacillus anthracis
Blood, sputum,
skin
Brucellosis
(undulant fever)
Brucella melitensis,
Brucella abortus,
Brucella suis
Blood, bone
marrow, CSF,
tissue, lymph
node, urine
Yersinia pestis
Buboes
(enlarged and
inflamed lymph
nodes), blood,
sputum
Bubonic plague
Chancre
Haemophilus ducreyi
Genital lesion
Cholera
Vibrio cholerae
Feces
Psittacosis
Chlamydia psittaci
Blood, sputum,
lung tissue
Diphtheria
Corynebacterium
diphtheriae
Nasopharynx
Erysipeloid
Erysipelothrix
rhusiopathiae
Lesion, blood
Gonorrhea
Neisseria
gonorrhoeae
Cervix, urethra,
CSF, blood,
joint fluid,
throat
Granuloma
inguinale
(donovanosis)
Calymmatobacterium
granulomatis
Groin lesion
Gastritis, gastric
ulcer
Helicobacter pylori
Gastric tissue
biopsy
Relapsing fever
Borrelia recurrentis
Peripheral
blood
Blood, CSF,
Lyme disease
Borrelia burgdorferi
skin lesion
Legionnaire's
disease
Legionella
pneumophila
Sputum
Leprosy
(Hansen's
disease)
Mycobacterium
leprae
Skin scrapings
Lymphogranuloma
venereum
Chlamydia
trachomatis
Genital,
conjunctiva,
urethra, urine
Listeriosis
Listeria
monocytogenes
Stool, blood,
CSF, amniotic
fluid, placenta,
vagina
Pneumonia
Haemophilus
influenzae,
Klebsiella
pneumoniae,
Staphylococcus
aureus,
Streptococcus
pneumoniae
Bronchoscopy,
secretions,
sputum, blood,
lung aspirate or
biopsy, pleural
fluid
Strep throat,
Streptococcus
scarlet fever,
impetigo
pyogenes
Throat, lesion
Tetanus
Clostridium tetani
W ound
Toxic shock
syndrome
Staphylococcus
aureus
Tissue
Tuberculosis
Mycobacterium
tuberculosis
Sputum, gastric
washings,
urine, CSF
Francisella
tularensis
Skin, lymph
node, ulcer
tissue biopsy,
sputum, bone
marrow
Typhoid
Salmonella typhi
Blood (after
first week of
infection); feces
(after second
week of
infection)
W hooping cough
Bordetella pertussis
Nasopharyngea
swab
Tularemia
Nocardiosis
Mycoplasma
Nocardia asteroides
Sputum, lesion
Mycoplasma
pneumoniae
Sputum,
nasopharyngea
and throat
swabs
Some quest ions t hat need t o be asked w hen searching f or bact eria as t he cause
of a disease process include t he f ollow ing: (1) Are bact eria responsible f or t his
disease? (2) I s ant imicrobial t herapy indicat ed? Most bact eria-relat ed diseases
have a f ebrile course. From a pract ical st andpoint during evaluat ion of t he f ebrile
pat ient , t he sooner a diagnosis can be reached and t he sooner a decision can be
made concerning ant imicrobial t herapy, t he less prot ract ed t he period of
recovery.
Anaerobic bact erial inf ect ions are commonly associat ed w it h localized necrot ic
abscesses: t hey may yield several diff erent st rains of bact eria. Because of t his,
t he t erm pol ymi crobi c di sease is somet imes used t o ref er t o anaerobic bact erial
diseases. This view is in sharp cont rast t o t he one organism, one disease
concept t hat charact erizes ot her inf ect ions, such as t yphoid f ever, cholera, or
dipht heria. I solat ion and ident if icat ion of t he diff erent st rains of anaerobic
bact eria t hrough sensit ivit y st udies is desirable so t hat appropriat e t herapy may
be given.
Studies of the Susceptibility of Bacteria to

Antimicrobial Agents The susceptibility test detects the
type and amount of antibiotic or chemotherapeutic
agent required to inhibit bacteria growth. Often, culture
and susceptibility tests are ordered together.
Susceptibility studies also may be indicated when an
established regimen or treatment is to be altered.
A common and usef ul t est f or evaluat ing ant ibiot ic suscept ibilit y is t he disk
diff usion met hod. A set of ant ibiot ic-impregnat ed disks on agar is inoculat ed w it h
a cult ure derived f rom t he specif ic bact eria being t est ed. Af t er a suit able period
of incubat ion, t he degree of bact erial grow t h w it hin t he diff erent ant ibiot ic zones
on t he disks is det ermined and measured. G row t h zone diamet ers, measured in
millimet ers, are correlat ed t o t he minimum inhibit ory concent rat ion (MI C) t o
det ermine w het her t he organism is t ruly suscept ible t o t he ant ibiot ic. Anot her
met hod is a brot h dilut ion t est . The organism is grow n in t he presence of
doubling dilut ions of t he ant ibiot ic. The low est concent rat ion of t he ant ibiot ic t hat
inhibit s t he organism's grow t h is t he MI C. Many commercial syst ems are based
on t his met hod.
1. The t erms sensi ti ve and suscepti bl e imply t hat an inf ect ion caused by t he
bact erial st rain t est ed w ill respond f avorably in t he presence of t he indicat ed
ant imicrobial agent .
2. The t erms i ntermedi ate, parti al l y resi stant, and moderatel y suscepti bl e
mean t hat t he bact erial st rain t est ed is not complet ely inhibit ed by
t herapeut ic concent rat ions of a t est drug.
3. Indetermi nate means t hat t he bact eria has an MI C t hat approaches
achievable blood and t issue concent rat ions. I t implies clinical eff icacy in
body sit es w here t he ant ibiot ic is physiologically concent rat ed. The
int ermediat e cat egory also includes a buff er zone, w hich should prevent
major errors due t o t echnical f act ors.
4. The t erm resi stant implies t hat t he organism is not inhibit ed by t he ant ibiot ic.
5. Some ant imicrobial agent s act in a bacteri ci dal manner, meaning t hat t hey
kill t he organism. O t hers act in a bacteri ostati c manner, meaning t hat t hey
inhibit grow t h of t he organism but do not necessarily kill it .
a. Bact ericidal agent s
1. Aminoglycoside
2. Cephalosporins
3. Met ronidazole
4. Penicillins
5. Q uinolones
6. Rif ampin
7. Vancomycin
b. Bact eriost at ic agent s
1. Chloramphenicol
2. Eryt hromycin
3. Sulf onamides
4. Tet racycline
6. Emergence of st rains of penicillin-resist ant Nei sseri a gonorrhoeae,
met hicillin (or oxacillin)-resist ant S. aureus, amikacin-resist ant Pseudomonas
spp. or ot her gram-negat ive rods, and vancomycin-resist ant Enterococcus
spp. present challenges t o t he clinician in regard t o t reat ment . Many
hospit als screen f or met hicillin-resist ant S. aureus (MRSA) and vancomycinresist ant Enterococcus (VRE) species so as t o isolat e pat ient s inf ect ed w it h
t hese organisms.
Diagnosis of Mycobacterial Infections The genus

Mycobacterium contains several species of bacteria
that are pathogenic to humans (Table 7.3). For example,
M. tuberculosis is spread from person to person
through inhalation of airborne respiratory secretions
containing mycobacteria expelled during coughing,
sneezing, or talking. In patients with the acquired
immunodeficiency syndrome (AIDS), Mycobacterium
aviumintracellulare (MAI) complex is acquired through
the GI tract, often through ingestion of contaminated
water or food.
Table 7.3 Mycobacterial Infections and Their
Laboratory Diagnosis
Causative
Organism
Source of
Specim en
Diagnostic
Test
Mycobacterium
tuberculosis
Sputum, urine, CSF,

tissue, bone marrow
Culture and
smear; skin
test; DNA
probe
Mycobacterium
avium
intracellulare
Sputum, stool, CSF,

tissue, blood,
semen, lymph
nodes
Culture and
smear; DNA
probe
Mycobacterium
kansasii
Skin, joint, lymph

nodes, sputum,
tissue
Culture and
smear
Mycobacterium
leprae
CSF, skin, bone

marrow, lymph
nodes
Histopathologic
examination of
lesion
Mycobacterium
marinum
Joint lesion
Culture and
smear
Mycobacterium
xenopi
Sputum
Culture and
smear
Mycobacterium
fortuitum
Surgical wound,
bone, joint, tissue,
sputum
Culture and
smear
Mycobacterium
chelonei
Surgical wound,
sputum, tissue
Culture and
smear
The disease progression of mycobact eriosis, part icularly in pat ient s w it h AI DS,
is rapid (a f ew w eeks). This short t ime span has required new met hods f or rapid
recovery and ident if icat ion of mycobact eria so t hat ant ibiot ic t herapy can be
inst it ut ed prompt ly. These new er t echniques involve t he use of inst rument s t hat
short en t he grow t h period f or mycobact eria t o 1 t o 2 w eeks. I sot opic nucleic
acid probes are available f or cult ure ident if icat ion of M. tubercul osi s, MAI
complex, Mycobacteri um kansasi i, and Mycobacteri um gordonae. Polymerase
chain react ion (PCR) t echniques, w hich use DNA t echnology t o det ect
mycobact eria direct ly in clinical specimens, is also available t o clinical
laborat ories.
A dist urbing problem t hat has arisen since t he resurgence of TB among persons
w it h AI DS is t he appearance of mult idrug-resist ant M. tubercul osi s st rains.
Collection of Specimens
1. Sput um and bronchial aspirat es and lavages are t he best samples f or
diagnosis of pulmonary inf ect ion. Purulent sput um (5 t o 10 mL) f rom t he f irst
product ive cough of t he morning should be expect orat ed int o a st erile
cont ainer. I f t he specimen is not processed immediat ely, it should be
ref rigerat ed. Pooled specimens collect ed over several hours are not
accept able. For best result s, t hree specimens should be collect ed over
several days. A prerequisit e of good specimen collect ion is t he use of st erile,
st urdy, leak-proof cont ainers placed int o biohazard bags.
2. I f t he pat ient is unable t o produce sput um, an early-morning gast ric sample
may be aspirat ed and cult ured. This specimen must be hand-delivered t o t he
laborat ory t o be processed or neut ralized immediat ely.
3. Pat ient s w it h suspect ed renal disease should provide early-morning urine
specimens collect ed f or 3 days in a row. Pooled 24-hour urine collect ions are
not recommended. Unless processed immediat ely, t he specimen should be
ref rigerat ed.
4. I f TB meningit is is suspect ed, at least 10 mL of CSF should be obt ained.
5. St erile body f luids, t issue biopsy samples, and mat erial aspirat ed f rom skin
lesions are accept able specimens f or mycobact erial cult ures. Tissue should
be placed in a neut ral t ransport medium t o avoid desiccat ion. Sw ab
specimens are not suit able f or mycobact erial cult ure.
6. Feces are commonly t he f irst specimens f rom w hich MAI complex can be
isolat ed in a pat ient w it h disseminat ed disease. An acid-f ast st ain is usually
perf ormed direct ly. Cult ure is perf ormed only if t he smear t est s posit ive.
7. MAI complex organisms can also be isolat ed f rom t he blood of
immunosuppressed pat ient s.
Diagnosis of Rickettsial Disease Rickettsiae are small,

gram-negative coccobacilli that structurally resemble
bacteria but are one tenth to one half as large.
Polychromatic stains (Giemsa stain) are better than
simple stains of the Gram stain for demonstrating
rickettsiae in cells.
Ri ckettsi osi s is t he general name given t o any disease caused by ricket t siae
(Table 7. 4). These organisms are considered t o be obl i gate i ntracel l ul ar
parasi tes; t hat is, t hey cannot exist anyw here except inside t he bodies of living
organisms. Diseases caused by ricket t siae are t ransmit t ed by arthropod vectors,
such as lice, f leas, t icks, or mit es. Ricket t sial diseases are divided int o t he
f ollow ing general groups:
Table 7.4 Rickettsial Diseases a
Disease
Natura
Geographic
Distribution
Group/Type
Agent
Anthropod
Typhus
epidemic*
Rickettsia
prowazekii
W orldwide
Body
louse
Endemic
(murine)
Rickettsia
typhi
W orldwide
Flea
Spotted
fever, Rocky
Mountain
spotted fever
Rickettsia
rickettsii
W estern
hemisphere
Ticks
Rickettsia
sibirica
Siberia,
Mongolia
Ticks
Buotonneuse
fever
Rickettsia
conorii
Africa,
Europe,
Mideast,
India
Ticks
Queensland
tick typhus
Rickettsia
australis
Australia
Ticks
Rickettsial
pox
Rickettsia
akari
North
America,
Europe
Bloodsucking
Scrub
typhus
Rickettsia
tsutsugamushi
Asia,
Australia,
Pacific
Islands
Tromiculid
Ehrlichiosis
Ehrlichia
canis,
Ehrlichia
sennetsu
Southeast
Asia
Ticks
North Asian
tick-borne
rickettsiosis
Q fever
Coxiella
burnetii
W orldwide
Ticks
Trench fever
Rochalimaea
quintana
Europe,
Africa, North
America
Body
louse
Bartonella
bacilliformis
Peru,
Ecuador,
Columbia,
Brazil
Sand fly
Oroya fever
*Recurrence years after original attack of epidemic typhus.
1. Typhus-like f evers
2. Spot t ed f ever
3. Scrub t yphus
4. Q f ever
5. O t her ricket t sial diseases
Q f ever, caused by Coxi el l a burneti i, is charact erized by an acut e f ebrile illness,
severe headache, rigors, and possibly pneumonia or hepat it is. I t can cause
encephalit is in children and has been isolat ed in breast milk and in t he placent a
of inf ect ed mot hers, making it possible f or a f et us t o be inf ect ed in ut ero. Bot h
complement f ixat ion and f luorescent ant ibody t est s can det ect ant ibodies t o t he
organism. C. burneti i displays an ant igenic variat ion during an inf ect ion. Phase I
ant ibodies are preponderant during t he chronic phase, w hereas phase I I
ant ibodies predominat e during t he acut e phase. A diagnosis is made w hen t he
phase I t it er in a convalescent serum specimen is f our t imes great er t han t hat in
an acut e serum specimen.
Early diagnosis of ricket t sial inf ect ion is usually based on observat ion of clinical
sympt oms such as f ever, rash, and exposure t o t icks. Biopsy specimens of skin
t issue f rom a pat ient w it h suspect ed Rocky Mount ain spot t ed f ever can be t est ed
w it h an immunof luorescent st ain and diagnosed 3 t o 4 days af t er sympt oms
appear. Signs and sympt oms include t he f ollow ing:
1. Fever
2. Skin rashes
3. Parasit ism of blood vessels
4. Prost rat ion
5. St upor and coma
6. Headache
7. Ringing in t he ears
8. Dizziness
NOTE
Ricket t sial diseases are of t en charact erized by an incubat ion period of 10 t o
14 days, f ollow ed by an abrupt onset of t he signs and sympt oms list ed, in a
pat ient w it h a hist ory of art hropod bit es. Cult ures of ricket t sia are perf ormed
only in ref erence laborat ories. Ricket t sial inf ect ions usually are diagnosed by
serologic met hods, using acut e and convalescent serum specimens. A f ourf old
rise in serum ant ibody t it er is pref erable, but a single t it er great er t han 1: 64
is highly suggest ive of inf ect ion (see Chap. 8).
Diagnosis of Parasitic Disease About 70 species of

animal parasites commonly infect the human body
(Table 7.5). More than half of these can be detected by
examination of stool specimens because the parasites
inhabit the GI tract and its environs. Of the parasites
that can be diagnosed by stool examinations, about
one third are single-celled protozoa, and two thirds are
multicellular worms. Only six or seven types of
intestinal protozoa are clinically important, but almost
all of the worm classes are potentially pathogenic.
Table 7.5 Parasitic Diseases and Their Laboratory Dia
Disease
Amebiasis
Causative
Organism
Entamoeba
Source of
Specim en
Stool, liver
Diagn
Tests
Stool
recta
biops
histolytica
Ascariasis
Ascaris
lumbricoides
Cestodiasis of
intestine
(tapeworm
disease)
Taenia
saginatus,
Taenia solium,
Diphyllobothrium,
Hymenolepis
nana,
Hymenolepis
diminuta
Chagas' disease
Cryptosporidiosis
Trypanosoma
cruzi
Cryptosporidium
parvum
serol
test
Stool,
sputum
Ova a
paras
exam
antig
recta
biops
serol
test
Stool
Ova a
paras
exam
Scotc
test f
Enter
vermi
Blood,
spinal fluid
Giem
W righ
Giem
staine
smea
Stool,
lung,
Ova a
paras
exam
antig
direc
gallbladder
Cysticercosis
Taenia solium
larvae
fluore
antib
test
Muscle
and brain
Musc
brain
biops
Ova a
paras
exam
direc
micro
exam
serol
test,
Caso
skin t
liver a
bone
Echinococcosis
Echinococcus
granulosus
Sputum
and urine,
liver,
spleen
Enterobiasis
(pinworm
disease)
Enterobius
vermicularis
Stool
Scotc
test
Blood
Blood
smea
lymph
biops
serol
test
Filariasis
Wuchereria
bancrofti, Brugia
malayi, Loa loa
Giardiasis
Giardia lamblia
Hookworm
Ancylostoma
duodenale,
Necator
americanus
Isospora
Kala-azar
Isospora belli
Leishmania
donovani
Plasmodium
Stool,
duodenal
aspirate or
biopsy
Ova a
paras
exam
antig
direc
fluore
antib
test,
micro
exam
of En
test
Stool
Ova a
paras
exam
Stool
Ova a
paras
exam
Liver,
bone
marrow,
blood
Giem
W righ
Giem
staine
smea
cultur
lymph
and s
biops
Blood,
bone
marrow
Giem
W righ
Giem
staine
smea
Acanthamoebiasis
Acanthamoeba
culbertsoni
CSF,
corneal
biopsy or
scraping
Smea
tissue
cultur
Naegleriosis
Naegleria fowleri
CSF
Smea
Sarcocystis
Sarcocystis
hominis or
Sarcocystis
suihominis
Stool
Ova a
paras
exam
Blastocystis
Blastocystis
hominis
Stool
Ova a
paras
exam
Onchocerciasis
Onchocerca
volvulus
Skin
Skin
Sputum,
stool
Ova a
paras
exam
serol
test,
test
Malaria
Paragonimiasis
falciparum,
Plasmodium
malariae,
Plasmodium
vivax,
Plasmodium
ovale
Paragonimus
westermani
Scabies
Schistosomiasis
of intestine and
bladder
Strongyloidiasis
Toxoplasmosis
Trichinosis
Trichomoniasis
Skin
Skin
direc
exam
Stool,
urine
Ova a
paras
exam
serol
test;
test;
bladd
liver b
Strongyloides
stercoralis
Stool,
duodenal
aspirate
Ova a
paras
exam
serol
test
Toxoplasma
gondii
Blood,
tissue,
CSF
Serol
test,
smea
biops
Muscle
Serol
test,
test,
biops
Sarcoptes
scabiei
Schistosoma
mansoni,
Schistosoma
japonicum,
Schistosoma
haematobium
Trichinella
spiralis
Trichomonas
vaginalis
Vagina,
bladder,
Vagin
ureth
smea
urethra
Trichuriasis
Trypanosomiasis
cultur
DNA
Trichuris
trichiura
Stool
Ova a
paras
exam
Trypanosoma
rhodesiense,
Trypanosoma
gambiense
Blood,
spinal
fluid,
lymph
node
Blood
spina
and l
node
serol
test
Liver
Serol
test,
test,
biops
Stool
Ova a
paras
exam
Visceral larva
migrans
Toxocara canis,
Toxocara cati
Trematodes
Fasciola
hepatica,
Clonorchis
sinensis,
Fasciolopsis
buski
Diagnosis of parasit es begins w it h ova and parasit e examinat ion. O t her

diagnost ic opt ions include sigmoidoscopy smears, biopsies, barium radiologic
st udies, and serologic t est s. Collect ion of f ecal specimens f or parasit es should
be done bef ore administ rat ion of barium sulf at e, mineral oil, bismut h, ant imalarial
drugs, and some ant ibiot ics (eg, t et racycline). For ova and
parasit e examinat ion, ideally, one specimen should be collect ed every ot her day
f or a t ot al of t hree specimens. At t he most , t hese specimens should be gat hered
w it hin 10 days.
For det ect ion of G i ardi a, ot her diagnost ic t est s such as t he Ent ero-Test capsule
(st ring t est ) and duodenal aspirat ion or biopsy may be necessary. The Ent eroTest consist s of a gelat in capsule cont aining a coiled lengt h of nylon yarn. The
capsule is sw allow ed, t he gelat in dissolves, and t he w eight ed st ring is carried
int o t he duodenum. Af t er about 4 hours, t he st ring is w it hdraw n, and t he
accompanying mucus is examined microscopically f or G i ardi a. Duodenal f luid
also can be submit t ed by t he physician t o be examined f or G i ardi a and
Strongyl oi des stercoral i s. The specimen should cont ain no preservat ives and
should be examined f or organisms w it hin 1 hour af t er collect ion.
Cryptospori di um parvum has long been recognized as an animal parasit e but is
also capable of inf ect ing humans, especially physically compromised pat ient s.
O rganisms have been recovered f rom t he gallbladder, t he lungs, and t he st ool.
Collection of Specimens
1. Mult iple specimens may be necessary t o det ect a parasit ic inf ect ion.
2. Most parasit es f ound in humans are ident if ied in blood or f eces but may also
be evident in urine, sput um, t issue f luids, or biopsy t issues.
3. Fecal specimens should not be cont aminat ed w it h w at er or urine. All
specimens should be labeled w it h t he pat ient 's name, clinician's name,
ident if icat ion number (if applicable), and dat e and t ime collect ed. Various
commercial collect ion syst ems are available t o allow collect ion of specimens
at home, in a nursing inst it ut ion, or in a hospit al set t ing. Clear inst ruct ions
should be communicat ed and given in w rit ing t o t he pat ient t o ensure proper
collect ion. See Chapt er 4, St ool St udies, f or more inf ormat ion.
4. When sput um is collect ed f or ova and parasit es, it should be deep sput um
f rom t he low er respirat ory t ract . I t should be collect ed early in t he morning,
bef ore t he pat ient eat s or brushes t he t eet h, and immediat ely delivered t o
t he laborat ory. See Appendix E, G uidelines f or Specimen Transport and
St orage, f or more inf ormat ion.
Clinical Considerations
1. G eneral considerat ions
a. Eosi nophi l i a is considered a def init e indicat or of parasit ic inf ect ion.
Prot ozoa also may produce associat ed eosinophilia.
b. Prot ozoa and helmint hs, part icularly larvae, may be f ound in organs,
t issues, and blood.
2. Specimen-relat ed considerat ions
a. Hepati c puncture can reveal visceral leishmaniasis. Liver biopsy may
yield t oxocaral larvae and schist osomal w orms and eggs. Hepat ic
abscess mat erial f rom t he peripheral area may reveal more organisms
t han t he necrot ic cent er.
b. Bone marrow may be posit ive f or t rypanosomiasis and malaria w hen
blood samples produce negat ive result s. Bone marrow specimens are
obt ained t hrough punct ure of t he st ernum, iliac crest , vert ebral
processes, t rochant er, or t ibia.
c. Punct ure or biopsy samples f rom a l ymph node may be examined f or t he
presence of t rypanosomiasis, leishmaniasis, t oxoplasmosis, and
f ilariasis.
d. Mucous membrane lesion or ski n sampl es may be obt ained t hrough
scraping, needle aspirat ion, or biopsy.
e. CSF may cont ain t rypanosomes and Toxopl asma organisms.
f. Sputum may reveal Paragoni mus westermani (lung f luke) eggs.
O ccasionally, t he larvae and hookw orm of S. stercoral i s or Ascari s
l umbri coi des may be expect orat ed during pulmonary migrat ion. I n
pulmonary echi nococcosi s (hydat id disease), hydat id cyst cont ent s may
be f ound in sput um.
g. Specimens t aken f rom cutaneous ul cers should be aspirat ed below t he
ulcer bed rat her t han at t he surf ace. A f ew drops of saline may be
int roduced by needle and syringe t o aspirat e t he int racellular leishmanial
organisms.
h. Corneal scrapings or biopsy specimens can be examined hist ologically or
cult ured f or t he presence of Acanthamoeba. This organism is rare but
can cause kerat it is among cont act lens w earers.
i. Films f or bl ood parasi tes are usually prepared w hen t he pat ient is
admit t ed. Samples should be t aken at 6- t o 18-hour int ervals f or at least
3 successive days.
Diagnosis of Fungal Disease Fungal diseases, also

known as mycoses, are believed to be more common
now than in the past because of increased use of
antibacterial and immunosuppressive drugs (Table 7.6).
Fungi prefer the debilitated host, the person with

chronic disease or impaired immunity, or a patient who
has been receiving prolonged antibiotic therapy.
Table 7.6 Fungal Diseases and Their Laboratory Dia
Disease
Causative
Organism
Source of
Specim en
Aspergillosis
Aspergillus
fumigatus,
Aspergillus
flavus,
Aspergillus
terreus
Sputum,
tissue,
ear,
corneal
scraping
Blastomyces
dermatitidis
Skin
lesion,
sputum,
bone, joint
Blastomycosis
Candidiasis
Candida
albicans
Mucous
membrane,
sputum,
blood,
tissue,
urine, CSF
Coccidioidomycosis
Coccidioides
immitis
Sputum,
bone, skin,
joint, CSF
Cryptococcosis
Cryptococcus
neoformans
CSF,
sputum,
urine
Histoplasmosis
Histoplasma
capsulatum
Sputum,
urine,
blood,
bone
marrow
Mucormycosis
Members of
order Mucorales
(Absidia,
Rhizopus,
Mucor)
Nose,
pharynx,
stool,
CSF,
sputum,
ear
Paracoccidioides
Lung
tissue,
sputum,
bone, CSF
Paracoccidioidomycosis
Allescheria
boydii
Lesions of
skin, bone,
brain, joint
Sporotrichosis
Sporothrix
schenckii
Skin
lesion,
CSF, bone
marrow,
ear
Tinea pedis (athlete's

foot)
Epidermophyton
spp. and
Candida
albicans,
Trichophyton
mentagrophytes,
Trichophyton
rubrum
Skin
Tinea capitis (ringworm

of scalp)
Microsporum
(any spp.) and
Trichophyton (all
except T.
concentricum)
Skin, hair
Tinea barbae (ringworm

of beard, barber's itch)
Trichophyton
and
Microsporum
spp.
Skin, hair
Pseudallescheriasis
Tinea cruris (jock itch)
Epidermophyton
spp. and
Candida
Skin
albicans
Tinea corporis
(ringworm of the body)
Trichophyton
rubrum,
Trichophyton
tonsurans
Skin
Tinea unguum (nail)
Trichophyton
rubrum,
Trichophyton
tonsurans,
Trichophyton
verrucosum,
Epidermophyton
spp.
Nail
O f more t han 200, 000 species of f ungi, approximat ely 200 species are generally
recognized as being pat hogenic f or humans. Fungi live in soil enriched by
decaying nit rogenous mat t er and are capable of maint aining a separat e
exist ence t hrough a parasit ic cycle in humans or animals. The syst emic mycoses
are not communicable in t he usual sense of human-t o-human or animal-t o-animal
t ransf er. Humans become accident al host s t hrough inhalat ion of spores or by
int roduct ion of spores int o t issues t hrough t rauma. Alt ered suscept ibilit y may
result in f ungal lesions; t his f requent ly occurs in pat ient s w ho have a debilit at ing
disease, diabet es, or impaired immunologic responses due t o st eroid or
ant imet abolit e t herapy. Prolonged administ rat ion of ant ibiot ics can result in a
f ungal superinf ect ion.
Fungal diseases may be classif ied according t o t he t ype of t issues involved:
1. Dermatophytoses include superf icial and cut aneous mycoses, such as
at hlet e's f oot , ringw orm, and jock it ch. Species of Mi crosporum,
Epi dermophyton, and Tri chophyton are t he causat ive organisms.
2. Subcutaneous mycoses involve t he subcut aneous t issues and muscles.
3. Systemi c mycoses involve t he deep t issues and organs and are t he most
serious of t he t hree groups.
Amphot ericin B, int roduced int o pract ice in 1958, w as f or many years t he only
drug available t o t reat invasive f ungal inf ect ions. Now ket oconazole, f luconazole,
it raconazole, and lipid f ormulat ions of amphot ericin B provide alt ernat ive choices
w hen t reat ment of f ungal disease is w arrant ed.
Collection of Hair and Skin Specimens

1. Clean t he suspect ed area w it h 70% alcohol t o remove bact eria. Use st erile
t echniques and st andard precaut ions.
2. Scrape t he peripheral eryt hemat ous margin of put at ive ringw orm lesions
w it h a st erile scalpel or w ooden spat ula and place t he scrapings in a covered
st erile cont ainer.
3. Clip samples of inf ect ed scalp or beard hair and place in a covered st erile
cont ainer.
4. Pluck hair st ubs out w it h t w eezers because t he f ungus is usually f ound at t he
base of t he hair shaf t . Use of a Wood's light in a darkened room helps
ident if y t he inf ect ed hairs.
5. Samples f rom inf ect ed nails should be procured f rom beneat h t he nail plat e
t o obt ain sof t ened mat erial f rom t he nail bed. I f t his is not possible, collect
shavings f rom t he deeper port ions of t he nail and place t hem in a covered
st erile cont ainer.
Common Diagnostic M ethods for Fungal Diseases

1. A Wood's light is used t o det ermine presence of a f ungus direct ly on hair. A
Wood's light is a lamp t hat uses ult raviolet rays of 3660A. I n a darkened
room, inf ect ed hairs f luoresce a bright yellow -green under t he Wood's light .
2. Direct microscopic examinat ion of t issue samples placed on a slide is
perf ormed t o det ermine w het her a f ungus is act ually present . The pot assium
hydroxide (KO H) t est or Calcof luor w hit e st ain t est is used t o det ect t he
presence of mycelial f ragment s, art hrospores, spherules, or budding yeast
cells and involves mixing t he specimen w it h t he reagent on a glass slide. The
slide is t hen microscopically examined f or f ungal element s.
3. A f luorescent bright ener, Calcof luor w hit e, f luoresces w hen exposed t o
ult raviolet light . This reagent st ains t he f ungi, causing t hem t o exhibit a
f luorescence t hat can be det ect ed microscopically. I t can be used on t issue
and has t he same sensit ivit y as KO H. Moreover, it allow s f or easier and
f ast er det ect ion of f ungal element s. Calcof luor w hit est ained specimens can
also be examined under bright f ield or phase-cont rast microscopy.
4. Cult ures are done t o ident if y t he specif ic t ype of f ungus. Fungi are slow
grow ing and are subject t o overgrow t h by cont aminat ing and more rapidly
grow ing organisms. Fungemia (f ungus in t he blood) is an opport unist ic
inf ect ion, and of t en a blood cult ure reveals t he earliest suggest ion of t he
causat ive organism.
5. For f ungal serology t est s, single t it ers great er t han 1: 32 usually indicat e t he
presence of disease. A f ourf old or great er rise in t it er of samples draw n 3
w eeks apart is signif icant . How ever, serologic diagnosis of Candi da and
Aspergi l l us species can be disappoint ing. Complement f ixat ion t est s f or
hi stopl asmosi s and cocci di oi domycosi s can aid in t he diagnosis of t hese
diseases. The immunodiff usion t est is helpf ul f or t he diagnosis of
bl astomycosi s.
Types of specimens
1. Skin
2. Nails
3. Hair
4. Ulcer scrapings
5. Pus
6.
CSF
7. Urine
8. Blood
9. Bone marrow
10. St ool
11. Bronchial w ashings
12. Tissue biopsy specimens
13. Prost at ic secret ions
14. Sput um
Diagnosis of Spirochetal Disease Spirochetes appear

as spiral and curved bacteria. The four genera of spiral
and curved bacteriaBorrelia, Treponema, Leptospira,
and Spirillum ( Table 7.7)include several human
pathogens. Most spirochetes multiply within a living
host. Pathogenic Treponema organisms are transmitted
from person to person through direct contact. Borrelia
pass through an arthropod vector. Leptospira are
usually contracted accidentally by humans through
water contaminated with animal urine or a bite by an
infected animal.
Table 7.7 Spirochetal Diseases and Their Laboratory
Diagnosis
Disease
Causative
Organism
Source of
Specim en
Diagnostic
Tests
Pinta
Treponema
carateum
Skin
Skin
smear,
serologic
test
Rat-bite
fever
Spirillum
minor,
Streptobacillus
moniliformis
Blood,
joint fluid,
abscess
Culture
serology
Relapsing
fever
Borrelia
recurrentis
Blood
Blood
smear
Syphilis
Treponema
pallidum
Skin
lesion
Skin
smear,
nonspecific
treponemal
(VDRL,
RPR) and
specific
treponemal
(FTA-ABS)
serologic
tests
W eil's
disease
(leptospiral
jaundice)
Leptospira
interrogans
Urine,
blood,
CSF
Culture
serologic
test
Skin
Culture,
serologic
Yaws
Treponema
pertenue
test
Lyme
disease
Borrelia
burgdorferi
Skin
lesion,
blood,
CSF
Nonvenereal
syphilis
Treponema
endemicum
Skin,
blood
Serologic
test
Serologic
test
1. Borrel i a appear in t he blood at t he onset of relapsing f ever. Louse-borne
relapsing f ever is caused by Borrel i a recurrenti s, t ick-borne relapsing f ever
by several ot her Borrel i a species, and Lyme disease by Borrel i a burgdorf eri .
2. Treponema (Borrel i a) vi ncenti i is t he species responsible f or ulcerat ive
gingivit is (t rench mout h).
a. Treponema pal l i dum is t he species responsible f or venereal syphilis in
humans.
b. Treponema pal l i dum subsp. pertenue is t he causat ive agent of yaw s (an
inf ect ious nonvenereal disease).
c. Treponema carateum causes pint a (carat e).
d. Treponema pal l i dum subsp. endemi cum is t he cause of endemic
nonvenereal syphilis (bejel).
3. Leptospi ra is t he genus of microorganism responsible f or Weil's disease
(inf ect ious jaundice), sw amp f ever, sw ineherd's disease, and canicola f ever.
a. The organism is w idely dist ribut ed in t he inf ect ed person and appears in
t he blood early in t he disease process.
b. Af t er 10 t o 14 days, t he organisms appear in considerable numbers in
t he urine.
c. Pat ient s w it h Weil's disease show st riking ant ibody responses; serologic
t est ing is usef ul f or diagnosis of t his disease.
4. Streptobaci l l us moni l i f ormi s and Spi ri l l um mi nor are t he species responsible
f or rat -bit e f ever. Alt hough t his condit ion occurs w orldw ide and is common in
Japan and Asia, it is uncommon in Nort h and Sout h America and most
European count ries. Cases in t he Unit ed St at es have been linked t o bit es by
laborat ory rat s.
Diagnosis of Viral and Mycoplasmal Disease Viral

diseases are the most common of all human infections.
Once thought to be confined to the childhood years,
viral infections in adults have increasingly been
recognized as the cause of significant morbidity and
mortality. They also affect immunosuppressed and
elderly patients (Chart 7.1). Viruses are responsible for
such infectious diseases as hepatitis, AIDS, and other
sexually transmitted diseases (STDs).
Ch art 7.1 Viral Infections in Infants, Children, and Adults
Disease or Syndrom e
Suspected Viral Agents
INFANT S AND CHILDREN
Upper respiratory tract

infection
Rhinovirus, coronavirus,
parainfluenza, adenovirus,
respiratory syncytial virus,
influenza
Pharyngitis
Adenovirus, coxsackie A,
herpes simplex, EpsteinBarr, rhinovirus,
parainfluenza, influenza
Croup
Parainfluenza, respiratory
syncytial
Bronchitis
Parainfluenza, respiratory
syncytial
Bronchiolitis
Respiratory syncytial,
parainfluenza
Pneumonia
Respiratory syncytial,
adenovirus, influenza,
parainfluenza
Gastroenteritis
Rotavirus, adenoviruses
4041, calicivirus,
astrovirus, Norwalk-like
ADULT S
Upper respiratory tract
infection
Rhinovirus, coronavirus,
adenovirus, influenza,
parainfluenza
Pneumonia
Coxsackie B
Gastroenteritis
Norwalk-like virus
ALL PERSONS
Parotitis
Mumps, parainfluenza
Myocarditis/pericarditis
Coxsackie and echoviruses
Keratitis/conjunctivitis
Herpes simplex, varicellazoster, adenovirus
Pleurodynia
Coxsackie B
Herpangina
Coxsackie A
Febrile illness with

rash
Echo and coxsackie viruses
Infectious
mononucleosis
Epstein-Barr,
cytomegalovirus
Meningitis
Echo and coxsackie

viruses, lymphocytic
choriomeningitis, herpes
simplex virus
Encephalitis
Herpes simplex,
togaviruses, bunyaviruses,
flaviviruses, rabies,
enteroviruses, measles,
human immunodeficiency
virus (HIV), JC virus
Hepatitis
Hepatitis A, B, C, non-A,
non-B; delta agent; E
Hemorrhagic cystitis
Adenovirus, BK virus
Cutaneous infection
with rash
Herpes simplex, varicellazoster, enteroviruses,

Epstein-Barr, measles,
rubella, parvovirus, human
herpes virus 6
Hemorrhagic fever
Ebola, Marburg, Lassa,

hantavirus
Acute respiratory
failure
Hantavirus
Viruses are submicroscopic, f ilt erable, inf ect ious organisms t hat exist as
int racellular parasit es. They are divided int o t w o groups according t o t he t ype of
nucleic acid t hey cont ain: RNA or DNA.
The mycopl asmas are scot obact eria w it hout cell w alls t hat are surrounded by a
single t riple-layered membrane; t hey are also know n as pl europneumoni a-l i ke
organisms (PPLO s). Physiologically, mycoplasmal diseases are considered t o be
int ermediat e bet w een t hose caused by bact eria and t hose caused by ricket t siae.
O ne species, Mycopl asma pneumoni ae, is recognized as t he causat ive agent of
primary at ypical pneumonia and bronchit is. O t her species are suspect ed as
possible causal agent s f or uret hrit is, inf ert ilit y, early-t erm spont aneous abort ion,
rheumat oid art hrit is, myringit is, and eryt hema mult if orme.
Viruses and mycoplasmas are inf ect ious agent s small enough t o pass t hrough
bact eria-ret aining f ilt ers. Alt hough small size is t he only propert y t hey have in
common, viruses and mycoplasmas cause illnesses t hat are of t en
indist inguishable f rom each ot her in t erms of clinical signs and sympt oms; in
addit ion, bot h f requent ly occur t oget her as dual inf ect ions. Theref ore, t he
serologic (ant igen-ant ibody) procedures commonly used f or diagnosing viral
disease are also used f or diagnosing mycoplasmal inf ect ions (Table 7. 8).
Table 7.8 Viral Inf
Infection Type
and Virus
Inform ation
T hroat
Stool/Rectal
Swab
CSF
Urine
RESPIRATORY
Adenovirus
Enterovirus
Herpes simplex
virus (HSV)
Influenza virus
Mumps virus
Parainfluenza
virus
Respiratory
syncytial virus
(RSV)
Rhinovirus
RASH
M aculopapular
Adenovirus
Enterovirus
Rubella virus
Measles
(rubeola)
Vesicular
Coxsackie virus
A or echovirus
HSV
Varicella-zoster
virus (VZV)
Vaccinia and
other poxviruses
Central
nervous
system
(asceptic
meningitis,
encephalitis)
Arbovirus
Enterovirus
HSV
Mumps virus
Rabies virus
CONGENITAL AND PERINATAL

Cytomegalovirus
(CMV)
Enterovirus
HSV
GASTROINTESTINAL
Adenovirus
X
(PCR)
X
(PCR)
Parvovirus
(Norwalk-like
agents)
X (Antigen
test)
Rotavirus
EYE
Adenovirus
Enterovirus
HSV
HEART
Coxsackie virus
B
CMV
Influenza A, V
Infectious
mononucleosis
Epstein-Barr
virus (EBV)
Immunodeficient
patient CMV
HEPATITIS
CMV
EBV
HEPATITIS A, B,
AND C
GENITAL
HSV
URINARY
Adenovirus
CMV
*Enterovirus serology is not routinely available but can be p
Approach to Diagnosis
1. I solat ion of t he virus in t issue cult ure remains t he gold st andard f or det ect ion
of many common viruses. Diagnost ic modalit ies include t he f ollow ing:
a. Tissue cult ure
b. Direct det ect ion in specimens
c. I dent if icat ion t hrough specif ic cyt opat hic eff ect
d. Use of immunof luorescence and immunoperoxidase, lat ex agglut inat ion,
or enzyme-linked immunosorbent assay (ELI SA) t o ident if y
e. Visualizat ion t hrough an elect ron microscope
f. Direct nucleic acid probe and PCR t echnology
2. Serologic st udies f or ant igen-ant ibody det ect ion are valuable in regard t o
viral disease. Epst ein-Barr virus (EBV) and human hepat it is viruses are
rout inely serodiagnosed. Classically, a f ourf old rise in ant ibody t it er is used
t o ident if y a part icular inf ect ious agent , provided
t hat t he pat hogenesis of t he agent agrees w it h t he sympt oms of t he inf ect ed
pat ient . An acut e-phase serum is collect ed w it hin t he f irst several days af t er
sympt om onset . A convalescent -phase serum is collect ed 2 t o 4 w eeks lat er.
A f ourf old diff erence in ant ibody t it er bet w een t he t w o sera is st at ist ically
signif icant . Alt ernat ively, det ect ion of specif ic immunoglobulin M (I gM)
suggest s acut e inf ect ion. I gG ant ibody w it hout I gM suggest s inf ect ion
somet ime in t he past .
3. Available cell cult ures vary great ly in t heir sensit ivit y t o diff erent viruses.
O ne cell t ype or species may be more sensit ive t han anot her f or det ect ing
t he virus in low t it ers. For example, human embryonic kidney (HEK) or
monkey kidney (1 MK) can be used f or adenovirus, ent erovirus, herpes
simplex, measles, inf luenza, parainf luenza, and rubella; how ever, HEK cannot
be used f or cyt omegalovirus (CMV) or inf luenza.
4. The crit ical f irst st ep in successf ul viral diagnosis is t he t imely and proper
collect ion of specimens. The choice of w hich specimen t o collect depends on
t ypical signs and sympt oms and t he suspect ed virus. I mproper specimen
choice and collect ion is one of t he biggest f act ors in diagnost ic delays.
Specimen Collection
1. Collect specimens f or viruses as early as possible during t he course of t he
illness, pref erably w it hin t he f irst 4 days af t er sympt om onset . I f specimen
collect ion is delayed f or 7 or more days af t er sympt oms appear, diagnosis
w ill be compromised. Virus t it ers are highest in t he early part of t he illness,
w hen t he host has not yet mount ed a robust immune response. Lit t le
neut ralizing ant ibody is present . Det ect ion of a virus by cult ure, direct
det ect ion, or serology is great ly enhanced w hen t he virus t it ers are high.
2. Sampling procedure
a. For localized inf ect ion:
1. Direct sampling of aff ect ed sit e (eg, t hroat sw ab, skin scraping)
2. I ndirect sampling. For example, if CSF is t he t arget sample in a
cent ral nervous syst em inf ect ion, t he indirect approach w ould involve
obt aining t hroat or rect al sw abs f or cult ure.
b. Sampling f rom more t han one sit e, f or example, in disseminat ed disease
or w it h nonspecif ic clinical f indings
c. The t ype of applicat or used t o obt ain specimens may aff ect accuracy of
result s. Do not use w ooden applicat ors or cot t on sw abs because t hey
are t oxic t o viruses. A self -cont ained t ransport syst em is recommended
t o ensure t hat t he specimen remains moist .
3. When t ransport ing specimens:
a. Keep in mind t hat viral specimens are unst able and rapidly lose inf ect ivit y
out side of living cells. Prompt delivery t o t he laborat ory is essent ial.
Samples must be ref rigerat ed or placed on ice or cold packs w hile in
t ransit .
b. Freezing and t haw ing of specimens diminishes t he quant it y of available
viable virus.
4. Accurat e pat ient inf ormat ion must accompany t he specimen t o t he
laborat ory. I n addit ion t o t he required pat ient ident if icat ion inf ormat ion, t he
requisit ion should include:
a. Pert inent inf ormat ion t hat w ould inf luence processing of t he specimen
(eg, pat ient is immunocompromised ow ing t o renal t ransplant at ion)
b. Exact nat ure of t he specimen
c. Pat ient demographics
d. Cont act person or clinic so as t o expedit e t he not if icat ion of posit ive
result s
5. Specimens of small volume (eg, vesicular f luid, f ine-needle aspirat ion, biopsy
samples) should be t ransport ed in a liquid medium. Suggest ed viral t ransport
media are Hank's balanced salt solut ion, 0. 2 mol/ L sucrose-phosphat e, and
bact eriologic brot h (t rypt ic soy or veal inf usion).
O f t en, a complet e microbiologic w orkup of a specimen (t issue, bronchoscopy) is
request ed along w it h a viral w orkup. Because viral t ransport media cont ain
ant ibiot ics, st erile saline is recommended. Personnel in t he laborat ory can t hen
divide t he specimen f or w orkup w it hin t he microbiology subsect ions.
Specimens of a liquid nat ure (urine, CSF, sput um, body f luids) are collect ed in a
st erile cont ainer. For pat ient s w it h suspect ed viremia, a viral cult ure of t he buff y
coat of peripheral blood is submit t ed. Blood specimens are collect ed in
evacuat ed t ubes cont aining heparin or et hylene diamine t et raacet ic acid (EDTA).
1. Herpes simplex is t he virus most f requent ly isolat ed and diagnosed virus in
t he laborat ory.
2. Viral cult ure result s are normally available w it hin 3 t o 5 days, alt hough rapid
t est result s (24 hours) are accurat e and available f or cert ain viruses, such
as CMV.
3. Signif icance of viral cult ures
a. Posit ive viral cult ure result s f rom t he f ollow ing sources are
di agnosti cal l y accurate:
1. Aut opsy specimens
2. Blood (leukocyt e buff y coat )
3. Biopsy
4.
CSF
5. O t her body f luids

6. Cervix
7. Eye
8. Skin lesions
9. Fine-needle aspirat es
10. Bronchial alveolar w ash brushing
b. Probabl y di agnosti cal l y accurate are:
1. Throat
2. Urine
3. Sput um
4. G enit al (cervical, penile)
5. Nasal aspirat es or w ashes
6. Vesicular
7. Skin (mout h, lip)
c. Possi bl y di agnosti cal l y accurate is st ool or rect al sw ab
d. Viruses do not compromise normal f lora in t he body. How ever, bact erial
or f ungal cont aminat ion of specimens can occur.
Diagnosis of West Nile Virus, West Nile Fever, and West

Nile Encephalitis The West Nile virus (WNV) is a singlestranded RNA flavivirus first isolated in Uganda about
1937. The virus first appeared in the United States in
1999 and, to date, has been documented in almost
every state. The routes of transmission include the
common household mosquito, which serves as the
vector, and birds (eg, crows, sparrows, and jays),
which are the reservoir hosts. The infected mosquito
can then carry the virus particles in its salivary glands
and infect susceptible bird species as well as humans.
There is no evidence that the virus can be spread by
human-to-human transmission or by handling infected

birds. Symptoms of WNV include fever, headache, neck
stiffness, and skin rash. West Nile fever is the mild
form of the disease, characterized by flu-like symptoms
lasting only a few days with no long-term effects. West
Nile encephalitis is the more severe form of the
disease, characterized by encephalitis and/or
meningitis, which can lead to stupor, disorientation,
coma, convulsions, and occasionally death.
This t est is used t o measure ant ibodies (I gM) produced early in t he inf ect ed
person.
Reference Values
Normal
Negat ive f or t he West Nile virus I gM ant ibody
Procedure
Collect eit her a blood or CSF sample. Not all laborat ories are equipped t o
measure t he ant ibody, and t he sample may have t o be f orw arded t o a
commercial or public healt h laborat ory.
Clin ical Alert

The blood t est may be negat ive early in t he course of t he inf ect ion; how ever,
w it hin 8 days of t he onset of sympt oms, 90% of inf ect ed people w ill become
posit ive. The Cent ers f or Disease Cont rol and Prevent ion may perf orm a
plague reduct ion neut ralizat ion t est (PRNT) on a specimen f or conf irmat ion.
Interfering Factors
Exposure t o t he St . Louis encephalit is virus may result in a f alse-posit ive t est
result f or WNV.
Clin ical Alert

Current ly, t here is no vaccinat ion against WNV. Treat ment is aimed at
prevent ion of secondary inf ect ions (eg, pneumonia and urinary t ract inf ect ion),
airw ay management , and good nursing care.
Interventions
1. Explain purpose and procedure.

1. I nt erpret t est result s, monit or and counsel pat ient appropriat ely.
Diagnosis of Sexually Transmitted Disease STDs

present a serious and increasing public health
problem. They are caused by a variety of etiologic
agents (Table 7.9). Some conditions, such as
chlamydial and nongonococcal urethritis, have reached
epidemic proportions. Although nongonococcal
urethritis is a nonreportable disease in the United
States, it is estimated that more than two million new
cases occur each year. Manifestations of these
infections range from the carrier state (asymptomatic)
to diseases with obvious symptoms such as cervicitis,
conjunctivitis, endometritis, epididymitis, infertility,
pharyngitis, proctitis, lymphogranuloma venereum,
salpingitis, trachoma, urethritis, and in the neonate,
conjunctivitis and pneumonia.
Table 7.9 Sexually Transmitted Diseases and Their

Laboratory Diagnoses
Disease
Causative Agents*
Diagnosis
Haemophilus ducreyi
Culture of les
or aspirate.
Differential
diagnosis sho
include syphil
herpes, and
lymphadenopa
associated vir
(LAV) monoclo
antibody test
Gonorrhea
Neisseria
gonorrhoeae
Gram stain of
male urethra,
culture or PCR
male urethra o
female cervix,
rectum, or
pharynx. DNA
probe, PCR o
urine
Granuloma
inguinale
(donovanosis)
Calymmatobacterium
granulomatis
(formerly Donovania
granulomatis)
W right-Giems
stain of lesion
tissue biopsy
Chancroid
Hepatitis B virus
Hepatitis B
Serologic
testing, hepat
(HBV)
B antigen and
antibody
Genital herpes
Herpes simplex virus

(HSV) types 1 and 2
Viral culture f
unroofed blist
scrapings
examined by
fluorescent
microscopy or
cytologic stain
Lymphogranuloma
venereum (LGV)
Chlamydia
trachomatis
serotypes L1 , L2 ,
and L3
Culture of
aspirate of bu
serologic test
Molluscum
contagiosum virus
Clinical
appearance o
lesions (pearl
white, painles
umbilicated
papules),
microscopic
examination o
scrapings
Chlamydia
trachomatis
serotypes DK
Cell culture,
urogenital swa
for direct anti
test, DNA pro
technology, P
Molluscum
contagiosum
Chlamydia
Culture,
Candidosis
(monilia)
Candida albicans
potassium
hydroxide (KO
wet mount, G
stain, DNA pr
Pelvic inflammatory
disease (PID)
Neisseria
gonorrhoeae,
Chlamydia
trachomatis
Clinical
symptoms,
cervical cultur
DNA probe, P
laparoscopy o
culdocentesis
Pediculosis pubis
Phthirus pubis
(pubic or crab louse)
Adult lice or n
appear on bod
hairs
Sarcoptes scabiei
Characteristic
lesions,
scrapings for
microscopy
Treponema pallidum
Darkfield
microscopy,
serologic test
Trichomonas
vaginalis
Vaginal, ureth
prostatic
secretion
examined
microscopical
culture; PCR
Scabies
Syphilis
Trichomoniasis
Chlamydia
Nonspecific
urethritis
(nongonococcal
urethritisNGU)
Nonspecific
vaginitis
Condylomata
acuminata
(venereal warts)
trachomatis (50% of
cases), Ureaplasma
urealyticum, a
human T-strain
mycoplasma
(Mycoplasma
hominis),
Trichomonas
vaginalis, Candida
albicans, herpes
simplex virus
Gardnerella
vaginalis,
Mobiluncus cortisii,
Mobiluncus mulieris
Human papilloma
DNA virus
Identification
smear, culture
or molecular
tests of speci
etiologic agen
W et mount fo
clue cells or
Pap smear; fis
smell is relea
when specime
fluid is mixed
with 10% KOH
Culture; DNA
probe. Culture
enzyme
immunoassay
rule out
gonorrhea
Typical clinica
lesion:
cauliflower-lik
soft, pink grow
around vulva,
anus, labia,
vagina, glans
penis, urethra
and perineum
rule out syphi
Acquired
immunodeficiency
syndrome (AIDS)
Human
immunodeficiency
virus (HIV)
Serologic test
Gastrointestinal
(giardiasis,
amebiasis,
shigellosis
campylobacteriosis,
and anorectal
infections)
Enteric infections:
Giardia lamblia,
Entamoeba
histolytica, and
Cryptosporidum spp.
Ova and para

examination
Shigella spp.
Stool culture
Campylobacter fetus
Stool culture
Strongyloides spp.
(worms)
Ova and para

examination
Anorectal:
Neisseria
gonorrhoeae
Chlamydia
trachomatis
Treponema pallidum
Anal swab
specimen,
culture, DNA
probe
Anal swab
culture, DNA
probe
Darkfield
Herpes simplex virus

Human papilloma
virus
microscopy pl
serologic test
Tissue culture
Signs and
symptoms, DN
probe
*The pathogens causing sexually transmitted diseases span

the full range of medical microbiology; their only common
characteristic is that they may cause genital disease or be
transmitted by genital contact.
Suggested Specimens
1. Uret hral, vaginal, cervical sw abs
2. Semen
3. Urine
4. Prost at ic secret ion
5. Tissue biopsy
6. Sw abs of oral lesions
7. Blood f or serologic t est s
Common Diagnostic M ethods

1. Viral isolat ion in t issue cell cult ures
2. Specif ic serologic ant ibody assays and syphilis det ect ion t est s
3. Cyt ologic t echniques, such as Papanicolaou (Pap) and Tzanck smears t o
demonst rat e giant cells associat ed w it h herpes virus inf ect ion
4. G ram st ain and bact erial cult ure; saline w et prep
5. ELI SA and immunoperoxidase assay t o det ect et iologic agent
6. Fluorescein or enzyme-t agged monoclonal ant ibodies t o det ect and ident if y
et iologic agent s
7. DNA probe
8.
PCR
1. Pat ient s present ing w it h one STD are f requent ly inf ect ed w it h ot her t ypes of
sexually t ransmit t ed pat hogens.
2. Asympt omat ic carriers are common.
3. Tracing and t est ing of sexual part ners is a very import ant part of diagnosis
and t reat ment .
4. The disease may recur if t he pat ient is reinf ect ed by t he nont reat ed sexual
part ner.
5. G enit al t ract inf ect ions caused by sexually t ransmit t ed organisms in children
are of t en t he result of sexual abuse. Cult ures should alw ays be obt ained,
especially f or Chl amydi a, w hen required as legal evidence.
6. For suspect ed herpet ic lesions, t he virus is best recovered f rom t he base of
an act ive lesion. The older t he lesion, t he less likely it is t o yield viable virus.
O pen t he vesicle w it h a small-gauge needle or Dacron sw ab. Rub t he base of
t he lesion vigorously t o recover inf ect ed cells ont o t he sw ab, and place t he
sw ab in a viral t ransport medium. I f large vesicles are present , aspirat e
mat erial direct ly by needle and syringe. A separat e sw ab can be collect ed
f or a Tzanck preparat ion (hist ology st ain).
7. For darkf ield examinat ion (eg, syphilis), cleanse t he area around t he lesion
w it h st erile saline. Abrade t he surf ace w it h st erile dry gauze unt il blood is
expressed. Cont inue t o blot unt il blood ceases; squeeze t he area unt il serous
f luid is expressed. Touch t he mat erial t o a clean glass slide, add a cover
slip, and examine t he specimen immediat ely f or mot ile spirochet es.
8. Complicat ions of unt reat ed STDs include ect opic (t ubal) pregnancy, inf ert ilit y,
chronic pelvic pain, and poor pregnancy out comes.
Diagnosis of Food Poisoning Most cases of food

poisoning in the United States are associated with
Bacillus cereus, a species found in soil, water,
airborne dust, vegetation, cereals, pasteurized food,
and powdered milk. GI anthrax due to ingestion of
contaminated meat has been reported in developing
nations, not in the United States. (Spices in meat have
been reported to be contaminated with the B. cereus
spores.) B. cereus produces two toxins, an emetic toxin

that causes vomiting and an enterotoxin that causes
diarrhea. Unrefrigerated fried rice has been associated
with the emetic toxin, whereas poultry, cooked meats,
mashed potatoes, soups, and desserts have been
associated with the enterotoxin.
This t est is used t o det ect one of t he t w o t oxins produced by B. cereus.
Reference Values
Normal
Negat ive f or cult ure of B. cereus colonies by DNA probe or ot her microbiologic
t est s
Procedure
Collect st ool specimens (2550 g) f or cult ure. Call your laborat ory about special
st ool cult ure collect ion.
Clin ical Alert

Suspect ed f ood specimens may also be t est ed.
Ref rigerat e specimen in clean, sealed, leak-proof cont ainers.
I f a delay of more t han 2 hours is ant icipat ed, t he specimen should be
placed in a Cary-Blair t ransport medium.
Posit ive abnormal f indings of t he special charact erist ics of B. cereus are
consist ent w it h f ood poisoning.
Interventions
Explain purpose and procedure f or diagnosing f ood poisoning. Take hist ory of
recent ly ingest ed f oods. Report sympt oms.
I nt erpret t est out comes, monit or prescribed drug t reat ment (vancomycin,
eryt hromycin).
BIOTERRORISM : INFECTIOUS AGENTS

Diagnosis of Botulism Infection Human botulism is
caused by the spore-forming, obligate anaerobe
Clostridium botulinum. C. botulinum produces the
botulinum toxin, which is the most poisonous
substance known (1 g evenly dispersed would kill more
than 1 million people). There are seven distinct
antigenic types of the botulinum toxin designated types
A through G. All forms of botulism are the result of
absorption from a mucosal surface (eg, GI tract or
lung) or a wound into the circulatory system. C.
botulinum can be found in the soil and in undercooked
food that is not kept hot. Cases of waterborne botulism
have not been documented, although aerosolization of
the toxin and subsequent inhalation has been done
experimentally. Foil-wrapped baked potatoes held at
room temperature after baking can cause botulism, as
can contaminated condiments, such as sauted onions
or cheese sauce.
This t est is used t o conf irm t he presence of C. botul i num, w hich produces t he
bot ulinum t oxin.
Reference Values
Normal
Absence of bot ulinum t oxin
Absence of increment al response t o repet it ive nerve st imulat ion on an
elect romyogram
Procedure
1. O bt ain specimens f rom blood, st ool, gast ric aspirat es or vomit us, and, if
available, suspect ed f ood.
2. O bt ain at least 30 mL of venous blood in a red-t opped Vacut ainer.
3. Use an enema (w it h st erile w at er) t o obt ain an adequat e f ecal sample if t he
pat ient is const ipat ed.
4. Ref rigerat e all samples.
5. Use t he mouse bioassay t o det ermine w het her t here is any bot ulinum t oxin
present .
Clin ical Alert

1. I n some cases, an elect romyogram is perf ormed t o diff erent iat e cause of
acut e f laccid paralysis.
2. Ant ibiot ics can be used t o t reat secondary inf ect ions; how ever, t hey do
not have a direct eff ect on t he bot ulinum t oxin.
3. Post exposure prophylaxis is limit ed ow ing t o ant it oxin scarcit y and
react ogenicit y.
4. By law, in most areas of t he count ry, suspect ed bot ulism must be report ed
t o local public healt h aut horit ies.
1. The ident if icat ion of bot ulism neurot oxin is evidence of bot ulism poisoning.
2. Tell f amily t hat bot ulism paralyzes muscles and pat ient s die quickly because
t hey cannot breat he.
Interventions
1. Explain t he purpose, procedure, and risks of obt aining a specimen.

1. Do not isolat e pat ient s diagnosed w it h bot ulism because it is not cont agious
and cannot be t ransmit t ed f rom person t o person.

2. I nt erpret t est result s, provide support ive care, and monit or appropriat ely.
3. Administ er an ant it oxin (ie, equine ant it oxin) in a t imely manner t o minimize
subsequent nerve damage.
4. The pat ient should be monit ored f or impending respirat ory f ailure.
NOTE
I n t he Unit ed St at es, t he bot ulinum ant it oxin is available f rom t he Cent ers f or
Disease Cont rol and Prevent ion.
NOTE
The need f or mechanical vent ilat ion has varied f rom 20% in adult s t o 60% in
children.
Clin ical Alert

1. Laborat ory personnel should observe universal st andard precaut ions.
2. St erile w at er, not saline, should be used f or t he enema solut ion because
saline w ill int erf ere w it h t he bioassay.
3. The use of ant icholinest erases (eg, physost igmine salicylat e or
pralidoxime chloride) by t he pat ient can int erf ere w it h t he bioassay.
4. Decont aminat e surf aces w it h 0. 1% hypochlorit e bleach solut ion.
5. Cont aminat ed clot hing should be w ashed w it h soap and w at er.
NOTE
About 20 st at e laborat ories, including t he Cent ers f or Disease Cont rol and
Prevent ion, can t est f or bot ulism.
Diagnosis of Anthrax Infection Anthrax is a

communicable disease transmitted from animals to
humans. Humans can contact Bacillus anthracis
(spore-forming, gram-positive bacillus) from handling
or consuming undercooked meat from infected animals.
The organism can also be inhaled from animal products
(eg, wool) or during intentional release of spores (ie,
bioterrorism). There are three forms of anthrax:
cutaneous, GI, and inhalational.
Clin ical Alert
1. As soon as ant hrax is suspect ed, not if y t he st at e public healt h laborat ory
and Cent ers f or Disease Cont rol and Prevent ion.
2. Take precaut ions t o avoid product ion of aerosols of inf ect ed mat erial.
3. I f G I ant hrax is suspect ed, collect samples of gast ric aspirat e, f eces, or
f ood along w it h t hree blood cult ures.
4. Household bleach solut ions (5. 25% hypochlorit e) dilut ed 1: 10 can be used
t o decont aminat e surf aces. Cont aminat ed inst rument s should be
aut oclaved af t er immersion in decont aminat ion solut ion.
5. Proper immunizat ion is required f or persons w ho w ork direct ly w it h
cont aminat ed animal hides or animal t issues or spores.
6. Skin inf ect ions const it ut e 95% of ant hrax inf ect ions, w it h a 20% deat h rat e
in unt reat ed skin (cut aneous) ant hrax.
7. All cases of ant hrax inf ect ion due t o inhaled spores are f at al.
8. Abnormal chest x-ray f indings show w idening of t he mediast inum due t o
hemorrhage.
9. Person-t o-person t ransmission of ant hrax inf ect ion has not been observed.
Reference Values
Normal
Negat ive f or t he B. anthraci s organism (appears as t w o t o f our cells,
encapsulat ed)
Procedure
1. Use sput um, blood, or st ool specimens t o isolat e B. anthraci s.
2. Perf orm procedure in a Biological Saf et y Level 2 (BSL 2) microbiologic
laborat ory.
3. Analyze samples in a cert if ied Class I I biologic saf et y cabinet (BSC).
4. Subcult ure a rout ine sput um, blood, or st ool sample t o sheep blood agar
(SBA), MacConkey agar, or phenyl et hyl alcohol (PEA) plat es.
5. I ncubat e cult ures at 3537C and examine w it hin 1824 hours of incubat ion.
6. Test isolat es f or mot ilit y, morphology, -hemolysis, and G ram st ain t o
diff erent iat e colonies of B. anthraci s f rom ot her bacilli.
7. Remember t hat B. anthraci s is an encapsulat ed gram-posit ive rod, w it h ovalshaped, nonsw elling spores, and ground-glass appearance of colonies, and
is nonmot ile and nonhemolyt ic.
8. Soak t w o dry st erile sw abs in vesicular f luid (previously unopened vesicle)
f or cut aneous ant hrax.
9. Use a st ool specimen f or G I ant hrax.
10. Use a sput um specimen f or inhalat ion ant hrax; in t he lat er st ages, use a
blood sample.
Procedu ral Alert

B. anthraci s grow s w ell in SBA plat es but does not grow on MacConkey agar.
The isolat ion of B. anthraci s rods conf irms t he diagnosis of ant hrax.
Interventions
1. Explain t he purpose, procedure, and risks of obt aining a specimen.
2. O bt ain current hist ory of occupat ions, signs, and sympt oms. Ant hrax, usually
f at al, is accompanied by f ever, dyspnea, coughing, chest pain, heavy
perspirat ion, and bluish skin due t o lack of oxygen.
3. See guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed pretest care .

1. Cont act t he FBI and st at e public healt h depart ment if B. anthraci s is
ident if ied.
2. I nt erpret t est out comes and monit or t reat ment , eg, penicillin or t et racycline.
Report signs and sympt oms.
Diagnosis of Hemorrhagic Fever, Hantaan Virus, Ebola

Virus, and Yellow Fever Infections This test is done to
diagnose hemorrhagic fever (HF; with renal symptoms,
HFRS), an endemic threat in the United States, and
yellow fever associated with hepatitis. Signs and
symptoms include fever, thrombocytopenia, renal
failure, shock, multiorgan failure, and lung edema.
Jaundice occurs in yellow fever. Heavy rains are
associated with an increase in number of rodents
(which are the vectors in HF) and mosquitoes in yellow
fever. The hantavirus, called sin nombre (no name), is
responsible for hantavirus pulmonary syndrome (HPS).
See microbiology references for more information.
Reference Values
Normal
No evidence of Hant aan virus, Ebola virus, or 17 ot her viruses t hat may cause
HF in rodent s or deer mice
No evidence of yellow f ever virus t hat may cause hepat it is.
Negat ive f or presence of hant aviral ant igens in humans
Procedure
1. O bt ain specimen of blood, sput um, t issue, and possibly urine using st andard
precaut ions.
2. Place specimens in biohazard bags. All specimens are considered inf ect ious.
Clin ical Alert

1. Follow airborne precaut ions w it h negat ive-pressure rooms if available.
2. Use personal prot ect ive equipment .
G row t h of Hant aan virus (or any of t he ot her 17 causat ive viruses) in cult ure or
presence of hant aviral ant igens is evidence of disease. Thrombocyt openia is
present in blood samples.
Clin ical Alert

Evidence of HF is report ed t o local, st at e, and f ederal aut horit ies.
Interventions
1. Explain necessit y, purpose, and procedure of t est ing. Know ledge of signs
and sympt oms, eg, pneumonia, f ever, muscular pain, somet imes jaundice,
hemorrhage f rom nose or G I t ract , f acial sw elling, is needed. Q uest ions
regarding occupat ion, living accommodat ions, and circumst ances (eg, recent
heavy rains, mosquit oes, t ropical climat e, port cit y) are import ant .
2. Be aw are t hat no person-t o-person t ransmission has been described, but
close cont act is usual.

1. Counsel, monit or, and t reat appropriat ely. Report signs and sympt oms.
Pat ient s are usually very ill. I f t he HF viruses are isolat ed, or t he Hant aan
ant igens (or ot her causat ive viruses) are ident if ied, support ive t herapy and
ant ibiot ics are used t o t reat secondary bact erial inf ect ions. Correct
dehydrat ion and t reat acidosis and blood cell abnormalit ies.
2. I mmunit y t o yellow f ever occurs af t er recovery
Clin ical Alert

Monit or close and high-risk cont act f or 21 days.
Diagnosis of Plague, Bubonic Plague, and Primary

Septicemic Plague Infection This test is done to
diagnose plague. Plague (enzootic infection of rats,
squirrels, prairie dogs, and other rodents) can be found
on every continent except Australia. Plague is
transmitted by the bite of an infected flea. Signs and
symptoms include a sudden onset of fever, chills,
generalized weakness, and bubo (swollen tender lymph
nodes). Bubo typically develops in the axilla, cervical,
or groin regions.
Reference Values
Normal
Negat ive f or t he presence of Yersi ni a pesti s
Procedure
1. O bt ain specimens of blood, sput um, or a lymph node aspirat e f ollow ing
2. Transport specimens per laborat ory prot ocol.
Clin ical Alert

Specimens should be processed in biosaf et y level 2 pract ices or biosaf et y
level 3 if t here is a high pot ent ial f or aerosolizat ion (eg, cent rif ugat ion
procedures). There are no rapid available diagnost ic t est s f or plague. Cult ures
t ake about 24 t o 48 hours.
A posit ive t est f or Y. pesti s is evidence of t he disease, and t reat ment (eg,
st rept omycin, t et racycline, doxycycline) should begin immediat ely. Because
person-t o-person t ransmission has not been ident if ied, isolat ion is not
necessary.
Clin ical Alert

1. Evidence of plague must be report ed t o t he local, st at e, and f ederal healt h
depart ment s.
2. Persons having close cont act (<2 met ers) w it h an inf ect ed individual
should receive post exposure ant ibiot ic prophylaxis f or 7 days.
Interventions
1. Explain necessit y, purpose, and procedure of t est ing. O bt ain hist ory of
pert inent signs and sympt oms.
2. There is limit ed evidence of person-t o-person spread, t hus isolat ion is not
necessary.

1. Counsel, monit or, and t reat appropriat ely. Evidence does not support t hat
residual Y. pesti s poses an environment al t hreat , and t he organism does not
survive long out side t he host .
Diagnosis of Smallpox Infection Smallpox, a DNA virus,

was once worldwide in scope; however, vaccination
has all but eliminated the disease. Recently, concerns
of its use as a biological weapon has prompted

medical and public health care professionals to make
recommendations for steps to be taken in case of
exposure. There are two principal forms of smallpox:
variola minor and variola major. Smallpox is spread
from person to person by means of coughing, direct
contact, or contaminated clothing or bedding. Only a
few virions are required for transmission. Two other
forms of smallpox, hemorrhagic and malignant, are
difficult to recognize.
This t est is used t o det ermine t he presence of t he DNA virus responsible f or
smallpox.
Reference Values
Normal
No G uarnieri's bodies isolat ed in scrapings of skin lesions Absence of brickshaped virions (ie, variola virus) by elect ron microscopy Low levels of
neut ralizing, hemagglut inin-inhibit ing or complement -f ixing ant ibodies
Procedure
1. O pen skin lesions w it h a blunt inst rument (eg, blunt edge of a scalpel) and
collect t he vesicular or pust ular f luid on a cot t on sw ab.
2. Remove scabs w it h a f orceps; t hey can also be used.
3. Place specimens in a Vacut ainer t ube; re-st opper and seal it w it h adhesive
t ape.
4. Place t he Vacut ainer t ube in a durable, w at ert ight cont ainer f or t ransport .
5. Ensure t hat t he laborat ory examining t he specimens is Biosaf et y Level 4
(saf et y equipment , and f acilit y design and const ruct ion are applicable f or
w ork w it h dangerous and exot ic agent s t hat pose a high individual risk of lif et hreat ening disease, w hich may be t ransmit t ed via t he aerosol rout e).
6. Conf irm smallpox inf ect ion by t he appearance of brick-shaped virions under
t he elect ron microscope.
7. Remember t hat def init ive laborat ory ident if icat ion requires grow t h of t he
virus in cell cult ure.
8. Use a cot t on sw ab t o obt ain specimens f rom t he oral cavit y or oropharynx if
necessary.
1. Evidence of virions or G uarnieri's bodies indicat e presence of smallpox
inf ect ion.
2. High levels of ant ibodies indicat e inf ect ion.
Interventions
1. Explain t he purpose, procedure, and risks of obt aining a specimen. O bt ain
pert inent hist ory of signs and sympt oms (eg, chills, high f ever, backache,
pust ules t hat leave a pockmark).

1. I solat e t he individual immediat ely if t he smallpox virus is ident if ied.
2. Report signs and sympt oms.
Clin ical Alert

1. A conf irmed case of smallpox should be brought t o t he at t ent ion of local,
st at e, and f ederal healt h aut horit ies.
2. Universal st andard precaut ions should be observed (ie, gloves, gow ns,
and mask should be w orn by laborat ory personnel). All laundry and w ast e
should be t ransport ed in biohazard bags and aut oclaved bef ore being
laundered or incinerat ed.
3. Specimen collect ion and examinat ion should be perf ormed by laborat ory
personnel w ho have recent ly been vaccinat ed.
4. All surf aces should be cleaned w it h hypochlorit e (bleach) or quat ernary
ammonia.
5. Because t here are no ant iviral drugs, support ive t herapy and ant ibiot ics
f or secondary bact erial inf ect ions should be off ered t o t he pat ient .
6. Household members should be vaccinat ed and w at ched closely.
Diagnosis of Tularemia Infection Tularemia is primarily

a rural disease, although occasionally it occurs in
urban and suburban areas. Francisella tularensis is an
intracellular parasite that is spread to humans by
infected animals (eg, mice, squirrels, rabbits) or
contaminated water, soil, and vegetation. Animals
become infected through tick, fly, and mosquito bites.
Once infected, person-to-person transmission has not
been documented. Two major subspecies of F.
tularensis have been identified: type A (F. tularensis
biovar. tularensis), which is highly virulent in humans,
and type B (F. tularensis biovar. palaearctica), which is
relatively avirulent.
Humans can cont ract F. tul arensi s t hrough t he skin, mucous membranes, lungs,
and G I t ract . Because F. tul arensi s is one of t he most inf ect ious pat hogenic
bact eria know n, it s use in biological t errorism cannot be overlooked. Some
report s have indicat ed t hat it t akes only 10 organisms t o cause disease.
This t est is used t o det ermine t he presence of t he F. tul arensi s organism.
Reference Values
Normal
Absence of t he F. tul arensi s organism Negat ive serum ant ibody t it ers
Procedure
1. O bt ain specimens of respirat ory secret ions (ie, sput um), blood, lymph node
biopsy samples, or scrapings f rom inf ect ed ulcers.
2. Collect sput um samples af t er a f orced deep cough and place in a st erile,
screw -t op cont ainer.
3. O bt ain a 5- t o 7-mL Vacut ainer f rom a venipunct ure f or blood samples.
4. O bt ain a skin scraping at t he leading edge of a lesion f rom an inf ect ed ulcer
and place in a clean, screw -t op t ube.

5. Perf orm presumpt ive ident if icat ion of F. tul arensi s in a Biological Saf et y
Level 2 clinical laborat ory (pract ices, equipment , f acilit y design and
const ruct ion are applicable t o clinical, diagnost ic, t eaching, and ot her
laborat ories in w hich w ork is done w it h t he broad spect rum of indigenous
moderat e-risk agent s t hat are present in t he communit y and associat ed w it h
human disease).
6. Ensure t hat conf irmat ion of t he organism is done in a Biological Saf et y Level
3 clinical laborat ory (w ork is done w it h indigenous or exot ic agent s w it h a
pot ent ial f or respirat ory t ransmission, and w hich may cause serious and
pot ent ially let hal inf ect ion).
Clin ical Alert

1. Universal st andard precaut ions should be observed by laborat ory
personnel (ie, f ace shields, gow ns, gloves).
2. Cont aminat ed clot hing or linens should be disinf ect ed per st andard
precaut ions prot ocols.
3. Decont aminat e surf aces w it h a 10% bleach solut ion.
4. Laborat ory personnel w ho may have had a pot ent ial inf ect ive exposure
should be given prophylact ic ant ibiot ics if t he risk f or inf ect ion is high (eg,
needle st ick).
I dent if icat ion of F. tul arensi s and increased ant ibody t it ers indicat e t he presence
of t ularemia.
Interventions
1. Explain t he purpose, procedure, and risks of obt aining a specimen. O bt ain
hist ory of signs and sympt oms, urban or rural living, and occupat ion (eg,
handling inf ect ed animal carcasses).
1. I f t he F. tul arensi s organism is cult ured f rom t he pat ient , isolat ion is not
recommended because human-t o-human t ransmission has not been
document ed.
2. Post exposure t reat ment includes ant ibiot ics such as st rept omycin,
gent amicin, or ciprof loxacin.
3. I nt erpret t est result s, counsel, and monit or appropriat ely.
Clin ical Alert

1. Post exposure prophylact ic ant ibiot ic t reat ment of persons in close cont act
w it h t he inf ect ed pat ient is not recommended because person-t o-person
t ransmission has not been document ed.
2. Pregnant w omen should be t reat ed w it h ciprof loxacin because rare cases
of f et al nerve deaf ness and renal damage have been report ed w it h some
of t he aminoglycosides.
3. Suspicion of inhalat ional t ularemia (ie, signs and sympt oms) must be
report ed t o local or st at e public healt h aut horit ies and t he CDC.
DIAGNOSTIC PROCEDURES
Five diff erent cat egories of laborat ory t est s are used f or t he diagnosis of
inf ect ious diseases: smears and st ains, cult ures, t issue biopsy, serologic t est ing,
and skin t est ing. Cult ures and skin t est ing are described in det ail in t his chapt er;
serologic t est ing is described in Chapt er 8. A brief descript ion of each of t hese
procedures f ollow s.
The Smear and Stain

A smear specimen f or microscopic st udy is prepared by rolling a small quant it y
of t he specimen mat erial across a glass slide. I f t he mat erial is also t o be
st ained, it is generally f ixed t o t he slide by rinsing in met hanol. For direct
examinat ion of unst ained mat erial, phase-cont rast microscopy can be used.
Smears are most of t en observed af t er t hey have been st ained. St ains are salt s
composed of a posit ive and a negat ive ion, one of w hich is colored. St ruct ures
present in t he specimen pick up t he st ain and make t he organism visible under
t he light microscope. O ne st aining procedure, called t he negati ve stai n, colors
t he background but leaves t he organisms t hemselves uncolored. The gross
st ruct ure of t he organisms can t hen be st udied.
Bact erial st ains are of t w o major t ypes: simple and diff erent ial. A si mpl e stai n
consist s of a coloring agent such as gent ian violet , cryst al violet , carbol-f uchsin,
met hylene blue, or saf ranine O . A t hin smear of sampled organisms is st ained
and t hen observed under an oil-immersion lens. A di f f erenti al stai n is one in
w hich t w o chemically diff erent st ains are applied t o t he same smear. O rganisms
t hat are physiologically diff erent pick up diff erent st ains.
The G ram stai n is t he most import ant of all bact eriologic diff erent ial st ains. I t
divides bact eria int o t w o physiologic groups: gram-posit ive and gram-negat ive
organisms. The st aining procedure consist s of f our major st eps: (1) st aining t he
smear w it h gent ian or cryst al violet ; (2) w ashing off t he violet st ain and f looding
t he smear w it h an iodine solut ion; (3) w ashing off t he iodine solut ion and f looding
t he smear w it h 95% alcohol, or an acet one-alcohol mixt ure; and (4)
count erst aining t he smear w it h saf ranine O , a red dye. The G ram st ain permit s
morphologic st udy of t he sampled bact eria and divides all bact eria according t o
t heir abilit y or inabilit y t o pick up one or bot h of t he st ains. G ram-posit ive and
gram-negat ive bact eria exhibit diff erent propert ies, w hich helps t o ident if y and
diff erent iat e t hem.
St ains ot her t han t he G ram st ain are used f or examining bact eriologic smears.
Some, such as t he aci d-f ast stai n, can ident if y organisms of t he genus
Mycobacteri um. O t her st ains diff erent iat e cert ain st ruct ures, such as capsules,
endospores, or f lagella.
Cultures
Preparat ion of a cult ure involves grow ing microorganisms or living t issue cells on
a special medium t hat support s t he grow t h of a given mat erial. Cult ures may be
maint ained in t est t ubes or Pet ri dishes. The cont ainer holds t he cul ture medi um,
w hich is eit her solid, semisolid, or liquid. Each organism has it s ow n special
requirement s f or grow t h (proper combinat ion of nut rit ive ingredient s,
t emperat ure, and presence or absence of oxygen). The cult ure is prepared in
accordance w it h t he needs of t he organism. Lat er, it is usually incubat ed t o
enhance grow t h.
Tissue Biopsy
At t imes, microorganisms are isolat ed f rom small quant it ies of body t issue t hat
have been surgically removed. Such t issue is removed asept ically and
t ransf erred t o a st erile cont ainer t o be rapidly t ransport ed t o t he laborat ory f or
analysis. G enerally, t he specimens are f inely ground in a st erile homogenizer and
t hen st rained and cult ured.
Serologic Testing
I nf ect ious diseases can be diagnosed by det ect ion of an immunologic response
specif ic t o an inf ect ing agent in a pat ient 's serum. Normal humans produce bot h
I gM (f irst -response ant ibodies) and I gG (ant ibodies t hat may persist long af t er
an inf ect ion) t o most pat hogens. For
most pat hogens, det ect ion of I gM ant ibodies or a f ourf old increase in t he
pat ient 's ant ibody t it er is considered t o be diagnost ic of current inf ect ion. I f t he
inf ect ing agent is rare or previous exposure is unlikely (eg, rabies virus, bot ulin),
t he presence of specif ic I gG ant ibody in a single serum specimen can be
diagnost ic. Met hods f or det ect ing t he presence of ant ibodies include
immunodiff usion assay, complement f ixat ion, ELI SA, indirect or direct f luorescent
ant ibody, radioimmunoassay, and West ern blot immunoassay (see Chap. 8).
Skin Testing
Skin t est ing det ermines hypersensit ivit y t o t he t oxic product s f ormed in t he body
by pat hogens. I n general, t hree t ypes of skin t est s are perf ormed: scrat ch t est s,
pat ch t est s, and int radermal t est s.
Blood Cultures
Blood cult ures are collect ed w henever t here is reason t o suspect bact eremia or
sept icemia. Alt hough mild t ransit ory bact eremia is a f requent f inding in many
inf ect ious diseases, a persist ent , cont inuous, or recurrent bact eremia indicat es a
more serious condit ion t hat may require immediat e t reat ment . The expedit ious
det ect ion and ident if icat ion of pat hogens (bact eria, f ungi, viruses, and parasit es)
in t he blood may aid in making a clinical and et iologic diagnosis.
Indications for Blood Culture

1. Bact eremia
2. Sept icemia
3. Shock
4. Unexplained post operat ive shock
5. Post operat ive shock af t er genit ourinary t ract manipulat ion or surgery
6. Unexplained f ever of several days' durat ion
7. Chills and f ever in pat ient s w it h:
a. I nf ect ed burns
b. Urinary t ract inf ect ion
c. Rapidly progressing t issue inf ect ion
d. Post operat ive w ound sepsis
e. I ndw elling venous or art erial cat het er
8. Debilit at ed pat ient s receiving:
a. Ant ibiot ics
b. Cort icost eroids
c. I mmunosuppressives
d. Ant imet abolit es
e. Parent eral hyperaliment at ion
9. Follow ing body piercing (nose, t ongue, nipples, umbilicus) w it h signs of
inf ect ion and bact eremia
NOTE
1. During an acut e f ebrile illness, immediat ely draw t w o separat e blood
samples f rom opposit e arms and prompt ly begin ant ibiot ic t herapy.
2. For f ever of unknow n origin, t w o blood cult ures can be init ially draw n 45
t o 60 minut es apart . I f necessary, t w o more set s of samples can be draw n
24 t o 48 hours lat er.
3. I n cases of acut e endocardit is, draw blood cult ures as above. I f result s
are negat ive, t w o more set s of samples may be obt ained on subsequent
days.
4. Parasit es in t he blood (Pl asmodi um, Trypanosoma, and Babesi a) are
usually det ect ed by direct microscopic observat ion.
P.
5. For inf ant s and small children, only 1 t o 5 mL of blood can saf ely be
draw n f or cult ure. Q uant it ies < 1 mL may be insuff icient t o det ect bact erial
organisms.
Reference Values
Normal
Negat ive f or pat hogens
Procedure of Obtaining Blood Culture During

venipuncture, because of the high potential for
infecting the patient, aseptic technique must be used.
Key points are listed as follow s:
1. O bserve st andard precaut ions. The proposed punct ure sit e should be
scrubbed w it h an ant isept ic agent such as povidone-iodine, 70% alcohol, or
chlorhexidine. Allow t o dry f or 1 t o 2 minut es.
2. Cleanse t he rubber st oppers of cult ure bot t les w it h iodine and allow t o air
dry. They should t hen be cleansed w it h 70% alcohol.
3. Perf orm venipunct ure w it h a st erile syringe and needle; avoid cont aminat ion
of t he cleansed punct ure sit e.
4. Wit hdraw about 10 t o 30 mL of blood int o a 20-mL syringe or direct ly int o
t he cult ure t ubes. Because of t he danger of accident al needle st icks, t he
pract ice of changing needles t o t ransf er t he specimen int o blood cult ure
bot t les has been replaced by direct inject ion w it h t he original phlebot omy
needle.
5. I noculat e t he anaerobic bot t le bef ore t he aerobic bot t le if t w o cult ure bot t les
are t o be inoculat ed (one anaerobic and one aerobic). Be cert ain t o inoculat e
each bot t le w it h t he opt imum blood volume.
6. Mix bot h bot t les gent ly.
7. Properly label t he specimens and immediat ely t ransf er t hem t o t he
laborat ory.
8. Cleanse t he sit e w it h alcohol af t er t he venipunct ure because some pat ient s
are sensit ive t o iodine.
Clin ical Alert

1. Handle all blood specimens according t o universal precaut ions.
2. Af t er disinf ect ion, do not palpat e t he venipunct ure sit e unless st erile
gloves are w orn. Palpat ion is t he great est pot ent ial cause of blood cult ure
cont aminat ion.
3. The at t ending physician should be not if ied immediat ely about posit ive
cult ure result s so t hat appropriat e t reat ment may be st art ed.
4. Specimens can be draw n f rom t w o or t hree diff erent sit es t o exclude a
skin-cont aminat ing organism.
5. Collect ion of more t han t hree blood cult ures in a 24-hour period does not
improve t he det ect ion of bact eria.
6. I t is recommended t o draw blood below an int ravenous line (if possible) t o
prevent dilut ion of t he sample.
1. Negati ve cult ures: I f all cult ures, subcult ures (if perf ormed), and G ramst ained smears are negat ive, t he blood cult ure may be report ed as no
grow t h af t er 5 t o 7 days of incubat ion.
2. Posi ti ve cult ures: Pat hogens most commonly f ound in blood cult ures include:
a. Bacteroi des spp.
b. Brucel l a spp.
c. Ent erobact eriaceae
d. Pseudomonas aerugi nosa
e. Haemophi l us i nf l uenzae
f. Li steri a monocytogenes
g. Streptococcus pneumoni ae
h. Enterococcus spp.
i. S. aureus, Staphyl ococcus epi dermi di s
j. Streptococcus spp. including -hemolyt ic st rept ococci
k. Candi da al bi cans
l. Cl ostri di um perf ri ngens
3. Endocardit is f ollow ing body piercing
Interfering Factors
Blood cult ures are subject t o cont aminat ion, especially by skin bact eria. These
skin organisms should be ident if ied if possible.
Interventions
1. Explain cult ure purpose and procedure. O bt ain pert inent hist ory of signs and
sympt oms (chills, f ever, shock)

1. I nt erpret t est result s; monit or f or bact eremia, sept icemia, and ot her f ebrile
illness; and counsel appropriat ely about t reat ment (t riple ant ibiot ic t herapy).
Urine Cultures
Urine cult ures are most commonly used t o diagnose bact erial urinary t ract
inf ect ion (kidneys, uret er, bladder, and uret hra). Urine is an excellent cult ure and
grow t h medium f or most organisms t hat inf ect t he urinary t ract . The combinat ion
of pyuria (pus in t he urine) and signif icant bact eriuria st rongly suggest s t he
presence of a urinary t ract inf ect ion.
Collection of Specimens for Culture: General Principles
1. Early-morning specimens should be obt ained w henever possible because

bact erial count s are highest at t hat t ime.
2. A clean-voided urine specimen of at least 3 t o 5 mL should be collect ed int o
a st erile cont ainer. Cat het erizat ion and aspirat ion of a suprapubic or
indw elling cat het er are alt ernat ive met hods f or procuring urine specimens.
3. Urine specimens f or cult ure must never be ret rieved f rom a urine collect ion
bag t hat is part of an indw elling cat het er drainage syst em.
4. I deally, urine should be t aken t o t he laborat ory and examined as soon as
possible. When t his is not possible, t he urine can be ref rigerat ed f or up t o 24
hours bef ore being cult ured.
5. Whenever possible, specimens should be obt ained bef ore ant ibiot ic or
ant imicrobial t herapy begins.
6. Prof essional healt h personnel should inst ruct t he pat ient concerning proper
specimen collect ion t echnique. Failure t o isolat e a causat ive organism is
f requent ly t he result of f ault y cleansing or collect ion t echniques t hat can
come f rom lack of inf ormat ion about t he proper collect ion procedure.
7. Provide proper supplies and privacy f or cleansing and urine collect ion.
I nst ruct pat ient s in proper cleansing t echniques. The pat ient w ho is unable t o
comply w it h inst ruct ions should be assist ed by healt h care personnel.
8. The urine specimen should be properly labeled. Pert inent inf ormat ion
includes:
a. Pat ient 's ident if icat ion inf ormat ion
b. Physician's name
c. Suspect ed clinical diagnosis
d. Met hod of collect ion
e. Precise t ime obt ained
f. Specif ic chemot herapeut ic agent s being administ ered
Clin ical Alert

Cat het erizat ion height ens t he risk f or int roducing bact eria.
Clin ical Alert

1. Urine is an excellent cult ure medium. At room t emperat ure, it promot es t he
grow t h of many organisms. Specimen collect ion should be as asept ic as
possible. Samples should be t ransport ed t o t he laborat ory and examined
as soon as possible. The specimen must be ref rigerat ed if t here is a delay
in examinat ion.
2. I n t he case of suspect ed urinary TB, t hree consecut ive early-morning
specimens should be collect ed. Special care should be t aken w hen
cleaning t he ext ernal genit alia t o reduce t he risk f or cont aminat ion w it h
commensal acid-f ast Mycopl asma/ Smegmati s.
Reference Values
Normal
Negat ive
Procedure for Collection of Clean-Catch Urine

Specimen or M idstream Specimen
1. For w omen:
a. Wash and dry hands t horoughly.
b. Remove t he cap f rom t he st erile cont ainer and place it so t hat only t he
out er surf ace t ouches w hat ever it is placed on.
c. Cleanse t he area around t he urinary meat us f rom f ront t o back w it h an
ant isept ic sponge.
d. Spread t he labia apart w it h one hand. Hold t he st erile cont ainer in t he
ot her hand, using care not t o cont aminat e t he inside surf ace.
e. Void t he f irst 25 mL int o t he t oilet , t hen cat ch t he rest of t he urine
direct ly int o t he st erile cont ainer w it hout st opping t he urine st ream unt il
suff icient quant it y is collect ed. Hold t he collect ion cup in such a w ay t hat
it avoids cont act w it h t he legs, vulva, or clot hing. Keep f ingers aw ay
f rom t he rim and inner surf ace of t he cont ainer.
f. Recap t he specimen cont ainer, t aking care not t o cont aminat e t he inside
surf ace of t he cap.
g. Wash and dry hands t horoughly.
h. O bserve st andard precaut ions w hen handling specimens.
2. For men:
a. Wash and dry hands t horoughly.
b. Remove t he cap f rom t he st erile cont ainer and place it so t hat only t he
out er surf ace t ouches w hat ever it is placed on.
c. Ret ract t he f oreskin complet ely t o expose t he glans.

d. Cleanse t he area around t he meat us w it h ant isept ic sponges.
e. Void t he f irst 25 mL of urine direct ly int o t he t oilet and t hen void a
suff icient amount of urine int o t he st erile specimen cont ainer. Do not
collect t he last f ew drops of urine.
f. Recap t he specimen cont ainer, t aking care not t o cont aminat e t he inside
surf ace of t he cap.
g. Wash and dry hands t horoughly.
h. O bserve st andard precaut ions w hen handling specimens.
3. For inf ant s and young children:
a. Use a suit able plast ic collect ion apparat us t o collect urine. Because t he
collect ion bag t ouches skin surf aces and picks up commensal organisms,
t he specimen must be analyzed as soon as possible.
b. Cleanse and dry t he uret hral area t horoughly bef ore applying t he
collect ion bag.
c. Cover collect ion bag w it h a diaper or undergarment t o prevent
dislodging.
d. Be aw are t hat specimens collect ed by cat het erizat ion may be necessary
t o det ect a urinary t ract inf ect ion because of t he cont aminat ion
associat ed w it h collect ion bags.
1. A bact erial count > 100, 000 colony f orming unit s (CFU)/ mL indicat es
inf ect ion. A mixed bact erial count < 10, 000 CFU/ mL does not necessarily
indicat e inf ect ion but rat her indicat es possible cont aminat ion. How ever,
grow t h of a single pot ent ial pat hogen > 10, 000 CFU/ mL may be clinically
signif icant in a sympt omat ic pat ient .
2. The f ollow ing organisms, w hen present in t he urine in suff icient quant it y, may
be considered pat hogenic:
a. Escheri chi a col i and ot her Ent erobact eriaceae
b. Enterococcus spp.
c. N. gonorrhoeae
d. M. tubercul osi s (requires special cult ure media)
e. P. aerugi nosa
f. S. aureus
g. Staphyl ococcus saprophyti cus

h. St rept ococci ( -hemolyt ic, usually group B)
i. C. al bi cans and ot her yeast s
3. Urine samples obt ained by st raight cat het erizat ion, suprapubic aspirat ion, or
cyst oscopy or during surgery represent bladder urine. G row t h of any isolat e
is considered clinically signif icant .
Interfering Factors
1. Pat ient s w ho are receiving f orced f luids may have urine t hat is suff icient ly
dilut e t o reduce t he bact erial count t o < 100, 000 CFU/ mL.
2. Bact erial cont aminat ion comes f rom sources such as:
a. Perineal hair
b. Bact eria beneat h t he prepuce in male pat ient s
c. Bact eria f rom vaginal secret ions, f rom t he vulva, or f rom t he dist al
uret hra in f emale pat ient s
d. Bact eria f rom t he hands, skin, or clot hing
Interventions
2. Ensure t hat t he cleansing procedure is done correct ly t o remove
cont aminat ing organisms f rom t he vulva, uret hral meat us, and perineal area
so t hat any bact eria f ound in t he urine can be assumed t o have come only
f rom t he bladder and uret hra.

1. I nt erpret t est out comes, monit or f or urinary t ract inf ect ion, and counsel
appropriat ely about t reat ment and possible f urt her t est ing.
Clin ical Alert

The urine cult ure sample should not be t aken f rom a urinal or bedpan and
should not be brought f rom home. The urine should be collect ed direct ly int o
t he st erile cont ainer t hat w ill be used f or cult ure.
Eye and Ear Cultures

Bact erial conjunct ivit is, caused by S. pneumoni ae, S. aureus, and H. i nf l uenzae,
is t he most common t ype of inf ect ious conjunct ivit is. I nf lammat ion of t he cornea
usually f ollow s some t ype of t rauma t o t he ocular surf ace. Post surgical and
post t raumat ic endopht halmit is is of t en associat ed w it h Baci l l us spp. and
Ent erobact eriaceae in addit ion t o t he above organisms.
Acut e ot it is media occurs in t he f orm of a pust ule and is of t en caused by S.
aureus. Sw immer's ear is relat ed t o macerat ion of t he ear f rom sw imming or hot ,
humid w eat her; it of t en is caused by P. aerugi nosa. O t it is media of t en begins as
a viral inf ect ion, w it h a bact erial inf ect ion occurring soon af t erw ard. I n children,
t he most common pat hogens are S. pneumoni ae, H. i nf l uenzae, and M.
catarrhal i s.
Reference Values
Normal
Low count s of S. epi dermi di s, Lactobaci l l us spp. , and Propi oni bacteri um acnes
may be f ound in eye cult ures.
The same is t rue f or t he f lora of t he ext ernal ear.
Procedure for Eye Cultures

1. O bserve st andard precaut ions. Purulent mat erial f rom t he low er conjunct ival
sac or inner cant hus of t he eye is collect ed on a st erile sw ab and placed in
t ransport medium. Bot h eyes should be cult ured separat ely.
2. Make scrapings of t he cornea w it h a heat -st erilized plat inum spat ula direct ly
ont o t he medium (blood or chocolat e agar, brain-heart inf usion medium f or
f ungi, or t hioglycolat e brot h) in cases of kerat it is. For viral cult ure, t he
mat erial is placed int o viral t ransport brot h.
3. Do not ref rigerat e specimens or t ransport on ice. Deliver t o t he laborat ory
as soon as possible af t er collect ion.
Procedure for Ear Cultures
1. Cleanse t he ear w it h a mild germicide t o exclude cont aminat ing skin f lora in
cases of ext ernal ot it is.
2. Use a st erile sw ab or syringe and needle t o collect middle ear f luid. Cult ures
f rom t he mast oid usually are t aken during surgery.
3. Do not ref rigerat e specimens, and deliver t o t he laborat ory as soon as
possible af t er collect ion.
Interventions
1. Explain t he purpose and procedure f or t he cult ure. Record signs and
sympt oms of ear inf ect ion, pain, redness, and/ or drainage.

1. I nt erpret t est out comes, monit or sit e of inf ect ion, and counsel appropriat ely.
RESPIRATORY TRACT CULTURES

Explanation of Test
Four major t ypes of cult ure may be used t o diagnose inf ect ious respirat ory t ract
diseases: sput um, t hroat sw abs, nasal sw abs, and nasopharyngeal sw abs. At
t imes, t he purposes f or w hich cert ain t est s are ordered overlap.
Reference Values
The f ollow ing organisms may be present in t he nasopharynx of apparent ly
healt hy persons:
1. C. al bi cans
2. Dipht heroid bacilli
3. Haemophi l us hemol yti cus
4. St aphylococci (coagulase-negat ive)
5. St rept ococci ( -hemolyt ic)
6. St rept ococci (nonhemolyt ic)
7. Micrococci
8. Lactobaci l l us spp.
9. Vei l l onel l a spp.
Clin ical Alert

1. Tw ent y percent of normal adult s carry S. aureus; 10% are carriers of
group A hemolyt ic st rept ococci.
2. A rapid st rep t est gives result s af t er 10 minut es inst ead of 24 t o 48 hours.
I t has a f alse-negat ive rat e of 5% t o 10%, about t he same as t radit ional
met hods. I t permit s rapid diagnosis and t reat ment .
3. Bot h t hroat and urine cult ures are done t o det ect CMV.
Sputum Cultures
Sput um is not mat erial f rom t he post nasal region and i s not spit t le or saliva. A
sput um specimen comes f rom deep w it hin t he bronchi. Eff ect ive coughing usually
enables t he pat ient t o produce a sat isf act ory sput um specimen.
Indications for Collection Sputum cultures are

important for diagnosis of the follow ing conditions:
1. Bact erial pneumonia
2. Pulmonary TB
3. Chronic bronchit is
4. Bronchiect asis
5. Suspect ed pulmonary mycot ic inf ect ions
6. Mycoplasmal pneumonia
7. Suspect ed viral pneumonia
Reference Values
Normal
Negat ive: Normal oral f lora
Procedure
1. I nst ruct pat ient s t o provide a deep coughed specimen int o a st erile
cont ainer. O f t en, an early-morning specimen is best . Expect orat ed mat erial
of 1 t o 3 mL is suff icient f or most examinat ions. Remember t hat good sput um
samples depend on t horough healt h care w orker educat ion and pat ient
underst anding during t he collect ion process.
2. Label specimens properly and not e t he suspect ed disease on t he
accompanying requisit ion.
3. Do not ref rigerat e specimens, and deliver t o t he laborat ory as soon as
possible.
Interventions
1. Record signs and sympt oms (eg, coughing, product ive sput um, blood in
sput um)
2. I nst ruct t he pat ient t hat t his t est requires t racheobronchial sput um f rom deep
in t he lungs. I nst ruct t he pat ient t o t ake t w o or t hree deep breat hs, t hen t o
t ake anot her deep breat h and f orcef ully cough w it h exhalat ion.
3. Ask respirat ory t herapy personnel t o assist t he pat ient in obt aining an
aerosol-induced specimen if t he cough is not product ive. Pat ient s breat he
aerosolized droplet s of a sodium chloride-glycerin solut ion unt il a st rong
cough ref lex is init iat ed. The specimen of t en appears w at ery but is in f act
mat erial direct ly f rom alveolar spaces. I t should be not ed on t he requisit ion
as being aerosol induced.
4. Remember t hat w hen pleural empyema is present , t horacent esis f luid and
blood cult ure are excellent diagnost ic specimens. Bronchial w ashings, BAL,
and bronchial brush cult ures are excellent f or det ect ing most major
pat hogens of t he respirat ory t ract .

1. I nt erpret t est out comes, counsel about t reat ment , and monit or f or
respirat ory t ract inf ect ions.
Throat Cultures (Swab or Washings)

1. Throat cult ures are import ant f or diagnosis of t he f ollow ing condit ions:
a. St rept ococcal sore t hroat
b. Dipht heriaobt ain bot h t hroat and nasopharyngeal cult ures
c. Thrush (candidal inf ect ion)
d. Viral inf ect ion
e. Tonsillar inf ect ion
f. G onococcal pharyngit is
g. Bordetel l a pertussi s
2. Throat cult ures can est ablish t he f ocus of inf ect ion in:
a. Scarlet f ever
b. Rheumat ic f ever
c. Acut e hemorrhagic glomerulonephrit is
3. Throat cult ures can be used t o det ect t he carrier st at e of persons harboring
such organisms as:
a. -Hemolyt ic st rept ococcus

b. Nei sseri a meni ngi ti di s
c. Corynebacteri um di phtheri ae
d. S. aureus
Reference Values
Normal
Posit ive f indings are associat ed w it h inf ect ion in t he presence of :
1. G roup A hemolyt ic st rept ococci
2. N. gonorrhoeae
3. C. di phtheri ae
4. B. pertussi s
5. Adenovirus and herpesvirus
6. Mycopl asma and Chl amydi a
Procedure
1. For adult pat ient s:
a. Place t he pat ient 's mout h in good visual light .
b. Use a st erile t hroat cult ure kit w it h a polyest er-t ipped applicat or or sw ab
and a st erile cont ainer or t ube of cult ure medium.
c. Tilt head back. Depress t he pat ient 's t ongue w it h a t ongue blade and
visualize t he t hroat as w ell as possible. Rot at e t he sw ab f irmly and
gent ly over t he back of t he t hroat , around bot h t onsils or f ossae, and on
areas of inf lammat ion, exudat ion, or ulcerat ion.
1. Avoid t ouching t he t ongue or lips w it h t he sw ab.
2. Because most pat ient s gag or cough, t he collect or should w ear a
f acemask f or prot ect ion.
d. Place t he sw ab int o t he designat ed recept acle so t hat it comes in
cont act w it h t he cult ure medium. I mmediat ely send t he specimen t o t he
laborat ory.
e. Ref rigerat e t he t hroat cult ure if examinat ion is delayed.
2. For pediat ric pat ient s:
a. Seat t he pat ient in t he adult 's lap.
b. Have t he adult encircle t he child's arms and chest t o prevent t he child
f rom moving.
c. Place one hand on t he child's f orehead t o st abilize t he head and t o
prevent movement .
d. Proceed w it h t he t echnique used f or collect ion of t he t hroat and nose
cult ure as described f or adult s.
3. For t hroat w ashings:
a. Have t he pat ient gargle w it h 5 t o 10 mL of st erile saline solut ion and t hen
expect orat e it int o a st erile cup.
b. Remember t hat t his met hod provides more specimen t han a t hroat sw ab
and is more def init ive f or viral isolat ion.
Interventions
1. Explain purpose and procedure t o pat ient or parent s. Record signs and
sympt oms of sore t hroat , color of t hroat , et c.

1. I nt erpret t est out comes, monit or f or t hroat inf ect ion, and counsel
appropriat ely. Report signs and sympt oms.
Nasopharyngeal Cultures (Swab) Nasopharyngeal

swabs are the optimal specimen for detection of B.
pertussis. Nasopharyngeal swabs, aspirates, and
washes are better suited for recovery of respiratory
syncytial virus, parainfluenza virus, and viruses

causing rhinitis.
Indications for Collection
1. Submit t ed primarily f or viral cult ures
2. B. pertussi s
3. C. di phtheri ae
Reference Values
Normal
Procedure
1. Tip t he pat ient 's head back t o collect a nasopharyngeal specimen.
2. I nsert a f lexible, calcium alginat et ipped sw ab caref ully t hrough t he nose int o
t he post erior nasopharynx and rot at e t he sw ab.
3. Pass t w o sw abs simult aneously t hrough one nost ril, leave in nasopharynx f or
1530 seconds. Repeat procedure on ot her nost ril w it h same t w o sw abs.
Alt hough t he calcium alginat et ipped sw abs are most commonly used,
aspirat ed nasopharyngeal specimens, t hrough a sof t rubber bulb or plast ict ipped cat het er, can be used.
4. Take specimens f rom bot h t he nasopharyngeal area and t he t hroat f or C.
di phtheri ae conf irmat ion.
5. Handle specimens as f ollow s:
a. Transport specimens f or viral inf ect ion in appropriat e t ransport media
and ref rigerat e if not cult ured w it hin a f ew hours.
b. Do not ref rigerat e samples unless f or dipht heria or pert ussis (w hooping
cough).
OTHER CULTURES AND SM EARS

Wound and Abscess Cultures Wound infections and
abscesses occur as complications of surgery, trauma,
or disease that interrupts a skin surface. Material from
infected wounds reveals a variety of aerobic and
anaerobic microorganisms. Because anaerobic
microorganisms are the preponderant microflora in
humans
and are consistently present in the upper respiratory,
GI, and genitourinary tracts, they are also likely to
invade other parts of the body to cause severe, and
sometimes fatal, infections. Blood cultures should
always be drawn from patients with bullous lesions,
burn infections, or significant myonecrosis.
Reference Values
Normal
Clinical specimens t aken f rom w ounds can harbor any of t he f ollow ing
microorganisms. Pat hogenicit y depends on t he quant it y of organisms present .
Q uant it at ive or semi-quant it at ive report ing of cult ure result s may provide
inf ormat ion on t he relat ive import ance of t he various organisms present in t he
lesion and also t he response of t he inf ect ion t o ant ibiot ic t herapy.
1. Acti nomyces spp.
2. Bacteroi des and Fusobacteri um spp.
3. C. perf ri ngens and ot her species
4. E. col i
5. O t her gram-negat ive ent eric bacilli
6. Mycobacteri um mari num
7. Nocardi a spp.
8. Pseudomonas spp.
9. S. aureus
10. Corynebacteri um jei kei um
11. Enterococcus sp.
12. St rept ococci ( -hemolyt ic)
13. Candi da spp.
Procedure
1. Procedure f or w ound cult ure
a. O bserve st andard precaut ions.
b. Be aw are t hat most w ounds need some f orm of preparat ion t o reduce t he
risk f or int roducing ext raneous organisms int o t he collect ed specimen. I n
t he presence of moderat e t o heavy pus or drainage, irrigat e t he w ound
w it h st erile saline unt il all visible debris has been w ashed aw ay. When
cult uring chronically present w ounds (pressure sores), dbride t he w ound
surf ace of any loose necrot ic, sloughed mat erial bef ore cult uring.
Cult ures of t he surf ace alone may be misleading; biopsies of deeper
t issue are recommended.
c. Disinf ect t he surf ace of t he w ound w it h 70% alcohol or an iodine solut ion.
d. Apply st erile gauze pads t o absorb excess saline and t o expose t he
cult ure sit e. Alw ays cult ure highly vascular areas of granulat ion t issue.
Wearing st erile gloves, separat e margins of deep w ounds w it h t humb and
f oref inger t o permit insert ion of t he sw ab deep int o t he w ound cavit y.
Press and rot at e t he sw ab several t imes over t he clean w ound surf aces
t o ext ract t issue f luid cont aining t he pot ent ial pat hogen. Avoid t ouching
t he sw ab t o int act skin at t he w ound edges.
e. I mmediat ely place t he sw ab int o t he appropriat e t ransport cont ainer.
2. Procedure f or anaerobic collect ion of aspirat ed mat erial
a. Decont aminat e t he cult ure sit e w it h surgical soap and 70% et hyl or
isopropyl alcohol.
b. Aspirat e at least 1 mL of f luid using a st erile 3-mL syringe and a needle
of appropriat e gauge. I mmediat ely t ransf er t he aspirat e t o an anaerobic
t ransport medium.
c. Remember t hat aspirat ion cult ures are commonly done f or closed
w ounds, such as sof t t issue abscesses, cellulit is, or inf ect ed skin f laps.
Tissue biopsies are more of t en perf ormed during surgery, w hen inf ect ed
t issue is more easily accessible.
d. Never submit a sw ab w hen a t issue sample can be obt ained.
Properly label t he specimen f or t he microbiology laborat ory w it h t he f ollow ing:

1. Pat ient ident if icat ion inf ormat ion
2. Physician's name
3. Dat e and t ime t he specimen w as collect ed
4. Anat omic sit e or specif ic source of t he specimen
5. Type of specimen (eg, granulat ion t issue, abscess f luid, post surgical w ound)
6. Examinat ion request ed
7. Pat ient 's diagnosis
8. Current ant ibiot ic t herapy
Clin ical Alert

A microscopic examinat ion of pus and w ound exudat es can be very helpf ul in
diagnosing a pat hogenic organism. Consider t he f ollow ing:
1.
2.
3.
4.
5.
Pus f rom st rept ococcal inf ect ions is t hin and serous.
Pus f rom st aphylococcal inf ect ions is gelat inous.
Pus f rom P. aerugi nosa inf ect ions is blue-green.
Act inomycosis inf ect ions show sulf ur granules.
Bronze discolorat ion of t he skin and f luid-f illed blist ers are present in gas
gangrene.
Clinically signif icant pat hogens are likely t o be present in t he f ollow ing
specimens:
1. Pus f rom deep w ounds or abscesses, especially if associat ed w it h a f oul
odor
2. Necrot ic t issue or dbrided mat erial f rom suspect ed gas gangrene inf ect ion
3. Samples f rom inf ect ions bordering mucous membranes
4. Post operat ive w ound drainage
5. Low er-ext remit y ulcers f rom diabet ic pat ient s
6. Decubit us ulcers f rom elderly or bedridden pat ient s
Interventions
1. Explain purpose and w ound cult ure procedure. Record signs of w ound
inf ect ion, t ype of drainage, f ever, et c.

1. I nt erpret t est out comes, monit or sit e of inf ect ion, and counsel appropriat ely
about t reat ment .
Skin Cultures
The most common bact eria implicat ed in skin inf ect ions are S. aureus and S.
pyogenes (group A). The common abnormal skin condit ions include:
1. Pyoderma
a. St aphylococcal impet igo, charact erized by bullous lesions w it h t hin,
amber, varnish-like crust s
b. St rept ococcal impet igo, charact erized by t hick crust s
2. Erysipelas
3. Folliculit is
4. Furuncles
5. Carbuncles
6. Secondary invasion of burns, scabies, and ot her skin lesions
7. Dermat ophyt es, especially at hlet e's f oot , scalp and body ringw orm, and
jock it ch
Reference Values
Normal
The f ollow ing organisms may be present on t he skin of a healt hy person. When
present in low numbers, some of t hese organisms may be considered normal

commensals; at ot her t imes, w hen t hey mult iply t o excess, t hese same
organisms may become pat hogens.
1. Cl ostri di um spp.
2. Colif orm bacilli
3. Dipht heroids
4. Ent erococci
5. Mycobact eria
6. Proteus spp.
7. St aphylococci
8. St rept ococci
9. Yeast s and f ungi
Procedure for Obtaining Scrapings from Vesicular

Lesions or Skin
2. Clean t he aff ect ed sit e w it h st erile saline, w ipe gent ly w it h alcohol, and allow
it t o air dry.
3. Aspirat e a f luid sample f rom f resh, int act vesicles w it h a 25-gauge needle
at t ached t o a t uberculin syringe, and t ransf er t he specimen t o t he t ransport
medium by eject ing it f rom t he syringe.
4. I f f luid cannot be aspirat ed, open t he vesicles and use a cot t on-, rayon-, or
Dacron-t ipped applicat or t o sw ab t he base of t he lesion t o collect inf ect ed
cells. Place t he sw ab direct ly int o t ransport medium (eg, self -cont ained f oam
pad w it h St uart 's media).
5. To make smears f or st ains, use a scalpel blade t o scrape t he base of t he
lesion, t aking care not t o macerat e t he cells. Spread scraped mat erial in a
t hin layer on a slide.
6. Place t he specimen in biohazard bag; do not ref rigerat e. I mmediat ely
t ransport t he specimen t o t he laborat ory f or bact erial, f ungal, or viral
cult ures.
Clin ical Alert

The most usef ul and common specimens f or det ect ion of f ungal inf ect ion are
skin scrapings, nail scrapings, and hairs (see Diagnosis of Fungal Disease and
Appendix K).
When present on t he skin in signif icant quant it ies, t he f ollow ing organisms may
be considered pat hogenic and indicat ive of an abnormal condit ion:
1. Ent erobact eriaceae
2. Fungi (Sporotri chum, Acti nomyces, Nocardi a, C. al bi cans, Tri chophyton,
Mi crosporum, Epi dermophyton)
3. S. aureus
4. Streptococcus pyogenes
5. P. aerugi nosa
6. Varicella-zost er virus
7. Herpes simplex virus
Interventions
1. Explain purpose and skin cult ure procedure.

1. I nt erpret t est out comes, monit or sit e of inf ect ion, and counsel appropriat ely
about t reat ment . Report rashes, f ever, et c.
Stool and Anal Cultures and Smears Stool cultures are

commonly done to identify bacteria associated with
enteric disease. Of all specimens collected, feces are
likely to contain the greatest number and greatest
variety of organisms. For a routine stool culture, the

stool is examined to detect and to rule out Salmonella,
Shigella, Campylobacter, Aeromonas, Plesiomonas,
and predominating numbers of Staphylococcus
organisms; cultures for yeast, Bevdomonas, Yersinia,
Vibrio, and Shiga toxinproducing E. coli have to be
specifically requested, depending on laboratory
practice. Clostridium difficile causes antibioticassociated colitis. It is diagnosed by detection of the
toxins.
A single negat ive st ool cult ure should not be considered t he endpoint in t est ing.
At least t hree st ool cult ures collect ed on separat e days are recommended if t he
pat ient 's clinical pict ure suggest s bact erial involvement , despit e previous
negat ive cult ures. Moreover, once a posit ive diagnosis has been made, t he
pat ient 's personal cont act s should also be t est ed t o prevent a pot ent ial spread
of inf ect ion.
Reference Values
Normal
The f ollow ing organisms may be present in t he st ool of apparent ly healt hy
people:
1. C. al bi cans
2. Enterococcus spp.
3. E. col i
4. Proteus spp.
5. P. aerugi nosa
6. Streptococcus spp.
7. Staphyl ococcus spp.
Procedure
1. Procedure f or st ool specimen collect ion
b. Use a dry cont ainer or a clean, dry bedpan t o collect f eces. Do not
cont aminat e st ool specimen w it h urine, soap, or disinf ect ant s.
c. Remember t hat a f reshly passed st ool is best . Diarrheal st ool usually
gives accept able result s.
d. Select port ions cont aining pus, blood, or mucus. A 1- t o 2-gram quant it y
is suff icient .
e. Do not ret rieve st ool f rom t he t oilet f or specimen use.
f. Do not place t oilet t issue or diapers w it h t he specimen. I t may cont ain
bismut h, w hich int erf eres w it h laborat ory t est s.
g. Transf er st ool specimens f rom t he bedpan t o t he cont ainer w it h t ongue
blades.
h. Properly label t he sealed specimen cont ainer and immediat ely send it t o
t he laborat ory.
i. Place t he specimen in a t ransport medium, such as Cary-Blair medium, if
a delay of longer t han 2 hours f or st ool cult ure is ant icipat ed (f rom t ime
of collect ion unt il receipt in t he laborat ory). Specimens processed w it hin
2 hours of collect ion do not require added preservat ives. Place t he
designat ed volume of st ool int o t he t ransport cont ainer.
2. Procedure f or obt aining a rect al sw ab
b. I nsert t he sw ab gent ly int o t he rect um (t o a dept h of at least 3 cm) and
rot at e it t o ret rieve a visible amount of f ecal mat erial (Fig. 7. 1).
FI G URE 7. 1 Met hod f or obt aining t he rect al cult ure.
c. Place t he sw ab int o t he recept acle cont aining t ransport medium, such as

Cary-Blair medium.
d. Properly label t he specimen and send it in a biohazard bag t o t he
laborat ory as soon as possible.
3. Procedure f or perf orming cellophane t ape t est f or pinw orm (Enterobi us
vermi cul ari s)
a. O bserve st andard precaut ions. The t ape t est is indicat ed in cases of
suspect ed ent erobiasis (pinw orms).
b. Apply a st rip of clear cellophane t ape (not micropore or adhesive t ype
t ape) t o t he perineal region. Remove and spread t he t ape on a slide f or
microscopic examinat ion.
c. Remember t hat a paraff in-coat ed sw ab can be used in place of t he
cellophane t ape t est . I f used, place t he sw ab w it hin a st oppered t est
t ube.
d. Be aw are t hat it may be necessary t o make f our t o six examinat ions on
consecut ive days bef ore ruling out t he presence of pinw orms.
e. Test f or pinw orm eggs in t he morning, bef ore t he pat ient has def ecat ed
or bat hed. For small children, it is best t o collect t he specimen just
bef ore t he child aw akens.
Clin ical Alert

Fecal specimens are f ar superior t o rect al sw ab specimens. O f t en, rect al
sw abs reach only t he anal canal and provide mat erial of limit ed diagnost ic
signif icance.
1. C. al bi cans, S. aureus, and P. aerugi nosa, f ound in large numbers in t he
st ool, are considered pat hogenic in t he set t ing of previous ant ibiot ic t herapy.
Alt erat ions of normal f lora by ant ibiot ics of t en change t he environment so
t hat normally harmless organisms become pat hogens.
2. Cryptospori di osi s is a cause of severe, prot ract ed diarrhea in
immunosuppressed pat ient s. Cryptospori di um organisms can be det ect ed by
ova and parasit e examinat ion.
3. H. pyl ori has been associat ed w it h gast rit is and pept ic ulcer disease. H.
pyl ori is f ound only on t he mucus-secret ing epit helial cells of t he st omach.
Det ect ion of H. pyl ori in gast ric biopsy specimens necessit at es collect ion of
t he specimens in st erile cont ainers. Smears and cult ures should be examined
f or t he presence of t his organism. I nit ial cult ure incubat ion requires 7 days.
Theref ore, result s of gast ric biopsy specimen cult ures may t ake 8 t o 10 days
t o obt ain. A t est f or H. pyl ori ant igen in t he st ool provides rapid det ect ion of
H. pyl ori .
4. C. di f f i ci l e: Whenever normal f lora are reduced by ant ibiot ic t herapy or ot her
host f act ors, t he syndrome know n as pseudomembranous col i ti s occurs. This
condit ion is caused by C. di f f i ci l e. I t may be present in small numbers in t he
normal person, or it may occur in t he hospit al environment . When normal
f lora are reduced, C. di f f i ci l e can mult iply and produce it s t oxins.
The def init ive diagnosis of C. di f f i ci l eassociat ed diarrhea is based on clinical
crit eria. Endoscopic visualizat ion of a charact erist ic pseudomembrane or plaque,
t oget her w it h a hist ory of ant ibiot ic t herapy, is diagnost ic of C. di f f i ci l e. Three
laborat ory t est s are also available. These include st ool cult ure f or C. di f f i ci l e
(nonspecif ic; requires at least 48 hours); t issue cult ure f or det ect ion of cyt ot oxin
(48 hours); and rapid ant igen t est s f or t oxins t hat are sensit ive and specif ic f or
C. di f f i ci l e.
Interfering Factors
Feces f rom pat ient s receiving barium, bismut h, mineral oil, or ant ibiot ics are not
sat isf act ory specimens f or ident if ying prot ozoa.
Interventions
Pretest Patient Care for Stool Specimen Collection
1. Explain purpose and procedure. O bt ain hist ory of diarrhea including t ype and
lengt h of t ime. I nst ruct t he pat ient t o def ecat e int o a clean, dry bedpan or
large-mout hed cont ainer.
2. Do not allow pat ient t o def ecat e int o t he t oilet bow l or urinat e int o t he
bedpan or collect ing cont ainer because urine has an adverse eff ect on
prot ozoa.
3. Do not place t oilet paper int o t he bedpan or collect ion cont ainer; it may
cont ain bismut h, w hich can int erf ere w it h t est ing.

1. I nt erpret t est out comes, monit or f or int est inal inf ect ion, and counsel
appropriat ely about t reat ment and possible f urt her t est ing. Report signs and
sympt oms.
Clin ical Alert

1. I n t he inst it ut ional set t ing, pat ient s w it h diarrhea should remain in isolat ion
unt il t he cause f or t he diarrhea is det ermined.
2. When pat hogens are f ound in t he diarrheic st ool, t he pat ient usually
remains isolat ed unt il t he st ool becomes f ormed and ant ibiot ic t herapy is
complet ed.
Cerebrospinal Fluid (CSF) Cultures and Smears

Bacteriologic examination of CSF is an essential step
in the diagnosis of any case of suspected meningitis.
Acute bacterial meningitis is an infection of the
meninges (the membrane covering the brain and spinal
cord). It is a rapidly progressive, fatal disease if left
untreated or if treated inadequately. Death can occur
within hours of symptom onset. Prompt identification of
the causative agent is necessary for appropriate
antibiotic therapy and aggressive treatment. Meningitis
is caused by a variety of gram-positive and gramnegative microorganisms. Bacterial meningitis also
can be secondary to infections in other areas of the
body.
A smear and cult ure should be perf ormed on all CSF specimens obt ained f rom
persons w it h suspect ed meningit is, w het her t he CSF f luid appears clear (normal)
or cloudy.
I n bact erial meningit is (except TB meningit is), t he CSF show s t he f ollow ing
charact erist ics:
1. Purulence (usually)
2. I ncreased numbers of leukocyt es
3. Preponderance of polymorphonuclear cells

4. Decreased CSF glucose concent rat ion in relat ion t o serum glucose
5. Elevat ed CSF prot ein concent rat ion
I n meningit is caused by t he t ubercle bacillus, viruses, f ungi, or prot ozoa, t he
CSF show s t he f ollow ing charact erist ics:
1. Nonpurulent (usually)
2. Decreased mononuclear w hit e cell count ; increased lymphocyt es
3. Normal or decreased CSF glucose concent rat ion
4. Elevat ed CSF prot ein concent rat ion
I n t hose persons w it h suspect ed meningit is, t he CSF f luid is generally submit t ed
f or chemical and cyt ologic examinat ions as w ell as cult ure.
Indications for Collection

1. Viral meningit is
2. Pyogenic meningit is
3. TB meningit is
4. Chronic meningit is
Reference Values
Normal
1. Negat ive: No grow t h
2. Bact eria are not normally present in CSF. How ever, t he specimen may be
cont aminat ed by normal skin f lora during t he process of CSF procurement .
Procedure
1. Collect t he specimen under st erile condit ions. Three or f our t ubes (1. 0 mL
per t ube) of CSF should be collect ed. The t hird t ube is used f or cell count
and diff erent ial; t he ot hers can be used f or microbiologic and chemical
st udies.
2. Seal immediat ely t o prevent leakage or cont aminat ion, and send it t o t he
laborat ory w it hout delay.
3. Label t he specimen properly. Alert laborat ory st aff so t hat t he specimen can
be examined immediat ely.
4. Not if y t he at t ending physician as soon as result s are obt ained so t hat
appropriat e t reat ment can be st art ed in a t imely f ashion.
Clin ical Alert

I n cases of suspect ed meningit is, a cult ure should be done and a diagnosis
made as quickly as possible. This is import ant because some causat ive
organisms cannot t olerat e t emperat ure changes.
I f a viral cause is suspect ed, a port ion of t he CSF f luid should be ref rigerat ed
(0C t o 4C). Freezing is not recommended unless inoculat ion int o t issue
cult ure w ill t ake longer t han 5 days. I f PCR t est ing is t o be perf ormed,
specimens may need t o be f rozen immediat ely.
Clin ical Alert

New borns have t he highest prevalence of meningit is of any age group.
O rganisms causing disease in t he new born (usually acquired during t he birt h
process) include group B st rept ococcus, E. col i, and L. monocytogenes.
1. Pat hogens f ound in CSF include:
a. Cryptococcus and ot her f ungi
b. H. i nf l uenzae
c. Naegl eri a or Acanthamoeba spp.
d. Viruses (usually ent eroviruses)
e. L. monocytogenes
f. M. tubercul osi s
g. N. meni ngi ti di s
h. S. pneumoni ae
i. S. aureus
j. S. epi dermi di s
k. Streptococcus (group B)
l. T. pal l i dum
m. Toxopl asma gondi i

2. Posit ive CSF cult ures occur in:
a. Meningit is
b. Trauma
c. Abscess of brain or ependyma of spine
d. Sept ic t hrombophlebit is of venous sinuses
M aintenance of Culture
1. I f t he CSF specimen cannot be delivered t o t he laborat ory immediat ely, t he
cont ainer should be st ored at room t emperat ure.
2. No more t han 4 hours should elapse bef ore laborat ory analysis t akes place
because of t he low survival rat es of t he organisms causing meningit is
(especially H. i nf l uenzae and N. meni ngi ti di s).
Interventions
1. Explain purpose and lumbar punct ure procedure (see Chap. 5). Record
pert inent signs and sympt oms.

1. I nt erpret t est out comes, monit or f or meningit is, and counsel appropriat ely
(see Chap. 4).
Cervical, Urethral, Anal, and Oropharyngeal Cultures

and Smears for Gonorrhea and Other Sexually
Transmitted Diseases These tests are done for patients
with genital ulcers, vaginal lymphadenopathy, bacterial
vaginosis, lesions affecting epithelial surfaces, signs

and symptoms of bacterial STDs, pelvic inflammatory
disease, urethritis, or abnormal discharge and itching.
Reference Values
Normal
Negat ive: Normal f lora; pat hogens not det ect ed
Procedures for Specimens

1. Cervical (f emale pat ient s)
a. Be aw are t hat t he cervix is t he best sit e f rom w hich t o obt ain a cult ure
specimen.
b. O bserve st andard precaut ions.
c. Moist en t he vaginal speculum w it h w arm w at er; do not use a lubricant .
Remove cervical mucus, pref erably w it h a cot t on ball held in a ring
f orceps.
d. I nsert a st erile, cot t on-t ipped sw ab int o t he endocervical canal; move t he
sw ab f rom side t o side; allow 30 seconds f or absorpt ion or organisms by
t he sw ab (Fig. 7. 2).
FI G URE 7. 2 Met hod f or obt aining t he endocervical specimen.
2. Uret hral (male pat ient s)

a. Use a st erile sw ab t o obt ain t he specimen f rom t he ant erior uret hra by
gent ly scraping t he uret hral mucosa (Fig. 7. 3).
FI G URE 7. 3 Met hod f or obt aining t he uret hral specimen.
b. Rot at e t he sw ab 360 degrees t o dislodge some of t he epit helial cells f or

Chl amydi a. N. gonorrhoeae organisms inhabit t he exudat e, w hereas C.
trachomati s organisms are int racellular (w it hin t he epit helial cells).
3. Anal canal
a. I nsert a st erile, cot t on-t ipped sw ab approximat ely 2. 5 cm int o t he anal
canal. (I f t he sw ab is inadvert ent ly pushed int o f eces, use anot her sw ab
t o obt ain t he specimen. )
b. Move t he sw ab f rom side t o side in t he anal canal t o sample t he crypt s;
allow several seconds f or absorpt ion of organisms by t he sw ab.
c. Remember t hat t his sit e is likely t o be posit ive in a pat ient w it h STD,
w hen a cervical specimen is negat ive.
Because Tri chomonas vagi nal i s may be present in uret hral or vaginal discharge,
mat erial f or cult ure should be collect ed as described; how ever, an addit ional
sw ab should be placed in a t ube cont aining 0. 5 mL of st erile saline and be
delivered t o t he laborat ory immediat ely.
Sw abs f or cult ure should be t ransport ed t o t he laborat ory in St uart 's t ransport
medium and should be held at room t emperat ure unt il processed. I f specimens
are not processed w it hin 12 hours, t hey should be ref rigerat ed. Recovery of a
pat hologic organism may be more diff icult because of delay in processing.
Clin ical Alert

1. I f t he male uret hral cult ure is negat ive but gonorrhea is st ill suspect ed,
prost at ic massage may produce an increased number of organisms in t he
uret hral discharge. The f irst morning specimen bef ore urinat ion may be t he
best .
2. I n a f emale pat ient , t he anal canal specimen can be obt ained af t er t he
cervical specimen w it hout changing t he pat ient 's posit ion and w it hout using
t he anoscope. O bserve st andard precaut ions.
Clin ical Alert

The f inding of repeat ed negat ive cult ures f or gonococci does not alw ays
exclude a diagnosis of gonorrhea.
Interventions
1. Explain cult ure purpose and collect ion procedure. O bt ain hist ory of pert inent
signs and sympt oms (drainage, pain, it ching).
2. Place t he pat ient in t he dorsal lit hot omy posit ion and appropriat ely drape f or
genit al procedures. Provide as much privacy as possible.
3. Follow st andard precaut ions.

2. Explain need f or possible f ollow -up t est ing and t reat ment .
Tissue, Bone, and Body Fluid Cultures Types of fluid

collected for bacterial, viral, or fungal culture include
pleural, ascitic, synovial, and pericardial fluid. Tissues

may have to be minced or ground to release trapped
bacteria before culturing.
Reference Values
Normal
Negat ive f or pat hogens
Procedure for Collection of Specimens

1. Transport body f luids t o t he laborat ory in a st erile t ube or st erile capped
syringe. Ten t o 20 mL of f luid is adequat e f or cult ure examinat ion.
2. Collect bone during surgery and send t o t he laborat ory in a st erile cont ainer.
Place f ragment s direct ly ont o t he agar surf ace or int o enrichment brot h.
3. Collect pieces of t issue during surgery or during needle biopsy procedures.
They should be collect ed in a st erile specimen cup. Add a small amount of
st erile, nonbact eriost at ic saline t o keep specimen moist .
Interventions
1. Explain t he purpose and procedure f or t he cult ure.

1. I nt erpret t est out comes; monit or sit e of collect ion, and counsel
appropriat ely.
SKIN TESTS
Skin t est ing is done f or t hree major reasons: (1) t o det ect sensit ivit y t o allergens
such as dust and pollen, (2) t o det ermine sensit ivit y t o microorganisms believed
t o cause disease, and (3) t o det ermine w het her cell-mediat ed immune f unct ions
are normal. The t est t hat det ect s sensit ivit y t o allergens is ment ioned only brief ly
in t his chapt er below ; most of t his discussion f ocuses on skin t est s used t o
det ermine sensit ivit y t o pat hogens.
Reference Values
Normal
Posit ive react ions indicat e lack of immunit y t o a specif ic disease (eg, TBproducing agent ) or sensit ivit y t o a specif ic allergen (eg, mold).
Intradermal Tests
The subst ance being t est ed is inject ed int o t he layers of skin w it h a t uberculin
syringe f it t ed w it h a short -bevel, 26- or 27-gauge needle. A posit ive react ion
produces a red, inf lamed area at t he sit e of t he inject ion w it hin a given t ime
period (eg, 72 hours f or t he Mant oux t est f or TB).
Skin t est s t hat indicat e hypersensit ivit y t o a t oxin f rom a disease-producing
agent may also signal immunit y t o t he disease. Posit ive react ions may also
indicat e an act ive or inact ive phase of t he disease under st udy. Skin t est s can be
cat egorized according t o t heir nat ure and purpose as f ollow s:
1. Test t o reveal a present or past exposure t o t he inf ect ious agent ; f or
example, t uberculin t est (posit ive react ion indicat es presence of act ive or
inact ive TB).
2. Test s t o show sensit ivit y t o mat erials t ow ard w hich a person may react in an
exaggerat ed manner; f or example, allergenic ext ract s such as house dust
and pollen (posit ive react ion indicat es sensit ivit y t o allergen ext ract s).
3. Test s t o det ect impaired cellular immunit y. I nt radermal skin t est ing w it h
several common ant igenic microbial subst ances (eg, purif ied prot ein
derivat ive [ PPD] t uberculin, mumps virus, C. al bi cans, st rept okinasest rept odornase) can det ermine w het her immune f unct ion is normal. This
w ould be import ant in t reat ing leukemia and cancer w it h chemot herapy.
(Negat ive react ion t o any int radermal ant igen indicat es impaired immunit y. )
Procedure for Skin Tests
1. Follow t he manuf act urer's inst ruct ions f or t he diagnost ic skin t est s. Most are
prepackaged as st erile kit s.
2. I nject 0. 1 mL of t he t est mat erial int radermally on t he volar aspect of t he
f orearm.
3. Remember t hat a posit ive react ion is manif est ed by redness or sw elling > 1
cm in diamet er at t he inject ion sit e. A cent ral area of necrosis is a highly
signif icant f inding.
Clin ical Alert

Mat erial f or diagnost ic skin t est s may be inadvert ent ly inject ed int o
subcut aneous t issue rat her t han int radermal t issue. A subcut aneous inject ion
yields a f alse-negat ive result .
See individual skin t est s f or pret est and post t est int ervent ions.
Tuberculin Skin Test (TB Test); Two-Step TB Test The

intradermal tuberculin skin test detects TB infection; it
does not distinguish active TB from dormant TB. PPD
tuberculin is a protein fraction of the tubercle bacilli;
when it is introduced into the skin of a person with
active or dormant TB infection, it causes a localized
skin erythema and induration at the injection site
because of accumulated small, sensitized
lymphocytes.
The Mant oux t est is t he t est of choice. The t uberculin is inject ed int o t he
int radermal skin layer w it h a syringe and f ine-gauge needle. The mult iple
punct ure t est (t ine t est ) is used f or screening purposes f or asympt omat ic
persons, but t he Mant oux t est is f ar more accurat e.
The t w o-st ep TB skin t est is done t o reduce t he likelihood t hat a boost ed
react ion w ill be int erpret ed as a recent inf ect ion. The t w o-st ep skin t est is not
rout ine f or cont act case invest igat ion.

1. Persons w ho exhibit signs (x-ray f ilm abnormalit y) or sympt oms (eg, cough,
hemopt ysis, w eight loss) suggest ive of TB
2. Recent close cont act s w it h persons know n t o have or suspect ed of having TB
3. Persons w ho show abnormal chest radiographs compat ible w it h past TB

exposure
4. Members of groups at high risk f or M. tubercul osi s inf ect ion, such as
immigrant s f rom Asia, Af rica, and Lat in America; povert y-prone and skid
row populat ions; personnel and long-t erm resident s of healt h care f acilit ies
and inst it ut ions (eg, nursing homes, ment al inst it ut ions, prisons)
5. The t w o-st ep t est is indicat ed f or noninf ect ed new employees and new
resident s of inst it ut ions (eg, nursing homes, hospit als, homeless shelt ers,
correct ional inst it ut ions, alcohol and drug t reat ment cent ers), persons 55
years of age and older, and persons born in count ries w it h high prevalence.
Reference Values
Normal
React ion negat ive or not signif icant
Procedure for Intradermal Skin Test (M antoux)

1. O bserve st andard precaut ions. Draw up PPD t uberculin int o a t uberculin
syringe (f ollow manuf act urer's direct ions caref ully) w it h a 0. 5-inch, 26- or
27-gauge needle. Use 0. 1 mL (5 t uberculin unit s) f or each t est .
2. Cleanse t he skin on t he volar or dorsal aspect of t he f orearm w it h alcohol
and allow it t o dry.
3. St ret ch t he skin t aut .
4. Hold t he t uberculin syringe close t o t he skin so t hat t he hub of t he needle
t ouches t he skin as t he needle is int roduced under t he skin. A discret e, pale
elevat ion of t he skin (w heal) 6 t o
10 mm in diamet er should be produced w hen t he prescribed amount of PPD
t uberculin is inject ed int o t he int radermal skin layer.
5. For t he two-step test, administ er t he Mant oux int radermal skin t est , as
described, f or all persons f or w hom t est ing is indicat ed. St rict ly enf orce
reading of result s in 48 t o 72 hours. I f t he result is posit ive, do not
administ er a second PPD dose but ref er t he pat ient f or f ollow -up. I f
indurat ion is present but does not classif y as posit ive, ret est immediat ely on
t he pat ient 's ot her arm and read t he result s in 48 t o 72 hours. I f t he result of
t he f irst Mant oux t est is negat ive, ret est in 1 t o 2 w eeks, using t he same
PPD dose and t he same arm as f or t he f irst t est . Read t he result s in 48 t o
72 hours. I f t he react ion at second t est is negat ive (no durat ion), perf orm no
f urt her t est ing now. Make plans t o administ er t he one-st ep Mant oux t est
yearly (or every 3 t o 6 mont hs if t he pat ient is at high risk).

6. Document sit e of t est f or f ollow -up reading of result s.
1. The t est should be read at 48 t o 72 hours af t er inject ion. The larger t he area
of t he skin react ion, t he more likely it is t o represent TB inf ect ion. Posit ive
t est s show an indurat ed area of 5 t o 15 mm. How ever, a signif icant react ion
t o t he skin t est does not necessarily signif y t he presence of TB.
2. A signif icant react ion does not dist inguish bet w een act ive and dormant TB
inf ect ion; t he st age of inf ect ion can be det ermined f rom t he result s of clinical
bact eriologic sput um t est s and chest roent genograms.
3. A signif icant react ion in a clinically ill pat ient means t hat act ive TB should be
considered as a cause f or illness. Wit h HI V inf ect ion, a react ion of 5 mm or
more is considered posit ive.
4. A signif icant react ion in a healt hy person usually signif ies eit her healed TB or
an inf ect ion caused by a diff erent mycobact erium. Chest roent genograms can
conf irm t he absence of an act ive disease process.
Interfering Factors
False-negat ive result s may occur even in t he presence of act ive TB or w henever
sensit ized T lymphocyt es are t emporarily deplet ed in t he body.
Reading the Test Results

1. The t est should be read 48 t o 72 hours af t er inject ion.
2. Examine t he inject ion sit e in good light .
3. The pat ient should f lex t he f orearm at t he elbow.
4. I nspect t he skin f or indurat ion (hardening or t hickening).
5. Rub f inger light ly f rom t he normal skin area t o t he indurat ed zone (if
present ).
6. Circle t he zone of indurat ion w it h a pencil and measure t he diamet er in
millimet ers perpendicularly t o t he long axis of t he f orearm. Disregard
eryt hema; it is clinically insignif icant .
7. Large react ions may st ill be evident 7 days af t er t he t est .
Clin ical Alert
1. Tuberculin t est mat erial should never be t ransf erred f rom one cont ainer t o
anot her.
2. I nt radermal skin t est s should be given immediat ely af t er t he t uberculin is
draw n up.
3. The great est value of t uberculin skin t est ing is in t he negat ive result s; a
negat ive t est result in t he presence of signs and sympt oms of lung disease
is st rong evidence against act ive TB in most cases.
P.
4. A presumpt ive diagnosis of TB must be bact eriologically conf irmed.
5. I n t he Unit ed St at es, t he incidence of TB is higher among older persons,
men, nonw hit es, and f oreign-born persons.
6. Sixt een percent of TB cases are ext rapulmonary.
7. TB is acquired t hrough close, f requent , and prolonged exposure t o
inf ect ed persons.
8. A person diagnosed w it h TB has on average nine cont act s, of w hom 21%
are inf ect ed.
9. Persons w ho have received Bacille Calmet t e-G urin (BCG ) vaccine
prophylact ically or f or bladder cancer t reat ment t est posit ive f or TB.
React ions of 5 t o 10 mm may be caused by BCG vaccinat ion. How ever,
unless t he vaccinat ion w as very recent , t uberculin react ions great er t han
10 mm should not be at t ribut ed t o BCG .
10. Periodic chest x-ray f ilms are valuable adjunct s f or monit oring pat ient s
w ho t est posit ive because t here is no sure w ay of predict ing w ho w ill
develop act ive TB.
11. BCG is a f reeze-dried preparat ion of a live, at t enuat ed bovine st rain of
mycobact eria. I t is used f or TB immunizat ion in children (eg, inf ant w it h a
negat ive TB t est w ho lives in a household w it h unt reat ed or ineff ect ively
t reat ed cases of TB) in count ries w it h a high incidence of TB.
12. Clinicians in cont act w it h suspect ed or conf irmed TB must w ear a properly
f it t ed, high-eff iciency, dust - and mist -proof mask.
Interpreting the Test Results

1. The t est int erpret at ion is based on t he presence or absence of indurat ion.
2. Negat ive or insignif icant react ion: zone of indurat ion < 5 mm in diamet er.
Posit ive or signif icant react ion: zone of indurat ion > 10 mm in diamet er.
3. For persons in good healt h w it h no risk f act ors, an indurat ion of 15 t o 20 mm
usually is considered posit ive. How ever, because t hose w ho are at increased
risk f or TB (in poor healt h) have decreased hypersensit ivit y, a 5-mm
indurat ion may be considered posit ive. Ret est w it hin 3 w eeks. See Chart 7. 2
f or classif icat ion of t est result s.
Ch art 7.2 Classification of the Tuberculin Skin Test Reaction An

in du ration of 5 or more millimeters is con sidered positive for:
HI V-inf ect ed persons
close cont act s of a person w it h inf ect ious TB
persons w ho have abnormal chest radiographs
persons w ho inject drugs and w hose HI V st at us is unknow n
An indurat ion of 10 or more millimeters is considered posit ive f or:
f oreign-born persons
HI V-negat ive persons w ho inject drugs
medically underserved, low -income populat ions
resident s of long-t erm care f acilit ies
persons w it h cert ain medical condit ions*
children < 4 years old w it hout any ot her risk f act ors
st aff of long-t erm care f acilit ies and healt h care f acilit ies
An indurat ion of 15 or more millimeters is considered posit ive f or:
persons w ho do not have any risk f act ors f or TB
Footn ote
*For example, diabet es mellit us, prolonged cort icost eroid t herapy,
immunosuppressive t herapy, gast rect omy, some hemat ologic and
ret iculoendot helial diseases, end-st age renal disease, silicosis, and body
w eight t hat is 10% or more below ideal.
From Cent ers f or Disease Cont rol and Prevent ion (CDC), Tuberculosis
I nf ormat ion, Diagnosis of TB I nf ect ion and TB Disease, August 25, 1997,
Document 250102.
Potential Causes of False-Negative Results Reactions

can be categorized according to the follow ing factors:
1. Fact ors relat ed t o person being t est ed
a. Presence of inf ect ions
b. Viral (measles, mumps, chickenpox)

c. Live virus vaccinat ions (measles, mumps, polio)
d. Nut rit ional f act ors (severe prot ein deplet ion)
e. Diseases aff ect ing lymphoid organs (Hodgkin's disease, lymphoma,
chronic lymphocyt ic leukemia, sarcoidosis)
f. Drugs (cort icost eroids, ot her immunosuppressive agent s)
g. Age (new borns, elderly pat ient s w it h w aned sensit ivit y)
h. Recent or overw helming M. tubercul osi s inf ect ion
2. Fact ors relat ed t o t uberculin inject ed
a. I mproper st orage (exposure t o light , heat )
b. I mproper dilut ion
c. Chemical denat urat ion
d. Cont aminat ion
e. Absorpt ion (part ially cont rolled by adding Tw een-80)
f. O ut dat ed mat erial
3. Fact ors relat ed t o met hod of administ rat ion
a. I nject ion of t oo lit t le or t oo much ant igen
b. Delayed administ rat ion af t er draw ing up dose
c. I nject ion t oo deep or t oo shallow
4. Fact ors relat ed t o t est int erpret at ion and recording of result s
a. Test not read w it hin prescribed t ime f rame
b. I nexperienced reader
c. Conscious or unconscious bias
d. Recording error
e. Measurement error
Interventions
1. Explain TB skin t est purpose and procedure and t he necessit y of ret urning
f or reading of t he skin react ion. O bt ain hist ory of occupat ion, living
condit ion, and reason f or t est ing.


1. I nt erpret t est out comes at t he prescribed t ime; monit or and counsel
appropriat ely about need f or chest radiograph and sput um cult ures f or t hose
w it h posit ive TB skin t est s. Discuss init ial
and cont inued t herapy and inst it ut e inf ect ion and case cont rol as required.
The possibilit y of TB disease must be ruled out bef ore prevent ive t herapy
can st art . TB is a report able disease.
Mumps Test
Mumps, t he common disease t hat produces sw elling and t enderness of t he
parot id glands, is caused by a myxovirus.
An ant igen made f rom inf ect ed monkeys or chickens is inject ed int radermally. A
posit ive mumps skin t est may indicat e eit her a previous inf ect ion or an exist ing
inf ect ion; t heref ore, it is not very eff ect ive as a diagnost ic t ool. The t est is used
primarily as part of a bat t ery of skin t est s t o det ermine immunocompet ence.
Reference Values
Normal
Same as described subsequent ly under Clinical I mplicat ions
Procedure
1. O bserve st andard precaut ions. Bef ore inject ing ant igen, assess f or allergy t o
eggs. Persons w ho are allergic t o eggs are at risk f or an anaphylact ic
react ion t o mumps ant igen.
2. I nject mumps ant igen int radermally.
1. A posit ive react ion indicat es resist ance t o t he mumps virus.
2. A negat ive react ion indicat es suscept ibilit y t o mumps virus.
Interpretation of the Test Results

1. Read t he t est 48 hours af t er t he t ime of inject ion.
2. Posit ive react ion: eryt hema and a lesion > 10 mm in diamet er.
3. Negat ive react ion: no eryt hema and a lesion < 10 mm in diamet er.
Interventions
1. Explain skin t est purpose and procedure.

1. I nt erpret t est out comes regarding immunocompet ence.
Candida and Tetanus Toxoid Tests Candida and tetanus

toxoid are additional skin tests that can be done to
detect delayed-type hypersensitivity. The Candida
antigen is a mixture of trichophytin and Oidium. Both
antigens are administered in a manner similar to the
tuberculin skin test.
To int erpret t hese skin t est s f or anergy, t he f ollow ing Cent ers f or Disease
Cont rol and Prevent ion guidelines are recommended:
1. For high-risk pat ient s (HI V inf ect ion, int ravenous drug abuse,
immunocompromise), an indurat ion area > 5 mm is considered posit ive.
2. For pat ient s at moderat e risk (inst it ut ionalized pat ient s, healt h care
w orkers), an indurat ed area > 10 mm is signif icant .
3. I n pat ient s w it h no signif icant risk f act ors, an indurat ed area of 15 mm or
larger is considered posit ive.

These addit ional skin t est s are helpf ul in evaluat ing a negat ive PPD t est in an
immunosuppressed person. No react ion t o mumps, t et anus, or Candi da t est ing
may indicat e a f alse-negat ive PPD t est . How ever, an indurat ion > 2 mm w it h t he
mumps, Candi da, or t et anus ant igen conf irms t he negat ive PPD result .
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Wilkins
> Table of C ontents > 8 - Im m unodiagnos tic S tudies
8
Immunodiagnostic Studies
OVERVIEW OF IM M UNODIAGNOSTIC STUDIES

I mmunodiagnost ic or serodiagnost ic t est ing st udies ant igen-ant ibody react ions
f or diagnosis of inf ect ious disease, aut oimmune disorders, immune allergies, and
neoplast ic disease. These modalit ies also t est f or blood groups and t ypes,
t issue and graf t t ransplant mat ching, and cellular immunology. Blood serum is
t est ed f or ant ibodies against part icular ant igens, hence t he t erm bl ood serol ogy
testi ng.
Anti gens are subst ances t hat st imulat e and subsequent ly react w it h t he product s
of an immune response. They may be enzymes, t oxins, microorganisms (eg,
bact erial, viral, parasit ic, f ungal), t umors, or aut oimmune f act ors. Anti bodi es are
prot eins produced by t he body's immune syst em in response t o an ant igen or
ant igens. The ant igen-ant ibody response is t he body's nat ural def ense against
invading organisms. Red blood cell groups cont ain almost 400 ant igens. I mmune
react ions t o t hese ant igens result in a w ide variet y of clinical disorders, w hich
can be t est ed (eg, Coombs' t est ).
Pat hologically, autoi mmune di sorders are produced by aut oant ibodies, t hat is,
ant ibodies against sel f . Examples include syst emic rheumat ic diseases, such as
rheumat oid art hrit is and lupus eryt hemat osus.
Immunodef i ci ency diseases exhibit a lack of one or more basic component s of
t he immune syst em, w hich includes B lymphocyt es, T lymphocyt es, phagocyt ic
cells, and t he complement syst em. These diseases are classif ied as primary (eg,
congenit al, DiG eorge syndrome) and secondary (eg, acquired immunodef iciency
syndrome [ AI DS] ).
Hypersensi ti vi ty react ions are document ed using immediat e hypersensit ivit y t est s
and are def ined as abnormally increased immune responses t o some allergens
(eg, allergic react ion t o bee st ings or pollens). Delayed hypersensit ivit y skin
t est s are commonly used t o evaluat e cell-mediat ed immunit y. Hist ocompat ibilit y
ant igens (t ransplant at ion ant igens) and t est s f or human leukocyt e ant igen (HLA)
are import ant diagnost ic t ools t o det ect and prevent immune reject ion in
t ransplant at ion.
Types of Tests
Many met hods of varying sophist icat ion are used f or immunodiagnost ic st udies
(Table 8. 1).
Table 8.1 Some Tests That Determine Antigen-An
Nam e of Test
Observable
Reaction
Visible
Change
Agglutination,
hemagglutination
(HA), immune
hemagglutination
assay (IHA)
Particulate
antigen reacts
with
corresponding
antibody; antigen
may be in form of
RBCs
(hemagglutination,
latex, or charcoal
coated with
antigen).
Clumping
Precipitation (eg,
immunodiffusion
[ID], counterimmunoelectrophoresis [CIE])
Soluble antigen
reacts with
corresponding
antibody by ID or
count.
Precipitates
Complement fixation
(CF)
Competition
between two
antigen-antibody
systems (test and
indicator systems)
Complement
activation,
hemolysis
Immunofluorescence
(eg, indirect
Fluorescenttagged antibody
reacts with
Visible
fluorescent antibody
[IFA])
antigen-antibody
complex in the
presence of
ultraviolet light.
microscopic
fluorescence
Enzyme
immunoassay (EIA)
Enzymes are used

to label induced
antigen-antibody
reactions.
Chromogenic
fluorescent or
luminescent
change in
substrate
Enzyme-linked
immunosorbent
assay (ELISA)
Indirect EIA for

quantification of
an antigen or
antibody enzyme
and substrate
Color change
indicates
enzyme
substrate
reaction.
Immunoblot (eg,
W estern blot [W B])
Electrophoresis
separation of
antigen
subspecies
Detection of
antibodies of
specific
mobility
Polymerase chain
reaction (PCR)
Amplifies low
levels of specific
DNA sequences;
each cycle
doubles the
amount of specific
DNA sequence.
Exponential
accumulation
of DNA
fragment being
amplified;
defects in DNA
appear as
mutations
Rate nephelometry
Flow cytometry
Measures either
antigen or
antibody in
solution through
the scattering of a
light beam;
antibody reagent
used to detect
antigen IgA, IgG,
IgM; concurrent
controls are run to
establish amount
of background
scatter in
reagents and test
samples.
Light scatter
proportionately
increases as
numbered size
of immune
complexes
increases.
Blood cell types

are identified with
monoclonal
antibodies (mABs)
specific for cell
markers by means
of a flow
cytometer with an
argon laser beam;
as the cells pass
the beam, they
scatter the light;
light energy is
converted into
electrical energy
Light scatter
identifies cell
size and
granularity of
lymphocytes,
monocytes,
and
granulocytes;
color
fluorochromes
tagged to
monoclonal
antibodies
bend to
specific
surface
cells and stained

with green
(fluorescence) or
orange
(phytoerythrin).
Restriction fragment
length
polymorphism
(RFLP)
cDNA probes
antigens for
simultaneous
detection of
lymphocyte
subsets.
DNA-based typing
technique
Uses cDNA
probes directed
against ribosomal
RNA
Amplifies
nucleic acid to
identify
presence of
bacterial or
viral load
Collection of Serum for Immunologic Tests Specific

antibodies can be detected in serum and other body
fluids (eg, synovial fluid, cerebrospinal fluid [CSF]).
1. Procure sampl es. For diagnosis of inf ect ious disease, a blood sample
(serum pref erred) using a 7-mL red-t opped t ube should be obt ained at illness
onset (acut e phase), and t he ot her sample should be draw n 3 t o 4 w eeks
lat er (convalescent phase). I n general, serologic t est usef ulness depends on
a t it er increase in t he t ime int erval bet w een t he acut e and t he convalescent
phase. For some serologic t est s, one serum sample may be adequat e if t he
ant ibody presence indicat es an abnormal condit ion or t he ant ibody t it er is
unusually high. See Appendix A f or st andard precaut ions and Appendix B f or
lat ex precaut ions.
2. Perf orm the serol ogi c test bef ore doi ng ski n testi ng. Skin t est ing of t en
induces ant ibody product ion and could int erf ere w it h serologic t est result s.
3. Label the sampl e properl y and submi t requested i nf ormati on. Place
specimen in biohazard bag. Send samples t o t he laborat ory prompt ly.

Hemolyzed samples cannot yield accurat e result s. Hemoglobin in t he serum
sample can int erf ere w it h complement -f ixing ant ibody values.
Interpreting Results of Immunologic Tests The

following factors affect test results:
1. Hist ory of previous inf ect ion by t he same organism
2. Previous vaccinat ion (det ermine t ime f rame)
3. Anamnest ic react ions caused by het erologous ant igens: an anamnesti c
reacti on is t he appearance of ant ibodies in t he blood af t er administ rat ion of
an ant igen t o w hich t he pat ient has previously developed a primary immune
response
4. Cross-react ivit y: ant ibodies produced by one species of an organism can
react w it h an ent irely diff erent species (eg, Tul aremi a ant ibodies may
agglut inat e Brucel l a and vice versa, ricket t sial inf ect ions may produce
ant ibodies react ive w it h Proteus O X19)
5. Presence of ot her serious illness st at es (eg, lack of immunologic response in
agammaglobulinemia, cancer t reat ment w it h immunosuppressant drugs)
6. Seroconversion: t he det ect ion of specif ic ant ibody in t he serum of an
individual w hen t his ant ibody w as previously undet ect able
Serologic Versus Microbiologic Methods Serologic

testing for microbial immunology evaluates the
presence of antibodies produced by antigens of
bacteria, viruses, fungi, and parasites. The best means
of establishing infectious disease etiology is by
isolation and confirmation of the involved pathogen.
Serologic methods
can assist or confirm microbiologic analysis when the

patient is tested late in the disease course,
antimicrobial therapy has suppressed organism
growth, or culture methods cannot verify a causative

agent.
BACTERIAL TESTS
Syphilis Detection Tests
Syphilis is a venereal disease caused by Treponema pal l i dum, a spirochet e w it h
closely w ound coils approximat ely 8 t o 15 m long. Unt reat ed, t he disease
progresses t hrough t hree st ages t hat can ext end over many years.
Ant ibodies t o syphilis begin t o appear in t he blood 4 t o 6 w eeks af t er inf ect ion
(Table 8. 2). Nont reponemal t est s det ermine t he presence of reagin, w hich is a
nont reponemal aut oant ibody direct ed against cardiolipin ant igens. These t est s
include rapid plasma reagin (RPR) and Venereal Disease Research Laborat ory
(VDRL). The U. S. Cent ers f or Disease Cont rol and Prevent ion (CDC) recommend
t hese t est s f or syphilis screening; how ever, t hey may show negat ive result s in
some cases of lat e syphilis. Biologic f alse-posit ive result s can also occur (Table
8. 3).
Table 8.2 Sensitivity of Commonly Used Serologic

Tests for Syphilis
Stage
Test
Primary
(%)
Secondary
(%)
Late
(%)
99
1*
NONTREPONEMAL (REAGIN) TESTS

Venereal Disease
Research Laboratory test
(VDRL)
70
Rapid plasma reagin card

test (RPR); automated
reagin test (ART)
80
99
SPECIFIC TREPONEMAL TESTS

Fluorescent treponemal
antibody absorption test
(FTA-ABS)
85
100
98
Treponema pallidium
particle agglutination
(TP-PA)
65
100
95
(This new procedure has sensitivity similar to MHA-TP.)

*Treated late syphilis.
Modified from Tramont EC: Treponema pallidium. In
Mandell GI, Douglas RE, Bennett JE (eds): Principles
and Practice of Infectious Diseases. New York, John
W iley & Sons, 1985, p. 1329. Also product insert
Serodia TP-PA, Fujirebio, Inc., Tokyo, Japan, 2000.
Table 8.3 Nonsyphilitic Conditions Giving Biologic

False-Positive Results (BFPs) Using VDRL and RPR
Tests
Approxim ate
Percentage BFPs
Disease
Malaria
100
Leprosy
60
Relapsing fever
30
Active immunization in
children
20
Infectious mononucleosis
20
Lupus erythematosus
20
Lymphogranuloma
venereum
20
Pneumonia, atypical
20
Rat-bite fever
20
Typhus fever
20
Vaccinia
20
Infectious hepatitis
10
Leptospirosis (W eil's
disease)
10
Periarteritis nodosa
10
Trypanosomiasis
10
Chancroid
Chickenpox
Measles
Rheumatoid arthritis
57
Rheumatic fever
56
Scarlet fever
Subacute bacterial
endocarditis
Pneumonia, pneumococcal
35
Tuberculosis, advanced
pulmonary
35
Blood loss, repeated
? (low)
Common cold
? (low)
Pregnancy
? (low)
Conversely, t reponemal (ie, specif ic) t est s det ect ant ibodies t o T. pal l i dum.
These t est s include t he part icle agglut inat ion T. pal l i dum t est (TP-PA) and t he
f luorescent t reponemal ant ibody t est (FTA-ABS). These t est s conf irm syphilis
w hen a posit ive nont reponemal t est result is obt ained. Because t hese t est s are
more complex, t hey are not used f or screening. Cert ain st at es require aut omat ic
conf irmat ion f or all react ive screening t est s by using a t reponemal t est such as
t he TP-PA or FTA-ABS.
Reference Values
Normal
Nonreact ive negat ive f or syphilis
Procedure
1. Collect a 7-mL blood serum sample in a red-t opped t ube. O bserve st andard
precaut ions. Fast ing is usually not required.
1. Diagnosis of syphilis requires correlat ion of pat ient hist ory, physical f indings,
and result s of syphilis ant ibody t est s. T. pal l i dum is diagnosed w hen both t he
screening and t he conf irmat ory t est s are react ive.
2. Treat ment of syphilis may alt er bot h t he clinical course and t he serologic
pat t ern of t he disease. Treat ment relat ed t o t est s t hat measure reagi n (RPR
and VDRL) includes t he f ollow ing measures:
a. I f t he pat ient is t reat ed at t he seronegat ive primary st age (eg, af t er t he
appearance of t he syphilit ic chancre but bef ore t he appearance of
react ion or reagin), t he VDRL remains nonreact ive.
b. I f t he pat ient is t reat ed in t he seroposit ive primary st age (eg, af t er t he
appearance of a react ion), t he VDRL usually becomes nonreact ive w it hin
6 mont hs of t reat ment .
c. I f t he pat ient is t reat ed during t he secondary st age, t he VDRL usually
becomes nonreact ive w it hin 12 t o 18 mont hs.
d. I f t he pat ient is t reat ed >10 years af t er t he disease onset , t he VDRL
usually remains unchanged.
3. A negat ive serologic t est may indicat e one of t he f ollow ing circumst ances:
a. The pat ient does not have syphilis.
b. The inf ect ion is t oo recent f or ant ibodies t o be produced. Repeat t est s
should be perf ormed at 1-w eek, 1-mont h, and 3-mont h int ervals t o
est ablish t he presence or absence of disease.
c. The syphilis is in a lat ent or inact ive phase.
d. The pat ient has a f ault y immunodef ense mechanism.
e. Laborat ory t echniques w ere f ault y.
False-Positive and False-Negative Reactions A positive

reaction is not conclusive for syphilis. Several
conditions produce biologic false-positive results for
syphilis. Biologic false-positive reactions are by no
means false. They may reveal the presence of other
serious diseases. It is theorized that reagin (reaction) is
an antibody against tissue lipids. Lipids are presumed
to be liberated from body tissue in the normal course
of activity. These liberated lipids may then induce
antibody formation. Nontreponemal biologic falsepositive reactions can occur in the presence of drug
abuse, lupus erythematosus, mononucleosis, malaria,
leprosy, viral pneumonia, recent immunization, or, on
rare occasions, pregnancy. False-negative reactions
may occur early in the disease course or during
inactive or later stages of disease.
Interfering Factors
1. Excess chyle in t he blood int erf eres w it h t est result s.
2. Alcohol decreases react ion int ensit y in t est s t hat det ect reagin; t heref ore,
alcohol ingest ion should be avoided f or at least 24 hours bef ore blood is
draw n.
Clin ical Alert

Avoid draw ing t he blood sample immediat ely af t er a meal.
Interventions
1. Explain t est purpose and procedure. Assess f or int erf ering f act ors. I nst ruct
t he pat ient t o abst ain f rom alcohol f or at least 24 hours bef ore t he blood
sample is draw n.
care.

1. I nt erpret t est result s and counsel appropriat ely. Explain biologic f alseposit ive or f alse-negat ive react ions. Advise t hat repeat t est ing may be
necessary.
Clin ical Alert

1. Sexual part ners of pat ient s w it h syphilis should be evaluat ed f or t he
disease.
2. Af t er t reat ment , pat ient s w it h early-st age syphilis should be t est ed at 3mont h int ervals f or 1 year t o monit or f or declining react ivit y.
Lyme Disease Tests

Lyme disease is a mult isyst em disorder caused by t he spirochet e Borrel i a
burgdorf eri . I t is t ransmit t ed by t he bit e of t iny deer t icks, w hich reside on deer
and ot her w ild animals. Lyme disease is present w orldw ide, but cert ain
geographic areas show higher incidences. Transmission t o humans is highest
during t he spring, summer, and early f all mont hs. The t ick bit e usually produces
a charact erist ic rash, t ermed erythema chroni cum mi grans. I f unt reat ed,
sequelae lead t o serious joint , cardiac, and cent ral nervous syst em (CNS)
sympt oms.
Serologic t est ing f or ant ibodies t o Lyme disease includes enzyme-linked
immunosorbent assay (ELI SA) and West ern blot analysis. Ant ibody f ormat ion
t akes place in t he f ollow ing manner: immunoglobulin M (I gM) is det ect ed 3 t o 4
w eeks af t er Lyme disease onset , peaks at 6 t o 8 w eeks af t er onset , and t hen
gradually disappears. I gG is det ect ed 2 t o 3 mont hs af t er inf ect ion and may
remain elevat ed f or years. Current CDC recommendat ions f or t he serologic
diagnosis of Lyme disease are t o screen w it h a polyvalent ELI SA (I gG and I gM)
and t o perf orm supplement al t est ing (West ern blot ) on all equivocal and/ or
posit ive ELI SA result s.
West ern blot assays f or ant ibodies t o B. burgdorf eri are supplement al rat her
t han conf irmat ory because t heir specif icit y is less t han opt imal, part icularly f or
det ect ing I gM. Tw o-st ep posit ive result s provide support ive evidence of exposure
t o B. burgdorf eri, w hich could support a clinical diagnosis of Lyme disease but
should not be used as a crit erion f or diagnosis.
Reference Values
Normal
Negat ive f or bot h I gG and I gM Lyme ant ibodies by ELI SA and West ern blot
Procedure
1. Collect a 7-mL blood serum sample in a red-t opped t ube. Cerebrospinal f luid
may also be used f or t he t est .
3. Place specimen in a biohazard bag.
1. Serologic t est s lack t he degree of sensit ivit y, specif icit y, and st andardizat ion
necessary f or diagnosis in t he absence of clinical hist ory. The ant igen
det ect ion assay f or bact erial prot eins is of limit ed value in early st ages of
disease.
2. I n pat ient s present ing w it h a clinical pict ure of Lyme disease, negat ive
serologic t est s are inconclusive during t he f irst mont h of inf ect ion.
3. Repeat paired t est ing should be perf ormed if borderline values are report ed.
4. The CDC st at es t hat t he best clinical marker f or Lyme disease is t he init ial
skin lesion eryt hema migrans (EM), w hich occurs in 60% t o 80% of pat ient s.
5. CDC laborat ory crit eria f or t he diagnosis of Lyme disease include t he
f ollow ing f act ors:
a. I solat ion of B. burgdorf eri f rom a clinical specimen
b. I gM and I gG ant ibodies in blood or CSF

c. Paired acut e and convalescent blood samples show ing signif icant
ant ibody response t o B. burgdorf eri
Interfering Factors
1. False-posit ive result s may occur w it h high levels of rheumat oid f act ors or in
t he presence of ot her spirochet e inf ect ions, such as syphilis (crossreact ivit y).
2. Asympt omat ic individuals w ho spend t ime in endemic areas may have already
produced ant ibodies t o B. burgdorf eri .
Interventions
1. Assess pat ient 's clinical hist ory, exposure risk, and know ledge regarding t he
t est . Explain t est purpose and procedure as w ell as possible f ollow -up
t est ing.
care.

1. I nt erpret t est out comes f or a posit ive t est . Advise t hat f ollow -up t est ing may
be required t o monit or response t o ant ibiot ic t herapy.
2. Unlike ot her diseases, people do not develop resist ance t o Lyme disease
af t er inf ect ion and may conti nue to be at hi gh ri sk, especially if t hey live,
w ork, or recreat e in areas w here Lyme disease is present .
3. I f Lyme disease has been ruled out , f urt her t est ing may include Babesi a
mi croti , a parasit e t ransmit t ed t o humans by a t ick bit e. Sympt oms include
loss of appet it e, f ever, sw eat s, muscle pain, nausea, vomit ing, and
headaches.
care.
Legionnaire's Disease Antibody Test Legionnaire's
disease is a respiratory condition caused by Legionella

pneumophila. It is best diagnosed by organism culture;
however, the organism is difficult to grow.
Det ect ion of L. pneumophi l a in respirat ory specimens by means of direct
f luorescent ant ibody (DFA) t echnique is usef ul f or rapid diagnosis but lacks
sensit ivit y w hen only small numbers of organisms are available. Serologic t est s
should be used only if specimens f or cult ure are not available or if cult ure and
DFA produce negat ive result s.
Reference Values
Normal
Negat ive f or Legionnaire's disease by indirect f luorescent ant ibody (I FA) t est or
ELI SA
Procedure
precaut ions. Place specimen in a biohazard bag f or t ransport t o t he
laborat ory.
2. Be aw are t hat f ollow -up t est ing is usually request ed 3 t o 6 w eeks af t er init ial
sympt om appearance.
3. Alert pat ient t hat a urine specimen may be required if ant igen t est ing is
indicat ed.
1. A dramat ic rise of t it er t o levels t o more t han 1: 128 in t he int erval bet w een
acut e- and convalescent -phase specimens occurs w it h recent inf ect ions.
2. Serologic t est s, t o be usef ul, must be perf ormed on an acut e (w it hin 1 w eek
of onset ) and convalescent (3 t o 6 w eeks lat er) specimen.
3. Serologic t est ing is valuable because it provides a conf irmat ory diagnosis of
L. pneumophi l a inf ect ion w hen ot her t est s have f ailed. I FA is t he serologic
t est of choice because it can det ect all classes of ant ibodies.
4. Demonst rat ion of L. pneumophi l a ant igen in urine by ELI SA is indicat ive of
inf ect ion.
Interventions
1. Assess clinical hist ory and know ledge about t he t est . Explain purpose and
procedure of blood t est .
care.

1. I nt erpret t est out comes and signif icance. Advise t hat negat ive result s do not
rule out L. pneumophi l a. Follow -up t est ing is usually needed.
care.
Chlamydia Antibody IgG Test

Chlamydia is caused by a genus of bact eria (Chl amydi a spp. ) t hat require living
cells f or grow t h and are classif ied as obligat e cell parasit es. Recognized
species include Chl amydi a psi ttaci , Chl amydi a pneumoni ae, and Chl amydi a
trachomati s. C. psi ttaci causes psit t acosis in birds and humans. C. pneumoni ae
is responsible f or approximat ely 10% of cases of communit y-acquired
pneumonia. C. trachomati s is grouped int o t hree serot ypes. O ne group causes
lymphogranuloma venereum (LG V), a venereal disease. Anot her group causes
t rachoma, an eye disease. The t hird group causes genit al t ract inf ect ions
diff erent f rom LG V. Cult ure of t he organism is def init ive f or chlamydiae. C.
trachomati s inf ect ion is t he most common report able sexually t ransmit t ed
disease (STD) in t he Unit ed St at es. The nat ional inf ect ion rat e f or C.
trachomati s is est imat ed t o be 3 million cases annually.
Because Chl amydi a organisms are diff icult t o cult ure and grow, ant ibody t est ing
aids in diagnosis of chlamydial inf ect ion.
Reference Values
Normal
Negat ive f or chlamydia ant ibody by complement f ixat ion (CF), I FA, and PCR
t est s
Procedure
precaut ions.
1. Presence of ant ibody t it er indicat es past chlamydial inf ect ion. A f ourf old or
great er rise in ant ibody t it er bet w een acut e and convalescent specimens
indicat es recent inf ect ion. Serologic t est s cannot diff erent iat e among t he
species of Chl amydi a.
2. I nf ect ion w it h psit t acosis is revealed in an elevat ed ant ibody t it er. Hist ory
w ill reveal cont act w it h inf ect ed birds (pet s or poult ry).
3. LG V in males is charact erized by sw ollen and t ender inguinal lymph nodes. I n
f emales, sw elling occurs in t he int raabdominal, perirect al, and pelvic lymph
nodes. Chl amydi a causes uret hrit is in males. I t can inf ect t he f emale uret hra
and endocervix, and it is also a cause of pelvic inf lammat ory disease in
f emales. Eye disease caused by Chl amydi a is endemic in part s of Af rica, t he
Middle East , and Sout heast Asia, alt hough it s presence is est ablished
w orldw ide. Cult ure and st ained smear ident if icat ion of t he organism is
diagnost ic.
Interfering Factors
Depending on geographic locat ion, nonspecif ic t it ers can be f ound in t he general
healt hy populat ion.
Interventions
1. Assess pat ient know ledge regarding t he t est and explain purpose and
procedure. Elicit hist ory regarding possible exposure t o organism.
care.
1. I nt erpret t est out comes and signif icance of t est result s. Ref er t o page 532
f or int erpret at ion of immunodiagnost ic t est result s.
care.
Streptococcal Antibody Tests: Anti-Streptolysin O Titer

(ASO), Streptozyme, Anti-DNase B (ADB,
Streptodornase) Group A -hemolytic streptococci are
associated with streptococcal infections or illness.
These t est s det ect ant ibodies t o enzymes produced by organisms. G roup A hemolyt ic st rept ococci produce several enzymes, including st rept olysin O ,
hyaluronidase, and DNase B. Serologic t est s t hat det ect t hese enzyme
ant ibodies include ant ist rept olysin O t it er (ASO ), w hich det ect s st rept olysin O ;
st rept ozyme, w hich det ect s ant ibodies t o mult iple enzymes; and ant i-DNase B
(ADB), w hich det ect s DNase B. Serologic det ect ion of st rept ococcal ant ibodies
helps t o est ablish prior inf ect ion but is of no value f or diagnosing acut e
st rept ococcal inf ect ions. Acut e inf ect ions should be diagnosed by direct
st rept ococcal cult ures or t he presence of st rept ococcal ant igens.
The ASO t est aids in t he diagnosis of several condit ions associat ed w it h
st rept ococcal inf ect ions, such as rheumat ic f ever, glomerulonephrit is,
endocardit is, and scarlet f ever. Serial rising t it ers over several w eeks are more
signif icant t han a single result . ADB ant ibodies may appear earlier t han ASO in
st rept ococcal pharyngit is, and t his t est is more sensit ive f or st rept ococcal
pyoderma.
Reference Values
Normal
ASO t it er: <166 Todd unit s (or <200 I U) Ant i-DNase B (ADB)
Birt h4 years: <170 U
519 years: <480 U
>20 years: <340 U
St rept ozyme: negat ive f or st rept ococcal ant ibodies
Procedure

laborat ory.
2. Repeat t est ing 10 days af t er t he f irst t est is recommended.
1. I n general, a t it er >166 Todd unit s is considered a def init e elevat ion f or t he
ASO t est .
2. The ASO or t he ADB t est alone is posit ive in 80% t o 85% of group A
st rept ococcal inf ect ions (eg, st rept ococcal pharyngit is, rheumat ic f ever,
pyoderma, glomerulonephrit is).
3. When ASO and ADB t est s are run concurrent ly, 95% of st rept ococcal
inf ect ions can be det ect ed.
4. A repeat edly low t it er is good evidence f or t he absence of act ive rheumat ic
f ever. Conversely, a high t it er does not necessarily mean rheumat ic f ever of
glomerulonephrit is is present ; how ever, it does indicat e t he presence of a
st rept ococcal inf ect ion.
5. ASO product ion is especially high in rheumat ic f ever and glomerulonephrit is.
These condit ions show marked ASO t it er increases during t he sympt omless
period preceding an at t ack. Also, ADB t it ers are part icularly high in
pyoderma.
Interfering Factors
1. An increased t it er can occur in healt hy carriers.
2. Ant ibiot ic t herapy suppresses st rept ococcal ant ibody response.
3. I ncreased B-lipoprot ein levels inhibit st rept olysin O and produce f alsely high
ASO t it ers.
Clin ical Alert

The ASO t est is impract ical in pat ient s w ho have recent ly received ant ibiot ics
or w ho are scheduled f or ant ibiot ic t herapy because t he t reat ment suppresses
t he ant ibody response.
Interventions
1. Assess pat ient 's clinical hist ory and t est know ledge. Explain t est purpose
and procedure.
care.

1. I nt erpret t est out comes. Ref er t o page 532 f or int erpret at ion of immunologic
t est result s. Explain t est result s. I nf orm pat ient t hat repeat t est ing is
f requent ly required.
care.
Helicobacter pylori (HPY) IgG Antibody Serum, Stool,

and Breath (PY) Test H. pylori (previously known as
campylobacter pylori) is a bacterium associated with
gastritis, duodenal and gastric ulcers, and possibly
gastric carcinoma. The clinician orders this test when
screening a patient for possible H. pylori infection. The
organism is present in 95% to 98% of patients with
duodenal ulcers and 60% to 90% of patients with
gastric ulcers. A person with gastrointestinal
symptoms with evidence of H. pylori colonization (eg,
presence of specific antibodies, positive breath test,
positive culture, positive biopsy) is considered to be
infected with H. pylori. A person without
gastrointestinal symptoms having evidence of the
presence of H. pylori is said to be colonized rather than
infected.
This t est det ect s H. pyl ori inf ect ion of t he st omach. Tradit ionally, t he presence
of H. pyl ori has been det ect ed t hrough biopsy specimens obt ained by
endoscopy. As w it h any invasive procedure, t here is risk and discomf ort t o t he
pat ient . Noninvasive met hods of det ect ion include t he f ollow ing:
1. An H. pyl ori breat h t est , w hich uses a liquid scint illat ion count er t o det ect
gast ric urease and t o measure 14 CO 2 in breat h specimens
2. Serologyblood serum
3. St ool: H. pyl ori st ool ant igen t est (HpSa)
The presence of H. pyl orispecif ic I gG ant ibodies has been show n t o be an
accurat e indicat or of H. pyl ori colonizat ion. ELI SA t est ing relies on t he presence
of H. pyl ori I gG -specif ic ant ibody t o bind t o ant igen on t he solid phase, f orming
an ant igen-ant ibody complex t hat undergoes f urt her react ions t o produce a color
indicat ive of t he presence of ant ibody and is quant if ied using a
spect rophot omet er or ELI SA microw eld plat e reader. The sensit ivit y is 94% and
specif icit y 78%, compared w it h an invasive procedure, such as biopsy, f or w hich
t he sensit ivit y is 93% and specif icit y 99%.
Reference Values
Normal
Negat ive f or H. pyl ori by ELI SA indicat es no det ect able I gG ant ibody in serum or
st ool.
A posit ive result indicat es t he presence of det ect able I gG ant ibody in serum or
st ool.
Breath:
Negat ive: <50 DPM f or H. pyl ori 50199 DPM indet erminat e f or H. pyl ori >200
DPM posit ive f or H. pyl ori
Procedure
laborat ory.
2. Be aw are t hat a random st ool specimen may be ordered t o t est f or t he
presence of H. pyl ori ant igen.
3. Remember t hat t his is a complex procedure. Use a special kit f or t he breat h
t est . Ensure t hat t he collect ion balloon is f ully inf lat ed. Transf er t he breat h
specimen t o t he laborat ory. Keep at room t emperat ure.
1. This assay is int ended f or use as an aid in t he diagnosis of H. pyl ori, and
addit ionally, f alse-negat ive result s may occur. The clinical diagnosis should
not be based on serology alone but rat her on a combinat ion of serology (and
breat h or st ool t est s), sympt oms, and gast ric biopsybased t est s as
w arrant ed.
2. The st ool ant igen t est is used t o monit or response during t herapy and t o t est
f or cure af t er t reat ment .
Edu cation Alert for Breath Test

1. The pat ient should have no ant ibiot ics and bismut h f or 1 mont h and no
prot on pump inhibit ors and sucralf at e f or 2 w eeks bef ore t est .
2. I nst ruct t he pat ient not t o chew t he capsule.
3. The pat ient should be at rest during breat h collect ion.
Interventions
1. Explain t est purpose, procedure, and know ledge of signs and sympt oms and
risk f act ors f or t ransmission: close living quart ers, many persons in
household, poor household sanit at ion and hygiene. The pat ient sw allow s a
capsule bef ore a breat h specimen is obt ained. The serum ant ibody t est
w ould be appropriat e f or a previously unt reat ed pat ient w it h a document ed
hist ory of gast roduodenal ulcer disease and unknow n H. pyl ori inf ect ion
st at us.
care.

1. I nt erpret t est out comes in light of pat ient 's hist ory, including ot her clinical
and laborat ory f indings. Explain t reat ment (46 w eeks of ant ibiot ics t o
eradicat e H. pyl ori and medicat ion t o suppress acid product ion) and need f or
f ollow -up t est ing. Transmission is unknow n but pot ent ial f or t ransmission may
occur during episodes of G I illness, part icularly w it h vomit ing. Many persons
may be inf ect ed w it h H. pyl ori but are asympt omat ic.
care.
VIRAL TESTS
Epstein-Barr Virus (EBV) Antibody Tests: Infectious
Mononucleosis (IM) Slide (Screening) Test, Heterophile
Antibody Titer, Epstein-Barr Antibodies to Viral Capsid
Antigen and Nuclear Antigen Epstein-Barr virus (EBV)
is a herpesvirus found throughout the world. The most
common symptomatic manifestation of EBV infection is
a disease known as infectious mononucleosis (IM).
This disease induces formation of increased numbers
of abnormal lymphocytes in the lymph nodes and
stimulates increased heterophile antibody formation.
IM occurs most often in young adults who have not
been previously infected, through contact with
infectious oropharyngeal secretions. Symptoms
include fever, pharyngitis, and lymphadenopathy. EBV
is also thought to play a role in the etiology of Burkitt's
lymphoma, nasopharyngeal carcinoma, and chronic
fatigue syndrome.
The most common t est f or EBV is t he rapid slide t est (Monospot ) f or het erophile
ant ibody agglut inat ion. The het erophile ant ibody agglut inat ion t est is not specif ic
f or EBV and t heref ore is not usef ul f or evaluat ing chronic disease. I f t he
het erophile t est is negat ive in t he presence of acut e I M sympt oms, specif ic EBV
ant ibodies should be det ermined. These include ant ibodies t o viral capsid ant igen
(ant i-VCA) and ant ibodies t o EBV nuclear ant igen (EBNA) using I FA and ELI SA
t est s.
Diagnosis of I M is based on t he f ollow ing crit eria: clinical f eat ures compat ible
w it h I M, hemat ologic pict ure of relat ive and absolut e lymphocyt osis, and
presence of het erophile ant ibodies.
Reference Values
Normal
Negat ive f or I M and EBV ant ibodies by lat ex agglut inat ion (I M) and I FA or ELI SA
(EBV)
Procedure
precaut ions.
1. The presence of het erophile ant ibodies (Monospot ), along w it h clinical signs
and ot her hemat ologic f indings, is diagnost ic f or I M.
2. Het erophile ant ibodies remain elevat ed f or 8 t o 12 w eeks af t er sympt oms
appear.
3. Approximat ely 90% of adult s have ant ibodies t o t he virus.
4. The Monospot t est is negat ive more f requent ly in children and almost
unif ormly in inf ant s w it h primary EBV inf ect ion.
Interventions
1. Assess pat ient 's clinical hist ory, sympt oms, and t est know ledge. Explain t est
purpose and procedure. I f preliminary t est s are negat ive, f ollow -up t est s
may be necessary.
care.

t est result s. Explain t reat ment (eg, support ive t herapy [ I V f luids] ). Af t er
primary exposure, a person is considered immune. Recurrence of I M is rare.
2. Remember t hat resolut ion of I M usually f ollow s a predict able course:
pharyngit is disappears w it hin 14 days af t er onset ; f ever subsides w it hin 21
days; and f at igue, lymphadenopat hy, and liver and spleen enlargement
regress by 21 t o 28 days.
care.
Hepatitis Tests: Hepatitis A (HAV), Hepatitis B (HBV),

Hepatitis C (HCV), Hepatitis D (HDV), Hepatitis E (HEV),
Hepatitis G (HGV)
Hepat it is can be caused by viruses and several ot her agent s, including drugs and
t oxins. Approximat ely 95% of hepat it is cases are due t o f ive major virus t ypes:
hepat it is A, B, C, D, and E (Table 8. 4). Diagnosing t he specif ic virus is diff icult
because t he sympt oms (eg, chills, w eight loss, f ever, dist ast e f or cigaret t es and
f ood, darker urine and light er st ool) present ed by each viral t ype are similar.
Addit ionally, some individuals may be asympt omat ic or have very mild sympt oms
t hat are ascribed t o t he f lu. Serologic t est s f or hepat it is virus markers have
made it easier t o def ine t he specif ic t ype.
Table 8.4 Hepatitis Test Findings in Various Stages
Viral Specific and Serologic Tests

Disease
Stages
Acute
HAV
HBV
HCV
HDV
HEV
IgM antiHAV
IgM
antiHBc,
HBsAg
AntiHCV
HDAg
IgM an
HAV
Fecal
2%10%
of all
persons
6%
Chronic
Infectivity
Recovery
HAV 12
wk before
symptoms
85%
AntiHCV
Total
antiHDV
None
HBeAg,
HBsAg,
HBVDNA
AntiHCV
Total
antiHDV
None
None
AntiHBe,
anti-HBs
None
None
None
HBV
DNA
HCV
RNA
None
Uncerta
Viral load
(viral
genome)
Carrier
state
Immunity
Acute
viral
panel
>5 yr
will
progress
to
chronic
infection
None
HBsAg
None
HBAg,
antiHDV
Total antiHAV
AntiHBs,
total
anti-HBc
None
None
IgM antiHEV
HBsAg
AntiHCV,
HIV
test
None
also
Hepati ti s A vi rus (HAV), w hich is acquired t hrough ent eric t ransmission, inf ect s
t he gast roint est inal t ract and is eliminat ed t hrough t he f eces. Serologically, t he
presence of t he I gM ant ibody t o HAV (I gM ant i-HAV) and t he t ot al ant ibody t o
HAV (t ot al ant i-HAV) ident if ies t he disease and det ermines previous exposure or
recovery f rom HAV.
Hepati ti s B vi rus (HBV) demonst rat es a cent ral core cont aining t he core ant igen
and a surrounding envelope cont aining t he surf ace ant igen: less t han 0. 01 pg/ mL
f or viral load. Det ect ion of core ant igen (HBcAg), envelope ant igen (HBeAg), and
surf ace ant igen (HBsAg) or t heir corresponding ant ibodies const it ut es hepat it is B
serologic or plasma assessment . Viral t ransmission occurs t hrough exposure t o
cont aminat ed blood or blood product s t hrough an open w ound (eg, needle st icks,
lacerat ions). Hepat it is monit oring panel f or serial t est ing includes f our B
markers: HBsAg, HBeAg, ant i-HBe, and ant i-HBs. I nt erpret at ion depends on
clinical set t ing. Hepat it is B DNA Ult ra Sensit ive Q uant it at ive PCR is t he most
sensit ive t est available f or hepat it is B viral load.
Hepati ti s C vi rus (HCV), f ormerly know n as non-A, non-B hepat it is, is also
t ransmit t ed parent erally. HCV inf ect ion is charact erized by presence of
ant ibodies t o hepat it is C (ant i-HCV) and levels of alanine aminot ransf erase
(ALT), w hich f luct uat e bet w een normal and markedly elevat ed. Levels of ant iHCV remain posit ive f or many years; t heref ore, a react ive t est indicat es inf ect ion
w it h HCV or a carrier st at e but not inf ect ivit y or immunit y. Polymerase chain
react ion (PCR) or reverse t ranscript ase PCR (RT-PCR) (viral load), w hich
det ect s HCV RNA, should be used t o conf irm inf ect ion w hen acut e hepat it is C is
suspect ed. A negat ive hepat it is C
ant ibody (recombinant immunoblot assay [ RI BA] ) does not exclude t he possibilit y
of HCV inf ect ion because seroconversion may not occur f or up t o 6 mont hs af t er
exposure.
Hepati ti s D vi rus (HDV) is encapsulat ed by t he HBsAg. Wit hout t he HBsAg
coat ing, HDV cannot survive. Because HDV can cause inf ect ion only in t he
presence of act ive HBV inf ect ion, it is usually f ound w here a high incidence of
HBV occurs. Transmission is parent eral. Serologic HDV det erminat ion is made by
det ect ion of t he hepat it is D ant igen (HDAg) early in t he course of t he inf ect ion
and by det ect ion of ant i-HDV ant ibody (ant i-HDV) in t he lat er st ages of t he
disease.
Hepati ti s E vi rus (HEV) is t ransmit t ed ent erically and is associat ed w it h poor
hygienic pract ices and unsaf e w at er supplies, especially in developing count ries.
I t is quit e rare in t he Unit ed St at es. Specif ic serologic t est s include det ect ion of
I gM and I gG ant ibodies t o hepat it is E (ant i-HEV).
Hepati ti s G vi rus (HG V) is t ransmit t ed by cont aminat ed blood supply and is seen
w hen HCV and HBV are det ect ed t oget her. See Table 8. 5 f or a summary of t he
f eat ures of t he diff erent hepat it is agent s.
Table 8.5 Summary of Clinical and Epidemiologic Featu
Features
Hepatitis
A
Hepatitis
B
Hepatitis
C
Hepati
D
Incubation
period
4550 d
30150 d
15110 d
30150
Onset
Abrupt
Insidious
Insidious
Abrupt
Jaundice
Children:
10%;
adults:
70%
80%
25%
25%
Varies
Most
children
Most
children;
adults:
50%
About
75%
Rare
Asymptomatic
patients
Routes of transmission
Fecal/oral
Parenteral
Sexual
Perinatal
W ater/food
Chronic state
Case fatality
rate
Yes
Rare
No
No
Yes
No
Yes
Yes
Yes
No
No
Yes
Possible
Possible
No
No
Yes
Yes
Possib
No
No
Adults:
6%10%;
children:
25%
50%;
infants:
70%
90%
50%
10%
15%
1.4%
Liver
cancer
1%2%
Liver
cancer
with HBV
and HCV
30%
0.6%
The f ollow ing t erms are used: ALT (al ani ne ami notransf erase): an enzyme
normally produced by t he liver; blood levels may increase in cases of liver
damage Anti -HBc: ant ibody t o hepat it is B core ant igen Anti -HBe: ant ibody t o
hepat it is B envelope ant igen Anti -HBs: ant ibody t o hepat it is B surf ace ant igen
Anti body: a Y-shaped prot ein molecule (immunoglobulin) in serum or body f luid
t hat eit her neut ralizes an ant igen or t ags it f or at t ack by ot her cells or
chemicals; act s by unit ing w it h and f irmly binding t o an ant igen. The pref ix anti f ollow ed by init ials of a virus ref ers t o specif ic ant ibody against t he virus.
Chroni c hepati ti s: a condit ion in w hich sympt oms and/ or signs of hepat it is persist
f or >6 mont hs Ci rrhosi s: irreversible scarring of t he liver t hat may occur af t er
acut e or chronic hepat it is Del ta agent: a unique RNA virus t hat causes acut e or
chronic hepat it is; requires HBV f or replicat ion and inf ect s only pat ient s w ho are
HBsAg-posit ive; is composed of a delt a ant igen core and a HBsAg coat ; also
know n as HDV
Endemi c: present in a communit y at all t imes but occurring in a small number of
cases Enteri c route: spread of organisms t hrough t he oral-int est inal-f ecal cycle
Fl avi vi rus: a f amily of small RNA viruses; HCV is similar t o members of t he
Flavivirus f amily.
Ful mi nant hepati ti s: t he most severe f orm of hepat it is; may lead t o acut e liver
f ailure and deat h HBcAg: hepat it is B core ant igen HBsAg: hepat it is B surf ace
ant igen Hepatotropi c: having an aff init y f or or exert ing a specif ic eff ect on t he
liver IgG : a f orm of immunoglobulin t hat occurs lat e in an inf ect ious process IgM:
a f orm of immunoglobulin t hat occurs early in an inf ect ious process IgM anti HAV: M-class immunoglobulin ant ibody t o HAV
IgM anti -HBc: M-class immunoglobulin ant ibody t o HBcAg Immune gl obul i n: a
st erile solut ion of w at er-soluble prot eins t hat cont ains t hose ant ibodies normally
present in adult human blood; used as a passive immunizing agent against
various viruses such as HAV
Negati ve-sense RNA vi rus: a virus in w hich t he viral prot eins are encoded by
messenger RNA molecules t hat are complement ary t o t he viral genome Non-A,
non-B hepati ti s: viral hepat it is caused by viruses ot her t han A, B, or D (eg, C, E)
Parenteral : ent ering t he body subcut aneously, int ramuscularly, or int ravenously,
or ot her means w hereby t he organisms reach t he bloodst ream direct ly Posi ti vesense RNA vi rus: a virus in w hich t he parent eral (or genomic) RNA serves as t he
messenger RNA f or prot ein synt hesis Recombi nant anti gen: an ant igen t hat
result s f rom t he recombinat ion of genet ic component s, w hich t hen are art if icially
int roduced int o a cell, leading t o synt hesis of a new prot ein
Vi ral l oad: t he amount or concent rat ion of virus in t he circulat ion New vi ruses
G BV-A, G BV-B, and G BV-C: may be causat ive agent s in non-A t hrough E
hepat it is These measurement s are used f or diff erent ial diagnosis of viral
hepat it is, viral load. Serodiagnosis of previous exposure and recovery of viral
hepat it is is complex because of t he number of serum or plasma markers
necessary t o det ermine t he st age of illness. Test ing met hods include ELI SA,
micropart icle enzyme immunoassay (MEI A), PCR, and RT-PCR and t est s f or viral
genome (viral load).
Indications for Hepatitis B Vaccine

1. Family members of adopt ees f rom f oreign count ries w ho are HBsAg posit ive
2. Healt h care w orkers (dent ist , DO , MD, RN, and t rainees in healt h care
f ields)
3. Hemodialysis pat ient s or pat ient s w it h early renal f ailure
4. Household or sexual cont act s of persons chronically inf ect ed w it h hepat it is B
5. I mmigrant s f rom Af rica or Sout heast Asia; recommended f or children <11
years old and all suscept ible household cont act s of persons chronically
inf ect ed w it h hepat it is B
6. I nject ion drug users
7. I nmat es of long-t erm correct ional f acilit ies
8. Client s and st aff of inst it ut ions f or t he development ally disabled
9. I nt ernat ional t ravelers t o count ries of high or int ermediat e HBV endemicit y
10. Laborat ory w orkers
11. Public saf et y w orkers (eg, police, f ire f ight ers)
12. Recipient s of clot t ing f act ors. Use a f ine needle (<23 gauge) and f irm
pressure at inject ion sit e f or >2 minut es.
13. Persons w it h sexually t ransmit t ed diseases or mult iple sexual part ners in
previous 6 mont hs, prost it ut es, homosexual and bisexual men
14. Post vaccinat ion blood t est ing is recommended f or sexual cont act s of HBsAgposit ive persons; healt h care w orkers at high risk, recipient s of clot t ing
f act ors, t hose w ho are HBsAg-posit ive
15. Persons in nonresident ial day care programs should be vaccinat ed if an
HBsAg-posit ive classmat e behaves aggressively or has special medical
problems t hat increase t he risk f or exposure t o blood. St aff in nonresident ial
day care programs should be vaccinat ed if a client is HBsAg-posit ive.
a. O bserve ent eric and st andard precaut ions f or 7 days af t er onset of
sympt oms and/ or jaundice w it h hepat it is B. Hepat it is A is most
cont agious bef ore sympt oms and/ or jaundice appear.
b. Use st andard blood and body f luid precaut ions f or t ype B hepat it is and B
ant igen carriers. Precaut ions apply unt il t he pat ient is HBsAg negat ive
and t he ant i-HBs appears. Avoid sharps (eg, needles, scalpel blades)
injuries. Should accident al injury occur, encourage some bleeding, and
w ash area w ell w it h a germicidal soap. Report injury t o proper
depart ment , and f ollow up w it h necessary int ervent ions. Put on gow n
w hen blood splat t ering is ant icipat ed. A privat e hospit al room and
bat hroom may be indicat ed.
16. Persons w it h a hist ory of receiving blood t ransf usion should not donat e blood
f or 6 mont hs. Transf usion-acquired hepat it is may not show up f or 6 mont hs
af t er t ransf usion. Persons w ho t est posit ive f or HBsAg should never donat e
blood or plasma.
17. Persons w ho have sexual cont act w it h hepat it is Binf ect ed individuals run a
great er risk f or acquiring t hat same inf ect ion. HBsAg appears in most body
f luids, including saliva, semen, and cervical secret ions.
18. O bserve st andard precaut ions in all cases of suspect ed hepat it is unt il t he
diagnosis and hepat it is t ype are conf irmed.
Reference Values
Normal
1. Negat ive (nonreact ive) f or hepat it is A, B, C, D, or E by ELI SA, MEI A, PCR
or RI BA, or RT-PCR
2. Negat ive or undet ect ed viral load (not used f or primary inf ect ion, only t o
monit or). PCR requires a separat e specimen collect ion.
3. Hepat it is B viral DNA (HBV-DNA) negat ive or nonreact ive viral load (<0. 01
pg/ mL) in an inf ect ed individual bef ore t reat ment
Procedure
1. Collect a 7-mL blood serum sample in a red-t opped t ube or t w o lavendert opped et hylenediaminet et raacet ic acid (EDTA) t ubes, 5 mL each, f or
plasma. O bserve st andard precaut ions. Cent rif uge prompt ly and asept ically.
Place specimen in a biohazard bag f or t ransport t o t he laborat ory. Send
specimens f rozen on dry ice. Check w it h your laborat ory f or prot ocols and
w het her plasma or serum is needed.
2. Be aw are t hat some specimens need t o be split int o t w o plast ic vials bef ore
f reezing and sent f rozen on dry ice. Check w it h your laborat ory.
1. I ndividuals w it h hepat it is may have generalized sympt oms resembling t he f lu
and may dismiss t heir illness as such.
2. A specif ic t ype of hepat it is cannot be diff erent iat ed by clinical observat ions
alone. Test ing is t he only sure met hod t o def ine t he cat egory.
3. Rapid diagnosis of acut e hepat it is is essent ial f or t he pat ient so t hat
t reat ment can be inst it ut ed and f or t hose w ho have close pat ient cont act so
t hat prot ect ive measures can be t aken t o prevent disease spread.
4. Persons at higher risk f or acquiring hepat it is A include pat ient s and st aff in
healt h care and cust odial inst it ut ions, people in day care cent ers,
int ravenous drug abusers, and t hose w ho t ravel t o undeveloped count ries or
regions w here f ood and w at er supplies may be cont aminat ed.
5. Persons at higher risk f or hepat it is B include t hose w it h a hist ory of drug
abuse, t hose w ho have sexual cont act w it h inf ect ed persons, and t hose w ho
have household cont act w it h inf ect ed persons and especially t hose w it h skin
and mucosal surf ace lesions (eg, impet igo, saliva f rom chronic HBV persons
on t oot hbrush racks and coff ee cups in t heir homes); addit ionally, inf ant s
born t o inf ect ed mot hers (during delivery), hemodialysis pat ient s, and healt h
care employees are at higher risk f or inf ect ion. O f all persons w it h HBV
inf ect ion, 38% t o 40% cont ract HBV during early childhood.
6. Healt h care w orkers should be periodically t est ed f or hepat it is exposure and
should alw ays observe st andard precaut ions w hen caring f or pat ient s.
7. Persons at risk f or hepat it is C include t hose w ho have received blood
t ransf usions, engage in int ravenous drug abuse, undergo hemodialysis, have
had organ t ransplant at ion, or have sexual cont act w it h an inf ect ed person;
hepat it is C can also be t ransmit t ed during delivery f rom mot her t o neonat e.
Most people are asympt omat ic at t he t ime of diagnosis f or hepat it is C. See
Table 8. 6 f or hepat it is markers t hat appear af t er inf ect ion.
Table 8.6 Hepatitis Markers That Appear After

Infection
Serologic
Marker
Tim e
Marker
Appears
After
Infection
Clinical Im plications
HEPATITIS A VIRUS
HAVAb/IgM
46 wk
Positive for acute stage of

hepatitis A, develops early
in disease course
HAVAb/IgG
812 wk
Indicates previous
exposure and immunity to
hepatitis A
HEPATITIS B VIRUS
12 wk
Positive in acute stage of

hepatitis B; earliest
indicator of acute antigen
infection; also indicates
chronic infection
412 wk
Positive in acute active

stage with viral replication
(infectivity factor); highly
infective
HBcAb
614 wk
This marker may remain in

serum for a longer time;
together with HBsAB
represents convalescent
stage; indicates past
infection
HBcAb
IgM
614 wk
Indicates acute infection
HBeAb
antibody
816 wk
Indicates acute infection

resolution
HBsAghepatitis
B virus
HBeAg
Indicates previous
exposure, clinical recovery,
immunity to hepatitis B, not
HBsAb
antibody
410 mo
necessarily to other types

of hepatitis; marker for
permanent immunity to
hepatitis B
Interventions
1. Assess pat ient 's social and clinical hist ory and know ledge of t est . Explain
t est purpose and procedure.
care.

1. Explain signif icance of t est result s and counsel appropriat ely regarding
presence of inf ect ion, recovery, and immunit y. Counsel healt h care w orkers
and f amily regarding prot ect ive and prevent ive measures necessary t o avoid
t ransmission. I nst ruct pat ient t o alert healt h care w orkers and ot hers
regarding t heir hepat it is hist ory in sit uat ions in w hich exposure t o body f luids
and w ast es may occur.
2. Be aw are t hat pregnant w omen may need special counseling.
care.
Clin ical Alert

1. O bserve ent eric and st andard precaut ions f or 7 days af t er onset of
sympt oms and/ or jaundice in hepat it is A. Hepat it is A is most cont agious
bef ore sympt oms and/ or jaundice appear.
2. Use st andard blood and body f luid precaut ions w it h hepat it is B and
hepat it is B ant igen carriers. Precaut ions apply unt il t he pat ient is HBsAg
negat ive and ant i-HBs appears. Avoid sharps (eg, needles, scalpel
blades) injuries. Should accident al injury occur, encourage some bleeding,
3.
4.
5.
6.
and w ash area w ell w it h a germicidal soap. Report injury t o proper

depart ment and f ollow up w it h necessary int ervent ions. Put on gow n w hen
blood splat t ering is ant icipat ed. A privat e hospit al room and bat hroom may
be indicat ed.
I f pat ient has had a blood t ransf usion, he or she should not donat e blood
f or 6 mont hs. Transf usion-acquired hepat it is may not show up f or 6
mont hs af t er t ransf usion. Persons w ho t est posit ive f or HBsAg should
never donat e blood or plasma.
Persons w ho have sexual cont act w it h hepat it is Binf ect ed individuals run
a great er risk f or acquiring t he inf ect ion. HBsAg appears in most body
f luids, including saliva, semen, and cervical secret ions.
St andard precaut ions must be observed in all cases of suspect ed hepat it is
unt il t he diagnosis and hepat it is t ype are conf irmed.
I mmunizat ion of persons exposed t o t he inf ect ion should be done as soon
as possible. I n t he case of cont act w it h hepat it is B, bot h hepat it is B
immunoglobulin (HBI G ) and HBV vaccine should be administ ered w it hin 24
hours of skin-break cont act and w it hin 14 days of last sexual cont act . For
hepat it is A, I G should be given w it hin 2 w eeks of exposure. I n day care
cent ers, immune globulin (I G ) should be given t o all cont act s (children and
personnel).
Differential Diagnosis of Viral Hepatitis
Virus
Hepatitis
A
Transm ission
Fecal-oral by
person-toperson
contact or
ingestion of
Incubation
Period
Average,
30 d
(range,
Test for
Acute
Infection
IgM
antibody to
hepatitis A
capsid
So
C
H
Ho
se
co
an
pe
ca
an
contaminated
food
Hepatitis
B
Hepatitis
C
Sexual, blood
and other
body fluids
Blood
1550 d)
proteins
so
ou
fro
co
fo
Average,
120 d
(range,
45160 d)
HBsAg; the
best test for
acute or
recent
infection is
IgM
antibody to
HBcAg
Se
pr
m
m
fe
se
pr
in
dr
bi
in
m
Commonly
69 wk
(range, 2
wk6 mo)
ELISA is the
initial test to
show if ever
infected; it
should be
confirmed
by another
test such as
PCR
In
dr
oc
ex
bl
he
tra
po
se
tra
Total
antibody to
R
ac
in
Hepatitis
D
Hepatitis
E
Hepatitis
G
Sexual, blood
and other
body fluids
Fecal-oral
Blood
28 wk
(from
animal
studies)
delta
hepatitis
shows if
ever
infected;
IgM test is
in research
laboratories;
ELISA
HB
in
dr
an
re
cl
fa
co
ar
hi
fo
Average,
2642 d
(range,
1564 d)
Research
laboratories
No
ca
or
th
St
in
tra
th
hi
gr
Unknown
Occurs with
hepatitis B
and
hepatitis C
R
co
bl
Viruses for Which Clinical Signs and Symptoms M
Virus
Transm ission
Incubation
Period
Test for
Active
Infection
Epstein-Barr
virus (EBV)
Oropharyngeal
(saliva)
46 wk
IgM
antibody
EBV vira
capsid
Cytomegalovirus
(CMV, human
herpes-virus 5)
Intimate
contact with
infected fluids;
sexual,
perinatal,
blood
transfusion,
and infected
breast milk
About 38
wk for
transfusionacquired
CMV
Culture,
monoclon
antibody
early
antigen
Human Immunodeficiency Virus (HIV-1/2) Antibody

Tests, HIV Group O, Antibody to Human
Immunodeficiency Virus (HIV-1/2); Acquired
Immunodeficiency Syndrome (AIDS) Tests These tests
detect human immunodeficiency viruses types 1 and 2
(HIV-1/2), which cause AIDS. Infection with HIV-1 is
most prevalent in the United States and Western
Europe. Most cases associated with HIV-2 are reported

in West Africa. Tests to detect the presence of HIV-1
antibody screen blood and blood products that will be
used for transfusion and tissue and organs for
transplantation. They are also used to test people at
risk for developing AIDS, such as intravenous drug
users, sexual partners of HIV-infected persons, and
infants born to HIV-infected women. The diagnosis of
AIDS must be clinically established. Tests used to
determine the presence of antibodies to HIV-1 include
ELISA, Western blot, and PCR. PCR has been evaluated
as a means to detect viral load by viral nucleic acid
test (NAT) after infection but before seroconversion.
A single react ive ELI SA t est by it self cannot be used t o diagnose AI DS. The t est
should alw ays be repeat ed in duplicat e using t he same blood sample. I f
repeat edly react ive, f ollow -up t est s using West ern blot should be done. A
posit ive West ern blot is considered conf irmat ory f or HI V. The combinat ion HI V1/ 2 t est has replaced t he HI V-1 t est f or screening blood and blood product s f or
t ransf usion. I t is also used f or t est ing pot ent ial organ t ransplant donors (Table
8. 7).
Table 8.7 Diagnostic Testing for HIV
Whom to Test
How to Test
When to
Test
Screening EIA and

confirmatory tests.
As early a
detection as
possible so
Men who have

sex with men,
IV drug users,
recreational
drug users,
those engaging
in unprotected
sex, those
attending STD
clinics,
pregnant
women, those
with signs and
symptoms of
unusual
pneumonia,
skin lesions,
mononucleosislike syndrome;
persons known
to be infected
with HIV
W estern blot
confirmatory test
detects antibodies to
HIV-1 core antigens:
gp41, gp120, gp160,
p18, p24, p31, p40,
p65, p55/51. IFA
confirmatory test
detects potent
antibodies by
fluorescein-tagged
secondary
antibodies. Viral RNA
and p24 antigen are
used along with CD4
count to monitor
treatment. Nucleic
acid amplification
testing (NAT) to
monitor viral load.
Rapid testing:
single-use diagnostic
system (SUDS)
results in 1 hour.
that proper
treatment,
decrease in
transmission,
and modified
behaviors
can occur.
Mother-tochild (vertical
transmission)
treated
during
pregnancy
and delivery,
and exposed
infants within
48 hours of
delivery;
transmission
of HIV can
occur in
utero, during
birth, and by
breast
feeding.
Reference Values
Normal
Negat ive f or HI V ant ibodies against HI V ant igens t ypes 1 and 2 by ELI SA,
enzyme immunoassay (EI A) and West ern blot HI V proviral RNA: not react ive or
negat ive by PCR
HI V proviral DNA: not react ive or negat ive HI V core P24 ant igen: not react ive or
negat ive NAT: viral load is low
Procedure
1. Collect a 7-mL blood serum sample in a red-t opped t ube. Plasma may also
be used. O bserve st andard precaut ions. Place specimen in biohazard bag f or
t ransport t o t he laborat ory.
2. Be aw are t hat saliva specimens may be collect ed; usually indicat ed in clinic
set t ings or out reach environment s. See Appendix K f or prot ocols.
Clin ical Alert

Det ect able HI V ant ibodies develop w it hin 3 mont hs af t er exposure t o virus.
1. A posit ive t est is associat ed w it h viral replicat ion and appearance of HI V
ant ibodies (I gM, I gG ).
2. A posit ive ELI SA t hat f ails t o be conf irmed by West ern blot or I FA should not
be considered negat ive, especially in t he presence of sympt oms or signs of
AI DS. Repeat t est ing in 3 t o 6 mont hs is suggest ed.
3. A posit ive result may occur in noninf ect ed persons because of unknow n
f act ors.
4. Negat ive t est s t end t o rule out AI DS in high-risk pat ient s w ho do not have t he
charact erist ic opport unist ic inf ect ions or t umors.
5. An HI V inf ect ion is described as a cont inuum of st ages t hat range f rom t he
acut e, t ransient , mononucleosis-like syndrome associat ed w it h
seroconversion t o asympt omat ic HI V inf ect ion t o sympt omat ic HI V inf ect ion
and, f inally, t o AI DS. AI DS is end-st age HI V inf ect ion.
6. Treat ment s are more eff ect ive and less t oxic w hen begun early in t he course
of HI V inf ect ion.
7. HI V PCR met hod t o det ermine viral load may be perf ormed during HI V
t reat ment t o monit or pat ient prognosis and t reat ment .
8. Diagnosis of HI V in neonat es is diff icult because mat ernally acquired
ant ibodies may be present unt il t he child is 18 mont hs of age. Addit ionally,
PCR t o det ect ant igen is usually not successf ul unt il t he child is 6 mont hs of
age.
Interfering Factors
1. Nonreact ive HI V t est result s occur during t he acut e st age of disease w hen
t he virus is present but ant ibodies are not suff icient ly developed t o be
det ect ed. I t may t ake up t o 6 mont hs f or t he t est result t o become posit ive.
During t his st age, t he t est f or t he HI V ant igen may conf irm an HI V inf ect ion
(Fig. 8. 1).
FI G URE 8. 1 Time course f or appearance of viral and serological markers

during primary HI V inf ect ion. (Source: G renert JP, Nasses PS, Heller BL:
Human immunodef iciency virusdiagnost ic t est ing at t he st art of t he
21st cent ury. Cl i ni cal Laboratory News 1923, July 2002)
2. Test kit s f or HI V are ext remely sensit ive. As a result , nonspecif ic react ions
may occur if t he t est ed person has been previously exposed t o HI V human
cells or t he grow t h media.
Clin ical Alert

1. I ssues of conf ident ialit y surround HI V t est ing. Access t o t est result s
should be given judiciously on a need-t o-know basis unless t he pat ient
specif ically expresses ot herw ise. I nt ervent ions t o block general comput er
access t o t his inf ormat ion are necessary; each healt h care f acilit y must
det ermine how best t o accomplish t his.
2. Conversely, healt h care w orkers direct ly involved w it h t he care of an

HI V/ AI DS pat ient have a right t o know t he diagnosis so t hat t hey may
prot ect t hemselves f rom exposure.
3. All result s, bot h posit ive and negat ive, must be somehow ent ered in t he
pat ient 's healt h care records w hile maint aining conf ident ialit y. People are
more likely t o t est volunt arily w hen t hey t rust t hat inappropriat e disclosure
of HI V t est ing inf ormat ion w ill not occur. Long-t erm implicat ions include
pot ent ial loss of jobs, housing, insurance coverage, and personal
relat ionships.
4. The clinician must sign a legal f orm st at ing t hat t he pat ient has been
inf ormed regarding t est risks.
5. A person w ho exhibit s HI V ant ibodies is presumed t o be HI V inf ect ed;
appropriat e counseling, medical evaluat ion, and healt h care int ervent ions
should be discussed and inst it ut ed.
6. Posit ive t est result s must be report ed t o t he st at e and f ederal public
healt h aut horit ies according t o prescribed st at e regulat ions and prot ocols.
7. Anonymous t est ing and report ing is available, such as commercial home
t est s.
Interventions
1. An inf ormed, w it nessed consent f orm must be properly signed by any person
being t est ed f or HI V/ AI DS. This consent f orm must accompany t he pat ient
and t he specimen (see Appendix H f or sample f orm).
2. I t is essent ial t hat counseling precedes and f ollow s t he HI V ant ibody t est .
This t est should not be perf ormed w it hout t he subject 's inf ormed consent ,
and persons w ho need t o access result s legit imat ely must be ment ioned.
Discussion of t he clinical and behavioral implicat ions derived f rom t he t est
result s should address t he accuracy of t he t est and should encourage
behavioral modif icat ions (eg, sexual cont act , shared needles, blood
t ransf usions).
3. Assess f requency and int ensit y of sympt oms: elevat ed t emperat ure, anxiet y,
f ear, diarrhea, neuropat hy, nausea and vomit ing, depression, and f at igue.
4. I nf ect ion cont rol measures mandat e use of st andard precaut ions (see
Appendix A).
care.
Clin ical Alert

Vict ims or survivors t ransf used w it h t aint ed HI V blood or t ransplant s bet w een
July 1982 and t he end of 1987 may qualif y f or assist ance f rom t he St eve
G rissom Relief Fund. An est imat ed 2000 U. S. cit izens have cont ract ed HI V
f rom inf ect ed blood and blood product s.

1. I nt erpret t est out comes. Explain signif icance of t est result s along w it h CD4+
cell count s. Advise pat ient t hat screening t est s must be conf irmed bef ore t he
result s are report ed as HI V
react ive. Provide opt ions f or immediat e counseling if necessary. Explain
t reat ment w it h pot ent ant iviral drugs and prot ease inhibit ors.
care.
Additional Applications for Oral Specimen Testing

1. HI V-1 and HI V-2
2. Viral hepat it is A, B, and C
3. H. pyl ori
4. Measles
5. Mumps
6. Rubella
7. Syphilis
8. Cyt omegalovirus (CMV)
9. Aut oimmune diseases
10. Cancer (carcinoembryonic ant igen [ CEA] , prost at e-specif ic ant igen [ PSA] ,
CA 125)
11. Diabet es t ypes 1 and 2
12. Therapeut ic drug and hormone management and det ect ion of ot her drugs
(see Appendix K f or saliva, hair, nails specimen collect ion)
Clin ical Alert

Procedure for O ral Testi ng
1. Use a special t est ing kit such as t he commercial O rasure Test ing Syst em.
The kit 's component s consist of a specially t reat ed cot t on pad on a nylon
st ick and a vial cont aining preservat ive solut ion. Salt solut ion in t he pad
f acilit at es absorpt ion of t he required f luid.
2. Use precise t echnique. Place pad bet w een t he low er cheek and gum, rub
back and f ort h unt il moist ened, and leave in place f or 2 minut es. Remove
specially t reat ed pad and place it in t he vial of special ant imicrobial
preservat ive solut ion. Place specimen cont ainer in a biohazard bag and
t ransport t o laborat ory.
3. The O mni Sal device employs a diff erent collect ion met hod in w hich a
cot t on pad is placed under t he t ongue. An indicat or in t he collect ing device
changes color w hen an adequat e amount of oral f luid has been collect ed.
4. Recent f ood int ake, smoking, oral hygiene, or t reat ment w it h
ant icholinergic drugs do not aff ect t est result s.
VIRAL ANTIBODY TESTS TO ASSESS IM M UNE STATUS

Rubella Antibody Tests
Rubella, a mild, cont agious illness charact erized by an eryt hemat ous
maculopapular rash, is observed primarily in children 5 t o 14 years of age and in
young adult s. The disease, commonly called G erman or 3-day measles, may be
asympt omat ic or may involve a 1- t o 5-day prodromal period of malaise,
headache, cold sympt oms, low -grade f ever, and suboccipit al lymphadenopat hy.
Alt hough t he illness is mild in children, it may cause t he congenit al rubella
syndrome in t he f et us of a mot her inf ect ed early in pregnancy. As many as 85%
of inf ant s inf ect ed during t he f irst eight w eeks of gest at ion have det ect able
def ect s by 4 years of age. The classic abnormalit ies associat ed w it h t he rubella
syndrome include congenit al heart disease, cat aract s, and neurosensory
deaf ness. Af t er 20 t o 24 w eeks of gest at ion, congenit al abnormalit ies are rare.
The quant it at ive measurement of I gG ant ibodies t o rubella virus aids in t he
det erminat ion of immune st at us. Assay result s of 10 I nt ernat ional Unit s (I U) of
ant ibody per millilit er (mL) are negat ive or not immune. Assay result s >10 I U are
considered posit ive or immune. A posit ive result of I gM ant ibody indicat es a
congenit al or recent inf ect ion. The measurement of I gM class ant ibodies f or
det erminat ion of acut e phase inf ect ion is recommended in all age groups. I gM
rubella ant ibody det erminat ion is usually not recommended w hen t he pat ient is
>6 mont hs of age. Unlike I gG class ant ibodies, I gM ant ibodies are larger
molecules and cannot cross t he placent a, t hus det ermining t hat t he inf ant has an
act ive f orm of t he disease.
Reference Values
Normal
Negat ive f or rubella I gG and/ or I gM ant ibodies by ELI SA or chemilluminescence:
not immune.
Posit ive f or rubella I gG ant ibody: immune; indicat es a current or previous
exposure or immunizat ion t o rubella.
Posit ive f or rubella I gM ant ibody (w it h or w it hout posit ive I gG ); indicat es a
current or recent inf ect ion w it h rubella virus.
Procedure
laborat ory.
2. Follow -up t est ing may be required.
1. When t est ing f or I gG ant ibody, seroconversion bet w een acut e and
convalescent sera is considered st rong evidence of a current or recent
inf ect ion. The recommended int erval bet w een an acut e and convalescent
sample is 10 t o 14 days.
2. A serum specimen t aken very early during t he acut e st age of inf ect ion may
cont ain levels of I gG ant ibody below 10 I U/ mL.
3. While t he presence of I gM ant ibody suggest s current or recent inf ect ion, low
levels of I gM may occasionally persist f or more t han 12 mont hs af t er
inf ect ion or immunizat ion. Passively acquired rubella ant ibody levels (I gG ) in
t he inf ant (w hich can cross t he placent a because of t heir smaller molecular
size) decrease markedly w it hin 2 t o 3 mont hs post inf ect ion.
4. I gM is det ect able soon af t er clinical sympt oms occur and reaches peak
levels at 10 days.
Interventions
1. Assess pat ient 's t est know ledge. Explain t est purpose and procedure. Advise
pregnant w omen t hat rubella inf ect ion acquired in t he f irst t rimest er of
pregnancy is associat ed w it h an increased incidence of miscarriage,
st illbirt h, and congenit al abnormalit ies.
care.

1. I nt erpret t est out come and counsel appropriat ely. Advise w omen of
childbearing age w ho t est negat ive t o be immunized bef ore becoming
pregnant . I mmunizat ion is cont raindicat ed
during pregnancy. Pat ient s w ho t est posit ive are nat urally immune t o f urt her
rubella inf ect ions.
care.
Measles (Rubeola) Antibody Tests Classified as a

paramyxovirus, measles produces a highly contagious
respiratory infection. The disease is spread during the
prodrome phase through direct contact with respiratory
secretions in the form of droplets. Clinical infection
with measles virus is characterized by high fever,
cough, coryza, conjunctivitis, malaise, and Koplik's
spots on the buccal mucosa. An erythematous rash
then develops behind the ears and over the forehead,
spreading to the trunk.
Serology has become increasingly import ant as a t ool f or det ermining t he
immune st at us of t he young adult populat ion ent ering college or t he milit ary. I n
addit ion, t he linkage bet w een measles inf ect ion and premat ure delivery or
spont aneous abort ion support s screening pregnant mot hers f or suscept ibilit y.
These t est s det ermine suscept ibilit y and immunit y t o measles virus. Since
int ensive immunizat ion began in t he U. S. in t he 1970s, t he incidence of measles
inf ect ion has been reduced f rom approximat ely one half million cases annually
(l960s) t o f ew er t han 500 cases in recent years. Many individuals, how ever, may
remain suscept ible t o measles virus because of vaccine f ailure or
nonimmunizat ion. A posit ive I gG coupled w it h a negat ive I gM result indicat es
previous exposure t o measles virus and immunit y t o t his viral inf ect ion. Posit ive
I gM result s, w it h or w it hout posit ive I gG result s, indicat e a recent inf ect ion w it h
measles virus.
Reference Values
Normal
Negat ive f or measles I gG and/ or I gM ant ibodies by ELI SA: not immune.
Posit ive f or measles I gG ant ibody: immune; indicat es a current or previous
exposure or immunizat ion t o measles.
Posit ive f or measles I gM ant ibody (w it h or w it hout posit ive I gG ); indicat es a
recent inf ect ion w it h measles virus.
Procedure
laborat ory.
2. While t he presence of I gM ant ibody suggest s current or recent inf ect ion, low
levels of I gM may occasionally persist f or more t han 12 mont hs af t er
inf ect ion or immunizat ion.
3. I gM ant ibody response is det ect able 2 t o 3 w eeks af t er appearance of t he
rash.
Interventions
pregnant w omen t hat measles poses a high risk f or serious complicat ions
and may be linked t o premat ure delivery or spont aneous abort ion.
care.

1. I nt erpret t est out come and counsel appropriat ely. Advise w omen of
childbearing age w ho t est negat ive t o be immunized bef ore becoming
pregnant . I nf orm pat ient s w ho t est posit ive t hat t hey are nat urally immune t o
f urt her measles inf ect ion.
Mumps Antibody Tests

The mumps virus is a member of t he paramyxovirus group and t he et iological
agent of mumps in humans. Mumps is a generalized illness, usually accompanied
by parot id (salivary gland) sw elling and mild sympt oms. Parot it is as a present ing
sympt om in mumps is usually suff icient t o preclude conf irmat ion by serology.
How ever, one t hird of mumps inf ect ions are subclinical and may require viral
isolat ion t o conf irm mumps inf ect ion. I nf ect ion w it h mumps virus, w het her
sympt omat ic or subclinical, is generally t hought t o off er lif elong immunit y.
ELI SA t est ing can be bot h specif ic and sensit ive f or t he det ect ion and
measurement of serum prot eins. Current met hods f or serodiagnosis of mumps
include in vit ro serum neut ralizat ion, hemagglut inat ion inhibit ion (HAI ), indirect
immunof luorescence (I FA), and complement f ixat ion (CF). These t est met hods,
how ever, lack specif icit y, w hich limit s t heir usef ulness in est ablishing immune
st at us.
Reference Values
Normal
Negat ive f or mumps I gG and/ or I gM ant ibodies by ELI SA: nonimmune.
Posit ive f or mumps I gG ant ibody: immune; indicat es a current or previous
exposure or immunizat ion t o mumps virus.
Posit ive f or mumps I gM ant ibody; indicat es a current or recent inf ect ion.
Procedure
laborat ory.
inf ect ion.
2. The recommended int erval bet w een an acut e and convalescent sample is 10
t o 14 days.
Varicella-Zoster (Chickenpox) Antibody Test Varicellazoster virus (VZV) is a herpesvirus and causes
chickenpox with primary infection, a highly contagious
disease characterized by widely spread vesicular
eruptions and fever. The disease is endemic in the U.S.
and most commonly affects children from 5 to 8 years
of age, although adults and younger children, including
infants, may develop chickenpox. VZV infection in a
pregnant woman may spread through the placenta to
the fetus, causing congenital disease in the infant.
Though a primary inf ect ion result s in immunit y t o subsequent chickenpox, t he
virus remains lat ent in t he body. When it is react ivat ed, VZV causes shingles
(herpes zost er). Fever and painf ul localized vesicular erupt ions of t he skin along
t he dist ribut ion of t he involved nerves are t he most common clinical sympt oms.
The sensit ivit y, specif icit y, and reproducibilit y of ELI SA immunoassays are
comparable t o ot her serological t est s f or ant ibody such as immunof luorescence,
complement f ixat ion, and hemagglut inat ion. A posit ive I gG result coupled w it h a
posit ive I gM result indicat es a current inf ect ion w it h VZV.
Reference Values
Normal
Negat ive f or varicella-zost er I gG and/ or I gM ant ibodies by ELI SA: non-immune.
Posit ive f or varicella-zost er I gG ant ibody: indicat es a current or previous
inf ect ion; in t he absence of current clinical sympt oms, may indicat e immunit y.
Posit ive f or varicella-zost er I gM ant ibody; indicat es a current or recent inf ect ion.
Procedure
laborat ory.
2. Whereas t he presence of I gM ant ibody suggest s a current or recent
inf ect ion, low levels of I gM may occasionally persist f or more t han 12 mont hs
af t er inf ect ion or immunizat ion.
3. I mmunosuppressed pat ient s in hospit als may cont ract severe nosocomial
inf ect ions f rom ot hers inf ect ed w it h VZV. Theref ore, serologic screening of
direct healt h care providers (physicians, nurses, et c. ) is necessary t o avoid
spread of inf ect ion.
Interventions
pregnant w omen t hat VZV poses a high risk of congenit al disease in t he
inf ant .

1. I nt erpret t est out come and counsel appropriat ely. I nf orm pat ient s w ho t est
posit ive f or VZV I gG t hat t hey are nat urally immune t o chickenpox, but t he
virus can be react ivat ed and cause shingles at a lat er t ime.
care.
Cytomegalovirus (CMV) Antibody Test Cytomegalovirus

(CMV) is a ubiquitous human viral pathogen that
belongs to the herpesvirus family. Infection with CMV
is usually asymptomatic and can persist in the host as
a chronic or latent infection. Cytomegalovirus has been
linked with sexually transmitted infections. Blood
banks routinely screen for CMV antibodies and report
these as CMV-negative or CMV-positive.
This t est det ermines t he presence of CMV ant ibodies and is rout inely done in
congenit ally inf ect ed new borns, immunocompromised pat ient s, and sexually
act ive persons w ho present w it h mononucleosis-like sympt oms. Ant ibody result s
must be evaluat ed in t he cont ext of t he pat ient 's current clinical sympt oms and
viral cult ure result s. Test s t o det ect CMV ant igen are available and aid in early
det ect ion. Viral cult ure conf irms CMV inf ect ion.
Reference Values
Normal
Negat ive f or CMV-specif ic I gG and I gM by ELI SA.
Procedure
precaut ions. Place specimen in biohazard bag f or t ransport t o t he laborat ory.
2. I t is recommended t hat post t ransplant t it ers be monit ored at w eekly
int ervals, part icularly f ollow ing bone marrow t ransplant .
1. I nf ant s w ho acquire CMV during primary inf ect ion of t he mot her are prone t o
develop severe cyt omegalic inclusion disease (CI D). CI D may be f at al or
may cause neurologic sequelae such as ment al ret ardat ion, deaf ness,
microcephaly, or mot or dysf unct ion.
2. Transf usion of CMV-inf ect ed blood product s or t ransplant at ion of CMVinf ect ed donor organs may produce int erst it ial pneumonit is in an
immunocompromised recipient .
3. When t est ing f or I gG ant ibody, seroconversion or a signif icant rise in t it er
bet w een acut e and convalescent sera may indicat e presence of a current or
recent inf ect ion.
4. While t he presence of I gM ant ibodies suggest s current or recent inf ect ion,
low levels of I gM ant ibodies may occasionally persist f or more t han 12
mont hs post inf ect ion.
Interventions
care.

1. I nt erpret t est result s. Ref er t o page 532. Counsel appropriat ely.
care.
Herpes Simplex Virus (HSV) Antibodies (HSV-1 and

HSV-2 Tests) Two types of herpes simplex virus exist.
Herpes simplex virus type 1 (HSV-1) causes orofacial
herpes; type 2 (HSV-2) causes genital and neonatal
herpes. Serologic differentiation is difficult; therefore,
type-specific antibody tests are required.
These t est s ident if y t he herpes simplex inf ect ions. Human herpes simplex virus
(HSV) is f ound w orldw ide and is t ransmit t ed by close personal cont act . The
clinical course is variable, and sympt oms may be mild enough t o go
unrecognized. Major signs and sympt oms include oral and skin erupt ions, genit al
t ract inf ect ions and lesions, and neonat al herpes. Herpes simplex is also
common in individuals w it h immune syst em def iciencies (eg, cancers, HI V/ AI DS,
chemot herapy t reat ment ). HSV ant ibody t est ing is also w idely used f or bone
marrow recipient s and donors.
Reference Values
Normal
Negat ive f or HSV-l and HSV-2 by ELI SA and I FA.
Procedure
precaut ions. Place specimen in biohazard bag f or t ransport t o t he laborat ory.
2. Follow -up t est ing is usually required.
1. Most persons in t he general populat ion have been inf ect ed w it h HSV by 20
years of age. Af t er t he primary inf ect ion, ant ibody levels f all and st abilize
unt il a subsequent inf ect ion occurs.
2. Diagnosis of current inf ect ion is relat ed t o det ermining a signif icant increase
in ant ibody t it ers bet w een acut e-st age and convalescent -st age blood
samples.
3. Serologic t est s cannot indicat e t he presence of act ive genit al t ract
inf ect ions. I nst ead, direct examinat ion w it h procurement of lesion cult ures
should be done.
4. New born inf ect ions are acquired during delivery t hrough t he birt h canal and
may present as localized skin lesions or more generalized organ syst em
involvement .
Interventions
1. Assess pat ient 's know ledge regarding t he t est . Explain t est purpose and
procedure.
care.

t est result s. Advise pregnant w omen t hat t he new born may be inf ect ed during
birt h w hen act ive genit al-area inf ect ion is present . Explain need f or repeat
t est ing.
care.
Human T-Cell Lymphotropic Virus (HTLV-I/II) Antibody

Test This test detects antibodies to HTLV-I, a retrovirus
associated with adult T-cell leukemia (ATL) and
demyelinating neurologic disorders. The presence of
HTLV-I antibodies in an asymptomatic person excludes
that person from donating blood; however, this finding
does not mean that leukemia or a neurologic disorder
exists or will develop. Specimens with a positive test
result by EIA are referred for Western blot. The results
of Western blot are for investigational use only at the
time of this printing.
Reference Values
Normal
Negat ive f or HTLV-I / I I ant ibodies by EI A and West ern blot
Procedure
precaut ions.
1. Posit ive result s (ant ibodies t o HTLV-I ) occur in t he presence of HTLV-I
inf ect ion. I nf ect ion t ransmit t ed t o recipient s of HTLV-I inf ect ed blood is w ell
document ed.
2. The presence of ant ibodies t o HTLV-I bears no relat ion t o t he presence of
ant ibodies t o HI V-1; it s presence does not put a person at risk f or HI V/ AI DS,
but t hey of t en occur concurrent ly because of similar risk f act ors.
3. HTLV-I is endemic t o t he Caribbean, Sout heast ern Japan, and some areas of
Af rica.
4. I n t he Unit ed St at es, HTLV-I has been det ect ed in persons w it h ATL,
int ravenous drug users, and healt hy persons as w ell as in donat ed blood
product s. Transmission can also t ake place t hrough ingest ion of breast milk,
sexual cont act , and sharing of cont aminat ed int ravenous drug paraphernalia.
Interventions
1. Assess pat ient 's know ledge about t est . Explain t est purpose and procedure.
care.

1. I nt erpret t est result s. Ref er t o page 532 f or int erpret at ion of immunologic
t est result s. Counsel pat ient appropriat ely.
care.
Parvovirus B-19 Antibody Test These tests detect

parvovirus B-19, the only parvovirus known to cause
human disease. The B-19 virus destroys red blood cell
precursor cells and interferes with normal red blood
cell production. In young children, it is associated with
erythema infectiosum, a mild, self-limiting disease
characterized by a low-grade fever and rash. Recently,
it has been associated with aplastic crisis in patients
with chronic hemolytic anemia and in immunodeficient
patients who have bone marrow failure.

Reference Values
Normal
Negat ive f or parvovirus B-19specif ic I gG and I gM ant ibodies by ELI SA and
indirect f luorescent ant ibody (I FA)
Procedure
precaut ions.
2. Place sample in a biohazard bag f or t ransport t o t he laborat ory.
1. Posit ive parvovirus B-19 inf ect ion has been implicat ed in aplast ic anemia
associat ed w it h organ t ransplant at ion. I t is recommended, t heref ore, t hat
t his t est be included in t he serologic assessment of prospect ive organ
donors.
2. I mmunocompromised pat ient s may have a delayed or absent ant ibody
response. I t is recommended t hat parvovirus DNA det ect ion by PCR be
considered.
Interventions
1. Assess pat ient 's know ledge regarding t est . Explain purpose and blood t est
procedure. Advise any prospect ive organ donor t hat t his t est is part of a
panel of t est s perf ormed bef ore organ donat ion t o prot ect t he organ
recipient f rom pot ent ial inf ect ion.
care.

1. I nt erpret t est out come. Ref er t o page 532 f or int erpret at ion of immunologic
t est result s. Explain signif icance of t est result s.

care.
Rabies Antibody Tests

Serologic t est ing is diagnost ic f or t he presence of rabies in animals. I t also
indicat es t he degree of ant ibody responses t o rabies immunizat ion (eg, f or
people w ho rout inely w ork w it h animals).
Reference Values
Normal
I FA <1: 16 or DFA examinat ion of t he animal brain f or presence of t he virus.
Procedure for Humans

Collect a 7-mL blood serum sample in a red-t opped t ube. O bserve st andard
Procedure for Animals

1. I f t he suspect animal exhibit s abnormal behavior, st andard procedure is t o
sacrif ice it and examine it s brain f or Negri body inclusions in t he neurons.
2. Rabies t est ing is usually perf ormed in a public healt h laborat ory.
An elevat ed t it er in humans indicat es an adequat e response af t er immunizat ion. A
rabies t it er of 1: 16 or great er is considered prot ect ive.
Interventions
care.

1. I nt erpret t est result s af t er immunizat ion.
care.
Clin ical Alert

1. Prevent ion: Pre-exposure vaccine (human diploid cell rabies vaccine
[ HDCV] ) should be given t o persons at high-risk such as vet erinarians,
w ildlif e personnel, zoo w orkers, quarant ine kennel w orkers, and t hose
employed in laborat ories t hat use animals.
2. Post bit e: Administ er rabies immunoglobulin (RI G ) as soon as possible
af t er t he bit e, regardless of t ime int erval, t o neut ralize t he virus in t he
w ound. HDCV in f ive 1-mL int ramuscular doses should be given in t he
delt oid muscle. The f irst HDCV dose is given concurrent ly w it h t he RI G ,
and subsequent doses are given 3, 7, 14, and 28 days af t er t he f irst dose.
3. The animal brain should be t est ed as soon as possible. Holding t he animal
f or observat ion is not recommended.
FUNGAL TESTS
Fungal Antibody Tests: Histoplasmosis, Blastomycosis,
Coccidioidomycosis Certain fungal species are
associated with human respiratory diseases acquired
by inhaling spores from sources such as dust, soil,
and bird droppings. Serologic tests may be used for
diagnosis. Fungal diseases are categorized as either
superficial or deep. For the most part, superficial
mycoses are limited to the skin, mucous membranes,
nails, and hair. Deep mycoses involve the deeper
tissues and internal organs. Histoplasmosis,
coccidioidomycosis, and blastomycosis are caused by
deep mycoses.
These t est s det ect serum precipit in ant ibodies and CF ant ibodies present in t he
f ungal diseases of coccidioidomycosis, blast omycosis, and hist oplasmosis.
Coccidioidomycosis, also know n as desert f ever, San Joaquin f ever, and valley
f ever, is cont ract ed t hrough inhalat ion of Cocci di oi des i mmi ti s spores f ound in
dust or soil. Blast omycosis is caused by inf ect ion w it h organisms of t he genus
Bl astomyces. Hist oplasmosis is a granulomat ous inf ect ion caused by
Hi stopl asma capsul atum.
Reference Values
Normal
Negat ive f or f ungal ant ibodies CF t it er: <1: 8
I mmunodiff usion: negat ive
Procedure
precaut ions.
2. Place in a biohazard bag f or t ransport t o t he laborat ory.
1. Ant ibodies t o Cocci di oi des, Bl astomyces, and Hi stopl asma appear early in
t he course of t he disease (w eeks 14) and t hen disappear.
2. Negat ive f ungal serology does not rule out t he possibilit y of a current
inf ect ion.
Interfering Factors
1. Ant ibodies t o f ungi may be f ound in blood samples f rom apparent ly healt hy
people.
2. When t est ing f or blast omycosis, cross-react ions w it h hist oplasmosis may
occur.
3. More t han 50% of pat ient s having act ive blast omycosis yield a negat ive
result by CF.
4. Recent hist oplasmosis skin t est s must be avoided because t hey cause
elevat ed CF t est result s, w hich may be due t o t he st imulat ion f rom t he skin
t est and not t he syst emic inf ect ion.
Interventions
care.
3. Remember t hat specimens f or cult ure of t he organism may also be required.

t est result s. Counsel appropriat ely.
care.
Candida Antibody Test Candidiasis is usually caused
by Candida albicans and affects the mucous

membranes, skin, and nails (see Candida Skin Test,
page 527). Compromised individuals with depressed Tcell function are most likely to have invasive disease.
I dent if ying t he Candi da ant ibody can be helpf ul w hen t he diagnosis of syst emic
candidiasis cannot be show n by cult ure or t issue sample. Clinical
sympt omat ology must be present f or t he t est t o be meaningf ul. Test s used
include immunodiff usion; count er-immunoelect rophoresis
(CI E), w hich is part icularly valuable on CSF and urine specimens; and lat ex
agglut inat ion f or Candi da ant igen.
Reference Values
Normal
Negat ive f or Candida ant ibodies by immunodiff usion (I D)
Procedure
precaut ions.
2. Place in a biohazard bag f or t ransf er t o t he laborat ory.
1. A t it er great er t han 1: 8 by lat ex agglut inat ion f or Candi da ant igen indicat es
syst emic inf ect ion.
2. A f ourf old rise in t it ers of paired blood samples 10 t o 14 days apart
indicat es acut e inf ect ion.
3. Pat ient s on long-t erm int ravenous t herapy t reat ed w it h broad-spect rum
ant ibiot ics and diabet ic pat ient s commonly have disseminat ed inf ect ions
caused by Candi da al bi cans. The disease also occurs in bot t le-f ed new borns
and in t he urinary bladder of cat het erized pat ient s.
4. Vulvovaginal candidiasis, common in lat e pregnancy, can t ransmit candidiasis
t o t he inf ant t hrough t he birt h canal.
Interfering Factors
1. Approximat ely 25% of t he normal populat ion t est s posit ive f or t he presence
of Candi da.
2. Cross-react ion can occur w it h lat ex agglut inat ion t est ing in persons w ho have
crypt ococcosis or t uberculosis.
3. Posit ive result s can occur in t he presence of mucocut aneous candidiasis or
severe vaginit is.
Interventions
care.
3. Specimens f or cult ure of t he organism may also be required.

t est result s. Counsel pat ient appropriat ely. Repeat t est ing is usually
indicat ed.
care.
Aspergillus Antibody Test The aspergilli, especially

Aspergillus fumigatus, Aspergillus flavus, and
Aspergillus niger, are associated with pulmonary
infections and invasive fatal disease sequelae in
immunosuppressed patients. Manifestations of
Aspergillus infections include allergic
bronchopulmonary disease, lung mycetoma,
endophthalmitis, and disseminated brain, kidney, heart,
and bone disease.
This t est det ect s ant ibodies present in aspergillosis, primarily allergic
bronchopulmonary disease, or f ungus ball.
Reference Values
Normal
Negat ive f or Aspergi l l us ant ibody by immunodiff usion <1: 8 by CF
Procedure
1. Collect a 7-mL blood serum sample in a red-t opped t ube. CSF can also be
t est ed. O bserve st andard precaut ions.
1. Posit ive t est result s are associat ed w it h pulmonary inf ect ions in
compromised pat ient s and Aspergi l l us inf ect ions of prost het ic heart valves.
2. I f blood serum exhibit s one t o f our bands using immunodiff usion,
aspergillosis is st rongly suspect ed. Weak bands suggest an early disease
process or hypersensit ivit y pneumonit is.
3. Best use of t he CF t est is w it h paired sera t aken 3 w eeks apart t o det ect a
rise in t it er against a single ant igen.
Interventions
care.

1. I nt erpret t est out come. Ref er t o page 532 f or int erpret at ion of immunologic
care.
Cryptococcus Antibody Test Cryptococcus neoformans,

a yeast-like fungus, causes a lung infection thought to
be acquired by inhalation. The organism has been
isolated from several natural environments, especially
where weathered pigeon droppings accumulate.
This t est det ect s ant ibodies present in Cryptococcus inf ect ions. I t appears t hat
about 50% of pat ient s w ho present w it h ant ibodies have a predisposing condit ion
such as lymphoma or sarcoidosis or are being t reat ed w it h st eroid t herapy.
I nf ect ion w it h C. neof ormans has long been associat ed w it h Hodgkin's disease
and ot her malignant lymphomas. I n f act , C. neof ormans, in conjunct ion w it h
malignancy, occurs t o such a degree t hat some researchers have raised t he
quest ion regarding t he possible et iologic relat ion bet w een t he t w o diseases.
Test s ordered f or t his disease include lat ex agglut inat ion t est ing f or ant igens or
ant ibodies.
Reference Values
Normal
Negat ive f or Cryptococcus ant ibody by indirect f luorescent ant ibody (I FA)
Procedure
1. Collect a 7-mL blood serum sample in a red-t opped t ube. A 2-mL spinal f luid
sample may also be used. O bserve st andard precaut ions.
Posit ive C. neof ormans t est s are associat ed w it h inf ect ions of t he low er
respirat ory t ract t hrough inhalat ion of aerosols cont aining C. neof ormans cells
disseminat ed by t he f ecal droppings of pigeons.
Interventions
1. Explain t est purpose and procedure. O bt ain clinical hist ory and assess f or
exposure.
care.

care.
PARASITIC TESTS
Toxoplasmosis (TPM) Antibody Tests Toxoplasmosis is
caused by the sporozoan parasite Toxoplasma gondii
and is a severe, generalized, granulomatous CNS
disease. It may be either congenital or acquired and is
found in humans, domestic animals (eg, cats), and wild
animals. Humans may acquire the infection through
ingestion of inadequately cooked meat or other
contaminated material. Congenital toxoplasmosis may
cause fetal death. Symptoms of subacute infection may
appear shortly after birth or much later. Complications
of congenital toxoplasmosis include hydrocephaly,
microcephaly, convulsions, and chronic retinitis. It is
believed that one fourth to one half of the adult
population is asymptomatically infected with
toxoplasmosis. The CDC recommends serologic testing
during pregnancy.
The indirect f luorescent ant ibody (I FA) t est helps t o diff erent iat e t oxoplasmosis
f rom I M. Toxoplasmosis ant ibodies appear w it hin 1 t o 2 w eeks of inf ect ion and
peak at 6 t o 8 mont hs. I FA is also a valuable screening t est f or lat ent
t oxoplasmosis.
Reference Values
Normal
Tit er <1: 16: no previous inf ect ion (except f or ocular inf ect ion) by I FA Negat ive by
MEI A
Negat ive: T. gondi i DNA not det ect ed by PCR
Procedure
precaut ions.
The I FA t est is considered posit ive under any of t he f ollow ing condit ions:
1. Tit er of 1: 256 or higher indicat es recent exposure or current inf ect ion; rising
t it er is of great est signif icance.
2. Any t it er value is signif icant in a new born inf ant .
3. Tit er of 1: 1024 or great er is signif icant f or act ive disease.
4. Tit er of 1: 16 or less occurs w it h ocular t oxoplasmosis.
Interventions
care.

care.
Amebiasis (Entamoeba histolytica) Antibody Test

Entamoeba histolytica, the causative agent of
amebiasis, is a pathogenic intestinal parasite. The E.
histolytica test determines the presence or absence of
specific serum antibodies to this parasite. Stool
examination is considered the definitive diagnostic
tool; however, the absence of detectable stool
organisms does not necessarily rule out the disease.
Antibiotic therapy, oil enemas, and barium may
interfere with the ability to isolate this organism in the

stool.
Reference Values
Normal
Negat ive f or Entamoeba ant ibodies by indirect hemagglut inat ion, lat ent
agglut inat ion, and CI E.
Procedure
precaut ions.
1. Posit ive t est (t it er > 1: 128) indicat es act ive or recent inf ect ion.
2. Amebic liver abscess and amebic dysent ery indicat e t he presence of
amebiasis.
3. Tit ers range f rom 1: 256 t o 1: 2048 in t he presence of current act ive
amebiasis.
4. Tit ers <1: 32 generally exclude amebiasis.
NOTE
A posit ive t est may only ref lect past but not current inf ect ions.
Interventions
care.

care.
TORCH Test
TO RCH is an acronym t hat st ands f or Toxopl asma, rubella, CMV, and herpes
simplex virus (HSV). These pat hogens are f requent ly implicat ed in congenit al or
neonat al inf ect ions t hat are not clinically apparent but t hat may result in serious
CNS impairment .
Bot h mot hers and new born inf ant s are t est ed f or exposure t o t hese agent s. The
t est diff erent iat es acut e, congenit al, and int rapart um inf ect ions caused by T.
gondi i , rubella virus, CMV, and herpesvirus. The presence of I gM-associat ed
ant ibodies in new borns ref lect s act ual f et al ant ibody product ion. High levels of
I gM at birt h indicat e f et al in ut ero response t o an ant igen. I n t his inst ance, an
int raut erine inf ect ion should be considered. TO RCH is more usef ul in excluding
t han in est ablishing et iology.
Reference Values
Normal
Negat ive f or Toxopl asma, rubella, CMV, and HSV ant ibodies
Procedure
precaut ions.
1. Persist ent rubella ant ibodies in an inf ant >6 mont hs of age highly suggest s
congenit al inf ect ion. Congenit al rubella is charact erized by neurosensory
deaf ness, heart anomalies, cat aract s, grow t h ret ardat ion, and encephalit ic
sympt oms.
2. A diagnosis of t oxoplasmosis is est ablished t hrough sequent ial t est ing rat her
t han by a single posit ive result . Sequent ial examinat ion reveals rising
ant ibody t it ers, changing t it ers, and t he conversion of serologic t est s f rom
negat ive t o posit ive. A t it er of 1: 256 suggest s recent inf ect ion. About one
t hird of inf ant s w ho acquire inf ect ion in ut ero show signs of cerebral
calcif icat ions and chorioret init is at birt h; t he rest are born w it hout sympt oms.
3. A marked and persist ent rise in CF ant ibody t it er over t ime is consist ent w it h
a diagnosis of rubella in inf ant s <6 mont hs of age.
4. Presence of herpes ant ibodies in CSF, t oget her w it h signs of herpet ic
encephalit is and persist ent HSV-1 or HSV-2 ant ibody levels in a new born
show ing no obvious ext ernal lesions is consist ent w it h a diagnosis of HSV.
Interventions
care.

t est result s. Monit or and counsel appropriat ely f or int raut erine and
congenit al inf ect ions.
care.
IM M UNOLOGIC TESTS FOR IM M UNE DYSFUNCTION

AND RELATED DISORDERS OF THE IM M UNE SYSTEM
Quantitative Immunoglobulins: IgA, IgG, IgM
Five classes of immunoglobulins (ant ibodies)I gA, I gG (w it h f our subclasses,
I gG 1 , I gG2 , I gG3 , and I gG4 ), I gM, I gD, and I gEhave been isolat ed.
I mmunoglobulins f unct ion t o neut ralize t oxic subst ances, support phagocyt osis,
and dest roy microorganism f unct ions. For example, I gA t akes t w o f orms: serum
and secret ory. Serum I gA is present in blood serum; secret ory I gA is f ound in
saliva, t ears, colost rum, and bronchial, gast roint est inal, and genit ourinary
secret ions, w here it can prot ect against microorganism invasion. I gE is involved
in allergic react ions, w hereas I gD is involved in humoral immunit y.
I gG , t he only immunoglobulin t hat can cross t he placent a, is responsible f or
prot ect ion of t he new born during t he f irst mont hs of lif e. I gM possesses ant ibody
act ivit y against gram-negat ive organisms and rheumat oid f act ors and f orms
nat ural ant ibodies such as t he ABO blood group.
I gM does not cross t he placent a and is t heref ore usually absent in t he new born.
I t is observed about 5 days af t er birt h.
Q uant it at ive immunoglobulin measurement s can monit or t he course of a disease
and it s t reat ment . I f t here is a monoclonal prot ein or M component present on
serum prot ein elect rophoresis (SPEP), a quant it at ive measurement of I gA, I gG ,
and I gM can ident if y t he specif ic immunoglobulin. I gD and I gE are present in
t race amount s.
Reference Values
These values are derived f rom rat e nephelomet ry.
1. Adul ts
a. I gG : 7001500 mg/ dL
b. I gA: 60400 mg/ dL
c. I gM: 60300 mg/ dL
d. I gE: 3423 I U/ mL (3423 KI U/ L)
e. I gD: 5651765 mg/ dL
2. Chi l dren
a. I gA (boys and girls)

1. 04 mont hs: 664 mg/ dL
2. 58 mont hs: 1087 mg/ dL
3. 914 mont hs: 1794 mg/ dL
4. 1523 mont hs: 1794 mg/ dL
5. 23 years: 24192 mg/ dL
6. 46 years: 26232 mg/ dL
7. 79 years: 33258 mg/ dL
8. 1012 years: 45285 mg/ dL
9. 1315 years: 47317 mg/ dL
10. 1617 years: 55377 mg/ dL
b. I gM (boys)
1. 04 mont hs: 14142 mg/ dL
2. 58 mont hs: 24167 mg/ dL
3. 923 mont hs: 35200 mg/ dL
4. 23 years: 41200 mg/ dL
5. 417 years: 47200 mg/ dL
c. I gM (girls)
1. 04 mont hs: 14142 mg/ dL
2. 58 mont hs: 24167 mg/ dL
3. 923 mont hs: 35242 mg/ dL
4. 23 years: 41242 mg/ dL
5. 417 years: 56242 mg/ dL
d. I gG (boys and girls)
1. 04 mont hs: 141930 mg/ dL
2. 58 mont hs: 2501190 mg/ dL
3. 911 mont hs: 3201250 mg/ dL
4. 13 years: 4001250 mg/ dL
5. 46 years: 5601307 mg/ dL
6. 79 years: 5981379 mg/ dL
7. 1012 years: 6381453 mg/ dL
8. 1315 years: 6801531 mg/ dL
9. 1617 years: 7241611 mg/ dL
Procedure
precaut ions.
2. Place specimen in biohazard bag f or t ransport t o t he laborat ory.
1. I gA account s f or 10% t o 15% of t ot al immunoglobulin. Increases occur in t he
a. Chronic, nonalcoholic liver diseases, especially primary biliary cirrhosis
(PBC)
b. O bst ruct ive jaundice
c. Exercise
d. Alcoholism
e. Subacut e and chronic inf ect ions
2. I gA decreases occur in t he f ollow ing condit ions:
a. At axia-t elangiect asia
b. Chronic sinopulmonary disease
c. Congenit al def icit
d. Lat e pregnancy
e. Prolonged exposure t o benzene immunosuppressive t herapy
f. Abst inence f rom alcohol af t er a period of 1 year
g. Drugs and dext rin
h. Prot ein-losing gast roent eropat hies
3. I gG const it ut es 75% t o 80% of t ot al immunoglobulins. Increases occur in t he
a. Chronic granulomat ous inf ect ions
b. Hyperimmunizat ion
c. Liver disease
d. Malnut rit ion (severe)
e. Dysprot einemia
f. Disease associat ed w it h hypersensit ivit y granulomas, dermat ologic
disorders, and I gG myeloma
g. Rheumat oid art hrit is
4. I gG decreases occur in t he f ollow ing condit ions:
a. Agammaglobulinemia
b. Lymphoid aplasia
c. Select ive I gG , I gA def iciency
d. I gA myeloma
e. Bence Jones prot einemia
f. Chronic lymphoblast ic leukemia
5. I gM const it ut es 5% t o 10% of t ot al ant ibody. Increases in adult s occur in t he
a. Waldenst rm's macroglobulinemia
b. Trypanosomiasis
c. Malaria
d. I nf ect ious mononucleosis
e. Lupus eryt hemat osus
g. Dysgammaglobulinemia (cert ain cases)
6. I gM decreases occur in t he f ollow ing condit ions:
b. Lymphoprolif erat ive disorders (cert ain cases)
c. Lymphoid aplasia
d. I gG and I gA myeloma
e. Dysgammaglobulinemia
f. Chronic lymphoblast ic leukemia
Clin ical Alert

Persons w it h I gA def iciency are predisposed t o aut oimmune disorders and can
develop ant ibody t o I gA, w it h possible anaphylaxis occurring if t ransf used w it h
blood cont aining I gA.
Clin ical Alert

I n t he new born, a level of I gM >20 mg/ dL indicat es in ut ero st imulat ion of t he
immune syst em (eg, rubella virus, cyt omegalovirus, syphilis, t oxoplasmosis).
Interventions
care.

1. See post t est care f or prot ein elect rophoresis.
2. I nt erpret t est out come. Follow -up immunoglobulin t est ing may be necessary,
along w it h serum viscosit y, t o monit or a pat ient w it h monoclonal
gammopat hy.
care.
Protein Electrophoresis (PEP), Serum and Urine Serum

proteins represent a diverse microenvironment. They
are a source of nutrition and a buffer system.
Immunoglobulins and related proteins function as
immunologic agents. Carrier proteins (eg, haptoglobin,
prealbumin, transferrin) transport certain ions and
molecules to their destinations. Antiproteases (eg,
alpha 1 -antitrypsin, alpha2 -macroglobulin) regulate the
activity of various proteolytic enzymes, and other
classes of proteins regulate oncotic pressure, genetic
component pressures (eg, chromosomal), and
metabolic substances (eg, hormones). Blood serum
and urine are commonly screened for the monoclonal
immunoglobulin component by means of serum protein

electrophoresis (SPEP). Immunoglobulins are the major
component of the serum gamma-globulin fraction. In
health, the immunoglobulins are polyclonal instead of
monoclonal. When a monoclonal band is observed, it
frequently signals a neoplastic process such as
multiple myeloma or Waldenstrm's
macroglobulinemia. SPEP enhances follow-up
procedures such as specific protein quantification of
immunoglobulins (IgA, IgG, IgM) and immunofixation. It
provides one of the best tools for general screening of
the human health state.
These t est s can diagnose some inf lammat ory and neoplast ic st at es, nephrot ic
syndromes, liver disease, and immune dysf unct ions and can evaluat e nut rit ional
st at es and osmot ic pressures in edemat ous and malnourished pat ient s. SPEP
produces elect rophoret ic separat ion of t he f ive major prot ein f ract ions (albumin,
alpha 1 -globulin, alpha2 -globulin, bet a-globulin, and gamma-globulin) in serum and
urine specimens so t hat a more def init ive diagnosis can be made. Major
component s present in each prot ein f ract ion or zone exhibit charact erist ic,
unique elect rophoret ic pat t erns and are def ined as t he albumin zone (albumin);
t he alpha1 zone (alpha1 -lipoprot eins, high-densit y lipoprot ein, alpha1 ant rit rypsin); t he alpha2 zone (alpha2 -macroglobulin, hapt oglobin, bet alipoprot ein); t he bet a zone (t ransf errin, C3 [ complement ] ); and t he gamma zone
(f ibrinogen, I gA, I gM, I gG ).
Reference Values: Urine Protein Electrophoresis (UPE)

A descriptive report is prepared by the pathologist.
Reference Values: Serum Protein Electrophoresis
(SPE)
Total Protein
SI
Units
Album in
SI
Units
Adult: 6.08.0
g/dL
6080
g/L
Adult: 3.85.0
g/dL
3850
g/L
<5 d: 5.47.0
g/dL
5470
g/L
Newborn: 2.6
3.6 g/dL
2636
g/L
13 yr: 5.97.0
g/dL
5970
g/L
13 yr: 3.44.2
g/dL
3442
g/L
46 yr: 5.97.8
g/dL
5978
g/L
46 yr: 3.55.2
g/dL
3552
g/L
79 yr: 6.28.1
g/dL
6281
g/L
79 yr: 3.75.6
g/dL
3756
g/L
1019 yr: 6.3

8.6 g/dL
6386
g/L
1019 yr: 3.7

5.6 g/dL
3756
g/L
1 -Globulin: 0.10.3 g/dL

2 -Globulin: 0.61.0 g/dL
-Globulin: 0.71.4 g/dL
Gamma-globulin: 0.71.6 g/dL
Procedure
precaut ions.
2. First voided morning urine specimen or 24-hour t imed urine specimen is
pref erred. A 100-mL sample f rom a 24-hour urine collect ion is submit t ed f or
a urine prot ein elect rophoresis.
3. I f blood or urine sample demonst rat es t he presence of a paraprot ein, a
f ollow -up or conf irmat ory immunof ixat ion elect rophoresis (I FE; see page
578) can be perf ormed on t he same specimen submit t ed f or t he prot ein
elect rophoresis.
4. To quant if y t he amount of prot ein in each f ract ion, separat e prot eins are
scanned and separat ed according t o net molecular charge by means of a
densit omet er and are expressed in grams per decilit er (g/ dL).
The f ollow ing are t he most f requent prot ein abnormalit ies in prot ein
quant if icat ion and SPEP:
1. Tot al serum prot ein (t he sum of circulat ing serum prot eins) i ncreases
(hyperprot einemia) in dehydrat ion and hemoconcent rat ion st at es because of
f luid loss (eg, vomit ing, diarrhea, poor kidney f unct ion); increases are also
f ound in t he f ollow ing condit ions:
a. Liver disease
b. Mult iple myeloma and ot her gammopat hies
c. Waldenst rm's macroglobulinemia
d. Tropical disease
e. Sarcoidosis and ot her granulomat ous diseases
f. Collagen disorders such as syst emic lupus eryt hemat osus (SLE) and
rheumat oid art hrit is (RA)
g. Chronic inf lammat ory st at es
h. Chronic inf ect ions
2. Tot al serum prot ein decreases (hypoprot einemia) in t he f ollow ing condit ions:
a. I nsuff icient nut rit ional int ake (st arvat ion or malabsorpt ion)
b. Severe liver disease or alcoholism
c. Renal disease, nephrot ic syndrome
d. Diarrhea (Crohn's disease, ulcerat ive colit is)
e. Severe skin diseases or burns
f. Severe hemorrhage (w hen plasma volume is replaced more rapidly t han
prot ein)
g. Heart f ailure
h. Hypot hyroidism
i. Prolonged immobilizat ion (t rauma, ort hopedic surgery)
3. Serum albumin i ncreases w it h int ravenous inf usions and dehydrat ion
(elevat ed hemoglobin and hemat ocrit indicat e higher albumin levels).
4. Serum albumin decreases in t he f ollow ing condit ions:
a. Decreased synt hesis st at es such as liver disease, alcoholism,
malabsorpt ion syndromes, Crohn's disease, ot her prot ein-losing
ent eropat hies, st arvat ion st at es, and congenit al analbuminemia
b. Increased albumin loss (eg, nephrot ic syndrome, t hird-degree burns)
c. Poor nut rit ion st at es and inadequat e iron int ake
d. Low albumin-t o-globulin (A/ G ) rat io (eg, collagen disease, chronic
inf lammat ion, liver diseases, macroglobulinemia, severe inf ect ions,
cachexia, burns, ulcerat ive colit is)
5. Alpha 1 -globulin i ncreases w it h inf ect ions (acut e and chronic) and f ebrile
react ions.
6. Alpha 1 -globulin decreases w it h nephrosis and alpha-ant it rypsin diff erence.
7. Alpha 1 -globulin i ncreases in t he f ollow ing condit ions:
a. Biliary cirrhosis
b. O bst ruct ive jaundice
c. Nephrosis
d. Mult iple myeloma (rare)
e. Ulcerat ive colit is
8. Alpha 1 -globulin decreases in acut e hemolyt ic anemia.
9. Bet a-globulin i ncreases in biliary cirrhosis, obst ruct ive jaundice, and mult iple
myeloma (occasional).
10. Bet a-globulin decreases in nephrosis.
11. G amma-globulin i ncreases in t he f ollow ing condit ions:
a. Chronic inf ect ions
b. Hepat ic diseases
c. Aut oimmune diseases
d. Collagen diseases
f. Waldenst rm's macroglobulinemia

g. Leukemia and ot her cancers
12. G amma-globulin decreases in t he f ollow ing condit ions:
b. Hypogammaglobulinemia
Interfering Factors
1. Decreased albumin can be seen w it h rapid int ravenous f luid inf usions and
hydrat ion and during all t rimest ers of pregnancy.
2. Excessive hemolysis decreases albumin 0. 5 g/ mL w hen pat ient s are in t he
supine posit ion. Conversely, hemolysis and dehydrat ion elevat e t he t ot al
serum prot ein.
3. Prolonged bed rest and t he last t rimest er of pregnancy produce low er t ot al
prot ein levels.
Interventions
2. I f a 24-hour urine specimen is t o be collect ed, t he pat ient w ill require
specif ic inst ruct ions, an appropriat e cont ainer, and a recept acle f or cat ching
t he voided urine (see Chap. 3, Urine St udies).
care.

1. I nt erpret t est out come and monit or appropriat ely. Very low levels of prot ein
and albumin are associat ed w it h edema and hypocalcemia.
2. Assess t he pat ient f or signs and sympt oms relat ed t o t hese condit ions and
report and document same. Rarely is any one t ype of elect rophoret ic
analysis used t o diagnose a gammopat hy. Follow -up t est ing may include
immunof ixat ion (I FE), quant it at ive immunoglobulins, and bone marrow
st udies.
care.
Clin ical Alert

Normally, very lit t le prot ein is excret ed in t he urine; how ever, relat ively large
amount s may be excret ed in cert ain disease st at es. I n t he presence of lipoid
nephrosis, select ive prot einuria produces excess albumin excret ion. Wit h
nonselect ive prot einuria (eg, glomerulonephrit is), all t ypes of serum prot eins
usually appear in t he urine. Urine prot ein elect rophoresis can ident if y Bence
Jones prot eins, w hich migrat e in t he -globulin and gamma-globulin regions.
See Chap. 3 f or a complet e explanat ion of urine prot ein and albumin.
Immunofixation Electrophoresis (IFE), Serum and Urine

Monoclonal immunoglobulins consist of heavy and
light chains. IFE identifies presence or absence of a
monoclonal protein and determines its heavy-chain and
light-chain types.
This t est measures immune st at us and compet ence by ident if ying monoclonal and
part icle prot ein band immunoglobulins involved in t he immune response. I FE is a
f ollow -up t est perf ormed w hen monoclonal spike is observed on SPEP or w hen a
monoclonal gammopat hy is suspect ed on t he basis of t he pat ient 's
immunoglobulin concent rat ions.
Reference Values
Normal
No abnormalit y present
Procedure
1. Collect a 7-mL blood serum sample in a red-t opped t ube and/ or a 24-hour
urine specimen. O bserve st andard precaut ions. Submit 25 mL f rom a 24-hour
urine collect ion, if a urine I FE is t o be run simult aneously.
2. I f t he I FE is a f ollow -up t o a paraprot ein being demonst rat ed by prot ein
elect rophoresis (see page 575), t he same specimen (blood, urine, or bot h)
used f or t he elect rophoresis can be used f or t his procedure as w ell.
3. I n I FE, high-resolut ion elect rophoresis produces st ained bands. By

comparing t he locat ion of t he st ained immunof ixed band w it h a band in t he
same locat ion in t he SPEP ref erence pat t ern, a part icular prot ein band can
be ident if ied.
1. Monocl onal prot ein in t he serum or urine suggest s a neoplast ic process; a
pol ycl onal increase in immunoglobulins is seen in chronic liver disease,
connect ive t issue disease, and inf ect ion.
2. I n mult iple myeloma, 99% of pat ient s have a monoclonal prot ein in t he serum
or urine. Waldenst rm's macroglobulinemia is charact erized by t he presence
of a serum monoclonal I gM prot ein in all cases.
3. A monoclonal light chain (K or Bence Jones prot ein) is f ound in t he urine of
about 75% of pat ient s w it h mult iple myeloma. Approximat ely 75% of pat ient s
w it h Waldenst rm's macroglobulinemia have a monoclonal light chain in t he
urine. Heavy-chain f ragment s as w ell as f ree light chains may be seen in t he
urine of pat ient s w it h mult iple myeloma or amyloidosis.
Interventions
2. Submit t he same specimen f or t he serum prot ein elect rophoresis, if a blood
sample is needed. I f t he t est is t o be perf ormed separat ely, anot her 7-mL
blood sample collect ed in a red-t opped t ube is required. Not e pat ient 's age;
t his procedure is seldom indicat ed in pat ient s <30 years of age because
monoclonal prot eins are rarely ident if ied in t his age group.
3. Be aw are t hat a 24-hour urine specimen is pref erred. Provide inst ruct ions
and a 24-hour collect ion cont ainer (see Chap. 3, Urine St udies, f or
prot ocols).
care.

1. I nt erpret t est out comes and monit or appropriat ely f or neoplasms, inf ect ion,
and liver and connect ive t issue disease.
care.
Cold Agglutinin
This t est most commonly diagnoses primary at ypical viral pneumonia caused by
Mycopl asma pneumoni ae; it is used t o diagnose cert ain hemolyt ic anemias (eg,
cold agglut inat ion disease) as w ell. The diagnosis depends on demonst rat ing a
f ourf old or higher increase in ant ibody t it ers bet w een an early acut e-phase blood
serum sample and a blood serum sample t aken in t he convalescence phase, 7 t o
10 days af t er t he f irst sample. Posit ive react ion f requency and t it er elevat ion
bot h appear t o be direct ly relat ed t o inf ect ion severit y.
Pat ient 's serum is serially dilut ed, human red cells are added, and t he t est is
incubat ed at 4C (ref rigerat or, 010C). The cold agglut inin ant ibodies react
opt imally at 4C w it h t he I ant igen present on human red cells. The react ion is
reversed by incubat ion of t he agglut inat ed serum/ cell mixt ure at 37C.
Reference Values
Normal
<1: 16 by red cell agglut inat ion at 4C
Procedure
laborat ory.
2. Be aw are t hat t he sample should be prew armed t o 37C f or at least 15
minut es bef ore t he serum is separat ed f rom t he cells. This allow s t he cold
agglut inat ing ant ibodies t o be elut ed f rom t he red cell membranes so t hat
t hey can be det ect ed in t he agglut inat ion procedure using O -negat ive
indicat or cells (pooled group O donors).
1. I n viral pneumonia, t he t it er rises 8 t o 10 days af t er onset , peaks in 12 t o 25
days, and decreases 30 days af t er onset . Up t o 90% of people w it h severe
illness exhibit posit ive t it ers.
2. Chronic increased t it er levels are associat ed w it h t he f ollow ing condit ions:
a. Cold ant ibody hemolyt ic anemia

b. Chronic cold agglut inin disease
c. Paroxysmal cold hemoglobinuria
d. Severe Raynaud's phenomenon (may lead t o gangrene)
e. B-cell chronic lymphocyt ic leukemia
3. More import ant t han any single high value is t he rise in t it er during t he
course of illness. The t it er usually decreases by 4 t o 6 w eeks af t er t he onset
of illness.
4. Transient increases in t it ers are associat ed w it h primary at ypical viral
pneumonia, inf ect ious mononucleosis, measles, mumps, CMV, congenit al
syphilis, hepat ic cirrhosis, and t rypanosomiasis.
Interfering Factors
1. A high cold agglut inin t it er int erf eres w it h blood t yping and crossmat ching.
2. High t it ers are somet imes spont aneous in older persons and may persist f or
years.
3. Ant ibiot ic t herapy may int erf ere w it h cold agglut inin development .
Interventions
care.

t est result s. Counsel appropriat ely. Cold agglut inin t it ers rise during t he
second and t hird w eek of illness bef ore rapidly ret urning t o baseline levels.
The t est should be repeat ed at appropriat e int ervals.
care.
Cryoglobulin Test
Cryoglobulins are prot eins t hat reversibly precipit at e or gel at 0 t o 4C. They
are classif ied as f ollow s:
1. Type I (monoclonal)
2. Type I I (mixed cryoglobulins, in w hich a monoclonal is direct ed against a
polyclonal immunoglobulin)
3. Type I I I (polyclonal, of w hich no monoclonal prot ein is f ound)
Types I and I I are associat ed w it h monoclonal gammopat hies, a group of
diseases (see I mmunof ixat ion Elect rophoresis, pages 578579) in w hich a
monoclonal prot ein is produced by neoplast ic plasma cells or lymphocyt es.
Types I I and I I I cryoglobulins are circulat ing immune complexes produced in
response t o a variet y of ant igens, including viral, bact erial, and aut ologous
ant igens.
The normal prot eins of serum do not precipit at e in t he cold. Blood should be
collect ed, allow ed t o clot , and cent rif uged at 37C. The serum should be
separat ed at 37C t o ensure t hat t he cryoglobulins w ill remain in t he serum. The
serum is t hen ref rigerat ed and checked each day (up t o 7 days) f or t he presence
of a w hit e precipit at e or gel. Warming t he serum t o 37C w ill reverse t he
precipit at ion.
The amount of cryoglobulin present can be quant if ied by f illing a hemat ocrit t ube
w it h serum, incubat ing at 1C, cent rif uging at 1C at 750 g f or 30 minut es, and
reading t he cryocrit .
To charact erize t he cryoprot ein, t he precipit at e is w ashed (cold saline) and
redissolved (w arm saline). I FE, as described on page 578, w ill ident if y t he
immunoglobulin classes present .
Reference Values
Normal
Negat ive f or cryoglobulin
I f posit ive af t er 3 t o 7 days at 4C, I FE on t he cryoprecipit at e is perf ormed t o
ident if y t he prot ein complex.
Procedure
precaut ions. Keep t he specimen at 37C unt il t he cells are separat ed.
2. Ref rigerat e t he serum f or a minimum of 72 hours, alt hough 7 days is bet t er
t o det ermine t he presence of a cryoglobulin.
The t endency of cryoglobulins t o precipit at e at low t emperat ures may occlude
blood vessels; sympt oms include Raynaud's phenomenon, vascular purpura,
bleeding t endencies, cold-induced urt icaria, pain, and cyanosis.
Type I cryoglobulinemia is associat ed w it h monoclonal gammopat hy of
undet ermined signif icance (MG US), macroglobulinemia, or mult iple myeloma.
Type I I cryoglobulinemia is associat ed w it h aut oimmune disorders such as
vasculit is, glomerulonephrit is, syst emic lupus eryt hemat osus, rheumat oid
art hrit is, and Sjgren's syndrome. I t may also be seen in diseases such as
hepat it is, inf ect ious mononucleosis, CMV, and t oxoplasmosis.
Type I I I cryoglobulinemia is usually associat ed w it h t he same disease spect rum
as t ype I I and may t ake t he f ull 7 days t o appear.
A cryoprecipit at e in plasma but not serum is caused by cryof i bri nogen.
Cryof ibrinogens are rare and can be associat ed w it h vasculit is.
Clin ical Alert

The presence of cryoglobulins may cause erroneous result s w it h some
aut omat ed hemat ology inst rument s.
Interventions
care.

1. I nt erpret t est result s. Counsel and monit or appropriat ely f or inf ect ions,
collagen disorders, and malignant blood cell disease. Follow -up t est ing is
usually needed.
care.
Total Hemolytic Complement (CH50) Complement (C) is

a complex sequential cascade system in which inactive
proteins become active and interact much like the
clotting system. The complement system is important
as part of the body's defense mechanism against
infection. Activation of complement results in cell
lysis, release of histamine from mast cells and
platelets, increased vascular permeability, contraction
of smooth muscle, and chemotaxis of leukocytes and
neutralization of certain viruses. These inactive
proteins constitute about 10% of the globulins in
normal blood serum. The complement system is also
interrelated with the coagulation, fibrinolytic, and kinin
systems. The action of complement, however, is not
always beneficial. The potent reactions mediated by
this complex system are not always contained. In the
presence of gram-negative bacteremia, the complement
can escape its built-in control mechanisms, causing
severe damage to the body. It is not clear how this
happens, but it is known that complement
abnormalities develop before shock occurs.
This t est screens f or cert ain aut oimmune diseases, est imat es t he ext ent of
immune complex f ormat ion, and det ect s all inherit ed and most acquired immune
def iciencies. Serial measurement s monit or disease course and t reat ment in SLE,
RA, and glomerulonephrit is. I t is a usef ul adjunct f or rheumat oid f act or and
ant inuclear ant ibody (ANA) t est ing w hen immune complexes appear t o be t he
primary mediat ors of t issue injury.
Reference Values
Normal
60144 complement act ivit y enzyme (CAE) Unit s by ELI SA
Procedure
precaut ions. A joint f luid specimen of at least 1 mL can also be used and
should be collect ed in a t ube t hat does not cont ain addit ives.
Clin ical Alert

Complement det eriorat es at room t emperat ure in serum or f luid; samples
should be brought t o t he laborat ory as soon as possible. Separat e serum f rom
clot and f reeze at -70C unt il t est is perf ormed. Bot h blood and f luid must be
processed and f rozen w it hin 2 hours af t er specimen collect ion. Failure t o
process t he specimen in t his manner may lead t o f alsely decreased f unct ional
act ivit y levels.
1. Increased total compl ement val ues are associat ed w it h most inf lammat ory
responses; t hese acquired elevat ions are usually t ransient , and
concent rat ions ret urn t o normal w hen t he sit uat ion is resolved.
2. Decreased total compl ement val ues are associat ed w it h heredit ary def ect s
of specif ic complement component s. I n C2 def iciency, aut oimmune disorders
occur as SLE, and C1q def iciency may cause heredit ary angioedema.
a. Complement consumpt ion by act ivat ion of t he alt ernat ive pat hw ay, an
amplif icat ion of t he classic pat hw ay not requiring an immunologic
st imulus, can be seen in t he f ollow ing condit ions:
1. G ram-negat ive sept icemia
2. Subacut e bact erial endocardit is
3. Acut e post st rept ococcal glomerulonephrit is
4. Membranoprolif erat ive glomerulonephrit is
b. Complement consumpt ion due t o act ivat ion of t he classic pat hw ay by
immune complex f ormat ion occurs in t he f ollow ing condit ions:
1.
SLE
2. Serum sickness
3. Acut e vasculit is
4. Severe RA
5. Hepat it is
6. Cryoglobulinemia
Interventions
See ANAs, page 586.
C3 Complement Component
C3 const it ut es 70% of t he t ot al prot ein in t he complement syst em and is
essent ial t o t he act ivat ion of bot h classic and alt ernat ive pat hw ays. Along w it h
t he ot her component s of t he complement syst em, C3 may be used up in
react ions t hat occur in some ant igen-ant ibody react ions. C3 is synt hesized in t he
liver, macrophages, f ibroblast s, lymphoid cells, and skin.
This t est is done w hen it is suspect ed t hat individual complement component
concent rat ions are abnormally reduced. This t est and t he C1q and C4 t est s are
t he most f requent ly ordered complement measurement s. There is a correlat ion
bet w een most f orms of nephrit is, t he degree of nephrit is severit y, and C3 levels.
C3 is usef ul f or assessing disease act ivit y in SLE.
Reference Values
Normal
75175 mg/ dL (0. 751. 75 g/ L) by rat e nephelomet ry
Procedure
precaut ions. This amount is suff icient f or bot h C3 and C4 t est ing.
2. Place specimen in biohazard bag f or t ransport t o laborat ory.
1. Decreased C3 l evel s are associat ed w it h most act ive diseases w it h immune
complex f ormat ion.

a. Severe recurrent bact erial inf ect ions due t o C3 homozygous def iciency
b. Absence of C3b inact ivat or f act or
c. Acut e post st rept ococcal glomerulonephrit is
d. I mmune complex disease
e. Act ive SLE
f. Membranoprolif erat ive glomerulonephrit is
g. Nephrit is
h. End-st age liver disease
2. Increased l evel s are f ound in numerous inf lammat ory st at es.
Interventions
See ANAs, page 586.
Clin ical Alert

Pat ient s w it h low C3 levels are in danger of shock leading t o deat h.
C4 Complement Component
C4 is anot her of t he component s of t he complement syst em and is synt hesized in
bone and lung t issue. C4 may be bypassed in t he alt ernat ive complement
pat hw ay w hen immune complexes are not involved, or it may be used up in t he
very complicat ed series of react ions t hat f ollow many ant igen-ant ibody
react ions.
This is a f ollow -up t est done w hen t ot al complement levels are abnormally
decreased. I t can also be ordered t o conf irm heredit ary angioedema if t he C1
inhibit or result is decreased.
Reference Values
Normal
1440 mg/ dL (140400 mg/ L) by rat e nephelomet ry
Procedure
precaut ions. This amount is suff icient f or bot h C3 and C4 t est ing.
1. Decreased C4 l evel s are associat ed w it h t he f ollow ing condit ions:
a. Acut e SLE
b. Early glomerulonephrit is
c. I mmune complex disease
d. Cryoglobulinemia
e. I nborn C4 def iciency
f. Heredit ary angioneurot ic edema
2. Increased C4 l evel s are associat ed w it h malignancies.
Interventions
See ANAs, page 586.
C1 Esterase Inhibitor (C1 INH) C1 esterase inhibitor is

a glycoprotein. It acts as a regulatory brake on the
complement activation process. Decreased production
of this glycoprotein results in hereditary angioedema
(HAE).
This det erminat ion is an import ant t ool f or diagnosing HAE, a disorder caused by
a low concent rat ion of C1 est erase inhibit or or by an abnormal st ruct ure of t he
prot ein. Aff ect ed persons are apparent ly het erozygous f or t he condit ion. I t is
also used in t he diff erent ial diagnosis of t he more prevalent but less serious
allergic and nonf amilial angioedema.
Reference Values
Normal
1840 mg/ dL (180400 mg/ L) by an immunot urbidimet ric assay
Procedure
1. Collect a 7-mL serum specimen in a red-t opped t ube. O bserve st andard

precaut ions. Place specimen in biohazard bag f or t ransport t o laborat ory.
2. Spin dow n, separat e f rom clot , and f reeze 1. 0 mL of serum at -70C unt il
t est ing is perf ormed.
1. Decreased values are associat ed w it h HAE, a genet ic disease charact erized
by acut e edema of subcut aneous t issue, gast roint est inal t ract , or upper
airw ay t ract .
2. During acut e at t acks of t he disease, C4 and C2 component s can be markedly
reduced.
Interventions
See ANAs, page 586.
Clin ical Alert

Prednisolone and t ransf usions of f resh-f rozen plasma have been successf ully
used t o t reat HAE.
TESTS FOR AUTOIM M UNITYAND SYSTEM IC

RHEUM ATIC DISEASE (SRD)
Antinuclear Antibody (ANA) Test

Measurement of ANAs in serum is the most
commonly performed screening test for
autoantibodies in patients suspected of
having systemic rheumatic disease (SRD).
SRDs are also called connective tissue or
collagen diseases. Examples of SRDs
include SLE, mixed connective tissue
disease, Sjgren's syndrome, scleroderma,
CREST (calcinosis, Raynaud's

phenomenon, esophageal dysfunction,
sclerodactyly, and telangiectasia)
syndrome, rheumatoid arthritis, and
polymyositis dermatomyositis.
The diagnosis of SLE is diff icult because clinical signs and sympt oms are varied
and mimic ot her SRDs. SLE is charact erized by t he product ion of aut oant ibodies
t o nuclear ant igens, t hat is, ant i-dsDNA. SLE is a mult isyst em disease t hat can
aff ect every organ syst em in t he body, especially t he kidneys.
Result s of t est s f or ANAs by ELI SA show t hat ELI SA and t radit ional indirect
immunof luorescence met hods f or ANA are subst ant ially equivalent . Many
laborat ories are using a combinat ion of bot h met hods. ANA samples are
screened using an ELI SA assay. All samples t hat screen posit ive or equivocal
are t it ered using Hep-2 cells, and t he t it er and pat t ern are report ed. I n general,
a t it er 1: 160 is considered a signif icant posit ive. Low -t it er ANAs are common
w it h advancing age. When cell cult ure subst rat es (Hep-2 cells) are used, t he
ANA incidence is 99% in SLE.
Reference Values
Normal
Negat ive by ELI SA and I FA met hods.
I f posit ive by I FA, t he specimen is t it ered and a pat t ern is report ed.
Procedure
precaut ions.
1. A posit ive result does not conf irm a disease; low t it ers of ANAs are present
in elderly people and some apparent ly healt hy normal persons.
2. The diagnosis of an SRD is based primarily on t he presence of compat ible
clinical signs and sympt oms. The result s of t est s f or aut oant ibodies,
including ANAs and specif ic aut oant ibodies (eg, RNP, Smit h, SSA, SSB, Scl70, Jo-1) are ancillary. Addit ional diagnost ic crit eria include consist ent
hist opat hology or specif ic radiographic f indings.
Interfering Factors
1. Drugs, such as procainamide and hydralazine, may cause a posit ive ANA
result .
2. Posit ive ANA levels may be f ound af t er viral illnesses and w it h some chronic
inf ect ions.
Interventions
1. Explain t est purpose and procedure. A st rong posit ive result , t hat is, >3 on
ELI SA or 1: 160 on I FA, may require f ollow -up t est ing of specif ic
aut oant ibodies.
care.

1. I nt erpret t est result s. Monit or and counsel pat ient about f ollow -up t est s and
t reat ment .
2. SRDs, such as SLE, must be dealt w it h on a cont inuing basis and may
require cert ain lif est yle changes. Repeat t est ing evaluat es t he eff ect iveness
of t herapy. Minor sympt oms, in t he absence of major organ involvement , are
f requent ly t reat ed w it h nonst eroidal ant i-inf lammat ory drugs (NSAI Ds) such
as salicylat es. Cut aneous manif est at ions respond t o t opical cort icost eroid
t reat ment s. Short -act ing cort icost eroids, such as prednisone, are necessary
if acut e serologic changes and severe clinical manif est at ions appear.
3. Long-t erm moderat e- t o high-dose cort icost eroids are cent ral regimens
prescribed f or diff use glomerulonephrit is as w ell as rheumat oid art hrit is.
4. Cort icost eroid dosage may be reduced and renal disease f avorably managed
by adding immunosuppressive drugs t o t he t herapy regimen. I nf ect ion,
secondary t o immunosuppressive t reat ment , is a leading cause of deat h in
pat ient s w it h SRDs. Pat ient educat ion plays a major role in prevent ion of
inf ect ion.

care.
Anticentromere Antibody Test The variant of

scleroderma, the CREST syndrome, is characterized by
calcinosis, Raynaud's phenomenon, esophageal
dysfunction, sclerodactyly, and telangiectasia.
Characteristically, anticentromere antibodies appear in
about 90% of these patients. This antibody is detected
by using Hep-2 cells in various stages of cell division.
The centromere region of the cell chromosomes will
stain if an anticentromere antibody is present.
Reference Values
Normal
Negat ive f or ant icent romere ant ibody by I FA or ELI SA. I f posit ive by I FA, t he
serum is t it ered.
Procedure
precaut ions.
Posit ive result s are associat ed w it h t he CREST syndrome in scleroderma.
Interventions
See ANAs, page 586.
Anti-dsDNA Antibody Test, IgG

Alt hough not complet ely underst ood, t he primary mechanism of t issue injury in
SLE and relat ed aut oimmune disease is t he f ormat ion of ant igen-ant ibody
immune complexes. Not all ANAs are pat hogenic. For t he f ew t hat are harmf ul,
pat hogenicit y depends on t he specif ic immunoglobulin class, abilit y t o act ivat e
complement , size of t he immune complex, and sit e of t issue deposit ion. For
example, st udies of immune complexmediat ed t issue injury in t he kidney have
show n a clear relat ion bet w een deposit ion of immune complexes and glomerular
disease.
The ant i-dsDNA t est is done specif ically t o ident if y or diff erent iat e nat ive (ie,
double-st randed) DNA ant ibodies, f ound in 40% t o 60% of pat ient s w it h SLE
during t he act ive phase of t heir disease, f rom ot her nonnat ive DNA ant ibodies
f ound in ot her rheumat ic diseases. The presence of ant ibodies t o dsDNA
generally correlat es w it h lupus nephrit is. An ant i-dsDNA t est support s a
diagnosis, allow s monit oring of disease act ivit y and response t o t herapy, and
est ablishes a prognosis f or SLE.
Reference Values
Normal
Negat ive: <25 I U by ELI SA
Borderline: 2530 I U
Posit ive: 31200 I U
St rongly posit ive: >200 I U
Procedure
precaut ions.
2. Place specimen in a biohazard bag f or t ransport t o laborat ory.
1. Ant i-dsDNA concent rat ions may decrease w it h successf ul t herapy and may
increase w it h an acut e recurrence of SLE.
2. DNAant i-dsDNA immune complexes play a role in SLE pat hogenesis t hrough
t he deposit of t hese complexes in t he kidney and ot her t issues.
Interfering Factors
1. The Farr assay, an RI A met hod, det ect s bot h single-st randed (ss) and
double-st randed (ds) DNA ant ibodies.

2. Ant ibodies t o ssDNA are nonspecif ic but are associat ed w it h various ot her
rheumat ic diseases.
Interventions
See ANAs, page 586.
Rheumatoid Factor (Rheumatoid Arthritis [RA] Factor)

Test The blood of many persons with RA contains a
macroglobulin-type antibody called rheumatoid factor
(RF). Evidence indicates that rheumatoid factors are
antigamma-globulin antibodies; however, until a
specific antigen that produces RF is discovered, the
exact nature of RF can only be speculated. Even more
uncertain is the role that RF plays in RA. Although RF
may cause or perpetuate the destructive changes
associated with RA, it may also be incidental to these
changes
or may even serve some beneficial purpose. RF is
sometimes found in blood serum from patients with
other diseases, even though RF incidence and values
are higher in patients with RA.
This t est is usef ul in t he diagnosis of RA. I t measures RFs (ant ibodies direct ed
against t he Fc f ragment of I gG ). These are usually I gM ant ibodies, but t hey may
also be I gG or I gA. Four of t he f ollow ing clinical crit eria must be present t o
diagnose rheumat oid art hrit is.
Revi sed Ameri can Col l ege of Rheumatol ogy Cri teri a f or Rheumatoi d Arthri ti s
1. Morning st iff ness f or at least 6 w eeks
2. Pain on mot ion or t enderness in at least one joint f or at least 6 w eeks
3. Sw elling in at least one joint f or at least 6 w eeks
4. Sw elling in at least one ot her joint f or at least 6 w eeks
5. Symmet rical joint sw elling w it h simult aneous involvement of t he same joint on
bot h sides of t he body

6. Subcut aneous nodules
7. X-ray changes, including bony decalcif icat ion
Reference Values
Normal
020 U/ mL or 020 kU/ L, based on rat e nephelomet ry
Procedure
precaut ions.
1. When a pat ient w ho t est s posit ive improves, subsequent t est s also remain
posit ive unless t it ers w ere init ially low.
2. A posit ive RF t est result of t en support s a t ent at ive diagnosis of early-onset
RA (eg, versus rheumat ic f ever).
3. RFs f requent ly occur in a variet y of ot her diseases, such as SLE,
endocardit is, t uberculosis, syphilis, sarcoidosis, cancer, viral inf ect ions,
Sjgren's syndrome, and diseases aff ect ing t he liver, lung, or kidney as w ell
as in pat ient s w ho have received skin and renal allograf t s.
4. Absence of RF does not exclude t he diagnosis or exist ence of RA.
Interfering Factors
The result is normally higher in older pat ient s and in t hose w ho have received
mult iple vaccinat ions and t ransf usions.
Interventions
See ANAs, page 586.
Antibodies to Extractable Nuclear Antigens (ENAs):

Anti-Ribonucleoprotein (RNP); Anti-Smith (Sm); Anti-
Sjgren's Syndrome (SSA, SSB); Anti-Scleroderma

(Scl-70); Anti-Jo-1 (Jo-1) The extractable nuclear
antigens (ENAs), another group of nuclear antigens
(nonhistone proteins) to which autoantibodies may
develop, are so named because of their presence in
saline solution extracts of certain nonhuman cells. The
most common ENAs are ribonucleoprotein (RNP) and
Smith (Sm).
Ant i-RNP is elevat ed in 35% t o 40% of SLE pat ient s and in pat ient s w it h ot her
connect ive t issue diseases, not ably mixed connect ive t issue disease (MCTD).
MCTD is charact erized by
high levels of ant i-RNP w it hout aut oant ibodies t o dsDNA or Sm. The disease
resembles SLE but is not accompanied by renal involvement .
Ant i-Sm is specif ic f or SLE but occurs in only approximat ely 30% of t he pat ient s.
The levels of ant i-Sm may be relat ed t o disease act ivit y in SLE.
Ant i-SSA (Ro) has been det ect ed in approximat ely 25% of pat ient s w it h SLE and
in 40% t o 45% of pat ient s w it h Sjgren's syndrome.
Ant i-SSB (La) is f ound in approximat ely 10% t o 15% of pat ient s w it h SLE and up
t o 60% of pat ient s w it h Sjgren's syndrome.
Ant i-Scl-70 is considered specif ic f or scleroderma (syst emic sclerosis). These
aut oant ibodies are f ound in up t o 60% of scleroderma pat ient s w it h ext ensive
cut aneous disease and int erst it ial pulmonary f ibrosis.
Ant i-Jo-1 occurs in approximat ely 20% of pat ient s w it h myosit is, usually in
pat ient s w it h int erst it ial pulmonary f ibrosis and symmet rical polyart hrit is.
The ELI SA assay is a screen f or several nuclear ant ibodies. I f t he ENA screen
result is borderline or posit ive, t he f ollow ing t est s (Table 8. 8) w ill be set up t o
det ermine t he part icular syst emic rheumat ic disease SRD.
Table 8.8 ELISA Screening for Specific Systemic

Rheumatic Disease (SRD)
Test
Specific SRD
Anti-RNP
Mixed connective tissue

disease (MCTD)
Anti-Sm (with or without

RNP)
SLE, MCTD, Sjgren's

syndrome
Anti-SSA(Ro) and/or
Anti-SSB(La)
Sjgren's syndrome
Anti-Scl-70
Scleroderma
Anti-Jo-1
Polymyositis
Reference Values for ENA and Individual Autoantibody

Tests
Normal
Negat ive: <20 U by ELI SA
Borderline: 2025 U
Posit ive: >26 U
Procedure
precaut ions.
1. Result s of serum t est s f or aut oant ibodies should not be relied on ext ensively
t o est ablish t he diagnosis of a connect ive t issue disease. They must alw ays
be int erpret ed in conjunct ion w it h clinical f indings.

2. Test ing f or aut oant ibodies t o ENAs is not usef ul in pat ient s w it hout
demonst rable ant inuclear ant ibodies.
Interventions
See ANAs, page 586.
Cardiolipin Antibodies, IgA, IgG, IgM

I n pat ient s w it h SLE, ant ibodies t o cardiolipin (a negat ively charged
phospholipid) have been associat ed w it h bot h art erial and venous t hrombosis,
t hrombocyt openia and recurrent f et al loss. Pat ient s w it h t he ant icardiolipin
syndrome have one of t he above clinical f eat ures and have ant ibodies t o
cardiolipin and/ or a posit ive lupus ant icoagulant t est .
The ant ibodies present t o cardiolipin may be of t he I gA, I gG , I gM isot ypes.
Test ing f or t he various ant ibody isot ypes t o cardiolipin aid in t he diagnosis of t he
ant iphospholipid syndrome in pat ient s w it h SLE or lupus-like disorders. They are
also usef ul f or t he prognost ic assessment of pregnant pat ient s w it h a hist ory of
recurrent f et al loss.
Reference Values
Normal
<12 APL (I gA phospholipid unit s): absent or none det ect ed <15 G PL (I gG
phospholipid unit s): absent or none det ect ed <12 MPL (I gM phospholipid unit s):
absent or none det ect ed
Procedure
precaut ions.
1. Most pat ient s w it h ant iphospholipid ant ibody syndrome have moderat e or
high levels of cardiolipin ant ibodies and are posit ive f or I gG only or I gG and
I gM.
2. Elevat ed values are seen in spont aneous t hrombosis and in pat ient s w it h
connect ive t issue disease.
3. Pat ient s w it h current or prior syphilis inf ect ion may have a f alse-posit ive
result w it hout t he risk f or t hrombosis.
Interventions
care.

1. I nt erpret t est out comes in light of t he pat ient 's hist ory, physical f indings, and
ot her diagnost ic procedures and result s. Transient ly posit ive t est s do occur
f or I gG and I gM ant ibodies, and it is recommended t hat posit ive result s be
conf irmed by f ollow -up assay in 8 w eeks.
care.
Autoimmune Thyroiditis, Thyroid Antibody Tests:

Thyroglobulin Antibody, Thyroid Microsomal Antibody,
Thyroperoxidase Antibody There are several
autoantibodies that are organ specific for the thyroid
gland, but anti-thyroglobulin and anti-thyroperoxidase
are ordered most frequently by clinicians when
evaluating patients for hyperthyroidism,
hypothyroidism, and thyroid cancer. In Graves'
disease, which is autoimmune hyperthyroidism, and in
Hashimoto's thyroiditis, which is autoimmune
hypothyroidism, the presence of both antibodies can
help confirm the diagnosis.
Thyroglobulin ant ibodies are direct ed against t he glycoprot ein t hyroglobulin

locat ed in t he t hyroid f ollicles; t hyroperoxidase, against t he membrane-bound
glycoprot ein t hyroperoxidase locat ed in t he cyt oplasm of t he epit helial cells
surrounding t he f ollicles.
Along w it h chemiluminescence t echnology has come t he use of highly purif ied
ant igens t o improve specif icit y. For t he ant i-t hyroperoxidase t est , inst ead of
using t he ent ire microsomal ant igen, t his assay uses just t he t hyroperoxidase
(TPO ) component . TPO is considered t he primary aut oant igenic component of
t he microsomal ant igen. Test syst ems t hat use t he purif ied TPO (in place of t he
microsomal ant igen) have great er specif icit y f or t he clinically signif icant
aut oant ibody. Assays using microsomal ant igen are det ect ing TPO ant ibody but
may also det ect ant ibodies t o ot her part s of t he microsomal ant igen t hat have
lit t le or no clinical signif icance.
Reference Values
Normal
<1: 100 f or t hyroglobulin and t hyroid microsomal ant ibodies by hemagglut inat ion
Negat ive f or t hyroglobulin and t hyroid microsomal ant ibodies by ELI SA Negat ive
f or t hyroglobulin and t hyroperoxidase ant ibodies by chemiluminescence
Procedure
1. Collect 7-mL blood serum in a red-t opped t ube. O bserve st andard
precaut ions.
1. High t it ers of t hyroglobulin and t hyroid microsomal ant ibodies (>1: 400) are
f ound in Hashimot o's disease, but elevat ions can also be seen in ot her
aut oimmune diseases.
2. I ncreased t hyroid ant ibodies also occur in t he f ollow ing condit ions:
a. G raves' disease
b. Thyroid carcinoma
c. I diopat hic myxedema
e. SLE, RA, Sjgren's syndrome
f. Subacut e t hyroidit is
g. Nont oxic nodular goit er
Interfering Factors
1. About 10% of t he normal populat ion may have low levels of t hyroid
ant ibodies w it h no sympt oms of t he disease. I ncidence of low t it er is higher
in w omen and increases w it h age.
2. Ant ibody product ion may be conf ined t o lymphocyt es w it hin t he t hyroid,
result ing in negat ive serum t est result s.
Interventions
1. Explain t est purpose. Thyroid ant ibody t est ing is done t o conf irm diagnosis.
I t is not t o be relied on, how ever, f or management of t he disease.
care.

1. I nt erpret t est out comes and det ermine t he need f or possible f ollow -up
t est ing. The diagnosis of aut oimmune t hyroidit is is made on t he basis of
clinical observat ions, t hyroid f unct ion t est s (see Chap. 6), and t he presence
of circulat ing aut oant ibodies, such as t hyroglobulin, microsomal (TPO ).
care.
AUTOIM M UNE LIVER DISEASE TESTS

AntiSmooth Muscle Antibody (ASMA) Test ASMA is
associated with liver and bile duct autoimmune
diseases. The immune response itself is believed to be
responsible for the disease process.
Sera f rom pat ient s w it h aut oimmune chronic act ive hepat it is (CAH) cont ain
ant ibodies t o smoot h muscle ant igens t hat are det ect able by I FA on t issues t hat
cont ain smoot h muscle, such as mouse st omach. The ant ibodies are
predominant ly I gG . This measurement diff erent iat es CAH and primary biliary
cirrhosis f rom ot her liver diseases in w hich ASMAs are seldom present (eg,
SLE).
Reference Values
Normal
Negat ive by I FA
I f posit ive, serum is t it ered.
Procedure
precaut ions. This amount is suff icient f or bot h ASMA and ant imit ochondrial
ant ibody (AMA) t est ing.
1. ASMAs are f ound in chronic act ive hepat it is, a progressive disease of
unknow n et iology f ound predominant ly in young w omen. I t has f act ors
charact erist ic of bot h acut e and chronic hepat it is (80% of pat ient s). I f t his
disease is associat ed w it h a posit ive ANA t est , t he disease is of t en called
lupoid hepat it is.
2. Ant ibody t it ers bet w een 80 and 320 occur commonly in pat ient s w it h CAH.
Prevalence of Autoantibodies in Liver Disease
Disease
Anti
Sm ooth
Muscle
(%)
Antim itochondrial
(%)
ANA
(%)
Chronic
active
hepatitis
7090
3060
60
Chronic
persistent
hepatitis
45
1520
15
30
Acute viral
hepatitis
1030
520
20
Acute
alcoholic
hepatitis
Biliary
cirrhosis
30
6070
Cryptogenic
cirrhosis
15
30
Alcoholic
(Laennec's)
cirrhosis
Extrahepatic
biliary
obstruction
510
510
Interventions
care.

1. I nt erpret t est out comes and monit or appropriat ely. Det ect ion of ASMA by
immunof luorescence assist s in det ermining t he presence of chronic act ive
hepat it is and need f or t herapy w hen used in conjunct ion w it h ot her laborat ory
t est s such as t hose used t o evaluat e liver enzymes, ANAs, and I gG levels.
All of t hese are elevat ed in t he majorit y of pat ient s w it h chronic act ive
hepat it is.
care.
Antimitochondrial Antibody (AMA) Test AMA is non

organ and nonspecies specific and is directed against
a lipoprotein in the inner mitochondrial membrane.
AMA is a marker for primary biliary cirrhosis, a chronic
inflammatory liver disease, characterized by the
progressive destruction of interlobular bile ducts with
development of cholestasis and eventually cirrhosis.
The mit ochondrial ant igens recognized by AMAs in pat ient s' sera have been
classif ied as M1 t hrough M9, w it h M2 recognized by AMAs in 99% of pat ient s
w it h primary biliary cirrhosis. The ant ibodies are predominant ly I gG . This
measurement aids in t he diagnosis of primary biliary cirrhosis (PBC), a
progressive disease most commonly seen in w omen in t he second half of t heir
reproduct ive years. There is also a genet ic predisposit ion.
Reference Values
Normal
Negat ive by indirect f luorescent ant ibody (I FA) I f posit ive, serum is t it ered.
Procedure
precaut ions. This amount is suff icient f or bot h AMA and ASMA t est ing.
1. Elevat ed concent rat ions of AMAs are present in >80% of pat ient s w it h PBC.
2. High t it ers are also associat ed w it h longst anding hepat ic obst ruct ion, chronic
hepat it is, and crypt ogenic cirrhosis.
3. Elevat ed levels are occasionally present in t he f ollow ing condit ions:
a.
SLE
b. RA
c. Thyroid disease
e. I diopat hic Addison's disease
Interventions
care.

1. I nt erpret t est out comes and monit or appropriat ely. I mmunof luorescence
t est ing, along w it h quant it at ion of I gM and liver enzymes, bot h of w hich t end
t o be elevat ed in PBC, are reliable f ollow -up prot ocols.
2. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive inf ormed posttest
care.
AntiLiver/Kidney Microsome Type 1 Antibody (LKM)

Test Antibodies to liver/kidney microsome antigens
(antiLKM-1) occur in a subset of patients with chronic
autoimmune hepatitis (AIH). The clinical diagnosis of
AIH is difficult because there are no particular signs,
symptoms, or liver function test abnormalities that are
specific enough to be considered diagnostic. Patients
with this type of chronic AIH are predominantly
children, but some patients are adults.
Diff erent aut oant ibodies are f ound in t he serum f rom pat ient s w it h AI H. The
discovery of t he LKM-1 ant ibody led t o t he est ablishment of t w o subt ypes of

AI H. The percent age of t ype 2 AI H pat ient s w hose serum cont ains LKM-1
ant ibodies is 90%.
Pat ient sera are incubat ed on slides w it h mouse kidney and st omach. Ant iLKM1 ant ibody produces a charact erist ic pat t ern, w hich allow s it t o be diff erent iat ed
f rom t he pat t erns produced by smoot h muscle and mit ochondrial ant ibodies on
mouse t issue.
Reference Values
Normal
Negat ive f or LKM-1 by indirect f luorescent ant ibody (I FA) I f posit ive, serum is
t it ered.
Procedure
precaut ions.
Interventions
care.

1. I nt erpret t est out comes and monit or appropriat ely. The primary t herapy f or
AI H is administ rat ion of cort icost eroids. St eroid t reat ment should lead t o
rapid reduct ion in AST and ALT (liver enzyme) levels.
care.
Antiparietal Cell Antibody (APCA) Test The disruption
of normal intrinsic factor production or function due to

autoimmune processes can lead to pernicious anemia.
Antibodies to two antigens of the gastric parietal cell
antiparietal cell antibodies (APCAs) and intrinsic factor
antibodiesare found in pernicious anemia.
This measurement is helpf ul in diagnosing chronic gast ric disease and
diff erent iat ing aut oimmune pernicious anemia f rom ot her megaloblast ic anemias.
Persons w it h ot her anemias do not have det ect able APCAs.
Reference Values
Normal
Negat ive f or APCA by I FA
I f posit ive, serum is t it ered.
Procedure
precaut ions.
1. APCAs occur in >80% of pat ient s w it h aut oimmune pernicious anemia; 50%
have ant ibodies t o int rinsic f act or.
2. O ccasionally, APCAs are present in t he f ollow ing condit ions:
a. G ast ric ulcer
b. G ast ric cancer
c. At rophic gast rit is
d. Thyroid disease
e. Diabet es mellit us
f. I ron-def iciency anemia
Interfering Factors
APCAs are present in many healt hy adult s >60 years of age.
Interventions
care.

1. I nt erpret t est out comes and monit or appropriat ely. Det ect ion of APCA may
suggest need f or more invasive t est ing, such as gast ric biopsy t o rule out
gast roint est inal disease.
care.
Antiglomerular Basement Membrane (AGBM) Antibody

Test Antibodies specific for renal structural
components such as the glomerular basement
membrane of the kidney can bind to respective tissuefixed antigens to produce an immune response.
This t est is primarily used in diff erent iat ing glomerular nephrit is induced by
ant iglomerular basement membrane ant ibodies (AG BMs) f rom ot her t ypes of
glomerular nephrit is. AG BMs cause about 5% of glomerular nephrit is; about t w o
t hirds of t hese pat ient s may also develop pulmonary hemorrhage (G oodpast ure's
syndrome).
Reference Values
Normal
Negat ive: <5 EU/ mL by ELI SA Borderline: 5. 120. 0 EU/ mL
Posit ive: 20. 1400 EU/ mL
Procedure
precaut ions.
AG BM ant ibodies are det ect ed in t he f ollow ing condit ions:
1. AG BM glomerular nephrit is
2. Tubuloint erst it ial nephrit is
3. AG BM G oodpast ure's syndrome
4. Some pat ient s w it h SLE
Interventions
care.

1. I nt erpret t est out comes and need f or f ollow -up t est ing and t reat ment s t hat
involve immunosuppressant s and plasmapheresis, w hich are eff ect ive if
t reat ment is st art ed bef ore renal f ailure is w ell advanced.
care.
Acetylcholine Receptor (AChR) Binding Antibody Test

Acetylcholine receptor antibodies (AChRs) appear in
myasthenia gravis (MG). It is believed that this disease
involves destruction by the muscle cells of
acetylcholine receptors bound by antibodies at the
skeletal muscle motor endplate.
This measurement is considered t o be t he f irst -order t est f or MG in sympt omat ic

pat ient s. I t also helps in managing response t o immunosuppressive t herapy.
Second- and t hird-order t est s f or modulat ing and blocking ant ibodies,
respect ively, are ordered t o conf irm t he diagnosis of acquired MG , dist inguish
acquired disease f rom congenit al disease, and monit or t he serologic process in
t he course of MG .
Reference Values
Normal
Negat ive f or AChR or <0. 02 nmol/ L by RI A
Procedure
precaut ions.
1. AChR ant ibodies are f ound in about 90% of persons w it h generalized MG ,
70% of persons w it h ocular MG , and 80% of persons in remission. These
f indings conf irm t he aut oimmune nat ure of t he disease.
2. Pat ient s w ho have only eye sympt oms t end t o have low er t it ers t han t hose
w it h generalized myast henia sympt oms.
Interfering Factors
Posit ive result s can be f ound in pat ient s w it h Lambert -Eat on myast henic
syndrome (LES) or aut oimmune liver disease.
Interventions
1. Explain t est purpose. Assess f or hist ory of immunosuppressive drug
t reat ment . Det ect ion of acet ylcholine recept or binding ant ibody is inf requent
in such cases.
care.

1. I nt erpret t est out comes and possible need f or ot her t est ing. O t her t est s now
available t o aid in t he serologic diagnosis of MG include acet ylcholine
recept or blocking ant ibody, acet ylcholine recept or modulat ing ant ibody, and
st riat ional ant ibodies. These are ordered according t o present at ion of
neurologic sympt oms. All of t hese ant ibodies are less f requent ly det ect ed
in t he early st ages of MG (w it hin 1 year of onset ) and in pat ient s t reat ed
w it h immunosuppressive drugs. None are f ound in cases of congenit al MG .
care.
Anti-Insulin Antibody Test

Persons w it h diabet es may f orm ant ibodies t o t he insulin t hey t ake and require
larger doses because insulin is not available f or glucose met abolism w hen it is
part ially complexed w it h t hese ant ibodies. I nsulin ant ibodies are immunoglobulins
called ant i-insulin ant ibodies; t hey act as insulin-t ransport ing prot eins. The most
common t ype of ant i-insulin ant ibody is I gG , but it is f ound in all f ive classes of
immunoglobulins in insulin-t reat ed pat ient s. These immunoglobulins, especially
I gE, may be responsible f or allergic manif est at ions: I gM may cause insulin
resist ance.
This insulin ant ibody level provides inf ormat ion f or det ermining t he most
appropriat e t reat ment f or cert ain diabet ic pat ient s. I t may f ocus t he reason f or
allergic manif est at ions. I t can ident if y a st at e of insulin resist ance in w hich t he
daily insulin requirement exceeds 200 U f or more t han 2 days, and may be
associat ed w it h elevat ed ant i-insulin ant ibody t it ers and insulin-binding capacit y.
Reference Values
Normal
Negat ive: <3% binding of t he pat ient 's serum w it h labeled beef , human, and pork
insulin SI unit s w hen perf ormed by RI A
Procedure
1. Collect a 7-mL blood serum sample f rom a f ast ing pat ient . Collect in a redt opped t ube. O bserve st andard precaut ions.
Ant i-insulin ant ibody elevat ions are associat ed w it h insulin resist ance and
allergies t o insulin.
Interventions
1. Explain purpose of t est . Fast ing is required. Check w it h individual laborat ory
f or t ime f rames.
care.

1. I nt erpret t est out comes. Based on ant ibody levels present and clinical
f indings, t he dosage of insulin is changed t o reduce or prevent f urt her
allergic manif est at ions and/ or insulin resist ance.
care.
Gliadin Antibodies, IgA and IgG

Ant ibodies t o gliadin (w heat prot ein) have been show n conclusively t o be t he
t oxic agent in celiac disease. O riginally, a series of mult iple int est inal biopsies
w ere required t o diagnose celiac and relat ed int est inal diseases. More recent ly,
serologic t est ing has been st rongly suggest ed f or screening pat ient s w it h
suspect ed glut en-sensit ive ent eropat hy as w ell as f or monit oring diet ary
compliance.
Celiac disease usually begins in inf ancy soon af t er int roduct ion of cereals t o t he
diet , but sympt oms may disappear spont aneously in lat er childhood, despit e
cont inued signs of malabsorpt ion. St rict avoidance of glut en in t he diet is
recommended t o cont rol t he disease.
Bot h I gG and I gA gliadin ant ibodies are det ect ed in sera of pat ient s w it h glut ensensit ive ent eropat hy. I gG ant igliadin ant ibodies seem more sensit ive but are
less specif ic t han t he I gA
class ant ibodies. The best st rat egy f or at -risk populat ions includes t est ing f or
bot h classes of gliadin ant ibodies.
Reference Values
Normal
Values are given f or >2 years of age.
Negat ive: <25 U/ mL by ELI SA Weakly posit ive: 2550 U/ mL
Posit ive: >50 U/ mL
Procedure
precaut ions.
1. The gliadin ant ibody assay has a sensit ivit y of 95% f or act ive, unt reat ed
celiac pat ient s w hen bot h I gG and I gA are used. The t est has an overall
specif icit y of 90%.
2. A negat ive I gA result in an unt reat ed pat ient does not rule out glut ensensit ive ent eropat hy, especially w hen associat ed w it h elevat ed levels of I gG
gliadin ant ibodies.
3. Signif icant port ions of celiac pat ient s are I gA def icient , w hich can serve as
an explanat ion f or t his occurrence.
4. I n t reat ed pat ient s know n t o express I gA ant ibodies, t he I gA gliadin ant ibody
level represent s a bet t er indicat or of diet ary compliance t han t he I gG level.
5. False-posit ive result s (high ant ibody levels w it hout t he corresponding
hist ologic f eat ures) are possible; ot her gast roint est inal disorders, especially
Crohn's disease, post inf ect ion malabsorpt ion, and f ood prot ein int olerance
(eg, cow 's milk), are know n t o induce circulat ing ant igliadin ant ibodies.
6. Result s of t his assay should be used in conjunct ion w it h clinical f indings and
ot her serologic t est s.
Interventions
2. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive inf ormed pretest
care.

1. I nt erpret t est out come in light of pat ient 's diet ary hist ory, including relat ed
clinical, laborat ory, and hist ologic dat a. Posit ive result s are possible in
pat ient s w it h ot her gast roint est inal disorders.
care.
Antineutrophil Cytoplasmic Antibodies (ANCA) There

are two types of antineutrophil cytoplasmic antibodies
distinguished by different immunofluorescent staining
patterns using human neutrophil substrates:
1. cANCAs produce a diff use cyt oplasmic st aining of neut rophils and monocyt es
and are specif ic f or prot einase 3. cANCA is f ound in t he sera of pat ient s w it h
Wegner's granulomat osis (WG ).
2. pANCAs produce a perinuclear st aining of neut rophils and are specif ic f or
ot her neut rophil enzymes including myeloperoxidase (MPO ), elast ase, and
lact of errin. pANCA specif ic f or MPO is f ound in t he sera of pat ient s w it h
syst emic vasculit is, most of w hom have renal involvement charact erized by
pauci-immune necrot izing glomerulonephrit is.
Test s f or ANCA are perf ormed by an indirect immunof luorescent t echnique.

Slides prepared f rom neut rophils are used as a subst rat e t o bind ANCA so t hat it
can be det ect ed microscopically. Depending on t he pat t ern of st aining, as
ment ioned previously, t w o t ypes of ANCAs exist : cANCA and pANCA.
Reference Values
Normal
Negat ive f or ANCAs by I FA
I f posit ive f or cANCA, result s are t it ered.
I f posit ive f or pANCA, MPO t est ing is perf ormed by ELI SA. Not all specimens
posit ive f or pANCA are MPO posit ive.
Procedure
precaut ions.
1. I n pat ient s w it h act ive generalized WG (pulmonary and/ or renal involvement ),
t he f requency of posit ive cANCA result s approaches 85%. A negat ive t est f or
cANCA does not rule out WG ; how ever, f alse-posit ive result s are rare.
2. I n pat ient s w it h know n WG , rising t it ers of cANCA suggest relapse, and
f alling t it ers suggest successf ul t reat ment .
3. I n pat ient s w it h act ive renal disease, a posit ive pANCA suggest s t he
presence of ant ibodies t o MPO and pauci-immune necrot izing
glomerulonephrit is.
4. Result s of t est s f or ANCA should be considered along w it h ot her clinical,
laborat ory, and hist opat hologic dat a in est ablishing t he diagnosis of WG or
syst emic vasculit is.
5. I nf lammat ory bow el disease (I BD)-associat ed ANCAs are f ound in ulcerat ive
colit is and Crohn's disease, specif ically pANCA.
Interventions
care.

1. I nt erpret t est out comes in light of t he pat ient 's hist ory, including ot her
clinical, laborat ory, and hist opat hologic dat a. Posit ive ANCA result s (pANCA
and, rarely, cANCA) may occur in pat ient s w it h diseases ot her t han WG or
vasculit is, including G oodpast ure's syndrome and SLE.
care.
SPERM ANTIBODIES
Antisperm Antibody Test
The majorit y of inf ert ile males have blocking of t he eff erent t est icular duct s. I t is
likely t hat , similar t o vasect omy, reabsorpt ion of sperm f rom blocked duct s
result s in t he f ormat ion of aut oant ibodies t o sperm.
Test ing f or sperm ant ibodies is not recommended f or rout ine inf ert ilit y t est ing.
The f ollow ing indicat ions, how ever, might w arrant ordering t his evaluat ion:
1. Males
a. Sperm agglut inat ion in t he ejaculat e
b. Hist ory of t est icular t rauma
c. Hist ory of biopsy
d. Vasect omy reversal
e. G enit al t ract inf ect ion
f. O bst ruct ive lesions of t he male duct al syst em
2. Females
a. Abnormal post coit al t est
b. Unexplained inf ert ilit y
c. Hist ory of genit al t ract inf ect ions
Reference Values
Normal
Normals display <20% t ot al binding.
Report ed as percent age of sperm w it h posit ive binding by immunobead
t echnique; >20% binding is usually required t o low er pat ient 's f ert ilit y.
Signif icance of percent age of binding is inversely relat ed t o pat ient 's sperm
count .
Procedure
A semen t est sample is pref erred f or values. I f semen procurement present s a
problem f or a male pat ient , a blood serum sample can be t est ed. For f emales,
blood serum is pref erred because of t he diff icult y of cervical mucus collect ion.
1. Blood
a. Collect a 7-mL blood serum sample in a red-t opped t ube.
b. Spin dow n and send 2. 0 mL of serum t o laborat ory f rozen in plast ic vial
on dry ice.
2. Semen
a. Collect cont ent s of semen ejaculat e.
b. Send specimen t o laborat ory f rozen in plast ic vial on dry ice.
3. Cervical mucus
a. Collect 1. 0 mL of cervical mucus.
b. Send specimen t o laborat ory f rozen in plast ic vial on dry ice.
Ant isperm ant ibodies are associat ed w it h t he f ollow ing condit ions:
1. Blocked t est icular eff erent duct s and t he result ant resorpt ion of sperm can
produce ant ibodies.
2. Af t er vasect omy, ant ibodies and probable cellular immunit y t o sperm develop
in most males as a result of t he int eract ion of sperm ant igens w it h t he
immune syst em.
3. I n some st udies, about 75% of w omen w it h primary inf ert ilit y had sperm
agglut inins. How ever, 11% t o 15% of pregnant w omen had t he same sperm
ant ibody t it ers.
Clin ical Alert

The pot ent ial adverse consequences of an immune sperm response t o sperm
include possible syst emic eff ect s in ot her organ syst ems and possible
inf ert ilit y af t er vasect omy reversal.
Interventions
1. Explain t est purpose and procedure. See det ails under Procedure f or
Specimen Required. Pat ient should be advised of t he need f or repeat
t est ing.
care.
3. See I nf ert ilit y Test ing in Chapt er 6.

1. I nt erpret t est result s and counsel appropriat ely. I t may be necessary t o
repeat t his procedure on diff erent sample t ypes (eg, semen, blood) t o
est ablish a possible cause f or inf ert ilit y.
care.
ALLERGY TESTING
IgE Antibody, Single Allergen A large number of
substances have been found to have allergic potential.
Measurements of IgE antibodies are useful to establish
the presence of allergic diseases and to define the
allergen specificity of immediate hypersensitivity
reactions. Examples of allergic diseases include
asthma, allergic rhinitis, dermatitis, anaphylaxis, and
urticaria.
The f luorescent enzyme immunoassay (FEI A) t est s measure t he increase and
quant it y of allergen-specif ic I gE ant ibodies and diagnose an allergy t o a specif ic
allergen (eg, molds, w eeds, f oods, insect s). These measurement s are used in
persons, especially children, w it h ext rinsic ast hma, hay f ever, and at opic eczema
and are an accurat e and convenient alt ernat ive t o skin t est ing. Alt hough more
expensive, t hey do not cause hypersensit ivit y react ions.
Addit ional ant igens are cont inually being added; up-t o-dat e inf ormat ion should be
sought . Examples of cat egories t hat can be t est ed f or include grasses, t rees,
molds, venoms, w eeds, animal dander, f oods, house dust , mit es, ant ibiot ics, and
insect s.
Reference Values
Normal
Based on FEI A, t he f luorescence is proport ional t o t he amount of specif ic I gE
present in t he pat ient 's sample.
Fluorescent Enzyme Immunoassay (FEIA)

Class
Interpretation
Negative
Equivocal
Positive
Positive
Strongly positive
Strongly positive
Strongly positive
Procedure
precaut ions.
Posit ive result s great er t han or equal t o class 2 are st rongly associat ed w it h
allergic sympt oms on exposure t o allergen.
Interventions
care.

1. I nt erpret t est out comes and counsel appropriat ely regarding result s and
need f or ot her t est s. Negat ive result s eff ect ively rule out allergy induced by
t hat allergen.
care.
Latex Allergy Testing (Latex-specific IgE) Latexcontaining medical devices include gloves, catheters,
and bandages, among many others. Millions of people,
especially those in the health care profession, are
susceptible to allergic reactions ranging from mild to
severe when exposed to such products. It is
recommended that patients at risk for latex allergy be
tested before undergoing medical procedures that
would expose them to latex. High-risk groups include
health care workers, workers with industrial exposure
to latex, children with spina bifida or urologic
abnormalities due to high exposure to latex, and people
who have undergone multiple surgeries.
This t est measures I gE-mediat ed lat ex sensit ivit y and not irrit at ion or delayed
(t ype I V) react ion t o lat ex. The met hod f or t est ing is EI A in w hich t he color
react ion measured is direct ly relat ed t o t he amount of I gE specif ic f or t he t est
allergen in t he sample.
Reference Values
Normal
Negat ive f or lat ex allergen: <0. 35 I U/ mL by EI A Posit ive f or lat ex allergen: >0. 35
I U/ mL
Procedure
precaut ions.
1. Posit ive result s are st rongly associat ed w it h a lat ex allergy.

2. I n st udies comparing lat ex-specif ic I gE result s w it h clinical hist ory,
sympt oms, and ot her conf irmat ory t est s, t he sensit ivit y has been >80% and
t he specif icit y >90%.
Interventions
1. Explain t est purpose and procedure. Posit ive hist ory f or lat ex may include
t he f ollow ing f act ors:
a. Sw elling or it ching f rom lat ex exposure
b. Hand eczema
c. Previously unexplained anaphylaxis
d. O ral it ching f rom cross-react ive f oods (eg, banana, kiw i, avocado,
chest nut s)
e. Mult iple surgical procedures in inf ancy
care.

1. I nt erpret t est out comes based on pat ient 's clinical hist ory (ie, lat ex exposure
and laborat ory ref erence values). I f negat ive by t his t est procedure, yet
sympt omat ic, or if posit ive f or t his t est , ref er pat ient t o an allergist .
care.
PROTEIN CHEM ISTRY TESTING/SERUM PROTEINS:

ACUTE-PHASE PROTEINS AND CYTOKINES
Ceruloplasmin
Measurement of ceruloplasmin aids in t he diagnosis of copper met abolism
disorders, ie, Wilson's disease. Copper bound t o ceruloplasmin const it ut es t he
largest amount of Cu2+ in circulat ion. I n Wilson's disease, Cu2+ mobilizat ion f rom
t he liver is drast ically reduced because of t he low product ion of ceruloplasmin.

The t est gives a quant it at ive measurement of t he amount of ceruloplasmin in t he
pat ient 's serum. Values <14 mg/ dL are expect ed in Wilson's disease. Values can
vary considerably f rom pat ient t o pat ient and may be 50% of normal (point ing t o
some ot her primary def ect ). Pat ient s w it h Wilson's disease are not alw ays
ext remely low in ceruloplasmin.
Reference Values
Normal
2563 mg/ dL (250630 mg/ L) by nephelomet ry
Procedure
precaut ions.
Def icient ceruloplasmin is not t he primary def ect in Wilson's disease t hat
remains unknow n, and can, t heref ore, vary considerably in it s def iciency f rom
pat ient t o pat ient .
Interfering Factors
1. Ceruloplasmin is aff ect ed by inf ect ions (a lat e acut e-phase react ant ) and
liver f unct ion.
2. Birt h cont rol pills increase ceruloplasmin, as does pregnancy.
Interventions
1. Explain t est purpose. Measurement of t his serum prot ein aids in diagnosing a
copper met abolism disorder know n as Wilson's disease.
care.

1. I nt erpret t est out comes and det ermine t he need f or f ollow -up t est ing. Values
vary f rom pat ient t o pat ient and may be 50% or more of normal, point ing t o
some ot her def ect .
care.
Alpha 1 -Antitrypsin Alpha 1 -antitrypsin (AAT) is the most

abundant serum protease inhibitor and inhibits trypsin
and elastin as well as several other proteases. The
release of proteolytic enzymes from plasma onto
surface organs and into tissue spaces results in tissue
damage unless inhibitors are present.
Measurement of AAT aids in t he diagnosis of juvenile and adult cirrhosis of t he
liver. AAT def iciency has been associat ed w it h neonat al respirat ory dist ress
syndrome, severe prot ein-losing disorders, and pulmonary emphysema. The t est
is usef ul f or individuals suspect ed of f amilial chronic obst ruct ive lung disease.
Reference Values
Normal
100200 mg/ dL (18. 436. 8 mol/ L) by nephelomet ry
Procedure
precaut ions.
1. Pat ient s w it h a serum AAT <70 mg/ dL (<12. 9 mol/ L) may have a
homozygous def iciency and are at risk f or early lung disease. AAT
phenot yping should be done t o conf irm t he presence of t he homozygous
def iciency.
2. I f clinically indicat ed, pat ient s w it h serum levels <125 mg/ dL (<23 mol/ L)
should be phenot yped t o ident if y het erozygous individuals. The lat t er do not
appear t o be at increased risk f or early emphysema.
Interfering Factors
AAT is an acut e-phase react ant , and any inf lammat ory process w ill elevat e
serum AAT levels.
Interventions
1. Explain t est purpose. Follow -up t est ing, t hat is, AAT phenot yping, may be
necessary if decreased result s are obt ained.
care.

1. I nt erpret t est result s and det ermine t he need f or phenot yping, w hich conf irms
t hat t he def iciency is homozygous (increased risk chronic lung disease) or
het erozygous (lit t le if no risk).
care.
C-Reactive Protein (CRP) and High-Sensitivity CReactive Protein (hs-CRP) During any inflammatory
process, a specific abnormal protein named C-reactive
protein (CRP) appears in the blood. This protein is
virtually absent from the blood serum of healthy
persons. CRP is one of the most sensitive acute-phase
reactants. Levels of CRP can increase dramatically
(100-fold or more) after severe trauma, bacterial
infection, inflammation, surgery, or neoplastic
proliferation. Measurement of CRP has been used
historically to assess activity of inflammatory disease,

to detect infections after surgery, to detect transplant
rejection, and to monitor these inflammatory
processes.
There are t w o t ypes of CRP assays. O ne measures a w ide range of CRP levels
t o include t hose f ound in pat ient s w it h acut e inf ect ions. The report able range is
t ypically 0. 3 t o 20 mg/ dL. The second is a high-sensit ivit y CRP (hs-CRP) assay.
The lat t er can det ect a low er level of CRP t o include t hose t hat may be of value
in measuring t he risk f or a cardiac event . The sensit ivit y is t o 0. 01 mg/ dL. The
hs-CRP is usef ul, t heref ore, f or assessment of risk f or developing myocardial
inf arct ion in pat ient s present ing w it h acut e coronary syndromes.
Reference Values
Normal
<0. 8 mg/ dL (<8 mg/ L) by rat e nephelomet ry f or CRP
0. 0200. 800 mg/ dL (0. 28. 0 mg/ L) by immunot urbidimet ric assay f or hs-CRP
Procedure
precaut ions.
2. Place t he specimen in a biohazard bag f or t ransport t o t he laborat ory.
1. The t radit ional t est f or CRP has added signif icance over t he elevat ed
eryt hrocyt e sediment at ion rat e (ESR), w hich may be inf luenced by alt ered
physiologic st at es. CRP t ends t o increase bef ore rises in ant ibody t it ers and
ESR levels occur. CRP levels also t end t o decrease sooner t han ESR levels.
2. The t radit ional t est f or CRP is elevat ed in rheumat ic f ever, RA, myocardial
inf arct ion, malignancy, bact erial and viral inf ect ions, and post operat ively
(declines af t er f ourt h post operat ive day).
3. A single t est f or hs-CRP may not ref lect an individual pat ient 's basal hs-CRP
level; t heref ore, f ollow -up t est s or serial measurement s may be required in
pat ient s present ing w it h increased hs-CRP levels.
Interventions

1. Explain t he t est purpose and procedure. A f ast ing sample is pref erred. Wat er
may be t aken.
care.

1. I nt erpret t est result s, counsel and monit or appropriat ely. Repeat t est ing is
of t en necessary t o est ablish an individual's basal hs-CRP concent rat ion. A
posit ive t est indicat es act ive inf lammat ion but not it s cause. CRP is an
excellent t ool f or monit oring disease act ivit y. hs-CRP is a t ool f or assessing
cardiovascular risk.
2. I n RA, t he t radit ional t est f or CRP becomes negat ive w it h successf ul
t reat ment and indicat es t hat t he inf lammat ion has subsided.
care.
Prion Proteins
Prions are prot eins t hat occur in bot h heredit y f orms and inf ect ious disease.
Prions do not cont ain RNA or DNA. No immune response has been det ect ed. This
t est is done t o diagnose prion brain disease, such as Creut zf eldt -Jacob disease
and spongif orm encephalit is (mad cow disease).
Reference Values
Normal
St ruct ural f orm named PrPc is f ound in lymphocyt es and in CNS neurons.
Procedure
Brain t issue samples are examined f or evidence of t he inf ect ious prion or
mut at ed gene in chromosome 20.
1. Abnormal f inding of PrPc prot ein (disease-causing f orm) is pat hogenic, w hich
aff ect s t he cerebral cort ex and cerebellum.

2. G erst mann-St russler-Scheinker syndrome (G SS), cause of heredit ary
dement ia, occurs because of mut at ion in prion gene
3. Evidence of prion inf ect ious disease may be t ransf usion-relat ed
Interventions
1. Explain t est purpose and procedure. O bt ain f rom pat ient or f amily signs,
sympt oms, and hist ory of encephalopat hy or dement ia (heredit ary). Pat ient s
are usually very sick and inf ect ious disease is usually f at al.
2. Behavioral changes include at axia, peripheral sensory changes, dement ia

1. I nt erpret t est result s and explain possible t reat ment . Monit or f or encephalit is
and/ or dement ia.
2. Provide comf ort and support and special counseling regarding progression of
disease. Deat h occurs about 12 mont hs af t er appearance of f irst signs.
Cytokines Cytokines, a diverse group of proteins and

peptides secreted by many cells (eg, lymphocytes, T
cells, monocytes, B cells, eosinophils), respond to an
immunologic challenge. They are involved in immunity,
allergy, and long-term memory (ie, degenerative
aspects of aging) and include interferons, interleukins,
chemokines, inflammatory cytokines, and
hematopoietic growth factors. Cytokines have been
directly implicated in a number of diseases, such as
asthma, interstitial cystitis, RA, septic shock,
transplant rejection, cirrhosis, and multiple sclerosis.
Most interleukins are produced by macrophages and
lymphocytes. Interleukins need adequate amounts of
fats and pyridoxine to be effective. Some, such as

interleukin-3, are involved in fever, slow-wave sleep,
bone resorption, and use of protein by muscles.
These t est s are done t o evaluat e allergy, skin hypersensit ivit y, ast hma, f ever,
inf lammat ion, and healing. They are also used as t umor markers and t o assess
immune f act ors and rheumat ic disorders.
Reference Values
Normal
1. I nt erleukin-1
a. 3, 5, 7, 9, 11, 12, 13, 14, 15, 16, 17, and 18
b. Normal: Physiologic levels are normally very low (f ew pg/ mL or ng/ L)
2. I nt erleukin-1a
a. Plasma: 0. 1 + 1. 4 pg/ mL or ng/ L
b. Urine median: 14 pg/ mol creat inine or g/ mol creat inine
3. I nt erleukin-1b
a. Blood: 4. 60 + 300 pg/ mL or ng/ L
b. Serum: 0. 07 + 0. 02 ng/ mL or g/ L
4. I nt erleukin-2
a. Amniot ic f luid (AMF): median, 1. 35 ng/ mL or g/ L
b. Plasma: 0. 3 + 0. 47 pg/ mL or 0. 3 + 0. 5 ng/ L
5. I nt erleukin-4
a. Serum: 0. 75 + 0. 1 ng/ mL or 0. 75 + 0. 10 g/ L
b. See eosinophil count ; T cells st imulat e eosinophil product ion.
6. I nt erleukin-6
a. Urine: 237 + 92 ng/ L or 237 + 92 g/ L
b. Blood: 1609 + 710 pg/ mL or 1. 61 + 0. 71 g/ L
c. Plasma: 2. 50 + 0. 35 pg/ mL or 2. 50 + 0. 55 ng/ L
d. Serum: 0. 42. 1 pg/ mL or 0. 42. 1 ng/ L
e. CSF: 0. 0412. 5 ng/ mL or 0. 012. 5 g/ L
7. I nt erleukin-10
a. Serum: 0. 44 + 9. 5 ng/ mL or 44 + 10 g/ L
b. Amniot ic f luid: <40 pg/ mL or <40 ng/ L
8. I nt erleukin-8
a. Amniot ic f luid 237 + 92 ng/ L or same
9. Chemokines
a. Feces: <224077 pg/ g w et st ool or 0. 024. 08 ng/ g w et st ool
b. Plasma: 3. 3 + 0. 3 pg/ mL or ng/ L
10. Tumor necrosis f act ors (TNF- )
a. ACSF: 22. 3 + 9. 5 pg/ mL or 1. 31 + 0. 56 pmol/ L
b. Feces: <1231 pg/ g w et st ool or <1231 ng/ g w et st ool
c. Plasma: 6. 4 + pg/ mL or 6. 4 + 4. 6 ng/ L
d. Serum: 0. 12 + 0. 02 ng/ mL or 7. 0 + 1. 2 nmol/ L
11. I nt erf eron-
a. Serum (S): 0. 7 + 1. 8 pg/ mL or 0. 7 + ng/ L
b. Plasma (P): 3 + 1 I U/ mL or 3 + K I U/ L
Procedure
1. Collect a st ool, urine, or venous blood sample f or serum analysis.
2. Be aw are t hat cells f rom synovial f luid, bronchial secret ions, and CSF may
also be t est ed.
Clin ical Alert

Examine specimens w it hin 5 hours. Avoid a f reezing/ t haw ing cycle w hile
st ored.
1. Pat hophysiologic blood levels may indicat e inf lammat ion or cancer. I ncreases
are associat ed w it h severit y of disease.
2. Elevat ed levels in synovial f luid, CSF, amniot ic f luid, urine, f eces, and
bronchoalveolar f luid may indicat e immune disorders, SLE, and ot her
pat hologic or degenerat ive condit ions.
Interfering Factors
1. Cyt okines can cont inue t o be produced af t er sample collect ion by t he various
cells in t he f luid, urine, or f eces.
2. Collect ion t ubes can become cont aminat ed by microorganisms, a pot ent
st imulus of cyt okine product ion.
3. Cyt okines can degrade in t he collect ion cont ainer.
4. Cyt okines can bind t o cell recept ors during st orage.
5. Circadian rhyt hms may aff ect result s.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of cyt okine t est s and t he
complexit ies involved. For specimens ot her t han plasma or serum, ref er t o
specif ic chapt ers regarding specimen collect ion and pat ient care (eg, urine in
Chap. 3, spinal f luid in Chap. 5, CSF st udies, amniot ic f luid, st ool [ f eces] ).
2. O bt ain properly signed inf ormed consent w hen necessary (eg, spinal f luid
sample collect ion). Explain t hat a local anest het ic w ill be inject ed int o t he
skin. Assess f or any previous react ions t o any numbing or local anest het ic
medicines.
Intratest Care
Provide psychological support during specimen collect ion t hat may require more
invasive procedures.

1. I nt erpret laborat ory t est out comes and counsel appropriat ely about f urt her
t est ing and t reat ment . Explain t he need f or possible ident if icat ion of chronic
disease.
2. Provide t he appropriat e af t ercare if more invasive specimen collect ion
procedures w ere used (see Chap. 5 f or spinal f luid collect ion af t ercare).
care.
Tumor Markers The underlying cause of cancer can be

divided into four major classifications: viral, chemical,
physical, and genetic. Cancers caused by viruses can
be either RNA viruses, eg, retrovirus human T-cell
leukemia virus type I (HTLV-I), which causes adult Tcell leukemia, or DNA viruses, eg., hepatitis B virus,
which causes hepatocellular carcinoma. Chemical
carcinogens can be classified as either genotoxic
(targeting the DNA), eg, nitroso compounds that when
heated release toxic fumes or solvents such as
trichloroethylene, or nongenotoxic (targeting cell death
directly or hormonal effects), eg, synthetic pesticides
or herbicides. Physical factors associated with causing
cancer include ultraviolet light (sunlight), ionizing
radiation (x-rays), and asbestos fibers. Hereditary or
genetic cancer can account for up to 30% of some
forms of childhood cancers and 5%10% of adult
cancers.
Cancerous cells diff er f rom normal cells in many respect s. Malignant cells grow
more rapidly in an uncont rolled f ashion, lack normal cell-t o-cell int eract ions, and
apopt ot ic (programmed cell deat h) mechanisms are disrupt ed w hen compared t o
normal cells. Normal cells, t hrough a series of mut at ions (ref erred t o as hi ts)
and alt erat ions of normal cell grow t h and cell int eract ions, can t ransit ion int o
cancerous cells. This unregulat ed and disorganized increase in cell grow t h is
st imulat ed by t he f act ors described above. Tumors, by def init ion, are
spont aneous grow t h of abnormal cells leading t o a sw elling or enlargement of
t he underlying t issue. This
abnormal cell grow t h, or cancer, can be det ect ed by cert ain subst ances (t umor
markers) f ound in t he blood.
Types of Cytokines, Cellular Origin, and Cli
Cytokine (Synonym )
Cellular
Origin
Target Cells
Monocytes,
macrophages,
antigenpresenting
cells (APCs),
endothelial
cells, T
lymphocytes,
Natural Killer
(NK) cells
Monocytes,
macrophages,
hepatocytes,
endothelial cell
epithelial cells,
fibroblasts,
keratinocytes,
lymphocytes, B
lymphocytes, N
cells, osteoclas
INTERLEUKIN-1
Also known as
B-cell accelerating
factor, catabolin,
endogenous pyrogen,
epidermal cell-derived
thymocyte-activity factor,
fibroblast-activity factor,
hemoposition-1,
hepatogenic stimulatory
factor (HSF), leukocyte
endogenous mediator,
lymphocyte-activating
factor, mononuclear cell
factor, osteoclastactivating factor,
proteolysis-inducing
factor, and serum
amyloid A inducer
INTERLEUKIN-2
Also known as
T-cell growth factor
(TCGF)
INTERLEUKIN-3
Colony-forming unit
T
lymphocytes
(CD4, Th0
and Th1
[CD8], NK
cells, B
lymphocytes,
mast cells
T lymphocytes
(CD4, CD8), B
lymphocytes, N
cells
(CFU) stimulating
activity, colonystimulating factor (CSF),
hematopoietic cell
growth factor, mast cell
growth factor (MCGF),
histamine-producing cellstimulating factor,
multilineage hemopoietic
growth factor, P-cell
stimulating factor
activity, persisting (P)cell stimulating factor,
synergistic activity (Thy1 inducing factor, and
W EHI-3 growth factor)
Most
interleukins
are produced
by
macrophages
or T
lymphocytes
(CD4, TH1
and TH2), NK
cells, mast
cells,
eosinophils.
Hematopoietic
stem cells,
progenitor cells
lymphocytes,
macrophages,
polymorphonuc
leukocytes, ma
cells,
keratinocytes.
T
lymphocytes
(CD4, TH2),
basophils,
T lymphocytes,
lymphocytes, m
cells, myeloid
progenitors,
erythroid
INTERLEUKIN-4
B-cell differentiating
factor (BCDF), B-cell
growth factor I (BCGF-I),
B-cell stimulating factor I
(BSF-I), MCGF-II, T-cell
growth factor II (TCGFII)
eosinophils,
mast cells
progenitors, NK
cells
T
lymphocytes
(CD4, TH2),
mast cells,
eosinophils
Eosinophils, B
lymphocytes,
basophils, mas
cells
INTERLEUKIN-5
BCDF for IgM (BCDFu),

BCGF-II, eosinophil
colony-stimulating factor,
eosinophil differentiation
factor, IgA-enhancing
factor, and T-cell
replacing factor
INTERLEUKIN-6
26-kd protein, BCDF, Bcell stimulating factor-2

(BSF-2), cytotoxic T-cell
differentiation factor,
hybridoma/plasmacytoma
growth factor, interferon2 (IFN-2) monocytic
granulocyte inducer type
2, and thrombopoietin
INTERLEUKIN-7
T
lymphocytes,
B
lymphocytes,
monocytes,
macrophages,
APCs,
endothelial
cells,
epithelial
cells,
fibroblasts,
mast cells
T lymphocytes,
lymphocytes,
hepatocytes,
endothelial cell
keratinocytes,
hematopoietic
cells, malignan
plasma cells
Lymphopoietin 1, B-cell
growth factor, and pre
B-cell growth factor
Stromal cells
(bone
marrow,
thymic), T
lymphocytes,
spleen cells,
epithelial
cells,
fibroblasts
T lymphocyte
progenitors, B
lymphocyte
progenitors, T
lymphocytes
(CD4, CD8)
T
lymphocytes
(CD4, Th2),
lymphoma
cells
T lymphocyte
progenitor cells
INTERLEUKIN-8
(see Chemokines)
INTERLEUKIN-9
B-cell derived T-cell

growth factor, cytokine
synthesis inhibiting
factor, MCGF, and
thymocyte growthpromoting factor)
INTERLEUKIN-10
B-cellderived T-cell
growth factor, cytokine
synthesis inhibiting
factor, MCGF, and
thymocyte growthpromoting factor
T
lymphocytes
(CD4 TH0,
T H2)(CD4,
T H1, CD8), B
lymphocytes,
macrophages,
keratinocytes
B lymphocytes,
lymphocytes, N
cells, monocyte
macrophages,
mast cells
Stromal cells
(bone
Hematopoietic
INTERLEUKIN-11
Adipogenesis inhibitor
factor
marrow),
trophoblasts,
glial cells,
fibroblasts
progenitors,
plasmocytes,
adipocytes,
neurons
B
lymphocytes,
monocytes,
macrophages,
APCs
T lymphocytes
(CD4, CD8), N
cells
INTERLEUKIN-12
Cytotoxic lymphocyte
maturation factor, K-cell
stimulating factor, and Tcell stimulating factor
INTERLEUKIN-13
NC30 (human CDNA)

and P6001 mouse CDNA
clone
T
lymphocytes
(CD4, TH2,
T H0, TH8),
mast cells
B lymphocytes,
monocytes,
macrophages,
endothelial cell
INTERLEUKIN-14
High-molecular-weight
BCGF
T
lymphocytes,
B
lymphocytes,
dendritic
cells,
malignant
B lymphocytes
cells
INTERLEUKIN-15
INTERLEUKIN-16
Monocytes,
macrophages,
epithelial
cells,
keratinocytes,
APCs, many
others
(tissue)
T lymphocytes,
cells
Lymphocytic
chemoattractant factor
T
lymphocytes
(CD8),
eosinophils,
epithelial
cells
T lymphocytes
(CD4), eosinop
(CD4), monocy
(CD4)
T
lymphocytes
(memory
CD4)
T lymphocytes,
fibroblasts,
epithelial cells,
endothelial cell
INTERLEUKIN-17
Cytotoxic T-lymphocyte
associated antigen 8
(CTLA-8)
INTERLEUKIN-18
IFN-inducing factor
Liver cells
NK cells, T
lymphocytes
INTERFERONS: IFN- AND IFN-
IFN-: acid-stable IFN,

B-cell IFN, buffy coat
IFN, leukocyte-derived
IFN, lymphoblast IFN,
Namoliva IFN, and type I
IFN. IFN-: acid-stable
IFN, fibroblast-derived
IFN, IFN- I and type I
IFN
IFN-:
Monocytes,
macrophages,
lymphocytes.
IFN-:
Fibroblasts,
epithelial
cells.
Interferons
are produced
by virusinfected cells
and are the
T lymphocytes,
cells,
macrophages
body's first
line of
defense
against many
viruses.
IFN-
Immune IFN,
macrophage-activating
factor T-cell IFN, and
type II IFN)
T
lymphocytes
(CD4, TH0,
T H1, CD8),
NK cells
T lymphocytes,
cells,
macrophages,
endothelial cell
APCs, B
lymphocytes
TUMOR NECROSIS FACTOR
TFN-: cachectin,
cytotoxin, cytotoxic
factor, differentiationinducing factor,
hemorrhagic factor,
macrophage cytotoxic
factor, and necrosis.
TNF-: Cytotoxin,
differentiation-inducing
factor, and lymphotoxin
(LT)
Monocytes,
macrophages,
T
lymphocytes,
B
lymphocytes,
NK cells,
mast cells,
endothelial
cells, APCs,
fibroblasts
T lymphocytes,
polymorphonuc
leukocytes
(PMNs),
macrophages,
endothelial cell
osteoclasts,
fibroblasts,
hepatocytes,
tumor cells
CHEMOKINES (CKS)
(Formerly known as
intercrines, the scy
[small cytokine] family,
and small, inducible,
secreted cytokines.) A
condensation of the term
Monocytes,
macrophages,
PMNs, T
lymphocytes,
B
lymphocytes,
NK cells,
mast cells,
Monocytes,
macrophages,
PMNs, T
lymphocytes, B
lymphocytes, N
cells, mast cell
chemoattractant
cytokines. Now defined
as a superfamily of lowmolecular-weight
proteins (810 kd).
endothelial
cells,
epithelial
cells, APCs,
stromal cells,
fibroblasts,
platelets
endothelial cell
epithelial cells,
APCs, stromal
cells, fibroblast
megakaryocyte
There are a number of f act ors t hat have eit her a prot ect ive eff ect or promot e
cancer grow t h.
Tumor Protectors
Tumor Promoters
Genetic resistance
Genetic susceptibility
Tumor suppressor genes
Age
Immune system
Smoking
Programmed cell death
Asbestos exposure
DNA repair
Resistance to cytotoxicity
Tumor markers include genet ic markers (abnormal chromosomes or oncogenes),
DNA analysis, oncof et al ant igens, enzymes, hormones, placent al prot eins,
st eroid recept ors, glucoprot eins, t umor-associat ed ant igens, t umor-specif ic
ant igens, and circulat ing immune complexes.
Tumor cells diff er f rom normal cells in many w ays. Physical examinat ion and
st andard x-ray t echniques can usually det ect t umors as small as 1 cm in volume.
A t umor mass of t his size has complet ed 30 doublings (t w o t hirds of it s grow t h)
and cont ains 1 billion (10- 9 ) cells. Cert ain t umor ant igens, hormones, oncof et al
prot eins, and enzymes are secret ed int o t he bloodst ream by t hese t umors.
Malignant t umor cells are produced w hen DNA is damaged by some f orm of
carcinogen, virus, radiat ion, or chemical causing t he process of mit osis t o go out
of cont rol. These grow ing, changed (mut ant ) cells express oncogenes. These
oncogenes are capable of inducing or t ransf orming cells int o cancer cells or
t umors. Tumor cells capable of f orming met ast ases are likely t o invade blood
vessel w alls; be released int o t he bloodst ream, regional lymphat ics, or
int erst it ial st oma; and event ually spread t o ot her organs. Tumor t est ing has
f ocused on ident if ying cert ain t umor-relat ed subst ances t hat might allow early
det ect ion of malignancy, det erminat ion of prognosis, and evaluat ion of t umor
burden (ie, size, locat ion, and encroachment on ot her t issues or organs).
Tumor markers are used and developed t o obt ain great er sensit ivit y and
specif icit y in det ermining t he presence of cancer and t umor act ivit y. These
subst ances are f ound in body cells, f luids, and t issue. I n general, t hese markers
lack specif icit y f or cancer; none is pat hognomonic f or any one t ype of neoplasm.
Diagnosis st ill derives f rom a biopsy and t issue examinat ion, comprehensive
pat ient hist ory, physical examinat ion, and ot her diagnost ic procedures.
Edu cation Alert

Tumor marker st udies do not replace biopsy and pat hologic t issue examinat ion
and are not ideal f or screening f or specif ic cancers, making a diagnosis, or
predict ing programs f or sympt omat ic pat ient s, but t hey are eff ect ive f or t umor
st aging, monit oring response t o t herapy, det ect ing disease recurrence, and
early det ect ion of cancer recurrence.
The f ollow ing are diagnost ic prognost ic and predict ive markers:
1. O ncof et al ant igens (O ncof et al ant igens, normally produced in t he f et us, are
react ivat ed w it h cancer cell t ransf ormat ion. )
a. Carcinoembryonic ant igen (CEA)
b. Alpha-f et oprot ein (AFP)
c. Prot eins
d. CA 125
e. CA 19-9
f. CA 15-3
g. CA 549
h. Tissue polypept ide ant igen (TPA)
i. Prost at e-specif ic ant igen (PSA)
j. hK2 and hK3 of gene f amily = kallikreins
k. Human glandular kallikrein f or prost at e cancer
2. Placent al prot eins
a. Human chorionic gonadot ropin (hCG and -hCG )
b. Human placent al lact ogen (HPL)
c. Placent al alkaline phosphat ase (PALP)
3. Enzymes and isoenzymes
a. Prost at ic acid phosphat ase (PAP)
b. Creat ine kinase (CK)-BB isoenzyme
c. Alkaline phosphat ase (ALP)
d. Neuron-specif ic enolase (NSE)
e. Lact at e dehydrogenase isoenzyme (LDI )
f. Lysozyme (muramidase)
4. Hormones
a. Hormones, bot h normally produced by t he t issue and ect opic
b.
GGT
c. F LNT
d. Amylase
e. TDD (t erminal deoxynucleot ydyl t ransf erase)
f. hCG t rophoblast ic t umors
g. Nonseminomat ous t est icular t umors
h.
HIAA
i. Epinephrine and norepinephrinepheochromocyt oma and relat ed

malignancies
j.
DM A
k. 17KS
l. G ast rin-Zollinger-Ellison syndrome (gast rinoma)
m. Renin-producing by kidney
n. Calcit oninmedullary carcinoma of t he t hyroid (not normally produced by
t he t issue)
o. Adrenocort icot ropic hormone (ACTH)small cell carcinoma of t he lung
p. Ant idiuret ic hormone (ADH)
q. Parat hyroid-relat ed pept ide
r. Eryt hropoiet in
s. G ast rin
t.
HIAA
5. (Serot onin) immunoglobulins

a. I gG
b. I gA
c. I gM
d. I gD
e. I gE
f. Kappa and lambda light chains
6. St eroid recept ors
a. Est rogen and progest erone recept ors (ER and PR)
b. Epidermal grow t h f act or (EDFR)
c. HER-2 (human epidermal grow t h f act or recept orsdet ermine suit abilit y
f or HER ept on t herapy)
d. Androgen recept ors
e. Cort icost eroid recept ors
7. I mmunocomplex t yping
a. Lymphoid cells
b. Myeloid cells
c. Cyt okines (see page 606 f or more inf ormat ion)
8. DNA analysis
a. Ploidy and S-phase f ract ion
b. See Chapt er 11 f or more inf ormat ion.
9. Molecular diagnosis
a. O ncogene and suppressor genes
b. G enet ic changes
c. See Chapt er 11 f or more inf ormat ion.
Reference Values
Normal
See Clinical I mplicat ions f or value f or each specif ic t umor marker.
Procedure
1. Be aw are t hat most t umor marker t est s involve obt aining eit her venous
plasma or serum; urine or bladder w ashings or CSF; some may require
f ast ing.
2. Follow t he specif ic direct ions f rom t he laborat ory or cancer cent er involved
in t he t est ing procedure. Be sure t o not e f act ors t hat int erf ere w it h t est
result s.
1. Tumor markers, subst ances produced and secret ed by t umor cells and f ound
in serum, urine, or t issue of persons w it h cancer, are indicat ive of t umor
act ivit y.
2. Table 8. 9 includes t umor-specif ic or t umor-associat ed ant igens (prot eins and
oncof et al ant igens), enzymes, hormones, and cyt okines.
Table 8.9 Tumor-specific and Tumor-associate
Nam e of Test
Clinical Marker in
Current Use and
Selected Norm al
Values
Type of Cancer in
Which Tum or
Marker May Be
Found
ENZYMES
1. Prostatic acid
phosphatase (PAP).
1a. Carcinoma of
prostate with the
following elevation:
Conditions
Cancer Ass
Abnorm al V
Major pretreatment
tumor marker and
used to predict
recurrence.
Increased values
due to increased
metabolism and
catabolism of
cancer cellslevels
increase with stage
of cancer and age
of individual.
Prostate-specific
antigen (PSA) done
to monitor prostate
cancer preferred
screening marker
(<2.7 ng/mL or <2.7
g/L). Monitor
therapy with
antineoplastic
drugs.
2. Lactate
dehydrogenase
carcinoma with no
metastasis 10%
20%; metastasis
with one 20%
40%; metastases
with bone
involvement 70%
90% (usually
osteoblastic). In
three fourths of
patients, arises in
posterior lobe of
prostate. Leukemia
(hairy-cell)
increased. Cancer
metastatic to bone
(increased
osteoblastic
lesions)
1. Increased
prostatic co
prostate pal
hyperplasia,
prostate foll
cystostomy,
surgery, and
prostatitis. O
increases: G
disease (lipi
disease), Ni
disease, Pa
osteoporosi
osteopathy,
cirrhosis, pu
embolism, a
hyperparath
1b. Is specific for

prostate cancer
2. Increased
neuroblastomic
carcinoma of
testis. Elevated in
60% of those with
stage III testicular
cancerserial LDH
may help to detect
recurrence of
cancer. Ewing's
2. Increased
(LDH); increased
isoenzymes I and
II. Total LDH: 166
280 U/L. Detect and
monitor testicular
cancer.
3. Neuron-specific
enolase (NSE)
<12.5 g/mL;
normal staining.
Produced by
neurons and
neuroendocrine
cells of the central
and peripheral
nervous system.
Used to monitor
disease
progression, small
cell lung cancer and
pheochromocytoma,
neuroblastoma,
medullary thyroid
sarcoma, acute
lymphocytic
leukemia, nonHodgkin's
lymphoma. LD-1
increased in germ
cell tumors; LD-3
increased in
leukemia; LD-5
increased in
breast, lung,
stomach, and
colon; elevated in
metastatic
carcinoma
3. NSE increased
in neuroblastomas,
APUD system
tumorsmall cell
lung cancers,
pancreatic islet
cell, medullary
thyroid carcinoma,
seminoma (20%) in
prostate, breast,
and
gastrointestinal
(GI) tract, also
W ilm's tumor and
pheochromocytoma
injury/hemol
myocardial i
hepatic dise
Cardiac Mar
Chap. 6).
3. Occasion
benign liver
cancer.
4. Alkaline
phosphatase (ALP)
originates in
osteoblasts, lining
of hepatobiliary tree
and intestinal tract,
and placenta.
Adults (2060 y):
3585 U/L; elderly:
slightly higher;
children (<2 yr):
85235 U/L; young
persons (221 yr):
30200 U/L.
Isoenzymes offer
greater specificity.
5. Other enzymes:
gamma-glutamyl
transpeptidase
(GGT);
muramidase,
creatinine,
phosphokinase
isoenzyme BB,
beta-glucuronidase,
terminal
deoxynucleotidyl
transferase,
ribonuclease,
histaminase
4. Increased in
osteosarcoma,
hepatocellular,
metastatic to liver,
primary or
secondary bone
tumors, liver and
bone leukemia,
lymphoma
5. Creatine
phosphokinase
(CPK)-BB
increased in
prostate, lung
(small cell),
bladder, breast and
GI tract cancer;
amylase increased
in lung and ovarian
4. Increased
disease, non
disease, nor
pregnancy,
fractures,
hyperparath
osteomalaci
sprue, and m
Decreased i
hypoparathy
malnutrition
pernicious a
5. CPK-BB i
cardiac mus
skeletal mus
brain and C
Reye's synd
hypothyroid
increased in
disease, alc
and antiepil
medications
increased in
(medullary cancer
of thyroid),
amylase, and
cystine
aminopeptidase
6. Squamous cell
cancer antigen
(SCCA). Used to
monitor and detect
recurrence of
squamous cell
cancer of uterus,
cervix, head and
neck, esophagus,
lung, skin, and
sinus; also
advanced cancer
cancer
6. Increased in
uterine cancer
(89% of stage IV
disease). Alert:
occurs in saliva,
sweat, and
respiratory
secretions.
diabetic, ke
intestinal ob
6. Elevated
infection, sk
renal failure
disease
HORMONES
1. Human chorionic
gonadotropin (hCG)
produced by
placental
syncytiotrophoblast;
not usually found in
sera of healthy,
nonpregnant
persons. <2 ng/mL.
Useful to monitor
testicular tumors
1. Increased in
gestational
trophoblastic
tumors,
seminomatous and
nonseminomatous
testes cancer,
ovarian tumors,
pancreatic isletcell cancer, liver
(21%), stomach
(22%), and less
1. Increased
trophoblasti
(choriocarci
neoplasm of
colon, pancr
and liver; m
pregnancy.
ectopic preg
abortion. Inc
and tumors of ovary

and to monitor
changes.
2. Calcitonin (CT):
malignant C-cell
thyroid tumor
produces increased
CT levels.
Calcitonin (see
Chap. 6) is a
hormone produced
by perifollicular C
cells of thyroid
gland. Ranges vary
with method.
Serum: Adult: <150
pg/mL. Plasma:
male, <19 pg/mL;
female, <14 pg/mL.
3. Other hormones:
adrenocorticotropic
hormone (ACTH)
(lungoat cell),
parathyroid
hormone (PTH)
(lungepidermoid),
insulin (lung),
glucagon
(pancreas), gastrin
(stomach and other
valuable with lung

and
lymphoproliferative
disease.
marijuana sm
2. Increased in
metastatic breast
(greatly elevated),
limited in primary
small-tumor-burden
breast cancer
because levels
lower, lung,
pancreas,
hepatoma, renal
cell carcinoid, and
skeletal
metastases.
2. Increased
Ellison synd
pernicious a
renal failure
pseudohypo
apudomas, a
cirrhosis, Pa
pregnancy,
breast or ov
Decreased w
an increase
suggests pr
disease
3. Increased in
endocrine tumor
tissue and
nonendocrine
tissue (ectopic)
tumors.
3. See Chap
substance in
carcinomas),
prostaglandins and
erythropoietin
(kidney).
4. Serotonin (5hydroxyindole
acetic acid [5HIAA]).
Hydroxyacetic acid:
used to detect and
monitor carcinoid
tumors.
4. Increased in
carcinoid tumors.
4. Increased
foods, eg, m
ONCOFETAL ANT IGENS

1. Alpha-fetoprotein
(AFP) is a
glycoprotein
produced by fetal
liver, yolk sac, and
intestinal
epithelium.
Disappears from
blood soon after
birth and is not
present in healthy
individuals <40
ng/mL. Diagnose
and monitor AFP
tumors. Follow-up
for therapy of
testicular, ovarian,
1. Increased in
primary
hepatocellular
cancer, embryonal
cell
(nonseminomatous
germ cell)
testicular tumors,
yolk sac ovarian
tumors,
teratocarcinoma,
gastric, pancreatic,
colonic, breast,
renal, and lung.
>50 ng/mL AFPproducing tumor.
1. Increased
distress and
tube defects
hepatitis, G
primary bilia
partial hepa
telangiectas
Aldrich synd
pregnancy,
and primary liver

tumors; used with
hCG.
2.
Carcinoembryonic
antigen (CEA).
Initially isolated in
endodermally
derived
adenocarcinoma
and fetal
gastrointestinal
tissue. <2.55
ng/mL; up to 5
ng/mL in smokers;
<6 ng/mL in spinal
fluid. Assess
therapy with
antineoplastic drugs
and following
surgery of
medullary thyroid
cancer, neoplasma
of breast, GI tract,
lung, and
colorectal; monitor
cancers of primary
colorectal cancer,
pancreas, breast,
GI, liver, lung,
ovaries, prostate.
Elevations signal
recurrence.
2. Increased in
cancer >3.0 ng/mL
(especially
metastatic or colon
recurrence and
germ cell cancer),
pancreas, lung,
stomach,
metastatic breast,
ovary, bladder,
limbs,
neuroblastoma,
leukemia, thyroid,
and osteogenic
carcinoma. >10
ng/mL with CEAproducing tumor.
Values <20 ng/mL
do not rule out
recurrent cancer.
2. Increased
inflammatory
disease, rec
active ulcera
pancreatitis
cirrhosis, pe
cholecystitis
failure, pulm
emphysema
pulmonary in
fibrocystic b
most levels
remission of
Increase ov
suggests re
PROT EINS
1. CA 15-3 antigen
(cancer-associated
antigen breast
cystic fluid protein
[BCFP]; used in
conjunction with
CEA); is a marker
for breast cancer
used for serial
testing. <30 U/mL
males and females
encoded by MUC-I
gene in stage II or
III and used with
CA 27 and CA 29.
Most useful to
monitor therapy and
disease progression
in metastatic
disease
1. Greatly
increased in
metastatic breast;
limited in smalltumor-burden
breast cancer.
Decreased with
therapy; an
increase after
therapy suggests
progressive
disease. Increased
in pancreas, lung,
colorectal, ovarian,
and liver cancer.
1. Increased
breast, ovar
diseases
2. NMP22 found in
urine, used to
manage transitional
cell cancer of the
urinary tract tissue
biopsy obtained by
cystoscopy
2. Present in
transitional cell
cancer (TCC) of
urinary tract
2. Further s
3. Bladder tumor
3. Presence of BTA
involves invasion
associated (BTA)
analyte found in
urine
of tumor and/or
tumor production
associated with
recurrence of
tumor
3. Further s
are needed
4. CA 2729
(similar to CA 15-3
serum) is a marker
for breast
carcinoma. Not
used for screening.
38 U/mL in female
and male breast
cancer. Serial
testing for prior
stage II or III to
detect recurrence.
4. Increased in
recurrence in
stage II or III
breast cancer. >38
U/mL indicates
recurrence of
breast cancer.
4. These an
increased b
MYC-1 gene
as MAM6, a
antigen-3. In
factors: Incr
due to expo
antigens in
treatment, o
imaging
5. 2 -Microglobulin
( 2 ) (HLA antigen
system). 412
mg/L.
5. Increased in
chronic
lymphocytic
leukemia, multiple
myeloma, other Bcell neoplasms,
lung cancer,
hepatoma, breast
cancer
5. Decrease
tubular injur
ankylosing s
Reiter's syn
failure, AIDS
6. PSAmore
sensitive than PAP
correlates with
stage of
6. Increased >10.0
ng/mL (in prostate
adenocarcinoma
disease and age.
Males: 80% <2.0
g/L; free: total
ratio = >0.24 total
210 ng/mL = <2.0
ng/mL. Free
cascade done. Free
PSA to assess risk
for cancer with
borderline PSA (2
10 ng/mL). PSA
screening for
prostate cancer
recommended only
for men >50 yr.
Useful for
monitoring and
staging prostate
cancer. PSA not
significantly
increased until
tumor has grown
out of prostate
gland.
7. CA 19-9
carbohydrate
antigen; <37 U/mL.
Occurs in serum
and tissue. Is a
marker for
colorectal and
biopsy) in prostate
cancer (the higher
the level, the
greater the tumor
burden);
successful surgery,
chemotherapy, or
radiation causes
marked reduction
in levels. PSA
screening for
prostate cancer
recommended only
for men >50 yr.
Useful for
monitoring and
staging prostate
cancer. PSA not
significantly
increased until
tumor has grown
out of prostate
gland.
7. Increased >37
U/mL (very high) in
pancreas,
hepatobiliary
cancer, lung
cancer; primarily
mild elevation
6. Increase
and tissue d
prostatic hy
prostate ma
surgery, and
Collect befo
biopsy or re
7. Increased
(<75 U/mL),
cirrhosis, ga
cystic fibros
elevations)
pancreatic cancer.
gastric and
colorectal cancer
8. CA 125 (ovarian
cancer)
(glycoprotein
antigen) and serum
carbohydrate
antigen. <35 U/mL.
Is a marker for
ovarian and
endometrial
carcinoma. Ovarian
and endometrial
cancer monitoring
8. Greater
concentration
related to poor
survival. Increased
in epithelial ovary,
fallopian tube,
endometrium,
endocervix,
pancreas, and
liver. >35 U/mL
indicates residual
cancer.
8. Increased
(first trimest
endometrios
inflammatory
menstruatio
chronic hep
peritonitis, p
disease, Me
pleural effus
disease, per
ovarian cyst
9. CA 50. <17
U/mL. Is a marker
for pancreatic and
colorectal
carcinoma. Used to
monitor therapy of
GI and pancreatic
cancer.
9. Less increased
in colon, breast,
lung, and GI
9. None iden
10. Increased in GI
and pancreatic
cancer and with
residual tumor
10. Increase
liver and bre
and in pregn
10. CA 72-4 TAG (a

micin-like hormone
adenocarcinoma
associated antigen)
<4.0 ng/mL. Is a
marker for GI and
ovarian cancer.
Used in gastric
carcinoma
monitoring
11. C549 (acidic
glycoprotein). <15.5
U/mL (results
correlate with those
using CA 15-3).
Used in monitoring
breast cancer
11. Increased in
ovarian and gastric
cancer
11. Informat
available
12. Tissue
polypeptide antigen
(TPA) 80100 U/L in
serummay also
be detected in
urine, washings,
and effusions. Is
not a specific
marker. Monitor GI,
genitourinary (GU),
breast, lung, and
thyroid cancer.
12. Increased in
GI, GU tract,
breast, lung,
thyroid, head and
neck, cervix,
ovarian, and
prostate cancer
12. Increase
cholangitis,
pneumonia,
tract infectio
13. Increased in
multiple myeloma,
macroglobulinemia,
amyloidosis, B-cell
13. Increase
agglutinin d
Sjgren's sy
Gaucher's d
myxedemato
13.
Immunoglobulins:
monoclonal proteins
(M proteins),
immunoglobulins
produced by B
lymphocytes.
Normal: Absent.
Refer to serum
protein
electrophoresis
(SPEP) or urine
protein
electrophoresis
(UPEP).
lymphoma, multiple
solid tumors
renal failure
sarcoidosis
14. Tumor-antigen 4
(TA-4). 2.6 ng/mL.
Diagnose and
monitor squamous
cancer.
14. Increased in
squamous cancer:
lung and cervix.
Elevations
correlate with
stage of cancer,
especially
abnormal high
levels. Rising
levels after therapy
associated with
recurrence.
14. Informat
available
15. CA 242 is a
marker for
pancreatic and
colorectal cancer.
15. Increased in
malignant and
colorectal cancers
15. Benign c
liver, pancre
biliary tract
16. Other antigens:

colon mucoprotein
antigen (CMA),
colon-specific
antigen (CSA), zinc
glycinate marker
(ZGMcolon),
pancreatic
oncofetal antigen
(POA), S-100
protein (malignant
melanoma),
sialoglycoprotein
(wide variety of
cancers), B protein
(wide variety of
antigens), and
Tennessee
antigen
glycoprotein (wide
variety of cancers)
16. Increased
levels in colon
cancer, malignant
melanoma, and a
wide variety of
cancers
16. Informat
available
1. Increased in
leukemias (adult Tcell leukemia)
1. HIV infec
CYTOKINES
1. Interleukin (IL)
(also known as
interleukin IL-2) Tcell growth factor I;
formed from helper
T cells and
activated B cells;
results highly
variable. Monitor
therapy in
leukemia. Results
highly variable
GENET IC MARKERS
Suppressor Genes
1. P-53 gene
mutation. No
mutation. Most
common genetic
mutate in cancer
used for prognosis
2. Retinoblastoma
gene
1. High mutation
over expression in
breast, BRCA,
head and neck,
colon, and small
cell lung cancer
(50%75%)
2. Found in ocular
tumors arising
spontaneously;
small portion are
hereditary
1. Increased
polyps
2. Informatio
3. BRCA1 and
BRCA2 monitor
development of
breast and ovarian
cancer
3. Found in
hereditary
predisposition to
developing breast
and ovarian cancer
3. Carriers o
mutation ha
of developin
cancer and
developing o
by age 85
4. p21WAF1 may be
clinically useful
4. Uncertain
4. Informatio
5. APC (antigen
presenting cells)
5. Increased in
patients with
hundreds of
polyps. Mutations
in hereditary colon
cancer, also breast
and esophageal
5. Premalign
6.
Neurofibromatosis
6. Inactivating
mutations in
inherited colorectal
cancer, melanoma
6. Informatio
7. W ilm's tumor
(nephroblastoma)
7. Mutations in
W ilm's tumor
7. Informatio
8. NM2, a marker
for metastasis
8. Increased in
metastatic breast,
colon, and prostate
cancer
8. Informatio
1. Ras oncogene.
No mutation
1. Oncogene
mutations found in
leukemia,
neuroblastoma,
lymphoma,
sarcomas, and
endotheliomas
1. Informatio
2. CMYC genedefect recurrence
2. Found in B- and
T-cell lymphoma
and small cell lung
cancer
2. Informatio
3. C-erb B-2, HER2/Neu gene, used

as prognostic
indicator in breast
cancer
3. Found in breast,
ovarian, and GI
carcinomas
3. Informatio
Oncogenes
4. bcl-2 (blocks
apoptosis),
presence
contributes to
programmed cell
death and survival
of cancer cells
4. Found in
leukemia and
lymphoma.
Detection may
predict resistance
to chemotherapy
4. Informatio
Recently, an inhibitor of apoptosis (programmed cell dea

has been detected in most forms of cancer. Survivin is n
during mitosis to ensure normal cell division and chromo
distribution. However, in cancerous cells, survivin prolon
span, thereby increasing the chances of mutations. Rese
targeted at developing drugs to inhibit survivin expressio
inhibit tumor growth. Clinical test are not yet commercial
measure blood levels of survivin.
3. Ref er t o Chapt er 6 and Chapt er 11 and t o ot her t est s in Chapt er 8 f or
complet e list ings of normal values, clinical implicat ions, and saf e, eff ect ive,
inf ormed int erpret at ions, pat ient preparat ion, and af t ercare.
Interventions
1. Explain purpose and procedure of t est .
2. Alleviat e f ears t he pat ient may have relat ed t o cancer t est result s. Test s f or
cancer are alw ays anxiet y provoking.
care.

1. I nt erpret t est result s using t he lat est know ledge in t he f ield, recognizing t hat
t est values, signif icance, and specif icit y of t est s are cont inually changing
w it h t echnology. G enerally, t umor markers are not helpf ul in predict ing t he
sit e of origin.
2. Provide consult at ion if t est result s reveal cancer. Tumor drug resist ant
assays are perf ormed on t issue obt ained in biopsy (see Chap. 11).
3. Provide support t hrough f ollow -up t est ing in st ages of illness and in f orming
a t herapeut ic and diagnost ic plan f or t reat ing and monit oring t he disease.
care regarding shock, denial, and f ear as normal response t o cancer
diagnosis.
BLOOD BANKING OR IM M UNOHEM ATOLOGY TESTS

These t est s are done t o select blood component s t hat w ill have accept able
survival w hen t ransf used and t o prevent possible t ransplant and t ransf usion
react ions; t o ident if y pot ent ial problems, such as hemolyt ic disease of new borns
and t he need f or int raut erine t ransf usion; and t o det ermine parent age.
I mmunohemat ology t est ing ident if ies highly react ive ant igens on blood cells and
t heir ant ibodies possibly present in serum.
Donated Blood Testing and Blood Processing

Pretransfusion testing of blood recipient and donor
blood:
1. All donat ed blood, as it is processed, must undergo several measurement s.
These include t est s f or t he f ollow ing f act ors:
a. ABO groups
b. Rh t ype
c. Ant ibody screen
d. Hepat it is B surf ace ant igen (HBsAg)
e. Hepat it is B core ant igen (HBcAg)
f. Hepat it is C virus (ant i-HCV)
g. Syphilis (VDRL)
h. HI V-1 and HI V-2
i. HTLV-I and HTLV-I I
j. HI V ant igen (HI V-1-Ag)
k. Nucleic acid t est s (NAT) (narrow w indow of inf ect ion f or HI V and
hepat it is C)
2. Required t est ing f or w hole-blood or red blood cell recipient s include t he
f ollow ing:
a. ABO group
b. Rh t ype
c. Ant ibody screen
d. Crossmat ch f or compat ibilit y bet w een donor's cells and recipient 's serum
Type and crossmat ch, w hen ordered t oget her, use one 10-mL red-t opped t ube.
Type and screen w hen ordered preoperat ively, ident if y ABO and Rh t ype group
and are used f or cases t hat usually do not require t ransf usion. Even t hough no
crossmat ch is needed f or plasma administ rat ion, compat ible ABO t yping should
be done. Rout inely, no crossmat ch is needed f or plat elet administ rat ion;
compat ible ABO and Rh t ypes should be given w hen possible. I f a pat ient
becomes ref ract ory, HLA-mat ched plat elet s may be administ ered. G ranulocyt es
should be t est ed f or HLA compat ibilit y. As a result of previous t ransf usions or
pregnancy, some pat ient s develop ant ibodies against t hese ant igens and, if given
plat elet s t hat have t hese ant igens, may have a t ransf usion react ion.
Pret ransf usion t est ing f or neonat es (younger t han 4 mont hs of age) requires
det erminat ion of ABO group, Rh t ype, and an ant ibody screen. The ant ibody
screen may be perf ormed on a specimen obt ained f rom t he inf ant or t he mot her.
I f t he ant ibody screen is negat ive, group O Rh compat ible pediat ric red blood
cells may be used w it hout f urt her crossmat ching f or t he remainder of t he
neonat al period. I f t he ant ibody screen is posit ive, t he ant ibody is ident if ied, and
ant igen negat ive blood w ill be crossmat ched and provided f or t ransf usion. All
inf ant s requiring plasma t ransf usions w ill receive group AB pediat ric f resh-f rozen
plasma.
A t ype and screen consist s of an ABO group, Rh t ype, and ant ibody screen and
can be ordered w hen t he need f or crossmat ched product s is unlikely but may be
required in an emergency sit uat ion. I f t he pat ient does have a clinically
signif icant unexpect ed ant ibody, at least 2 U of ant igen-negat ive blood w ill be
made available f or t hat pat ient bef ore surgery. A posit ive ant ibody screen w ill
aut omat ically init iat e ant ibody ident if icat ion t o det ermine t he specif icit y of t he
ant ibody det ect ed, if t he ant ibody ident if ied is det ermined t o be clinically
signif icant , ant igen-negat ive blood is required f or t ransf usion.
Procedure
1. Collect a 10-mL sample f or hospit al pret ransf usion t est ing. Use a 10-mL
plain, red-t opped t ube.
2. Label w it h t he f ollow ing inf ormat ion:
a. Pat ient 's f ull f irst and last names
b. Pat ient 's healt h care record number
c. Dat e and t ime of specimen collect ion
d. I nit ials (if collect ed by laborat ory personnel) or signat ure (if collect ed by
nonlaborat ory personnel) of phlebot omist
e. Possibly a unique blood bank number (f ound on special Blood Bank
ident if icat ion band)
3. At t ach a special Blood Bank band, at t he recipient 's bedside, at t he t ime of
specimen collect ion. The Blood Bank band must remain at t ached t o t he
pat ient 's w rist t hroughout t he t ransf usion period. The same band may be
used t hroughout one hospit al admission as long as t he inf ormat ion print ed on
t he band is legible and t he band is st ill securely at t ached t o t he pat ient 's
w rist .
4. Be aw are t hat a new specimen is required every 3 days if t he pat ient has a
hist ory of t ransf usion or pregnancy during t he previous 3 mont hs.
1. Autol ogous donati ons are blood product s donat ed by pat ient s f or t heir ow n
use (ie, blood donor and recipient are t he same person). Many pat ient s opt
t o donat e t heir ow n blood bef ore scheduled surgery because of t he concern
regarding t ransf usion-t ransmit t ed diseases. The f ollow ing are some general
guidelines f or aut ologous blood donat ion.
a. There is no age limit if donor is healt hy.
b. There are no w eight requirement s. The volume of blood collect ed must
comply w it h est ablished w eight provisions.
c. Pregnant w omen can donat e.
d. Hemat ocrit should be >33%. I f <33%, t he pat ient 's physician must
approve t he phlebot omy, usually in consult at ion w it h t he blood bank
medical direct or.
e. Normally, phlebot omy can be done at 3-day int ervals; t he f inal
phlebot omy can be done no sooner t han 72 hours bef ore t he t ime of t he
scheduled surgery. Tw o-unit collect ions using an aut omat ed red
cellopheresis machine may also be an opt ion. I ron supplement s may be
prescribed t o maint ain adequat e hemoglobin levels.
f. Aut ologous blood is not crossed over int o t he general (allogeneic)
blood supply. I t is discarded af t er it s expirat ion dat e.
2. Al l ogenei c donati ons are blood product s donat ed by one individual f or use by
ot her individuals (ie, blood donor and blood recipient are not t he same
person).
3. Di rect donati ons are t hose in w hich recipient s choose t hose w ho donat e
blood f or t heir t ransf usions. Law s in several st at es declare t hat t his request
must be honored in nonemergency sit uat ions. St andards and t est ing
procedures must be ident ical t o t hose required f or an allogeneic blood donor.
(Aut ologous donors do not need t o adhere t o t he same crit eria as do
allogeneic blood donors). Direct ed donor unit s can be crossed over int o t he
general (allogeneic) blood supply. Each est ablishment must have a policy
describing w hen t his can occur.
4. Cytomegal ovi rus (CMV) testi ng is done f or pat ient s at risk f or t ransf usionassociat ed CMV inf ect ions. These t ypes of CMV inf ect ions include
pneumonit is, hepat it is, ret init is, and disseminat ed inf ect ion. They generally
occur in immunosuppressed pat ient s, such as premat ure inf ant s w eighing
<1200 g at birt h, bone marrow and organ t ransplant recipient s, and cert ain
immunocompromised oncology pat ient s. Theref ore, t o prevent t hese
inf ect ions, CMV ant ibody t est ing is done. Pat ient s at risk should receive
CMV-seronegat ive blood and blood product s. CMV in blood is associat ed
w it h leukocyt es. Leukocyt e reduct ion using highly eff icient leukocyt ereduct ion f ilt ers also appears t o be an eff ect ive w ay of reducing CMV
inf ect ion.
5. Irradi ati on of bl ood products is somet imes done bef ore t ransf usion f or
cert ain immunosuppressed pat ient s. G raf t -versus-host disease (G VHD) is a
rare complicat ion t hat f ollow s t ransf usion in severely immunosuppressed
pat ient s. G VHD occurs if donor lymphocyt es f rom blood or blood product s
engraf t and mult iply in a severely immunodef icient recipient . The engraf t ed
lymphocyt es react against host (recipient ) t issues. Clinical sympt oms include
skin rash, f ever, diarrhea, hepat it is, bone marrow suppression, and inf ect ion,
w hich f requent ly leads t o deat h. G VHD can be prevent ed by irradiat ing blood
product s w it h a maximum dose (cesium-137) of 2. 5 cG y in t he cent er of t he
cont ainer and a minimum dose of 1. 5 cG y delivered t o all ot her part s of t he
component . This pract ice renders t he T lymphocyt es in a unit of blood
incapable of replicat ion w it hout aff ect ing plat elet s or granulocyt es.
I rradiat ion does aff ect t he red cell membrane, causing it t o leak pot assium.
All irradiat ed red cells are given a 28-day out dat e or may keep t heir
original out dat e of <28 days.
6. Leukocyte reducti on of bl ood products: Leukocyt es in blood product s have
long been know n t o be associat ed w it h nonhemolyt ic f ebrile t ransf usion
react ions, possibly ow ing more t o cyt okines produced by t he leukocyt es t han
t he leukocyt es t hemselves. Leukocyt e reduct ion may reduce t he number of
t hese react ions. I t may also decrease t he possibilit y of alloimmunizat ion t o
t he HLA ant igens on t he leukocyt es. Removing leukocyt es may eff ect ively
reduce t he danger of t ransf usion-t ransmit t ed CMV inf ect ion.
Clin ical Alert

Bef ore t ransf usion, t here is a requirement f or physicians t o document t hat all
t he alt ernat ives t o t ransf usion, risks of t ransf usion, and t ransf usion issues
w ere explained t o t he pat ient . Examples of discussion include need f or blood
or blood component s, risks (inf ect ion, disease, react ions, alloimmunizat ion),
benef it s (t reat ment f or act ive bleeding, anemia, clot t ing disorders), and
alt ernat ives t o random allogenic donat ion (predeposit aut ologous donat ion,
int raoperat ive salvage, direct ed donor donat ion). The physician must
document in t he healt h record t hat t he discussion of t hese issues t ook place.

The document at ion varies f rom inst it ut ion t o inst it ut ion. An example of
inf ormed consent used bef ore t ransf usion is included in Appendix H. Allow
suff icient t ime f or pat ient t o ask quest ions, resolve concerns, and t o give
volunt ary consent . There must be document at ion in t he chart bef ore t he
pat ient receives t he t ransf usion.
Edu cation Alert

1. I nf ormat ion f or pot ent ial blood donors can be obt ained at local blood
banks or t he American Red Cross.
2. Blood donat ion begins w it h meet ing requirement s: age (at least 17 years),
w eight (at least 110 pounds), and healt hy hist ory t hat is negat ive f or
cancer and inf ect ious diseases (no f ever in past 2 w eeks).
3. Here is how t he process w orks at a Red Cross Blood Bank: A pint of blood
is obt ained, f illing a bag and f our vials. Blood is divided int o t hree part s.
Each part (red blood cells, plat elet s, and plasma) is prepared by spinning
and t he blood is st ored by blood t ype unt il t he product is used or expired.
Blood is shipped t o hospit als upon request . Local communit y blood banks
also supply nearby hospit als. The donat ed pint of blood is also divided int o
many product s t hat t hen sell f or hundreds of dollars. Bags and product s
are quarant ined unt il t est s show no inf ect ion and are checked f or
ant ibodies t hat might cause a t ransf usion react ion. Unsuit able bags are
dest royed.
4. O nly donat ed blood in st orage (t hat has previously been t est ed) act ually
helps disast er vict ims.
Blood Groups (ABO Groups)

Human blood is grouped according t o t he presence or absence of specif ic blood
group ant igens (ABO ). These ant igens, f ound on t he surf ace of red blood cells,
can induce t he body t o produce ant ibodies. More t han 300 dist inct ant igens have
been ident if ied. Compat ibilit y of t he ABO group is t he f oundat ion f or all ot her
pret ransf usion t est ing.
All blood donors and pot ent ial blood recipient s must be t est ed f or blood t ype t o
prevent t ransf usion w it h incompat ible blood product s. Specif ically linked sugars
det ermine t he ant igenic act ivit ies named A and B. O ne sugar, Nacet ylgalact osamine, gives t he molecule A act ivit y; anot her sugar, galact ose,
det ermines B act ivit y. The backbone molecule, w it hout galact ose or Nacet ylgalact osamine, has ant igenic act ivit y t ermed H. This H subst ance, as w ell
as H gene act ivit y, is essent ial f or t he f unct ion of t he ABO ant igens. Table 8. 10
list s t he blood groups and t heir ABO ant igens.
Table 8.10 Antigen Values for Blood Types
Blood Group
ABO Antigen
AB
A and B
Neither
I n general, pat ient s are t ransf used w it h blood of t heir ow n ABO group because
ant ibodies against t he ot her blood ant igens may be present in t heir blood serum.
These ant ibodies are designat ed ant i-A or ant i-B, depending on t he ant igen t hey
act against . Under normal condit ions, a person's blood serum does not cont ain
t he ant ibody specif ically able t o dest roy it s ant igen. For example, a person w it h
ant igen A w ill not have ant i-A ant ibodies in t he serum; how ever, ant i-B ant ibodies
may be present . Theref ore, ant igen and ant ibody t est ing is necessary t o conf irm
ABO grouping.
Clin ical Alert

1. A t ransf usion react ion can be ext remely serious and pot ent ially f at al.
Theref ore, t he blood group must be det ermined in vit ro bef ore any blood is
t ransf used t o an individual. Bef ore blood administ rat ion, t w o healt h care
prof essionals (ie, physicians or nurses) must check t he recipient 's blood
group and t ype w it h t he donor group and t ype t o ensure compat ibilit y.
2. A blood group change or suppression may be induced by cancer, leukemia,
inf ect ion, or bone marrow t ransplant .
Reference Values
Normal
A, B, AB, and O group
Relationship Between Blood Antigens and Antibodies

Antigen
Present
on Red
Blood
Cell
Antibodies
Present in
Serum
Major Blood
Group
Designation
Distribution
in the
United
States
None
Anti-A,
anti-B
O (universal
donor* for red
blood cells)
O (46%)
Anti-B
A (41%)
Anti-A
B (9%)
AB (universal
recipient for
red blood
cells)
AB
None
(universal
donor for fresh
frozen
plasma)
AB (4%)
*Called universal donor because no antigens are

present on red blood cells; therefore, the person is able
to donate to all blood groups.
Called universal recipient because no serum
antibodies are present; therefore, the person is able to
receive blood from all blood groups.
Called universal donor for plasma because no serum
antibodies are present; therefore, the plasma can be
given to all blood groups.
Procedure
1. Collect a 7-mL venous clot t ed blood sample in a red-t opped t ube. O bserve
2. Do not use SST t ubes (cell barrier t ube).
Interventions
1. Explain t est purpose and procedure. The f ollow ing are condit ions t hat at
some point may require t ransf usion:
a. Malignant t umors (leukemias)
b. Cardiac surgical procedures
c. Surgical hip procedures
d. Anemias
e. Cert ain obst et ric or gynecologic procedures or complicat ions

f. Bone and joint diseases
g. Lung disease
h. Kidney disease or genit ourinary syst em surgical procedures
i. Massive t rauma
j. Liver disease
k. Cert ain blood dyscrasias
care.

1. I nf orm pat ient of blood group and int erpret meaning. Rh t ype (see next
sect ion) may have implicat ions f or t he pregnant w oman and f et us.
care.
Rh Typing
Human blood is classif ied as Rh posit ive or Rh negat ive. This relat es t o t he
presence or t he absence of t he D ant igen on t he red cell membrane. The D
ant igen (now called Rh1 [ D] ) is, af t er t he A and B ant igens, t he next most
import ant ant igen in t ransf usion pract ice.
Incidence and Frequency of Blood Group and Rh

Type
Group and
Type
Incidence
Frequency of
Occurrence (%)
O positive
1 in 3
37.4
O negative
1 in 15
6.6
A positive
1 in 3
35.7
A negative
1 in 16
6.3
B positive
1 in 12
8.5
B negative
1 in 67
1.5
AB positive
1 in 29
3.4
AB negative
1 in 167
0.6
The Rh syst em is composed of ant igens t est ed f or in conjunct ion w it h t he ABO

group. Rh1 (D) ant igen is of t en t he only f act or t est ed f or. When t his f act or is
absent , f urt her t est ing is t hen done on w omen of childbearing age t o ident if y if
t here is Rh1 (D) ant igen present in smaller amount s. This t est is called weak D
(f ormally know n as D t est ing). Rh-negat ive individuals may develop ant ibodies
against Rh-posit ive ant igens if t hey are challenged t hrough a t ransf usion of Rhposit ive blood or t hrough a f et omat ernal bleed f rom an Rh-posit ive f et us.
Reference Values
Normal
1. Caucasian
a. 85% Rh posit ive [ have t he Rh(O ) ant igen]
b. 15% Rh negat ive [ lack t he Rh(O ) ant igen]
2. Af rican Americans
a. 90% Rh posit ive [ have t he Rh(O ) ant igen]
b. 10% Rh negat ive [ lack t he Rh(O ) ant igen]
Procedure
1. Be aw are t hat blood Rh t yping must be done f or t he f ollow ing reasons:

a. Rh-posit ive blood administ ered t o an Rh-negat ive person may sensit ize
t he person t o f orm ant i-D (Rh1 ).
b. Rh1 (D)-posit ive blood administ ered t o a recipient having serum ant i-D
(Rh1 ) could be f at al.
2. I dent if y RhI G (Rh immunoglobulin) candidat es. Rh immunoglobulin is a
concent rat ed solut ion of I gG ant i-D (Rh1 ) derived f rom human plasma. A 1mL dose of RhI G cont ains 300 g and is suff icient t o count eract t he
immunizing eff ect s of 15 mL of packed red cells or 30 mL of w hole blood.
a. Rh-negat ive pregnant w omen w it h Rh-posit ive part ners may carry Rhposit ive f et uses. Fet al cells may cross t he placent a t o t he mot her and
cause product ion of ant ibodies in t he mat ernal blood. The mat ernal
ant ibody, in t urn, may cross t hrough t he placent a int o t he f et al circulat ion
and cause dest ruct ion of f et al blood cells. This condit ion, called
hemol yti c di sease of the newborn (f ormerly called eryt hroblast osis
f et alis), may cause react ions t hat range f rom anemia (slight or severe)
t o f et al deat h in ut ero. This condit ion may be prevent ed if an Rh-negat ive
pregnant w oman receives an RhI G dose ant epart um at 28 w eeks'
gest at ion and a post part um inject ion of RhI G short ly af t er delivery of an
Rh-D (Rh1 )-posit ive inf ant . Post part um Rh immunizat ion can occur
despit e an inject ion of RhI G if >30 mL of f et al blood ent ers t he mat ernal
circulat ion. The American Associat ion of Blood Banks recommends t hat a
post part um blood specimen of all Rh-D (Rh1 )-negat ive w omen (ie, t hose
at risk f or immunizat ion) be examined t o det ect a f et al mat ernal
hemorrhage of >30 mL.
b. Rh t yping and evaluat ion f or RhI G must also be done f or pat ient s w ho
have had abort ions, miscarriages, accident s, and amniocent esis.
Comparison of Terms Used in Rh System

Nomenclatures
Weiner
Fisher-Race
Rh1
Rh2
Rh3
Rh4
Rh5
Rh6
f (ce)
Rh12
1. The signif icance of Rh ant igens is based on t heir capacit y t o immunize as a
result of receiving a t ransf usion or becoming pregnant . The Rh1 (D) ant igen
is by f ar t he most ant igenic; t he ot her Rh ant igens are much less likely t o
produce isoimmunizat ion. The f ollow ing general condit ions must be met f or
immunizat ion t o Rh ant igens t o occur:
a. The Rh blood ant igen must be absent in t he immunized person.
b. The Rh blood ant igen must be present in t he immunizing blood.
c. The blood ant igen must be of suff icient ant igenic st rengt h t o produce a
react ion.
d. The amount of incompat ible blood must be large enough t o induce
ant ibody f ormat ion.
e. Fact ors ot her t han Rh1 (D) may induce f ormat ion of ant ibodies in Rhposit ive persons if t he preceding condit ions are met .
2. Ant ibodies f or Rh2 (C) are f requent ly f ound t oget her w it h ant i-Rh1 (D)
ant ibodies in t he Rh-negat ive pregnant w oman w hose f et us or child is t ype
Rh posit ive and possesses bot h ant igens.
3. Wit h exceedingly rare except ions, Rh ant ibodies do not f orm unless preceded
by ant igenic st imulat ion, as occurs w it h t he f ollow ing condit ions:

a. Pregnancy and abort ions
b. Blood t ransf usions
c. Deliberat e immunizat ion, most commonly of repeat ed int ravenous
inject ions of blood f or t he purpose of harvest ing a given Rh ant ibody
Interventions
1. Explain purpose and procedure of t he t yping.
care.

1. I nt erpret t est out come. I nf orm and counsel pat ient regarding Rh t ype.
Women of childbearing age may need special considerat ion. See page 634
f or incidences of Rh t ypes.
Rh Antibody Titer Test

This ant ibody st udy det ermines t he Rh ant ibody level in an Rh-negat ive or
pregnant w oman w hose part ner is Rh posit ive. I f t he Rh-negat ive w oman is
carrying an Rh-posit ive f et us, t he ant igen f rom t he f et al blood cells causes
ant ibody product ion in t he mot her's serum. The f irst born child usually show s no
ill eff ect s; how ever, w it h subsequent pregnancies, t he mot her's serum ant ibodies
increase and event ually dest roy t he f et al red blood cells, causing hemolyt ic
disease of t he new born.
Reference Values
Normal
Negat ive is 0 (no ant ibody det ect ed)
Procedure
1. O bt ain a 10-mL venous blood sample (plasma or serum) f rom t he mot her
using a yellow -t opped (ACD) and clot t ed blood (not SST) t ube.
Some inst it ut ions have est ablished a crit ical t it er f or ant i-D below w hich
hemolyt ic disease of t he new born is considered unlikely. No f urt her invest igat ions
are undert aken unless t he crit ical t it er level is reached.
Interventions
care.

care.
Rosette Test, Fetal Red Cells (Fetal-Maternal Bleed)

This qualitative test detects Rh-positive fetal cells in
the Rh-negative maternal circulation. The detection of
fetal erythrocytes is important when it is suspected
that a severe fetal red cell loss has occurred and when
serious risk for the mother becoming immunized
against the fetal red cell groups is anticipated. In these
instances, the mother's blood sample should be
collected immediately after delivery to be examined for
fetal cells. This test can be performed only if mother is
Rh-negative and newborn is known to be Rh-positive.
The Rosette test is 97% accurate for detecting a
fetomaternal bleed that exceeds 30 mL of whole blood.

This test cannot be performed on patients who have
had abortions, miscarriages, accidents, or
amniocentesis.
Reference Values
Normal
Negat ive f or f et al blood loss No Rh-posit ive f et al red blood cells det ect ed in
mat ernal blood
Procedure
1. O bt ain a 7-mL venous blood EDTA sample f rom t he mot her short ly af t er
delivery.
2. Perf orm t his t est and examine result s f or roset t es or mixed f ield
agglut inat es. Follow ing manuf act urer's guidelines, t he presence of roset t es
above a predet ermined number indicat es a f et al bleed t hat exceeds 30 mL of
w hole blood.
When t he t est sample cont ains f ew or new Rh1 -posit ive f et al cells, roset t ing or
agglut inat ion is absent , and t he f et omat ernal bleed is <30 mL, one dose of
parent al RhI G w ill prevent immunizat ion. I f t he f et al blood loss int o t he mat ernal
circulat ion exceeds 30 mL, a quant it at ive or semi-quant it at ive t est (ie, KleihauerBet ke) or a quant it at ive f low cyt omet ry (if available) must be perf ormed t o
calculat e t he amount of RhI G t o administ er.
Interventions
care.
1. I nt erpret t est out come. Counsel pat ient regarding RhI G administ rat ion and
f ollow -up mat ernal t est ing.
care.
Kleihauer-Betke Test (Fetal Hemoglobin Stain) The

Kleihauer-Betke test is a semi-quantitative test to
determine the amount of fetomaternal hemorrhage in an
Rh 1 -negative mother and the amount of RhIG necessary
to prevent antibody production. The test is done after
full-term delivery if newborn anemia is present or when
the mother is Rh negative or weak-negative D. The test
is also performed on mothers after invasive procedures
(eg, amniocentesis), miscarriages, or traumas.
Reference Values
Normal
Negat ive: No f et al cells in mat ernal circulat ion
Procedure
1. A 7-mL mat ernal venous blood EDTA sample is obt ained immediat ely af t er
delivery, invasive procedure (eg, amniocent esis), miscarriage, or t rauma.
2. Examine t he specimen immediat ely or ref rigerat e unt il it can be examined.
1. Result s indicat e moderat e t o great f et omat ernal hemorrhage (50%90% of
f et al red blood cells cont ain f et al hemoglobin [ HbF] ).
2. Wit h f ull-t erm delivery, new born red blood cells must be Rh-D-posit ive f or t he
Rh-D-negat ive mot her t o be a candidat e f or RhI G .
Interventions

care.

1. I nt erpret t est out comes and counsel appropriat ely regarding f et al bleed and
administ rat ion of RhI G t o suppress t he immunizat ion of f et al red cells or
w hole-blood hemorrhage (Table 8. 11). The calculat ed dose is as f ollow s:
Table 8.11 Recommendations for Dose of (RhIG) in

Massive Fetomaternal Blood Based on the Acid
Elution Test
Fetom aternal
Hem orrhage
Volum e (m L whole
blood)
Fetal Cells
(%)
Average
Range*
Vials of RhIG to
Inject
0.30.5
20
<50
0.60.8
35
1580
0.91.1
50
22110
1.21.4
65
30140
1.52.0
88
37200
2.12.5
115
52250
*The range provides for the poor precision of the acid

separation elution test. These recommendations are
based on one
vial needed for each 15 mL of red blood cells or 30 mL
of whole blood.
Many recommend doubling t he calculat ed dose of RhI G . The met hod of
calculat ing f et al blood is not ent irely accurat e. The result s of undert reat ment are
serious, but t he eff ect s of overt reat ment are minor.
Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, inf ormed posttest
care.
Crossmatch (Compatibility Test) The primary purpose

of the major crossmatch, or compatibility test, is to
prevent a possible transfusion reaction.
Major crossmat ch det ect s ant ibodies in t he recipient 's serum t hat may damage
or dest roy t he cells in t he blood donor (Table 8. 12). The t ype and screen
det ermines t he ABO and Rh-D t ype as w ell as t he presence or absence of
unexpect ed ant ibodies f rom t he recipient . The t ype and screen is a saf e
alt ernat ive f or t he rout ine t ype and crossmat ch ordered preoperat ively f or cases
t hat may, but usually do not , require t ransf usion (eg, hyst erect omy,
cholecyst ect omy). I f blood is needed, a major crossmat ch must be done bef ore
t ransf usion.
Table 8.12 Antibodies Found in Crossmatching
Blood
Grouping
System
Antibody
Description
Rh-hr
Anti-D
Rh1
May cause severe hemolytic
disease of newborn
Anti-C
Rh2
Often found with anti-D, Ce(rh 1 ) or Cw
Anti-E
Rh3
Often found with anti-c
Anti-c
Rh4
Often found with anti-E
Anti-e
Rh5
Often found with anti-C

Anti-C w
Rh8
Anti-V
Rh10
Alternative antigen names:
ce 5 , hrv
Kell
Anti-K
K1
Strongly immunogenic; some
nonred cell immune
Occasional Kell system
antibodies may not react
Anti-k
K2
Antigen may be depressed by
the presence of Kpa
Anti-Kp a
K3
Few nonred cell immune
Anti-Kp b
K4
Anti-Js a
K6
Few nonred cell immune
Duffy
Kidd
Anti-Js b
K7
Anti-Fy a
Some antibodies exhibit

dosage; quite common and
may cause HDN and HTRs
Anti-Fy b
Some antibodies may bind

complement
Anti-Jk a
Antibodies may exhibit

dosage
May cause severe delayed
hemolytic transfusion
reactions
Anti-Jk b
Antibody titers may drop

rapidly below detectable
levels
Antibodies may require antiC3 for detection
Lutheran
Anti-Lu a
Antibody gives mixed field-like

agglutination
Anti-Lu b
MN
Anti-M
Common antibody
Seldom clinically significant or
implicated in HDN; may be
pH-dependent or exhibit
dosage
Anti-N
Rare antibody
Formaldehyde-induced anti-N
commonly found in dialysis
patients
Anti-S
Antibody may be enhanced if

incubated below 37C before
AHG
Anti-s
Lewis
Anti-U
Rarely found in S-, s-patients
Anti-Le a
Frequently found in serum of

pregnant women
Anti-Le b
Neutralized by soluble antigen
-Le bh
Anti-Le b often found with antiLe a
-Le bL
Anti-Le b usually made by Le

(a - b - ) individuals
Anti-P1
Antigen strength variable;

neutralized by soluble antigen
Anti-P
Biphasic hemolytic IgG
autoantibody in PCH
Alloantibody is usually potent
IgM hemolysin
Anti-Pk
(Anti-T ja )
Have caused hemolytic

transfusion reactions and
occasionally HDN
Xg
Anti-Xg a
X-linked
Colton
Anti-Co a
Rare antibodies
Anti-Co b
Dombrock
Diego
Anti-Do a
Incidence of Doa lower in

African Americans, Native
Americans, and Asians
Anti-Do b
Infrequently reported
antibodies
Anti-Di a
Di a antigen frequently higher

in Asians and Native
Americans
Anti-Di b
W right
Anti-W r a
IgM and IgG forms of

antibody reported
Frequently occurring antibody
Vel
Anti-Vel
Antibodies usually IgM;

antigen strength variable,
binds complement
Sd a
Anti-Sd a
Antigen weaker during

pregnancy
W ide variation of antigen
expression
Agglutinates have refractile,
mixed-field appearance
HLAassociated
Anti-Bg a
Antigen strength variable
-Bg b
Antibodies often found in

multitransfused multiparous
patients
-Bg c
Antibodies characteristically
weakly reactive
Bg/HLA associations
Bg a /HLA-B7
Bg b /HLA-B17
Bg c /HLA-A28
Cartwright
HTLA
Anti-Yt a
Antibody not uncommon in Yt

(a) individuals
Anti-Yt b
Rare antibody usually found

in combination with other
antibodies
Anti
-Ch a
Antigen strength variable
-Kn a
Antibodies characteristically
weakly reactive
-McC a
-Yk a
-Cs a
-Gy a
-Hy
-JMH
Anti-I
Most frequently detected cold

autoagglutination
Anti-I in CHD has wide
thermal range, high titer
Binds complement
Seen as alloantibody in i
adults
Anti-i
Antibody seen in serum of

patients with infectious
mononucleosis
Rare cause of CHD
Antigen very weakly
expressed on the cells of
most adults
HDN, hemolytic disease of the newborn; CHD, cold

hemagglutin disease; HTR, hemolytic transfusion
reaction; AHG, antihuman globulin; Ig, immunoglobulin;
PCH, paroxysmal cold hemoglobinuria; HTLA, human Tlymphocyte antigen.
Clin ical Alert
Even t he most caref ully perf ormed crossmat ch w ill not det ect all possible
incompat ible sources.
Reference Values
Normal
No cell clumping or hemolysis, and absence of agglut inat ion w hen serum and
cells are appropriat ely mixed and incubat ed The major crossmat ch show s
compat ibilit y bet w een recipient serum and donor cells.
Procedure
1. Crossmat ch incompat ibilit y implies t hat t he recipient cannot receive t he
incompat ible unit of blood because ant ibodies are present .
2. A transf usi on reacti on occurs w hen incompat ible blood is t ransf used,
specif ically if ant ibodies in t he recipient 's serum cause rapid red blood cell
dest ruct ion in t he proposed donor.
a. Cert ain ant ibodies, alt hough not causing immediat e red cell dest ruct ion
and t ransf usion react ion, may nevert heless reduce t he normal lif e span
of t ransf used incompat ible cells; t his may necessit at e subsequent
t ransf usions.
b. The pat ient w ill derive t he most benef it f rom red cells t hat survive
longest .
Clin ical Alert

1. The most common cause of hemolyt ic t ransf usion react ion is t he
administ rat ion of incompat ible blood t o t he recipient because of f ault y
mat ching in t he laborat ory, improper pat ient ident if icat ion, and/ or incorrect
labeling of donor blood. I f a t ransf usion react ion is suspect ed, discont inue
t he t ransf usion and not if y t he blood bank and at t ending physician
immediat ely.
P.
2. Assess f or t he f ollow ing sympt oms of t ransf usion react ion:
a. Fever
b. Chills
c. Chest , abdomen, or f lank pain
d. Hypot ension or hypert ension
e. Nausea
f. Dyspnea
g. Shock
h. O liguria
i. Back pain
j. Feeling of heat along vein being t ransf used

k. Const rict ing chest and lumbar back muscles
l. Facial f lushing
m. Hemoglobinuria
n. O ozing blood f rom w ounds
o. Anemia
p. Allergic react ions such as local eryt hema, hives, and it ching
3. The probable benef it s of each blood t ransf usion must be w eighed against
t he risks, w hich include t he f ollow ing:
a. Hemolyt ic t ransf usion react ions due t o inf usion of incompat ible blood
(can be f at al)
b. Febrile or allergic react ions
c. Transmission of inf ect ious disease (eg, hepat it is)
Interventions
1. Explain purpose and procedure of crossmat ching.
care.

1. I nt erpret t est out come and counsel pat ient regarding pot ent ial t ransf usion
react ions.
care.
Coombs' Antiglobulin Test

The indirect Coombs' t est det ect s ant ibodies t hat react only t hrough a
pot ent iat ing medium. The direct Coombs' t est det ect s ant igen-ant ibody
complexes on t he red blood cell membrane in vivo as w ell as red blood cell
sensit izat ion. I t is diagnost ic f or t he f ollow ing condit ions:
1. Hemolyt ic disease of t he new born in w hich t he red cells of t he inf ant are
sensit ized and exhibit ant igen-ant ibody complexes in vivo
2. Acquired hemolyt ic anemia in w hich an ant ibody is produced t hat coat s t he

pat ient 's ow n cells (aut osensit izat ion in vivo)
3. Transf usion react ion in w hich t he pat ient may have received incompat ible
blood, w hich in t urn has sensit ized t he donor's and possibly t he pat ient 's ow n
red cells
4. Red blood cell sensit izat ion caused by drugs
The indirect Coombs' t est det ect s serum ant ibodies, reveals mat ernal ant i-Rh
ant ibodies during pregnancy, and can det ect incompat ibilit ies not f ound by ot her
met hods.
Reference Values
Normal
Direct Coombs' t est : negat ive f or red blood cells I ndirect Coombs' t est : negat ive
f or serum
Procedure
1. Be aw are t hat t he di rect Coombs' test i s posi ti ve (1+ t o 4+) in t he presence
of t he f ollow ing condit ions:
a. Transf usion react ions
b. Aut oimmune hemolyt ic anemia (most cases)
c. Cephalot hin t herapy (75% of cases)
d. Drugs such as -met hyldopa (Aldomet ), penicillin, insulin
e. Hemolyt ic disease of new born
f. Paroxysmal cold hemoglobinuria (PCH)
2. Be aw are t hat t he di rect Coombs' test i s posi ti ve (1+ t o 4+) in t he presence
of specif ic ant ibodies, usually f rom a previous t ransf usion or pregnancy, or
nonspecif ic ant ibodies, as in cold agglut inant s.
Interfering Factors
A number of drugs may cause t he direct Coombs' t est t o be posit ive.
Clin ical Alert
Ant ibody ident if icat ion is perf ormed w hen t he ant ibody screen or direct
ant iglobulin t est s produce posit ive result s and unexpect ed blood group
ant ibodies need t o be classif ied. Ant ibody ident if icat ion t est s are an import ant
part of pret ransf usion t est ing so t hat t he appropriat e ant igen-negat ive blood
can be t ransf used. These t est s are also helpf ul f or diagnosing hemolyt ic
disease of t he new born and aut oimmune hemolyt ic anemia. A 7-mL venous
blood sample w it h added EDTA and 20 mL of clot t ed blood are st udied. Not if y
t he laborat ory of diagnosis, hist ory of recent and past t ransf usions,
pregnancy, and any drug t herapy.
Interventions
1. Explain purpose and procedure of t est .
care.

1. I nt erpret t est out come and counsel appropriat ely. Hemolyt ic disease of
new born can occur w hen t he mot her is Rh negat ive and t he f et us is Rh
posit ive. Diagnosis is derived f rom t he f ollow ing inf ormat ion: mot her is Rh
negat ive, new born is Rh posit ive, and t he direct Coombs' t est is posit ive.
New born jaundice result s f rom Rh incompat ibilit y, but more of t en, t he
jaundice result s f rom an ABO incompat ibilit y.
care.
TYPES OF TRANSFUSION REACTIONS

Acute Hemolytic Transfusion Reaction (HTR) HTR
reaction is triggered by an antigen-antibody reaction
and activates the complement and coagulation
systems. These are most always due to ABO
incompatibility because of misidentification resulting
in the patient receiving incompatible blood. Symptoms
include fever, chills, backache, vague uneasiness, and
red urine. HTR reactions are potentially fatal.
Bacterial Contamination
Bact eria may ent er t he blood during phlebot omy. These microbes w ill mult iply
f ast er in component s st ored at room t emperat ure t han in ref rigerat ed
component s. Alt hough rare, bact eria in blood or it s component s can cause a
sept ic t ransf usion react ion. Sympt oms include high f ever, shock, hemoglobinuria,
DI C, and renal f ailure. Such react ions can be f at al.
Cutaneous Hypersensitivity Reactions Urticarial

reactions are very common, second in frequency only
to febrile nonhemolytic reactions and are usually
characterized by erythema, hives, and itching. Allergy
to some soluble substance in donor plasma is
suspected.
Noncardiogenic Pulmonary Reactions (NPR)
Transfusion-related acute lung injury (TRALI) should be
considered whenever a transfusion recipient
experiences acute respiratory insufficiency and/or xray films show findings consistent with pulmonary
edema without evidence of cardiac failure. These are
possibly reactions between the donor's leukocyte
antibodies and the recipient's leukocytes. TRALI
produces white cell aggregates that become trapped in
the pulmonary microcirculation. The findings on chest
x-ray films are typical of acute pulmonary edema. If

subsequent transfusions are needed, leukocytereduced red cells may prevent NPR reactions.
Febrile Nonhemolytic (FNH) Reactions FNH reactions
are defined as a temperature increase of >1C. They are
seldom dangerous and may be caused by an antibodyantigen reaction.
Anaphylactic Reactions
Anaphylact ic react ions occur af t er inf usion of as lit t le as a f ew millilit ers of blood
or plasma. Anaphylaxis is charact erized by coughing, bronchospasm, respirat ory
dist ress, vascular inst abilit y, nausea, abdominal cramps, vomit ing, diarrhea,
shock, and loss of consciousness. Some react ions occur in I gA-def icient pat ient s
w ho have developed ant i-I gA ant ibodies af t er immunizat ion t hrough previous
t ransf usion or pregnancy.
Circulatory Overload
Rapid increases in blood volume are not t olerat ed w ell by pat ient s w it h
compromised cardiac or pulmonary f unct ion. Sympt oms of circulat ory overload
include coughing, cyanosis, ort hopnea, diff icult y breat hing, and a rapid increase
in syst olic blood pressure.
Leukoagglutinin Test
Leukoagglut inins are ant ibodies t hat react w it h w hit e blood cells and somet imes
cause f ebrile, nonhemolyt ic t ransf usion react ions. Pat ient s w ho exhibit t his t ype
of t ransf usion react ion should receive leukocyt e-poor blood f or any subsequent
t ransf usions.
This st udy is done w hen a blood react ion occurs even t hough compat ible blood
has been given. The donor plasma cont ains an ant ibody t hat react s w it h recipient
w hit e cells t o produce an acut e clinical syndrome of f ever, dyspnea, cough,
pulmonary inf ilt rat es, and in more severe cases, cyanosis and hypert ension.
Pat ient s immunized by previous t ransf usions, pregnancy, or during allograf t s
of t en experience t hese f ebrile, nonhemolyt ic t ransf usion react ions because of
incompat ible t ransf used leukocyt es. This t ype of react ion must be conf irmed (as
compared w it h hemolyt ic react ions) bef ore addit ional t ransf usions can be saf ely
administ ered.
Reference Values
Normal
Negat ive f or leukoagglut inins
Procedure
1. Agglut inat ing ant ibodies may appear in t he donor's plasma.
2. When t he agglut inat ing ant ibody appears in t he recipient 's plasma, f ebrile
react ions are common; how ever, pulmonary manif est at ions do not occur.
3. Febrile react ions are more common in pregnant w omen and in individuals
w it h a hist ory of mult iple t ransf usions.
Clin ical Alert

1. Febrile react ions can be prevent ed by separat ing out w hit e cells f rom t he
donor blood bef ore t ransf usion.
2. Pat ient s w hose blood cont ains leukoagglut inins should be inst ruct ed t hat
t hey generally need t o be t ransf used w it h leukocyt e-reduced blood t o
minimize t hese react ions.
Interventions
care.

1. I nt erpret t est out come and counsel pat ient regarding f ut ure t ransf usion
precaut ions.
care.
Platelet Antibody Detection Test Platelet antibody

detection studies are used to diagnose posttransfusion
purpura, alloimmune neonatal thrombocytopenic
purpura, idiopathic thrombocytopenia purpura,
paroxysmal hemoglobinuria, and drug-induced
immunologic thrombocytopenia.
Reference Values
Normal
PLAI (negat ive plat elet hyperlysibilit y): negat ive ALTP (negat ive drug-dependent
plat elet ant ibodies): negat ive PAI gG (plat elet -associat ed I gG ant ibody): negat ive
Procedure
1. O bt ain a 10-mL t o 30-mL venous blood sample. O bt ain 30 mL of venous
blood w hen plat elet count is 50, 000100, 000/ mm 3 ; 20 mL of venous blood
w hen plat elet count is 100, 000150, 000 mm3 ; and 10 mL of venous blood
w hen plat elet count is >150, 000/ mm3 .
2. Use st andard precaut ions.
Interfering Factors
1. Alloant ibodies f ormed in response t o previous blood t ransf usions during
pregnancies may produce posit ive react ions. Such ant ibodies are usually
specif ic f or human leukocyt e ant igens (HLAs) f ound in plat elet s and ot her
cells.
2. Whenever possible, obt ain samples f or plat elet ant ibody t est ing bef ore
t ransf usion.
1. Ant ibodies t o plat elet ant igens are of t w o t ypes: Aut oant ibodies develop in
response t o one's ow n plat elet s as in idiopat hic t hrombocyt openia purpura,

and alloant ibodies develop f ollow ing exposure t o f oreign plat elet s during
t ransf usion.
2. Ant iplat elet ant ibody, usually having ant i-PLAI specif icit y, occurs in
post t ransf usion purpura.
3. A persist ent or rising ant ibody t it er during pregnancy is associat ed w it h
neonat al t hrombocyt openia.
4. PLAI incompat ibilit y bet w een mot her and f et us appears t o account f or >60%
of alloimmune neonat al t hrombocyt openic purpura. A f inding of a PLAI negat ive mot her and a PLAI -posit ive f at her provides presumpt ive diagnost ic
evidence.
5. Plat elet -associat ed I gG ant ibody (PAI gG ) is present in 95% of bot h acut e
and chronic cases of idiopat hic (aut oimmune) t hrombocyt openic purpura.
Pat ient s responding t o st eroid t herapy or undergoing spont aneous remission
show increased circulat ory t imes t hat correlat e w it h decreased PAI gG levels.
6. The plat elet hyperlysibilit y assay measures t he sensit ivit y of plat elet s t o
lysis. This t est is posit ive in and specif ic f or paroxysmal hemoglobinuria.
7. I n drug-induced immunologic t hrombocyt openia, ant ibodies t hat react only in
t he presence of t he incit ing drug can be det ect ed. Q uinidine, quinine,
chlordiazepoxide, sulf a drugs, and diphenylhydant oin most commonly cause
t his t ype of t hrombocyt openia. G old-dependent ant ibodies and heparindependent plat elet I gG ant ibodies can be det ect ed by direct assay.
Approximat ely 1% of persons receiving gold t herapy develop
t hrombocyt openia as a side eff ect . Thrombocyt openia is also a w ell-know n
side eff ect of heparin.
NOTE
Plat elet compat ibilit y t yping is done t o ensure t hat hemost at ically st able
plat elet s can be t ransf used (eg, f or aplast ic anemia and malignant disorders).
This is import ant because most pat ient s repeat edly t ransf used w it h plat elet s
f rom random donors become part ially or t ot ally ref ract ory t o f urt her plat elet
t ransf usion because of alloimmunizat ion. Plat elet t yping also provides
diagnost ic evidence of post t ransf usion purpura. Plat elet s are rout inely t yped
f or PLAI , HLH-A2, and PLEI . Those mat ched f or HLA ant igens generally
produce sat isf act ory post t ransf usion improvement . A st andard plat elet count
perf ormed 1 hour af t er t he end of a f resh plat elet concent rat e t ransf usion is a
sensit ive indicat or f or t he presence or absence of clinically import ant
ant ibodies against HLA ant igens.
Interventions
care.

1. I nt erpret t est out comes. Appropriat ely counsel and monit or pat ient f or
bleeding t endencies. Assess f or prescribed medicat ions as cause of purpura.
care.
Human Leukocyte Antigen (HLA) Test The major

histocompatibility antigens of humans belong to the
HLA system. They are present on all nucleated cells
but can be detected most easily on lymphocytes. Each
antigen results from a gene that shares a locus on the
chromosome with another gene, one paternal and one
maternal (two alleles). More than 27 of these antigens
have been identified. The HLA complex, located in the

short arm of chromosome 6, is a major
histocompatibility complex that is responsible for many
important immune functions in humans.
This t est det ermines t he leukocyt e ant igens present on human cell surf aces.
When t issue or organ t ransplant at ion is cont emplat ed, HLA t yping ident if ies t he
degree of hist ocompat ibilit y bet w een donor and recipient . By mat ching donors
and pot ent ial recipient s w it h compat ible lymphocyt es and similar HLA t ypes, it is
possible t o prolong t ransplant survival and t o reduce reject ion episodes. The HLA
also aids in diagnosis of parent age as w ell as correlat ion w it h cert ain disease
syndromes and rheumat oid diseases, part icularly ankylosing spondylit is. HLAB27, one of t he HLA ant igens, is f ound in 90% of pat ient s w it h ankylosing
spondylit is. G enerally, t he presence of a cert ain HLA ant igen may be associat ed
w it h increased suscept ibilit y t o a specif ic disease; how ever, it does not mandat e
t hat t hat person w ill develop t he disease. This t est is also done bef ore HLAmat ched plat elet t ransf usion.
Reference Values
Normal
Requires clinical correlat ion
Procedure
1. O bt ain a 10- t o 24 mL (t w o green-t opped t ubes) heparinized venous blood
sample in t hree lavender-t opped EDTA t ubes (14 mL) or t w o plain red-t opped
t ubes, 10 mL minimum, or 5 mL of clot t ed blood or t w o yellow -t opped (ACD)
t ubes.
3. Det ermine t he pat ient 's HLA t ype by t est ing t he pat ient 's lymphocyt es
against a panel of def ined HLA ant isera direct ed against t he current ly
recognized HLA ant igens. The HLA ant igens are ident if ied by let t er and
number. When viable human lymphocyt es are incubat ed w it h a know n HLA
cyt ot oxic ant ibody, an ant igen-ant ibody complex is f ormed on a cell surf ace.
The addit ion of serum t hat cont ains complement kills t he cells, w hich are
t hen recognized as possessing a def ined HLA ant igen.
4. Label caref ully w it h pat ient 's name, dat e and special laborat ory number.
I nclude diagnosis and hist ory.
Clin ical Alert
Some of t hese t est s may not be FDA approved.
1. Part icular HLA ant igens are associat ed w it h cert ain disease st at es:
a. Ankylosing spondylit is (HLA-B27)
b. Mult iple sclerosis (HLA-B27 + Dw 2 + A3 + B18)
c. Sarcoidosis (HLA-B8)
d. Psoriasis (HLA-A13 + B17)
e. Reit er's syndrome (B27)
f. Juvenile insulin-dependent diabet es (Bw 15 + B8)
g. Acut e ant erior uveit is (B27)
h. G raves' disease (B27)
i. Juvenile RA (B27)
j. Celiac disease (B8)
k. Aut oimmune chronic act ive hepat it is (B8)
2. Four groups of cell surf ace ant igens (HLA-A, HLA-B, HLA-C, and HLA-D)
const it ut e t he st rongest barriers t o t issue t ransplant at ion.
3. I n parent age det erminat ion, if a reput ed f at her present s a phenot ype
(genot ype complet ely det ermined by heredit y; t w o haplot ypes or gene
clust ers, one f rom f at her and one f rom mot her) w it h no haplot ype or ant igen
pair ident ical w it h one of t he child's, he is excluded as t he supposed f at her.
I f one of t he reput ed f at her's haplot ypes (gene clust ers) is t he same as one
of t he child's, he may be t he f at her. The chances of his being accurat ely
ident if ied as t he f at her increase in direct proport ion t o t he rarit y of t he
present ing haplot ype in t he general populat ion. Put anot her w ay, if t he
haplot ype is very common, t here is an increased probabilit y t hat anot her man
w it h t he same haplot ype also could be t he f at her. When t he f requency of t he
haplot ype is know n, t he probabilit y t hat t he nonexcluded man is t he f at her
can be calculat ed. How ever, t he degree of cert aint y diminishes as t he
incidence of t he haplot ype increases.
Interventions
1. Explain HLA t est purposes and procedure. I t is also used f or post mort em
t est ing bef ore a renal t ransplant at ion.
care.

1. I nt erpret t est out comes and counsel appropriat ely. HLA t est ing is best used
as a diagnost ic adjunct and should not be considered as diagnost ic by it self .
Explain t he need f or possible f urt her t est ing.
care.
ORGAN AND TISSUE TRANSPLANT TESTING

The number of t ransplant ed organs and t issues has been increasing yearly
(>23, 000 in t he U. S. in 2002), w it h an ever-grow ing number of pat ient s (>80, 000
in t he U. S. in 2003) on t he w ait ing list f or a t ransplant . The t ypes and number of
required diagnost ic t est s and procedures on t he donor and recipient have been
concomit ant ly increasing (Table 8. 13).
Table 8.13 Examples of Laboratory Tests Performed on

Transplant*
Lung
Liver
Tests of Donor
and Recipient**
Blood type
Donor
Recipient
Donor
Recipient
HLA typing
Bilirubin
BUN
W BC
CBC
Platelets
Hgb/Hct
X
X
PT/PTT
Electrolytes
Calcium
Magnesium
Phosphorous
Creatinine
X
X
Serum amylase
Albumin
Total protein
ALT
AST
Hepatitis A
Hepatitis B
Hepatitis C
Liver panel
Epstein-Barr
virus
X
X
Anti-HIV 1 and 2
Anti-HTLV 1
PRA
VDRL/RPR
CMV
VZV
Measles/Rubella
Mycology smear
Bronchoscopy
X
X
* Pretransplant testing is continually changing and can vary

therefore check with your transplant department and/or the
** Note: Female recipients of childbearing age will undergo
Although bronchoscopy is technically a procedure, it is list

lung transplant.
HLA = histocompatibility locus antigen, BUN = blood urea n

Hgb/Hct = hemoglobin/ hematocrit, PT/PTT = prothrombin ti
alanine aminotransferase, AST = aspartate aminotransferas
virus, HTLV 1 = human T-cell lymphotropic virus type 1, PRA
VDRL/RPR = Venereal Disease Research Laboratories/rapid

cytomegalovirus, VZV = varicella-zoster virus (chickenpox),
Pretest Donor
O bt ain a pert inent hist ory of cancer, f oreign t ravel, collagen and/ or immune
complex diseases, past exposure t o cert ain inf ect ious diseases, t rauma, social
hist ory f or high-risk behaviors,
exposure t o drugs, t oxic subst ances, or biological hazards. The goal of t est ing is
t o prevent t ransmission of bact erial, viral, or genet ic disease and t o provide t he
best qualit y donor organ or t issue.
Pretest and Posttest of Recipient

1. A review of healt h hist ory t hat includes past and present inf ect ion,
malignancies, neurodegenerat ive disease, recipient of human pit uit ary gland
hormones, high-risk behaviors (int ravenous drug use, jaundice, and/ or
ext ernal inf ect ions).
2. O bt ain a prof ile of t he immunological risk f act ors, ident if icat ion of HLA
ant igens t o be avoided, or not e irrelevant ant igens. The HLA mat ch varies f or
each organ or t issue. The goal is t o have a complet e mat ch w it h t he donor,
prevent reject ion, and ident if y acut e reject ion so t hat aggressive
ant ireject ion modalit ies can be st art ed.
3. The presence of cyt okines, c-react ive prot ein, complement , inf ect ions
(bact erial, viral, or f ungal), accelerat ed vascular disease, met abolic disease
and/ or diabet es all have an eff ect on a great er risk of t ransplant reject ion in
t he recipient .
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Wilkins
> Table of C ontents > 9 - Nuc lear Medic ine S tudies
9
Nuclear Medicine Studies
OVERVIEW OF NUCLEAR M EDICINE STUDIES

Nuclear medicine is a diagnost ic modalit y t hat st udies t he physi ol ogy or f uncti on
of any organ syst em in t he body. O t her diagnost ic imaging modalit ies, such as
ult rasound, magnet ic resonance imaging (MRI ), comput ed t omography (CT), and
x-ray, generally visualize anat omic st ruct ures.
A pharmaceut ical is labeled w it h a radioact ive isot ope t o f orm a
radi opharmaceuti cal . The radioisot ope emit s gamma and posit ron rays.
Radioisot opes are react or produced (iodine-131 [131 I ] ), cyclot ron produced
(f luorine-18 [18 F] f or posit ron emission t omography [ PET] ), or generat or
produced (t echnet ium-99m [99m Tc] ).
To visualize t he f unct ion of an organ syst em, a radiopharmaceut ical is
administ ered. A t ime delay may be required f or t he radiopharmaceut ical t o reach
it s t arget sit e(s), and t hen t he organ of int erest is imaged w it h a gamma camera.
I mage f ormat ion t echnology involves t he det ect ion w it h very great densit y of a
signal (gamma rays) emanat ing f rom t he radioact ive isot ope. There is very lit t le
signal in t he image t hat does not come f rom t he radiopharmaceut ical. The normal
background level of radiat ion w it hin t he human body is minimal, w it h small
amount s of radioact ive pot assium and some cesium. Rout es of
radiopharmaceut ical administ rat ion vary w it h t he specif ic st udy. Most commonly,
a radiopharmaceut ical is inject ed t hrough a vein in t he arm or hand. O t her rout es
of administ rat ion include t he oral, int ramuscular, inhalat ion, int rat hecal,
subcut aneous, and int raperit oneal rout es.
Nuclear medicine st udies are perf ormed by cert if ied nuclear medicine
t echnologist s, int erpret ed by radiologist s or nuclear medicine physicians, and
perf ormed in a hospit al or clinic-based nuclear medicine depart ment . The
collaborat ive approach t o care is evidenced by int ervent ions f rom pharmacist s,
laborat ory personnel, and nurses, among ot hers.
Principles of Nuclear Medicine The

radiopharmaceutical is generally made up of two parts
the pharmaceutical, which is targeted to a specific
organ; and the radionuclide, which emits gamma rays
and allows the organ to be visualized by the gamma
camera. Nuclear medicine imaging can yield
quantitative as well as qualitative data. A measurement
of the ejection fraction of the heart is an example of
quantitative data derived from a multigated acquisition
(MUGA) or a myocardial stress procedure.
I n general, nuclear medicine images visualize t he dist ribut ion of a part icular
radiopharmaceut ical, w it h hot spot s or cold spot s of act ivit y indicat ing an
abnormalit y. I n a hot spot, t here is an increased area of upt ake of t he
radiopharmaceut ical in diseased t issue compared w it h t he dist ribut ion in normal
t issue. Examples of t his t ype of upt ake can be seen on bone images. I n a col d
spot, t here is an area of decreased upt ake of t he radiopharmaceut ical compared
w it h t he dist ribut ion in normal t issue. Liver and lung imaging are examples of t his
t ype of upt ake. Prompt upt ake in t ransplant ed organs correlat es w it h 1)
adequat e perf usion, eg, reperf usion of t he t ransplant ed lungs or pancreas; 2)
excret ory f unct ion, eg, in kidney t ransplant s; and 3) evidence of cardiac viabilit y
and reinnervat ion. Poor upt ake and nonvisualizat ion of t he t ransplant ed organ
are evidence of reject ion.
Principles of Imaging
G amma cameras all have basically t he same component s. The camera may have
1, 2, or 3 heads, w it h t he capabilit y of imaging in mult iple conf igurat ions. The
camera is net w orked w it h a mult it asking comput er capable of acquiring and
processing t he dat a.
Several met hods of imaging are used: dynamic, st at ic w hole-body, and single
phot on emission comput ed t omography (SPECT). These imaging capabilit ies are
available on all current camera syst ems.
Dynamic imaging allow s serial display of mult iple f rames of dat a, each f rame
last ing 1 t o 3 seconds, t o visualize t he blood f low associat ed w it h a part icular
organ. St at ic imaging is also know n as pl anar imaging. The camera acquires one
image at a t ime, covering t he f ield of view. This image is 2-dimensional. Wholebody imaging acquires bot h ant erior and post erior sw eeps of t he pat ient 's body.
This t ype of imaging also gives 2-dimensional inf ormat ion.
SPECT imaging has revolut ionized t he f ield of nuclear medicine. SPECT imaging
provides t hree dimensions of dat a. SPECT imaging increased t he specif icit y and
sensit ivit y of nuclear imaging t hrough improved resolut ion and is of t en combined
w it h CT scans.
General Procedure
1. Alert t he pat ient t hat he or she may be required t o f ollow a st udy-specif ic
preparat ion regimen bef ore imaging det ermined by t he t ype of nuclear
medicine procedure (eg, not hing by mout h, no caff eine f or 24 hours,
hydrat ion, bow el preparat ion).
2. Administ er a radiopharmaceut ical t hrough one of several rout es: oral,
inhalat ion, int ravenous, int ramuscular, int rat hecal, or int raperit oneal. O n
occasion, addit ional pharmaceut icals may be administ ered t o enhance t he
f unct ion of t he organ of int erest .

3. Be aw are t hat a t ime delay may be necessary f or t he radiopharmaceut ical t o
reach t he organ of int erest .
4. Remember t hat imaging t ime depends on:
a. Specif ic st udy radiopharmaceut ical used and t he t ime t hat must be
allow ed f or concent rat ion in t issues
b. Type of imaging equipment used
c. Pat ient cooperat ion
d. Addit ional view s based on pat ient hist ory and nuclear medicine prot ocol
e. Pat ient 's physical size
Benefits and Risks

Benef it s and risks should be explained bef ore t est ing. Pat ient s ret ain t he
radioisot ope f or a relat ively short period. The radioact ivit y decays over t ime.
Some of t he radioisot ope is eliminat ed in urine, f eces, and ot her body f luids.
99m Tc, t he most commonly used radiopharmaceut ical, has a radioact ive half -lif e
of 6 hours. This means t hat half of t he dose decays in 6 hours. O t her

radioisot opes, such as iodine, indium, t hallium, and gallium, t ake f rom 13 hours
t o 8 days f or half of t he dose t o decay.
1. Benef it s
a. Nuclear medicine yields f unct ional dat a t hat are not provided by ot her
modalit ies.
b. Nuclear imaging is relat ively saf e, painless (except f or int ravenous
administ rat ion), and noninvasive.
2. Risks
a. Radiat ion exposure is minimal; t oxicit y is nil.
b. Hemat oma at int ravenous inject ion sit e.
c. React ions t o t he radiopharmaceut ical (hives, rash, it ching, const rict ion of
t hroat , dyspnea, bronchospasm, anaphylaxis).
Clinical Considerations The follow ing information

should be obtained before diagnostic nuclear imaging:
1. Pregnancy (conf irmed or suspect ed). Pregnancy is a cont raindicat ion f or
most nuclear imaging.
2. Lact at ing w omen may be advised t o st op nursing f or a set period (eg, 2 t o 3

days w it h 99m Tc). Most radiopharmaceut icals are excret ed in t he mot her's
milk.
3. Radiopharmaceut ical upt ake f rom a recent nuclear medicine examinat ion
could int erf ere w it h int erpret at ion of t he current st udy.
4. The presence of any prost heses in t he body must be recorded on t he
pat ient 's hist ory because cert ain devices can shield t he gamma rays f rom
imaging.
5. Current medicat ions, t reat ment s, and diagnost ic measures (eg, t elemet ry,
oxygen, urine collect ion, int ravenous lines)
6. Age and current w eight . This inf ormat ion is used t o calculat e t he
radiopharmaceut ical dose t o be administ ered. I f t he pat ient is younger t han
18 years of age, not if y t he examining depart ment bef ore t est ing. The amount
of radioact ive subst ance administ ered is adjust ed dow nw ard f or anyone
younger t han 18 years of age.
7. Allergies. Past hist ory of allergies, especially t o cont rast subst ances (eg,
iodine) used in diagnost ic procedures
Clin ical Alert

The nuclear medicine depart ment must be not if ied if t he pat ient may be
pregnant or is breast -f eeding or is younger t han 18 years of age.
Interventions
Pretest Patient Care and Standard Precautions for
Nuclear Medicine Scans
1. Explain t he purpose, procedure, benef it s, and risks of t he nuclear medicine
procedure.
2. Assess f or allergies t o subst ances such as iodine.
3. Reassure t he pat ient t hat t he procedure is saf e and painless.
4. I nf orm t he pat ient t hat t he procedure is perf ormed in t he nuclear medicine
depart ment . Cont act t he depart ment t o det ermine t he expect ed t ime and
lengt h of t he procedure.
5. Have t he pat ient appropriat ely dressed.
6. O bt ain an accurat e w eight because t he radiopharmaceut ical dose may be
calculat ed by w eight .
7. I f a f emale pat ient is premenopausal, det ermine w het her she may be
pregnant . Pregnancy is a cont raindicat ion t o most nuclear imaging.
8. I rradiat ion of t he f et us should be avoided w henever possible.
Clin ical Alert

1. Nuclear medicine procedures are usually cont raindicat ed in pregnant
w omen. Lact at ing w omen may need t o discard t heir breast milk f or several
days f ollow ing t he procedure.
2. These precaut ions are also t o be f ollow ed f or t he radionuclide laborat ory
procedures in Part 2 and PET imaging in Part 3 of t his chapt er.
Posttest Patient Aftercare and Standard Precautions for

Nuclear Medicine Scans
1. Use rout ine disposal procedures f or body f luids and excret ions unless
direct ed ot herw ise by t he nuclear medicine depart ment . Special
considerat ions f or disposal must be f ollow ed f or t herapeut ic procedures.
2. Record any problems t hat may have occurred during t he procedure.
3. Monit or t he inject ion sit e f or signs of bruising, hemat oma, inf ect ion,
discomf ort , or irrit at ion.
4. Assess f or side eff ect s of radiopharmaceut icals.
Clin ical Alert

These precaut ions are also t o be f ollow ed f or t he radionuclide laborat ory
procedures in Part 2 and PET imaging in Part 3 of t his chapt er.
Pediatric Nuclear Medicine Considerations Many of the

nuclear medicine procedures that are performed on
adults may be indicated in children.
Interventions
Pediatric Pretest Care
1. Be aw are t hat depending on hospit al policy, a valid consent f orm may be

request ed t o be signed by t he parent s or legal guardians of t he pat ient .
2. Explain t he procedure and it s purpose, benef it s, and risks t o t he parent s or
legal guardians and t o t he pat ient . Reassure t he pat ient t hat t he t est is saf e
and painless.
3. Assess f or allergy t o medicat ions.
4. Have t he pat ient appropriat ely dressed, ensuring t hat t here are no met al
object s on t he pat ient during t he procedure.
5. O bt ain an accurat e w eight ; t he dose is calculat ed based on t he pat ient 's
w eight . Because pediat ric pat ient s have a diff erent body met abolism t han
adult s, a low er dose is given.
6. Remember t hat immobilizat ion t echniques are of t en used during t he imaging
of pediat ric pat ient s. Wrapping an inf ant or small child is of t en necessary.
Head clamps, arm boards, or sandbags may be used f or pat ient
immobilizat ion.
7. Administ er sedat ive drugs t o reduce pat ient mot ion during t he examinat ion.
Disadvant ages of sedat ion may include nausea and vomit ing.
8. St art an int ravenous line f or administ rat ion of radiopharmaceut icals.
9. Do not leave pat ient s unat t ended during t he procedure.
10. Be aw are t hat pediat ric pat ient s need const ant reassurance and emot ional
support .
11. Be aw are t hat pat ient urinat ion is of t en diff icult t o cont rol. A urinary cat het er
may be required.
12. Verif y t hat t he adolescent f emale pat ient is not pregnant .
Pediatric Posttest Care

1. Same as t hose st at ed f or adult s
2. O bserve pediat ric pat ient s f or adverse react ions t o radiopharmaceut icals.
I nf ant s are more at risk f or react ions.
Part 1 Nuclear Medicine Scans
CARDIAC STUDIES
M yocardial Perfusion: Rest and Stress 99mTc sestamibi,
thallium-201 (201 Tl), and 99mTc tetrofosmin are the
radioactive imaging agents available for myocardial
perfusion imaging to diagnose ischemic heart disease
and allow differentiation of ischemia and infarction.
This test reveals myocardial w all defects and heart
pump performance during increased oxygen demands.
These scans may also be done before
and after streptokinase treatment for coronary artery
thrombosis, after surgery for great vessel
translocation, and after transplant to detect organ
rejection and myocardial viability. Pediatric indications
include evaluation for ventricular septal defects and
congenital heart disease and postsurgical evaluation of
congenital heart disease.
201
Tl is a physiologic analogue of pot assium. The myocardial cells ext ract

pot assium, as do ot her muscle cells. The 9 9 m Tc sest amibi is t aken up by t he
myocardium t hrough passive diff usion, f ollow ed by act ive upt ake w it hin t he
mit ochondria. Unlike t hallium, t echnet ium does not undergo signif icant
redist ribut ion. Theref ore, t here are some procedural diff erences. Myocardial
act ivit y also depends on blood f low. Consequent ly, w hen t he pat ient is inject ed
during peak exercise, t he normal myocardium has much great er act ivit y t han t he
abnormal myocardium. Cold spot s indicat e a decrease or absence of f low.
A complet ely normal myocardial perf usion st udy may eliminat e t he need f or
cardiac cat het erizat ion in t he evaluat ion of chest pain and nonspecif ic
abnormalit ies of t he elect rocardiogram (ECG ). SPECT imaging can accurat ely
localize regions of ischemia.
Administ rat ion of dipyridamole (Persant ine) or adenosine is indicat ed in adult s
and children w ho are unable t o exercise t o achieve t he desired cardiac st ress
level and maximum cardiac vasodilat ion. This medicat ion has an eff ect similar t o
t hat of exercise on t he heart . Physical st ress t est ing may be init iat ed in children
beginning at 4 t o 5 years. Candidat es f or drug-induced st ress t est ing are t hose
w it h lung disease, peripheral vascular disease w it h claudicat ion, amput at ion,
spinal cord injury, mult iple sclerosis, or morbid obesit y. Dipyridamole st ress
t est ing is also valuable as a signif icant predict or of cardiovascular deat h,
reinf arct ion, and risk f or post operat ive ischemic event s and t o reevaluat e
unst able angina.
I n some nuclear medicine depart ment s, an eject ion f ract ion and w all mot ion can
be assessed by comput er analysis.
Reference Values
Normal
Normal st ress t est : ECG and blood pressure normal Normal myocardial perf usion
under bot h rest and st ress condit ions
Procedures
1. Myocardial perf usion general imaging
a. Be aw are t hat t here are t w o phases t o t his procedure: t he rest scan and
t he st ress scan. Eit her 2 0 1 Tl, 9 9 m Tc sest amibi, or 9 9 m Tc t et rof osmin may
be used.
1. Rest scan
a. Perf orm an int ravenous inject ion of t he radioisot ope. Allow a 30t o 60-minut e delay f or t he radioisot ope t o localize in t he heart .
b. Perf orm SPECT imaging.
2. St ress scan
a. Be aw are t hat t he pat ient undergoes an exercise or a
pharmacologic cardiac st ress t est . At t he peak level of st ress,
inject t he pat ient w it h t he radioisot ope.
b. SPECT imaging may begin 30 minut es af t er inject ion.
b. Pharmacologic st ress t est s may be perf ormed w it h any of t hree rout ine
st ressing agent s:
1. I nf use di pyri damol e over 4 t o 6 minut es. I nject t he
radiopharmaceut ical. Tw o minut es lat er, administ er aminophylline, an
ant idot e t o t he dipyridamole, at t he cardiologist 's discret ion. Pat ient
monit oring may last 20 minut es. Cont raindicat ion: caff eine.
2. I nf use adenosi ne over 6 minut es. I nject t he radiopharmaceut ical 3
minut es int o t he inf usion. I nf use t he adenosine f or 3 addit ional
minut es. Be aw are t hat adenosine has an ext remely short half -lif e:
once t he inf usion has st opped, any sympt oms w ill subside.
Cont raindicat ions: caff eine and t heophylline-based drugs.

3. I nf use dobutami ne unt il t he predict ed heart rat e is achieved. The
inf usion prot ocol last s 3 minut es at each dose increment .
2.
201
Tl
a. During t he cardiac st ress t est , t he pat ient is monit ored by a cardiologist ,

a regist ered nurse, an elect rophysiologist , or an ECG t echnician.
b. Have t he pat ient begin w alking on t he t readmill.
c. When t he monit oring person det ermines t hat t he pat ient has reached
85% t o 95% of maximum heart rat e, inject radioact ive t hallium. Take t he
pat ient f or immediat e imaging.
d. Be aw are t hat SPECT imaging begins w it hin 5 minut es of inject ion.
e. Acquire a second image approximat ely 3 t o 4 hours lat er, w it h t he pat ient
at rest , t o det ermine redist ribut ion of t he t hallium.
f. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed i ntratest care .
3.
99m
Tc sest amibi and 9 9 m Tc t et rof osmin
a. Follow myocardial perf usion general imaging procedures on page 657.

b. O bserve st andard precaut ions.
Procedu ral Alert

Myocardial perf usion imaging prot ocols vary among nuclear medicine
depart ment s. Some depart ment s use a rest -st ress, st ress-rest , dual-isot ope,
or 2-day prot ocol, separat ing t he phases int o 2 diff erent days.
Procedu ral Alert

Some nuclear medicine prot ocols may require t he pat ient t o ret urn 24 hours
lat er f or delayed imaging.
1. I maging t hat is abnormal during exercise but remains normal at rest indicat es
t ransient ischemia.
2. A scan t hat is abnormal bot h at rest and under st ress indicat es a past
inf arct ion.
3. Hypert rophy produces an increase in upt ake.
4. The progress of disease can be est imat ed.
5. The locat ion and ext ent of myocardial disease can be assessed.
6. Specif ic and signif icant abnormalit ies in t he st ress ECG usually are
indicat ions f or cardiac cat het erizat ion or f urt her st udies.
Interfering Factors
1. I nadequat e cardiac st ress
2. Caff eine int ake
3. I nject ion of dipyridamole in t he upright or st anding posit ion or w it h isomet ric
handgrip may increase myocardial upt ake.
Interventions
Pretest Patient Care for Stress Testing
1. Explain t est purpose and procedure, benef it s, and risks. See st andard
nuclear scan pretest precaut ions on page 655.
2. Bef ore t he st ress t est has begun, st art an int ravenous line and prepare t he
pat ient . Perf orm a rest ing 12-lead ECG and blood pressure measurement .
3. Advise t he pat ient t hat t he exercise st ress period w ill be cont inued f or 1 t o 2
minut es af t er inject ion t o allow t he radiopharmaceut ical t o be cleared during
a period of maximum blood f low.
4. Be aw are t hat t he pat ient should experience no discomf ort during t he
imaging.
5. Alert t he pat ient t hat f ast ing may be recommended f or at least 2 hours
bef ore t he st ress t est . Caff eine int ake must be eliminat ed f or 24 hours
bef ore t he st ress t est .
6. For dipyridamole administ rat ion:
a. Fast ing may be required bef ore t he st ress t est and avoidance of any
caff eine product s f or at least 24 hours bef ore t he t est is necessary.
b. Blood pressure, heart rat e, and ECG result s are monit ored f or any
changes during dipyridamole inf usion. Aminophylline may be given t o
reverse t he eff ect s of t he dipyridamole.
Clin ical Alert
1. The st ress st udy is cont raindicat ed in pat ient s w ho:

a. Have a combinat ion of right and lef t bundle branch block
b. Have lef t vent ricular hypert rophy
c. Are t aking digit alis or quinidine
d. Are hypokalemic (because t he result s are diff icult t o evaluat e)
2. Adverse short -t erm eff ect s of dipyridamole may include nausea,
headache, dizziness, f acial f lush, angina, ST-segment depression, and
vent ricular arrhyt hmia.

1. O bserve t he pat ient f or possible eff ect s of dipyridamole inf usion.
2. I nt erpret t est out comes, counsel, and monit or appropriat ely.
3. Ref er t o nuclear scan posttest precaut ions on page 655.
M yocardial Infarction (PYP) Scan 99mTc pyrophosphate

( 99mTc-PYP) is the radioactive imaging agent used to
demonstrate the general location, size, and extent of
myocardial infarction 24 to 96 hours after suspected
myocardial infarction and as an indication of
myocardial necrosis, to differentiate betw een old and
new infarcts. In some instances, the test is sensitive
enough to detect an infarction 12 hours to 7 days after
its occurrence. Acute infarction is associated w ith an
area of increased radioactivity (hot spot) on the
myocardial image. This test is useful w hen ECG and
enzyme studies are not definitive.
Reference Values
Normal
Normal dist ribut ion of t he radiopharmaceut ical in st ernum, ribs, and ot her bone
st ruct ures No myocardial upt ake
Procedure
1. Remember t hat myocardial imaging involves a 4-hour delay bef ore imaging
af t er t he int ravenous inject ion of t he radionuclide. During t his w ait ing period,
t he radioact ive mat erial accumulat es in t he damaged heart muscle.
2. Alert t he pat ient t hat imaging t akes 30 t o 45 minut es, during w hich t ime t he
pat ient must lie st ill on an imaging t able.
3. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed i ntratest care .
1. I maging t hat is ent irely normal indicat es t hat an acut e inf arct ion is not
present and t he myocardium is viable.
2. Myocardial upt ake of t he PY P is compared w it h t he ribs (2+) and st ernum
(4+). Higher upt ake levels (4+) ref lect great er myocardial damage.
3. Larger def ect s have a poorer prognosis t han small def ect s.
Interfering Factors
False-posit ive inf arct -avid PY P can occur in cases of chest w all t rauma, recent
cardioversion, and unst able angina.
Interventions
1. Be aw are t hat imaging can be perf ormed at t he bedside in t he acut e phase
of inf arct ion if t he nuclear medicine depart ment has a port able camera.
2. Explain t he purpose, procedure, benef it s, and risks of t he nuclear medicine
procedure. See st andard pretest precaut ions on page 655.
3. Remember t hat imaging must occur w it hin a period of 12 hours t o 7 days
af t er t he onset of sympt oms of inf arct ion. O t herw ise, f alse-negat ive result s
may be report ed.
4. See Chapt er 1 f or addit ional guidelines f or saf e, eff ect ive, inf ormed pretest
care.
1. I nt erpret t he out come and monit or appropriat ely. I f heart surgery is needed,
counsel t he pat ient concerning f ollow -up t est ing af t er surgery.
2. Ref er t o st andard precaut ions and posttest care on page 655.
3. Follow addit ional guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed
posttest care .
M ultigated Acquisition (M UGA) Imaging: Rest and

Stress The term gated refers to the synchronization of
the imaging equipment and computer w ith the patient's
ECG to evaluate left ventricular function. The primary
purpose of this test is to provide an ejection fraction
(the amount of blood ejected from the ventricle during
cardiac cycle).
O nce inject ed, t he dist ribut ion of t he radiolabeled red blood cells (RBCs) is
imaged by synchronizat ion of t he recording of cardiac images w it h t he ECG . This
t echnique provides a means of obt aining inf ormat ion about cardiac out put , endsyst olic volume, end-diast olic volume, eject ion f ract ion, eject ion velocit y, and
regional w all mot ion of t he vent ricles. Comput er-aided imaging of w all mot ion of
t he vent ricles can be port rayed in t he cinemat ic mode t o visualize cont ract ion
and relaxat ion. This procedure may also be perf ormed as a st ress t est . MUG A
scans are not of t en perf ormed on children.
Reference Values
Normal
Normal myocardial w all mot ion and eject ion f ract ions under condit ions of st ress
and rest
Procedure
1. Remember t hat t his procedure may be perf ormed w it h or w it hout st ress. A
MUG A w it h t he pat ient at rest could be perf ormed at t he bedside if
necessary, if t he nuclear medicine depart ment has a port able camera.
2. Label t he pat ient 's ow n RBCs w it h 9 9 m Tc-PY P by any of several met hods.
I nject t he blood once it is labeled. I n children and adult s, administ er t he
99m
Tc-labeled RBCs slow ly t hrough
an int ravenous line. For children younger t han 3 years of age, sedat ion may
be required f or t he inject ion and t o allow t he pediat ric pat ient t o hold st ill f or
t he required 20 t o 30 minut es. Alt ernat ively, perf orm a cardiac f low st udy.
3. Be aw are t hat during an ECG , t he pat ient 's R w ave signals t he comput er and
camera t o t ake several image f rames f or each cardiac cycle.
4. I mage t he pat ient immediat ely af t er inject ion of t he labeled RBCs.
Abnormal MUG A procedures as associat ed w it h:
1. Congest ive cardiac f ailure
2. Change in vent ricular f unct ion due t o inf arct ion
3. Persist ent arrhyt hmias f rom poor vent ricular f unct ion
4. Regurgit at ion due t o valvular disease
5. Vent ricular aneurysm f ormat ion
Interfering Factors
I f a reliable ECG cannot be obt ained because of arrhyt hmias, t he t est cannot be
perf ormed.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks.
2. Follow st andard nuclear scan pretest precaut ions on page 655.
care.

1. I nt erpret MUG A out comes and monit or appropriat ely f or cardiac disease.
2. Ref er t o st andard nuclear scan posttest precaut ions on page 655.
3. Follow basic Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed posttest care .
Cardiac Flow Study (First-Pass Study; Shunt Imaging)

The cardiac flow study is performed to check for blood
flow through the great vessels and after vessel surgery;
it is useful in the determination of both right and left
ventricular ejection fractions. Immediately after the
injection, the camera traces the flow of the
radiopharmaceutical in its first pass through the
cardiac chambers in multiple rapid images. The firstpass study uses a jugular or antecubital vein injection
of the radiopharmaceutical. A large-bore needle is
used.
This st udy is usef ul in examining heart chamber disorders, especially lef t -t o-right
and right -t o-lef t shunt s. Children are commonly candidat es f or t his procedure.
I ndicat ions f or pediat ric pat ient s include evaluat ion f or congenit al heart disease,
t ransposit ion of t he great vessels, and at rial or vent ricular sept al def ect s and
quant it at ive assessment of valvular regurgit at ion. I n neonat es, t he cardiac f low
st udy can be used in conjunct ion w it h comput er sof t w are f or t he quant it at ive
assessment s. These quant it at ive values are usef ul in det ermining t he degree of
cardiac shunt ing w it h sept al def ect s in t he at ria or vent ricles.
Reference Values
Normal
Normal w all mot ion and eject ion f ract ion Normal pulmonary t ransit t imes and
normal sequence of chamber f illing
Procedure
1. Use a t hree-w ay st opcock w it h saline f lush f or radionuclide inject ion int o t he
jugular vein or t he ant ecubit al f ossa. For a shunt evaluat ion, inject t he
radionuclide int o t he ext ernal jugular vein t o ensure a compact bolus. Be
aw are t hat w it h pediat ric pat ient s, it is import ant t hat t he child not cry
because t his disrupt s t he f low of t he radiopharmaceut ical and negat es t he
result s of t he t est .
2. Have t he pat ient lie supine w it h t he head slight ly raised.
3. Be aw are t hat t he t ot al pat ient t ime is approximat ely 2030 minut es; t he
act ual imaging t ime is only 5 minut es.
4. Perf orm rest ing MUG A imaging w it h a shunt st udy.

1. Abnormal f irst -pass eject ion f ract ion values are associat ed w it h:
a. Congest ive heart f ailure
b. Change in vent ricular f unct ion due t o inf arct ion
c. Persist ent arrhyt hmias f rom poor vent ricular f unct ion
d. Regurgit at ion due t o valvular disease
e. Vent ricular aneurysm f ormat ion
2. Abnormal heart shunt s reveal:
a. Lef t -t o-right shunt
b. Right -t o-lef t shunt
c. Mean pulmonary t ransit t ime
d. Tet ralogy of Fallot (seen most of t en in children)
Interfering Factors
I nabilit y t o obt ain int ravenous access t o t he jugular vein or large-bore ant ecubit al
access.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks. An int ravenous line is
required.
care.
3. Ref er t o st andard nuclear scan pretest precaut ions on page 655.
4. O bt ain a signed, w it nessed consent f orm if st ress t est ing is t o be done.

1. I nt erpret t est out comes, monit or inject ion sit e, and counsel appropriat ely.

3. Follow basic Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed posttest care .
ENDOCRINE STUDIES
Thyroid Imaging
The t hyroid imaging t est syst emat ically measures t he updat e of radioact ive
iodine (eit her 131 I or 123 I ) by t he t hyroid. I odine (and, consequent ly, radioiodine)
is act ively t ransport ed t o t he t hyroid gland and is incorporat ed int o t he
product ion of t hyroid hormones. The t est is required f or t he evaluat ion of t hyroid
size, posit ion, and f unct ion. I t is used in t he diff erent ial diagnosis of masses in
t he neck, base of t he t ongue, or mediast inum. Thyroid t issue can be f ound in
each of t hese t hree locat ions.
Benign adenomas may appear as nodules of increased upt ake of iodine (hot
nodules), or t hey may appear as nodules of decreased upt ake (cold nodules).
Malignant areas generally t ake t he f orm of cold nodules. The most import ant use
of t hyroid imaging is t he f unct ional assessment of t hese t hyroid nodules.
Pediat ric indicat ions include evaluat ion of neonat al hypot hyroidism or
t hyrocarcinoma (low er incidence t han adult s).
Thyroid imaging perf ormed w it h iodine is usually acquired in conjunct ion w it h a
radioact ive iodine upt ake st udy, w hich is usually perf ormed 4 t o 6 hours and 24
hours af t er dosing. For a complet e t hyroid w orkup, in bot h adult s and children,
t hyroid hormone blood levels are usually measured. A t hyroid ult rasound
examinat ion also may be perf ormed.
Reference Values
Normal
Normal or evenly dist ribut ed concent rat ion of radioact ive iodine Normal size,
posit ion, shape, sit e, w eight , and f unct ion of t he t hyroid gland Absence of
nodules
Procedure
1. Have t he pat ient sw allow radioact ive iodine in a capsule or liquid f orm.
2. Det ermine an upt ake 4 t o 6 hours and 24 hours af t er dosing. Four hours
af t er dosing, t he t hyroid (neck area) is imaged.
3. Alert pat ient t hat normal scan t ime is 45 minut es.
1. Cancer of t he t hyroid most of t en manif est s as a nonf unct ioning cold nodule,
indicat ed by a f ocal area of decreased upt ake.
2. Some abnormal result s are:
a. Hypert hyroidism, represent ed by an area of diff use increased upt ake
b. Hypot hyroidism, represent ed by an area of diff use decreased upt ake
c. G raves' disease, represent ed by an area of diff use increased upt ake
d. Aut onomous nodules, represent ed by f ocal area of increased upt ake
e. Hashimot o's disease, represent ed by mot t led areas of decreased upt ake
3. I maging alone cannot def init ively det ermine t he diagnosis; upt ake inf ormat ion
is essent ial f or a def init ive diagnosis.
Interfering Factors
1. Thyroid imaging needs t o be complet ed bef ore radiographic examinat ions
using cont rast media (eg, int ravenous pyelogram, cardiac cat het erizat ion
myelogram) are perf ormed.
2. Any medicat ion cont aining iodine should not be given unt il nuclear t hyroid
medicine procedures are concluded. Not if y t he at t ending physician if t hyroid
st udies have been ordered or if t here are int erf ering radiographs or
medicat ions.
Interventions
Pretest Patien t Care
1. I nst ruct t he pat ient about nuclear medicine imaging purpose, procedure, and
special rest rict ions. Ref er t o st andard nuclear scan pretest precaut ions on
page 655.
2. Be aw are t hat because t he t hyroid gland responds t o small amount s of
iodine, t he pat ient may be request ed t o ref rain f rom iodine int ake f or at least
1 w eek bef ore t he t est . Pat ient s should consult w it h a physician. Rest rict ed
it ems include t he f ollow ing:
a. Cert ain t hyroid drugs
b. Weight -cont rol medicines
c. Mult iple vit amins
d. Some oral cont racept ives
e. X-ray cont rast mat erials cont aining iodine

f. Cough medicine
g. I odine-cont aining f oods, especially kelp and ot her nat ural f oods
3. Alleviat e any f ears t he pat ient may have about radionuclide procedures.
Clin ical Alert

1. Nuclear medicine t hyroid imaging is cont raindicat ed in pregnancy. Thyroid
t est ing in pregnancy is rout inely limit ed t o blood t est ing.
2. This st udy should be complet ed bef ore t hyroid-blocking radiographic
cont rast agent s are administ ered and bef ore t hyroid or iodine drugs are
given.
3. O ccasionally, t est s are perf ormed purposely w it h iodine or some t hyroid
drug in t he body. I n t hese cases, t he physician is t est ing t he response of
t he t hyroid t o t hese drugs. These st imulat ion and suppression t est s are
usually done t o det ermine t he nat ure of a part icular nodule and w het her
t he t issue is f unct ioning or nonf unct ioning.
Posttest Patien t Aftercare

1. I f iodine has been administ ered, observe t he pat ient f or signs and sympt oms
of allergic react ion as needed.
2. Explain t est out comes and possible t reat ment .
5. Follow Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed, posttest care .
Radioactive Iodine (RAI) Uptake Test This direct test of

the function of the thyroid gland measures the ability of
the gland to concentrate and retain iodine. When
radioactive iodine is administered, it is rapidly
absorbed into the bloodstream. This procedure
measures the rate of accumulation, incorporation, and
release of iodine by the thyroid. The rate of absorption
of the radioactive iodine, w hich is determined by the

increase in radioactivity of the thyroid gland, is a
measure of the ability of the thyroid to concentrate
iodine from blood plasma. The radioactive isotopes of
iodine used are 131 I and 123 I.
This procedure is indicat ed in t he evaluat ion of hypot hyroidism, hypert hyroidism,
t hyroidit is, goit er, and pit uit ary f ailure and f or post t reat ment evaluat ion. The
pat ient w ho is a candidat e f or t his t est may have a lumpy or sw ollen neck or
complain of pain in t he neck; t he pat ient may be jit t ery and ult rasensit ive t o heat
or sluggish and ult rasensit ive t o cold. The t est is more usef ul in t he diagnosis of
hypert hyroidism t han hypot hyroidism.
Reference Values
Normal
Absorpt ion (upt ake) by t he t hyroid gland: 1% t o 13% af t er 2 hours
5% t o 20% af t er 6 hours
15% t o 40% af t er 24 hours (Values are laborat ory dependent . )
Procedure
NOTE
The t est usually is done in conjunct ion w it h t hyroid imaging and assessment of
t hyroid hormone blood levels (see page 602).
1. Be aw are t hat a f ast ing st at e is pref erred. A complet e hist ory and list ing of
all medicat ions is a must f or t his t est . This hist ory should include
nonprescript ion medicat ions and pat ient diet ary habit s.
2. Administ er a liquid f orm or a t ast eless capsule of radioact ive iodine orally.
3. Measure t he amount of radioact ivit y by an upt ake calculat ion of t he t hyroid
gland 4 t o 6 and 24 hours lat er. There is no plan or discomf ort involved.
4. Have t he pat ient ret urn t o t he laborat ory at t he designat ed t ime because t he
exact t ime of measurement is crucial in det ermining t he upt ake.
1. I ncreased upt ake (eg, 20% in 1 hour, 25% in 6 hours, 45% in 24 hours)
suggest s hypert hyroidism but is not diagnost ic f or it .
2. Decreased upt ake (eg, 0% in 2 hours, 3% in 6 hours, 10% in 24 hours) may
be caused by hypot hyroidism but is not diagnost ic f or it .
a. I f t he administ ered iodine is not absorbed, as in severe diarrhea or
int est inal malabsorpt ion syndromes, t he upt ake may be low even t hough
t he gland is f unct ioning normally.
b. Rapid diuresis during t he t est period may deplet e t he supply of iodine,
causing an apparent ly low percent age of iodine upt ake.
c. I n renal f ailure, t he upt ake may be high even t hough t he gland is
f unct ioning normally.
Clin ical Alert

1. This t est is cont raindicat ed in pregnant or lact at ing w omen, in children, in
inf ant s, and in persons w it h iodine allergies.
2. Whenever possible, t his t est should be perf ormed bef ore any ot her
radionuclide procedures are done, bef ore any iodine medicat ions are
given, and bef ore any radiographs using iodine cont rast media are t aken.
Interfering Factors
1. The chemicals, drugs, and f oods t hat int erf ere w it h t he t est by l oweri ng t he
upt ake are:
a. I odized f ood and iodine-cont aining drugs such as Lugol solut ion,
expect orant s, cough medicat ions, sat urat ed solut ions of pot assium
iodide, and vit amin preparat ions t hat cont ain minerals. The durat ion of
t he eff ect s of t hese subst ances in t he body is 1 t o 3 w eeks.
b. Radiographic cont rast media such as iodopyracet (Diodrast ), sodium
diat rizoat e (Hypaque, Renograf in), poppy-seed oil (Lipiodol), et hiodized
oil (Et hiodol), iophendylat e (Pant opaque), and iopanoic acid (Telepaque).
The durat ion of t he eff ect s of t hese subst ances is 1 w eek t o 1 year or
more; consult w it h t he nuclear medicine laborat ory f or specif ic t imes.
c. Ant it hyroid drugs such as propylt hiouracil (PTU) and relat ed compounds
(durat ion, 2 t o 10 days)
d. Thyroid medicat ions such as liot hyronine sodium (Cyt omel), desiccat ed
t hyroid, t hyroxine (Synt hroid) (durat ion, 1 t o 2 w eeks)
e. Miscellaneous drugs such as t hiocyanat e, perchlorat e, nit rat es,
sulf onamides, t olbut amide (O rinase), cort icost eroids,
paraaminosalicylat e, isoniazid, phenylbut azone (But azolidin),
t hiopent al (Pent ot hal), ant ihist amines, adrenocort icot ropic hormone,
aminosalicylic acid, cobalt , and coumarin ant icoagulant s. Consult w it h t he
nuclear medicine depart ment f or durat ion of eff ect s of t hese drugs as
t hey vary w idely.
2. The compounds and condit ions t hat int erf ere by enhanci ng t he upt ake are:
a. Thyroid-st imulat ing hormone (t hyrot ropin)
b. Pregnancy
c. Cirrhosis
d. Barbit urat es
e. Lit hium carbonat e
f. Phenot hiazines (durat ion, 1 w eek)
g. I odine-def icient diet
h. Renal f ailure
Interventions
1. Explain t est purpose and procedure; t he t est t akes 24 hours t o complet e.

Assess and record pert inent diet ary and medicat ion hist ory.
2. Advise t hat iodine int ake is rest rict ed f or at least 1 w eek bef ore t est ing.

1. Explain t est out comes and possible t reat ment .
4. Follow Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed, posttest care .
Adrenal Gland (M IBG) Imaging The adrenal gland is

divided into tw o different components: cortex and
medulla. The scope of adrenal imaging is limited to the
medulla. Testing can be performed in both adults and
children.
The purpose of adrenal medulla imaging is t o ident if y sit es of cert ain t umors t hat
produce excessive amount s of cat echolamines. Pheochromocyt omas develop in
cells t hat make up t he adrenergic port ion of t he aut onomic nervous syst em. A
large number of t hese w ell-diff erent iat ed cells are f ound in adrenal medullas.
Adrenergic t umors have been called paragangl i omas w hen t hey are f ound
out side t he adrenal medulla, but many pract it ioners ref er t o all neoplasms t hat
secret e norepinephrine and epinephrine as pheochromocytomas. Because t he
only def init e and eff ect ive t herapy is surgery t o remove t he t umor, ident if icat ion
of t he sit e using t his t est , comput ed t omography, and ult rasound, is an essent ial
goal of t reat ment .
Reference Values
Normal
No evidence of t umors or hypersecret ing hormone sit es Normal salivary glands,
urinary bladder, and vague shape of liver and spleen can be seen.
Procedure
1. I nject int ravenously t he radionuclide 131 I met aiodobenzylguanidine (MI BG ).

2. Take sequent ial images at t he physician's discret ion, usually beginning 24
hours af t er inject ion.
3. Alert pat ient t hat imaging may t ake 2 hours.
1. Abnormal result s give subst ance t o t he rough rule of 10 f or t hese t umors:
a. Ten percent are in children.
b. Ten percent are f amilial.
c. Ten percent are bilat eral in t he adrenal glands.
d. Ten percent are malignant .
e. Ten percent are mult iple, in addit ion t o bilat eral.
f. Ten percent are ext rarenal.
2. More t han 90% of primary pheochromocyt omas occur in t he abdomen.
3. Pheochromocyt omas in children of t en represent a f amilial disorder.
4. Bilat eral adrenal t umors of t en indicat e a f amilial disease, and vice versa.
5. Mult iple ext rarenal pheochromocyt omas are of t en malignant .
6. The presence of t w o or more pheochromocyt omas st rongly indicat es
malignant disease.
Interfering Factors
Barium int erf eres w it h t he t est .
Interventions
1. Explain nuclear medical imaging purpose, procedure, benef it s, and risks.
2. G ive Lugol solut ion (pot assium iodine) f or 1 w eek bef ore t he inject ion t o
prevent upt ake of radioact ive iodine by t he t hyroid gland.

1. I nt erpret t est out come and counsel appropriat ely about t he need f or possible
f ollow -up t est s. Follow -up t est s include:
a. Kidney and bone imaging t o give f urt her orient at ion t o abnormalit ies
discovered by MI BG scan.
b. Comput ed t omography procedure if MI BG imaging f ailed t o locat e t he
t umor.
c. Ult rasound of t he pelvis if t he t umor produces urinary sympt oms.
Parathyroid Imaging
Parat hyroid imaging is done t o localize parat hyroid adenomas in clinically proven
cases of primary hyperparat hyroidism. I t is helpf ul in demonst rat ing int rinsic or
ext rinsic parat hyroid adenoma. Tw o t racers, 99m Tc sest amibi and 123 I capsules,
are administ ered. I n children, t his scan is done t o verif y presence of t he
parat hyroid gland af t er t hyroidect omy.
Reference Values
Normal
No areas of increased perf usion or upt ake in parat hyroid or t hyroid
Procedure
1. Administ er 123 I . Four hours lat er, image t he neck.
2. I nject 99m Tc sest amibi w it hout moving t he pat ient ; af t er 10 minut es, acquire
addit ional images. Comput er processing involves subt ract ing t he t echnet iumvisualized t hyroid st ruct ures f rom t he 123 I accumulat ion in a parat hyroid
adenoma.
3. Alert pat ient t hat t ot al examinat ion t ime is 1 hour.
Abnormal concent rat ions of t he radiopharmaceut icals reveal parat hyroid
adenoma, bot h int rinsic and ext rinsic, but cannot diff erent iat e bet w een benign
and malignant adenomas.
Interfering Factors
Recent ingest ion of iodine in f ood or medicat ion and recent t est s w it h iodine
cont rast are cont raindicat ions and reduce t he eff ect iveness of t he st udy.
Clinical Considerations Pregnancy is a relative

contraindication. However, if primary
hyperparathyroidism is suspected and surgical
exploration is essential before delivery, the study may
be performed.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of parat hyroid imaging.
2. Assess f or t he recent int ake of iodine. How ever, t his f inding is not a specif ic
cont raindicat ion t o perf orming t he st udy.
3. Palpat e t he t hyroid caref ully.

GENITOURINARY STUDIES
Renogram: Kidney Function and Renal Blood Flow
Imaging (With Furosemide or Captopril) The renogram
is performed in both adult and pediatric patients to
study the function of the kidneys and to detect renal
parenchymal or vascular disease or defects in
excretion. The radiopharmaceutical of choice, 99m Tc
mertiatide (MAG-3), permits visualization of renal
clearance. In pediatric patients, this procedure is done
to evaluate hydronephrosis, obstruction, reduced renal
function (premature neonates), renal trauma, and
urinary tract infections. The renogram is ideal for
pediatric evaluation because of the nontoxic nature of
the radiopharmaceuticals, compared with the contrast
media used in radiology procedures. Postkidney
transplant scans, which assess perfusion and
excretory function as a reflection of GFR, are done
when the serum creatinine level increases and
determine kidney damage leading to acute tubular
necrosis (ATN).
Reference Values
Normal
Equal blood f low in right and lef t kidneys I n 10 minut es, 50% of t he
radiopharmaceut ical should be excret ed.
Indications
1. To det ect t he presence or absence of unilat eral kidney disease
2. For long-t erm f ollow -up of hydrouret eronephrosis
3. To st udy t he hypert ensive pat ient t o evaluat e f or renal art ery st enosis. The
capt opril t est is a f irst -line st udy t o det ermine a renal basis f or hypert ension.
4. To st udy t he azot emic pat ient w hen uret hral cat het erizat ion is
cont raindicat ed or impossible
5. To evaluat e upper urinary t ract obst ruct ion
6. To assess renal t ransplant eff icacy
Procedure
1. Place t he pat ient in eit her an upright sit t ing or supine posit ion f or imaging;
t he supine posit ion is pref erred f or pediat ric pat ient s.
2. I nject t he radiopharmaceut ical int ravenously. An int ravenous diuret ic
(f urosemide [ Lasix] ) or angiot ensin-convert ing enzyme (ACE) inhibit or
(capt opril) may also be administ ered during a second phase of t he renogram.
3. St art imaging immediat ely af t er inject ion.
4. Alert pat ient t hat t ot al examinat ion t ime is approximat ely 45 minut es f or a
rout ine, one-phase renogram.
Clin ical Alert

1. A renogram may be perf ormed in a pregnant w oman if it is imperat ive t hat
renal f unct ion be ascert ained.
2. Some renal t ransplant recipient s may have more t han t w o kidneys, eg, t he
t ransplant , t heir ow n t w o kidneys, and an older f ailing t ransplant .
Somet imes, t w o pediat ric kidneys w ill bot h be t ransplant ed.
Abnormal dist ribut ion pat t erns may indicat e:
1. Hypert ension
2. O bst ruct ion due t o st ones or t umors
3. Renal f ailure
4. Decreased renal f unct ion
5. Diminished blood supply
6. Renal t ransplant reject ion
7. I n pediat ric pat ient s, urinary t ract inf ect ions in male neonat es; t he f inding
shif t s t o f emales af t er 3 mont hs of age.
Interfering Factors
Diuret ics, ACE inhibit ors, and bet a blockers are medicat ions t hat may int erf ere
w it h t he t est result s.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he procedure.
Pediat ric pat ient s have a det ect ible glomerular f ilt rat ion rat e af t er 6 mont hs
of age. I n t he neonat e, ult rasound is used in combinat ion w it h nuclear
medicine procedures f or a more complet e renal assessment . Ref er t o
st andard nuclear scan pretest precaut ions on page 655. An int ravenous line
is placed bef ore imaging. Check f or hist ory of previous t ransplant .
2. Unless cont raindicat ed, ensure t hat t he pat ient is w ell hydrat ed w it h t w o t o
t hree glasses of w at er (10 mL per kilogram of body w eight ) bef ore
undergoing t he t est .

1. Encourage f luids and f requent bladder empt ying t o promot e excret ion of
radioact ivit y.
Clin ical Alert

1. The t est should be perf ormed bef ore an int ravenous pyelogram.
2. Severe impairment of renal f unct ion or massive enlargement of t he renal
collect ing syst em may impair drainage even in t he absence of t rue
obst ruct ion.
Testicular (Scrotal) Imaging This test is performed on

an emergency basis to evaluate acute, painful
testicular swelling. It also is used in the differential
diagnosis of torsion or acute epididymitis and in
evaluation of injury, trauma, tumors, and masses. The
radiopharmaceutical 99m Tc pertechnetate is injected
intravenously. The images obtained differentiate
lesions associated with increased perfusion from those
that are primarily ischemic. In pediatric patients, the
procedure is done to diagnose acute or latent testicular
torsion, epididymitis, or testicular hydrocele and for
evaluation of testicular masses such as abscesses and
tumors.
Reference Values
Normal
Normal blood f low t o scrot al st ruct ures, w it h even dist ribut ion and concent rat ion
of t he radiopharmaceut ical
Procedures
1. Have t he pat ient lie supine under t he gamma camera. Tape t he penis gent ly
t o t he low er abdominal w all. For proper posit ioning, use t ow els t o support
t he scrot um. Place lead shielding in t he perineal area t o reduce any
background act ivit y.
2. I nject t he radionuclide int ravenously. I n pediat ric pat ient s, do not inject t he
radiopharmaceut ical t hrough veins in t he legs because t his int erf eres w it h t he
st udy.
3. Perf orm imaging in t w o phases: f irst , as a dynamic blood f low st udy of t he
scrot um; and second, as an assessment of dist ribut ion of t he
radiopharmaceut ical in t he scrot um.
4. Alert pat ient t hat t ot al examining t ime is 3045 minut es.
1. Abnormal concent rat ions reveal:
a. Tumors
b. Hemat omas
c. I nf ect ion
d. Torsion (w it h reduced blood f low ). I n t he neonat al pat ient , t orsion is
caused primarily by development al anomalies.
e. Acut e epididymit is
2. The nuclear scan is most specif ic soon af t er t he onset of pain, bef ore
abscess is a clinical considerat ion.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he t est . There is no
discomf ort involved in t est ing.
2. I f t he pat ient is a child, a parent should accompany t he boy t o t he
depart ment .
3. Tape t he penis t o t he low er abdominal w all.
4. Ref er t o st andard nuclear scan pretest precaut ions, page 655.

1. Ref er t o st andard nuclear scan posttest precaut ions, page 655.
Vesicoureteric Reflux (Bladder and Ureters) Imaging

Vesicoureteric reflux imaging usually is done on
pediatric patients to assess abnormal bladder filling
and possible reflux into the ureter. 99m Tc pentetate

(DTPA) is administered through a urinary catheter,
followed by sufficient saline until the patient has an
urge to urinate. The ureters and kidneys are scanned
by the camera during administration to detect the
reflux.
Reference Values
Normal
Normal bladder f illing w it hout any ref lux int o t he uret ers
Procedure
1. Place t he pat ient in t he supine posit ion. Use a special urinary cat het er kit ,
and insert a urinary cat het er.
2. St art t he camera immediat ely f or dynamic acquisit ion w hile t he
radiopharmaceut ical and saline are administ ered unt il t he bladder is f ull or
t here is pat ient discomf ort .
3. Remove t he cat het er once t he imaging is complet e.
Abnormal vesicouret eric ref lux may be eit her congenit al (immat ure development
of t he urinary t ract ) or caused by inf ect ion.
Interventions
1. See st andard pretest care f or nuclear scan of pediat ric pat ient s (see page
656).
2. Place a urinary cat het er w it h st erile saline. Place an absorbent , plast icbacked pad under t he pat ient t o absorb any leakage of radioact ive mat erial.
I f a urinary cat het er is cont raindicat ed f or t he pat ient , use an alt ernat ive
indirect renogram met hod.
1. Ref er t o st andard nuclear scan posttest precaut ions (see page 655), t he
same as f or adult s.
2. Be aw are t hat depending on cause and severit y, ant ibiot ic t herapy or surgery
is used t o t reat t he condit ion.
3. Remember t hat special handling of t he pat ient 's urine (gloves and
handw ashing bef ore and af t er gloves are removed) is necessary f or 24 hours
af t er complet ion of t he t est .
GASTROINTESTINAL STUDIES
Hepatobiliary (Gallbladder, Biliary) Imaging With
Cholecystokinin This study, using 99m Tc disofenin or
mebrofenin, is performed to visualize the gallbladder
and determine patency of the biliary system. In
pediatric patients, this test is done to differentiate
biliary atresia from neonatal hepatitis and to assess
liver trauma, right upper quadrant pain, and congenital
malformations.
A series of images t races t he excret ion of t he radionuclide. Through comput er
analysis, t he act ivit y in t he gallbladder is quant it at ed, and t he amount eject ed
(eject ion f ract ion) is calculat ed.

1. To evaluat e cholecyst it is
2. To diff erent iat e bet w een obst ruct ive and nonobst ruct ive jaundice
3. To invest igat e upper abdominal pain
4. Biliary assessment af t er surgery
5. Evaluat ion of biliary at resia
Reference Values
Normal
Rapid t ransit of t he radionuclide t hrough t he liver cells t o t he biliary t ract (15 t o
30 minut es) w it h signif icant upt ake in t he normal gallbladder
Normal dist ribut ion pat t erns in t he biliary syst em, f rom t he liver, t hrough t he
gallbladder, t o t he small int est ines
Procedure
1. I nject t he radionuclide int ravenously. I n adult s and older children, give
cholecyst okinin (CCK) t o st imulat e gallbladder cont ract ion. I n inf ant s, give
phenobarbit al t o dist inguish bet w een biliary at resia and neonat al jaundice.
2. St art imaging immediat ely af t er inject ion. Take a series of images at 5-
minut e int ervals f or as long as it t akes t o visualize t he gallbladder and small

int est ine.
3. I n t he event of biliary obst ruct ion, obt ain delayed view s.
4. Remember t hat if CCK is administ ered, comput er-assist ed quant it at ive
measurement s can det ermine an eject ion f ract ion.
1. Abnormal concent rat ion pat t erns reveal unusual bile communicat ions.
2. G allbladder visualizat ion excludes t he diagnosis of acut e cholecyst it is w it h a
high degree of cert aint y.
Interfering Factors
1. Pat ient s w it h high serum bilirubin levels (>10 mg/ dL or >171 mol/ L) have
less reliable t est result s.
2. Pat ient s receiving t ot al parent eral nut rit ion or w it h long-t erm f ast ing may not
have gallbladder visualizat ion.
Interventions
2. Ensure t hat t he pat ient is NPO f or at least 4 hours (34 hours f or pediat ric
pat ient s) bef ore t est ing. I n case of prolonged f ast ing (>24 hours), not if y t he
nuclear medicine depart ment . Fast ing does not apply w hen t he indicat ion is
f or biliary at resia or jaundice.
3. Discont inue opiat e- or morphine-based pain medicat ions 2 t o 6 hours bef ore
t he t est t o avoid int erf erence w it h t ransit of t he radiopharmaceut ical.

Gastroesophageal Reflux Imaging This test is indicated

for both adult and pediatric patients to evaluate
esophageal disorders such as regurgitation and to
identify the cause of persistent nausea and vomiting. In
infants, the study is used to distinguish between
vomiting and reflux (for those with more severe
symptoms). A certain amount of reflux occurs naturally
in infants. If timely diagnosis and treatment of
gastrointestinal reflux does not occur, additional
complications may result, such as recurrent
respiratory infections, apnea, or sudden infant death
syndrome (SIDS).
Af t er oral administ rat ion of t he radioisot ope 99m Tc sulf ur colloid in orange juice
or scrambled eggs, t he pat ient is immediat ely imaged t o verif y t hat t he dose is in
t he st omach. I mages are acquired in 2 hours. A comput er analysis is used t o
calculat e t he percent age of ref lux int o t he esophagus f or each image.
Reference Values
Normal
Less t han 40% gast ric ref lux across t he esophageal sphinct er
Procedure
1. Have t he pat ient ingest t he radionuclide in orange juice or in scrambled eggs.
For inf ant s, perf orm t he t est at t he normal inf ant f eeding t ime t o det ermine
esophageal t ransit . Have t he inf ant drink 99m Tc-labeled sulf ur colloid mixed
w it h milk. G ive a port ion of t he milk cont aining t he radioisot ope, and burp t he
inf ant bef ore t he remainder is given. G ive some unlabeled milk t o clear t he
esophagus of t he radioact ive mat erial. I f a nasogast ric t ube is required f or
radiopharmaceut ical administ rat ion, remove it bef ore t he imaging occurs t o
avoid a f alse-posit ive result .
2. Be aw are t hat images are obt ained in 2 hours.

3. Remember t hat a comput er analysis generat es a t ime-act ivit y curve t o
calculat e t he ref lux.
More t han 4% ref lux is abnormal. The percent age of ref lux is used t o evaluat e
pat ient s bef ore and af t er surgery f or gast roesophageal ref lux.
Clin ical Alert

Pat ient s w ho have esophageal mot or disorders, hiat al hernias, or sw allow ing
diff icult ies should have an endogast ric t ube insert ed f or t he procedure.
Interfering Factors
Previous upper gast roint est inal radiographic procedures may int erf ere w it h t his
t est .
Interventions
1. Explain t he purpose, procedure, benef it s, and risks. See st andard nuclear
scan pretest precaut ions on page 655.
2. Perf orm imaging w it h t he pat ient in a supine posit ion.
3. Ensure t hat t he pat ient is f ast ing f rom midnight of t he previous night unt il t he
examinat ion.
4. Monit or oral int ake of t he orange juice or scrambled eggs cont aining 99m Tc
sulf ur colloid.

1. Remove endogast ric t ubes, if placed f or t he examinat ion, af t er t he
radiopharmaceut ical is administ ered.

Gastric Emptying Imaging Gastric emptying imaging is

used in both adult and pediatric patients to assess
gastric motility disorders and in patients with
unexplained nausea, vomiting, diarrhea, and abdominal
cramping. The emptying of food by the stomach is a
complex process that is controlled by food
composition (fats, carbohydrates), food form (liquid,
solid), hormone secretion (gastrin, CCK), and nervous
innervation. Because clearance of liquids and
clearance of solids vary, the imaging procedure traces
both food forms. Indications for imaging include both
mechanical and nonmechanical gastric motility
disorders. Mechanical disorders include peptic
ulcerations, gastric surgery, trauma, and cancer.
Nonmechanical disorders include diabetes, uremia,
anorexia nervosa, certain drugs (opiates), and
neurologic disorders. Clearance of liquids, solids, or a
combination (dual-phase examination) may be studied.
Reference Values
Normal
Normal half -t ime clearance ranges: 45110 minut es f or solids 1065 minut es f or
liquids
Procedure
1. Have t he f ast ing pat ient consume t he solid phase (99m Tc sulf ur colloid,
usually in scrambled eggs or oat meal or chicken livers) f ollow ed by t he liquid
phase (indium-111 [111 I n] -DTPA in 300 mL w at er). For inf ant s, perf orm t he
t est at t he normal f eeding t ime. Have t he inf ant drink 99m Tc sulf ur colloid
mixed w it h milk. Provide older children solids such as scrambled eggs mixed
w it h 99m Tc sulf ur colloid.

2. Perf orm imaging immediat ely, w it h t he pat ient in t he supine posit ion.
3. O bt ain subsequent images over t he next 2 hours.
4. Use comput er processing t o det ermine t he half -t ime clearance f or bot h liquid
and solid phases of gast ric empt ying.
1. Sl ow or del ayed empt ying is usually seen in t he f ollow ing condit ions:
a. Pept ic ulcerat ion
b. Diabet es
c. Smoot h muscle disorders
d. Af t er radiat ion t herapy
e. I n pediat ric pat ient s, hypomot ilit y of t he ant rum port ion of t he st omach is
t he primary cause of delayed gast ric empt ying. How ever, all abnormal
f unct ions of t he st omach do cont ribut e t o t he delay.
2. Accel erated empt ying is of t en seen in t he f ollow ing condit ions:
a. Zollinger-Ellison syndrome
b. Cert ain malabsorpt ion syndromes
c. Af t er gast ric or duodenal surgery
Interfering Factors
Administ rat ion of cert ain medicat ions (eg, gast rin, CCK) int erf eres w it h gast ric
empt ying.
Interventions
2. Have t he adult pat ient f ast f or 8 hours bef ore t he t est .

1. Be aw are t hat t he pat ient may eat and drink normally.
4. Follow Chapt er 1 basic guidelines f or saf e, eff ect ive, inf ormed posttest care .
Gastrointestinal Bleeding Imaging This test is very

sensitive in the detection and location of acute
gastrointestinal bleeding that occurs distal to the
ligament of Treitz. (Gastroscopy is the procedure of
choice for diagnosis of upper gastrointestinal
bleeding.) Before this diagnostic technique was
refined, barium enemas were used to identify lesions
reflecting sites of bleeding, but that test was not
specific and frequently missed small sites of bleeding.
This procedure is also indicated for detection and
localization of recent hemorrhage, both peritoneal and
retroperitoneal. The radiopharmaceutical of choice for
suspected active bleeding is 99m Tc-labeled RBCs.
Reference Values
Normal
No sit es of act ive bleeding
Procedure
1. I nject 99m Tc-labeled RBCs int ravenously.
2. Begin imaging immediat ely af t er inject ion and cont inue every f ew minut es.
O bt ain images ant eriorly over t he abdomen at 5-minut e int ervals f or 60
minut es or unt il a bleeding
sit e is locat ed. I f t he st udy is negat ive af t er 1 hour, obt ain delayed images
2, 6, and somet imes 24 hours lat er, w hen necessary, t o ident if y t he locat ion
of diff icult -t o-det ermine bleeding sit es.
3. Be aw are t hat t ot al examining t imes varies.
Clin ical Alert

1. This t est is cont raindicat ed in pat ient s w ho are hemodynamically unst able.
I n t hese inst ances, angiography or surgery should be t he procedure of
choice.
2. Assess t he pat ient f or signs of act ive bleeding during t he examining
period.
3. Recent blood t ransf usion may be a cont raindicat ion f or t his st udy.
Abnormal concent rat ions of RBCs (hot spot s) are associat ed w it h act ive
gast roint est inal bleeding sit es, bot h perit oneal and ret roperit oneal.
Interfering Factors
Presence of barium in gast roint est inal t ract may obscure t he sit e of bleeding
because of t he high densit y of barium and t he inabilit y of t he t echnet ium t o
penet rat e t he barium.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he gast roint est inal
blood loss imaging.
2. Det ermine w het her t he pat ient has received barium as a diagnost ic agent
w it hin t he past 24 hours. I f t he presence of barium in t he gast roint est inal
t ract is quest ionable, an abdominal radiograph may be ordered.
3. Advise t he pat ient t hat delayed images may be necessary. Also, if act ive
bleeding is not seen on init ial imaging, addit ional images must be obt ained
f or up t o 24 hours af t er inject ion in a pat ient w it h clinical signs of act ive
bleeding.

Parotid (Salivary) Gland Imaging This study is helpful

in the evaluation of swelling masses in the parotid
region. This imaging is done to detect blocked tumors
of parotid or salivary glands and to diagnose Sjgren's
syndrome. The radionuclide injected intravenously is
99m
Tc pertechnetate. One of the limitations of the test is
that it cannot furnish an exact preoperative diagnosis.
Reference Values
Normal
No evidence of t umor-t ype act ivit y or blockage of duct s Normal size, shape, and
posit ion of t he glands
Procedure
1. I nject t he radionuclide pert echnet at e int ravenously. Perf orm imaging
immediat ely. There are t hree phases t o imaging: blood f low, upt ake or
t rapping mechanism, and secret ing capabilit y.
2. Take images of t he gland every minut e f or 30 minut es.
3. I f a secret ory f unct ion t est is being perf ormed t o det ect blockage of t he
salivary duct , t hree f ourt hs of t he w ay t hrough t he t est , ask t he pat ient t o
suck on a lemon slice. I f t he salivary duct is normal, t his causes t he gland t o
empt y. This is not done in st udies undert aken f or t umor det ect ion.
4. Alert pat ient t hat t ot al t est t ime is 45 t o 60 minut es.
1. The report ing of a hot nodule amidst normal t issue t hat accumulat es t he
radionuclide is associat ed w it h t umors of t he duct s, as in:
a. Wart hin's t umor
b. O ncocyt oma
c. Mucoepidermoid t umor
2. The report ing of a cold nodule amidst normal t issue t hat does not accumulat e
t he radionuclide is associat ed w it h:
a. Benign t umors, abscesses, or cyst s, w hich are indicat ed by smoot h,
sharply def ined out lines
b. Adenocarcinomas, w hich are indicat ed by ragged, irregular out lines
3. Diff use decreased act ivit y occurs in obst ruct ion, chronic sialadenit is, or
Sjgren's syndrome.
4. Diff use increased act ivit y occurs in acut e parot it is.
Interventions
2. No pain or discomf ort is involved.
3. Lemon may be given t o t he pat ient t o st imulat e parot id secret ion.

Liver/Spleen Imaging and Liver RBC Imaging This test

is used to demonstrate the anatomy and size of the
liver and spleen. It is helpful in determining the cause

of right upper quadrant pain and in the detection of
metastatic disease, cirrhosis, ascites, infarction due to
trauma, and liver damage due to radiation therapy.
Most liver and spleen imaging evaluates for metastatic
disease and for the differential diagnosis of jaundice.
Postliver transplant scans detect bile and
anastomoses leaks and rule out abnormal perfusion as
a sign of rejection.
The radioact ive mat erial, 99m Tc-labeled sulf ur colloid, is inject ed int ravenously.
Liver/ spleen SPECT imaging provides 3-dimensional images of
radiopharmaceut ical upt ake. The radiopharmaceut ical most specif ic f or det ect ion
of hemangioma in t he liver is 99m Tc labeled t o a pat ient 's ow n RBCs. I n many
inst ances, ult rasound imaging replaces t his t est .
Reference Values
Normal
Normal liver size, shape, and posit ion w it hin t he abdomen Normal spleen size,
cell f unct ion, and blood f low in t he spleen Normally f unct ioning liver and spleen
ret iculoendot helial syst em
NOTE
The amount of upt ake in t he spleen should alw ays be less t han in t he liver.
Procedure
1. I nject t he radiopharmaceut ical int ravenously.
2. Perf orm a SPECT st udy and planar images.
3. Be aw are t hat t he ent ire st udy usually t akes 60 minut es f rom inject ion t o
f inish.
1. Abnormal liver and spleen scan pat t erns occur in:
a. Cirrhosis
b. Hepat it is
c. Trauma
d. Hepat omas
e. Sarcoidosis
f. Met ast asis
g. Cyst s
h. Perihepat ic abscesses
i. Hemangiomas
j. Adenomas
k. Ascit es
2. Abnormal splenic concent rat ions reveal:
a. Unusual splenic size
b. I nf arct ion
c. Rupt ured spleen
d. Accessory spleen
e. Tumors
f. Met ast at ic spread
g. Leukemia
h. Hodgkin's disease
3. Spleens more t han 14 cm are abnormally enlarged; t hose less t han 7 cm are
abnormally small. Areas of absent radioact ivit y or holes in t he spleen scan
are associat ed w it h abnormalit ies t hat displace or dest roy normal splenic
pulp.
4. About 30% of persons w it h Hodgkin's disease w it h splenic involvement have
a normal splenic image.
Interventions
2. Be aw are t hat t his t est can be perf ormed in cases of t rauma or suspect ed
rupt ured spleen, at bedside or in t he emergency room.

2. I nt erpret t est out come and monit or appropriat ely. Explain need f or medical
t reat ment or surgery.
Meckel's Diverticulum Imaging The test for Meckel's

diverticulum usually is done in pediatric patients
diagnosed with congenital abnormality of the ileum,
which sometimes continues to the umbilicus with
fistula formation. The uptake of 99m Tc pertechnetate
occurs in the parietal cells of the gastric mucosa and
is detected by the gamma camera. Meckel's
diverticulum shows uptake in the distal portion of the
ileum. This anomaly contains secretory cells similar to

those of gastric mucosa. An alternative
radiopharmaceutical, 99m Tc-labeled RBCs, may be
considered in cases of suspected bleeding sites
associated with the diverticulum.
Reference Values
Normal
Normal blood pool dist ribut ion and clearance of t he radioact ive t racer int o t he
duodenum and jejunum
Procedure
1. Have t he pat ient lie supine and inject w it h t he radiopharmaceut ical.
2. St art t he camera immediat ely w it h a series of st at ic images obt ained at 5minut e int ervals of 30 minut es.
3. Be aw are t hat ext ra spot view s may be request ed by t he physician.
1. Abnormal result s reveal rect al bleeding, t he most common sympt om of
Meckel's divert iculum. Meckel's divert iculum can occur w it h or w it hout
abdominal sympt oms.
2. I f it is lef t undet ect ed and unt reat ed, ulcerat ion of t he ilium may occur, and
st rangulat ion may cause int est inal obst ruct ion.
Interventions
1. See st andard pretest care f or nuclear scan of pediat ric pat ient s (see page
656). Explain t he purpose and procedures of t he examinat ion. Pat ient s
should be f ast ing. O t her diagnost ic procedures involving t he gast roint est inal
t ract and medicat ions aff ect ing t he int est ines should be avoided f or 2 t o 3
days bef ore t he examinat ion. This is especially t rue of low er and upper
gast roint est inal radiographic procedures.

2. Have pat ient s void immediat ely bef ore t he examinat ion.

1. Ref er t o st andard posttest precaut ions (see page 655), t he same as f or
adult s. Special handling of t he pat ient 's urine (gloves and handw ashing
bef ore and af t er glove removal) is necessary f or 24 hours af t er t est
complet ion.
NEUROLOGIC STUDIES
Brain Scan and Cerebral Blood Flow Imaging Brain
imaging provides information about regional perfusion
and brain function, whereas CT and MRI show
structural changes. Recent developments in
radiopharmaceuticals and SPECT have rejuvenated
brain imaging. Newer technetium complexes, such as
99m
Tc bicisate (ECD) and 99m Tc exametazime, are
radiopharmaceuticals that cross the blood-brain
barrier. The blood-brain barrier is not an anatomic
structure but a complex system of select mechanisms
that oppose the passage of most ions and large
molecular-weight compounds from the blood to the
brain tissue, that includes capillary endothelium with
closed intracellular clefts, a small or absent
extravascular fluid space between endothelium and
glial sheaths, and the membrane of the neurons
themselves. SPECT technology allows for 3dimensional slices, providing depth resolution from
different angles. Although PET imaging is more
effective in functional diagnosis, SPECT is less
expensive and more readily available. This test is
indicated in both adults and children to determine brain
death or the presence of encephalitis; it is also used in
children with hydrocephalus, to localize epileptic foci,
to assess metabolic activity, to evaluate brain tumors,
and for the assessment of childhood development
disorders.
Reference Values
Normal
Normal ext racranial and int racranial blood f low Normal dist ribut ion, w it h highest
upt ake in t he gray mat t er, basal ganglia, t halamus, and peripheral cort ex and
less act ivit y in t he cent ral w hit e mat t er and vent ricles
Procedure
1. I nject t he radionuclide int ravenously. During t he inject ion, have t he pat ient in
a relaxed, cont rolled environment t o minimize anxiet y. I n uncooperat ive
children, do not use sedat ion unt il af t er t he inject ion because it may aff ect
brain act ivit y. Secure t he pat ient 's head during t he examinat ion.
2. Begin imaging immediat ely af t er administ rat ion of t he radiopharmaceut ical or
af t er a 1-hour delay. I t t akes about 1 hour t o complet e.
3. Wit h t he pat ient in t he supine posit ion, obt ain SPECT images around t he
circumf erence of t he head.
4. Be aw are t hat w it h administ rat ion of iodoamphet amines, some depart ment s
require a dark and quiet environment .
1. Abnormal radionuclide dist ribut ion pat t erns indicat e:
a. Alzheimer's disease
b. St roke
c. Dement ia
d. Seizure disorders
e. Epilepsy
f. Syst emic lupus eryt hemat osus
g. Hunt ingt on's disease
h. Parkinson's disease
i. Psychiat ric diagnosis (schizophrenia)
2. The cerebral blood f low in a pat ient w it h brain deat h show s a very dist inct
image: t here is a lack of t racer upt ake in t he ant erior and middle cerebral
art eries and in t he cerebral hemisphere, but perf usion is present in t he scalp
veins.
Interfering Factors
1. Any pat ient mot ion (eg, coughing, leg movement ) can alt er cerebral
alignment .
2. Sudden dist ract ions or loud noises can alt er t he dist ribut ion of t he
radionuclide.
Interventions
1. Explain t he purpose, procedure, benef it s, and risk.
2. Ref er t o st andard nuclear scan pretest precaut ions in page 655.
3. Because precise head alignment is crucial, advise t he pat ient t o remain quiet
and st ill.
4. O bt ain a caref ul neurologic hist ory bef ore t est ing.
5. See Chapt er 1 f or saf e, eff ect ive, inf ormed pretest care .

2. I nt erpret t est out come and monit or appropriat ely, especially if sedat ion is
used.
Cisternography (Cerebrospinal Fluid Flow Imaging)

This study, in which the radiopharmaceutical 111 In DTPA
is injected intrathecally during a lumbar puncture, is a
sensitive indicator of altered flow and reabsorption of
CSF. Congenital malformations are the most common
causes of hydrocephalus in the neonate. In older
patients and in cases of trauma, CT or MRI is often
used to identify anatomic origins of obstructive
hydrocephalus. In the treatment of hydrocephalus, this
test aids in selection of the type of shunt and pathway

and in determining the prognosis of both shunting and
hydrocephalus.
Reference Values
Normal
Unobst ruct ed f low of cerebrospinal f luid and normal reabsorpt ion
Procedure
1. Perf orm a st erile lumbar punct ure af t er t he pat ient has been posit ioned and
prepared (see Chapt er 5 f or lumbar punct ure procedure). At t his t ime, inject
t he radionuclide int o t he cerebrospinal circulat ion.
2. Have t he pat ient lie f lat af t er t he punct ure; t he lengt h of t ime depends on t he
physician's order.
3. Perf orm imaging 2 t o 6 hours af t er inject ion and repeat af t er 24 hours, 48
hours, and 72 hours if t he physician so direct s.
4. Be aw are t hat examining t ime is 1 hour f or each imaging.
Abnormal f illing pat t erns reveal:
1. Cause of hydrocephalus (eg, t rauma, inf lammat ion, bleeding, int racranial
t umor)
2. Subdural hemat oma
3. Spinal mass lesions
4. Post erior f ossa cyst s
5. Parencephalic and subarachnoid cyst s
6. Communicat ing versus noncommunicat ing hydrocephalus
7. Shunt pat ency
8. Diagnosis and localizat ion of rhinorrhea and ot orrhea
Interventions
1. Explain t he purposes, procedures, benef it s, and risks of bot h lumbar
punct ure and cist ernography.
3. Advise t he pat ient t hat it may t ake as long as 1 hour f or each imaging
session.
4. Because of t he lumbar punct ure, t ake t he pat ient by cart t o t he nuclear
medicine depart ment f or t he f irst imaging session.

1. Follow inst ruct ions f or lumbar punct ure (see Chapt er 5) and st andard nuclear
scan posttest precaut ions on page 655.
2. Be alert t o complicat ions of lumbar punct ure, such as meningit is, allergic
react ion t o anest het ic, bleeding int o spinal canal, herniat ion of brain t issue,
and mild t o severe headache.
PULM ONARY STUDIES

Lung Scan (Ventilation and Perfusion Imaging) The
lung imaging is performed for three major purposes:
1. To diagnose and locat e pulmonary emboli
2. To det ect t he percent age of t he lungs t hat is f unct ioning normally
3. To assess t he pulmonary vascular supply by providing an est imat e of regional
pulmonary blood f low
Lung imaging in bot h adult s and children is done t o assess pneumonia, cyst ic
f ibrosis, cyanosis, ast hma, airw ay obst ruct ion, inf ect ion, inf lammat ion, and
acquired immunodef iciency syndrome (AI DS)-relat ed pulmonary diseases. I t is a
simple met hod f or monit oring t he course of embolic disease because an area of
ischemia persist s af t er apparent resolut ion on chest radiographs. I n t he case of
pulmonary embolus, t he blood supply beyond an embolus is rest rict ed. I maging
result s in poor or no visualizat ion of t he aff ect ed area. Assessment of t he
adequacy of pulmonary art ery perf usion in areas of know n disease can also be
done reliably, as w ell as af t er lung t ransplant t o det ect reperf usion of lung and
bronchiolit is oblit erans.
There are t w o part s t o t he lung imaging: t he vent ilat ion ([ V w it h dot above] )
imaging and t he perf usion ([ Q w it h dot above] ) imaging. The vent ilat ion imaging
reveals t he movement or lack of air in t he lungs. An aerosol of 99m Tc DTPA or
xenon-133 (133 Xe) gas demonst rat es t he vent ilat ion propert ies of t he pat ient 's
lungs. The perf usion imaging demonst rat es t he blood supply t o t he t issues in t he
lungs.
When inhaled, t he radioact ive gas or aerosol f ollow s t he same pat hw ay as t he
air in normal breat hing. I n some pat hologic condit ions aff ect ing vent ilat ion, t here
is signif icant alt erat ion in t he normal vent ilat ion process. The [ V w it h dot
above] / [ Q w it h dot above] is signif icant in t he diagnosis of pulmonary emboli. I t
is also helpf ul in diagnosing bronchit is, ast hma, inf lammat ory f ibrosis,
pneumonia, chronic obst ruct ive pulmonary disease, and lung cancer.
The lung perf usion st udy can be perf ormed af t er t he vent ilat ion t est . A
macroaggregat ed albumin (MAA) labeled w it h t echnet ium is inject ed
int ravenously, and assessment of t he pulmonary vascular supply is achieved by
imaging.
Cert ain limit at ions exist w it h t hese t est s. Wit h a posit ive chest f ilm and a
posit ive [ V w it h dot above] / [ Q w it h dot above] , t he diff erent ial possibilit ies are
mult iple: pneumonia, abscess, bullae, at eliosis, and carcinoma, among ot hers. A
pulmonary art eriogram is st ill necessary bef ore an embolect omy can be
at t empt ed. Pulmonary embolism (PE) is det ermined by a mismat ch bet w een t he
vent ilat ion and perf usion images. I n ot her w ords, a normal vent ilat ion image and
an abnormal perf usion image w it h segment al def ect s indicat e PE.
Clin ical Alert

Pulmonary perf usion imaging is cont raindicat ed in pat ient s w it h primary
pulmonary hypert ension.
Reference Values
Normal
Normal f unct ioning lung
Normal pulmonary vascular supply Normal gas exchange
Procedure
1. Ask t he pat ient t o breat he f or approximat ely 4 minut es t hrough a closed,
nonpressurized vent ilat ion syst em. During t his t ime, administ er a small
amount of radioact ive gas or aerosol. I t is import ant t hat t he pat ient not
sw allow t he radioact ive aerosol during t he vent ilat ion port ion of t he lung
imaging. Doing so causes radioact ive int erf erence w it h t he low er lobes of t he
lung and makes an accurat e diagnost ic int erpret at ion diff icult . Also, t ake
care t hat t he pat ient does not aspirat e t he aerosol.
2. Alert t he pat ient t hat breat h holding w ill be required f or a brief period at
some t ime during t he imaging.
3. Be aw are t hat t he imaging t ime is 10 t o 15 minut es. When t he vent ilat ion
imaging is perf ormed w it h lung perf usion imaging (eg, in diff erent ial
diagnosis of PE), t he t est ing t ime is 30 t o 45 minut es.
4. Perf orm t he perf usion imaging immediat ely af t er t he vent ilat ion st udy.
5. I n t he pediat ric pat ient , reduce t he number of part icles given in t he MAA
dose because of t he smaller size of t he capillary beds. Use caut ion w it h MAA
in pat ient s w it h at rial and vent ricular sept al def ect s.
1. Abnormal vent ilat ion and perf usion pat t erns indicat e possible:
a. Tumors
b. Emboli
c. Pneumonia
d. At elect asis
e. Bronchit is
f. Ast hma
g. I nf lammat ory f ibrosis
h. Chronic obst ruct ive pulmonary disease
i. Lung cancer
2. I n pediat ric pat ient s, t here is an increased incidence of an airw ay obst ruct ion
caused by mucus plugs or f oreign bodies. How ever, pulmonary emboli do not
occur in children as of t en as in adult s.
Interfering Factors
1. False-posit ive imagings occur in vasculit is, mit ral st enosis, and pulmonary
hypert ension and w hen t umors obst ruct a pulmonary art ery w it h airw ay
involvement .
2. During t he inject ion of MAA, care must be t aken t hat t he pat ient 's blood does
not mix w it h t he radiopharmaceut ical in t he syringe. O t herw ise, hot spot s
may be seen in t he lungs.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he t est .
2. Alleviat e any f ears t he pat ient may have concerning nuclear medicine
procedures.
3. Be aw are t hat it is import ant t hat a recent chest radiograph be available.
4. Remember t hat t he pat ient must be able t o f ollow direct ions f or breat hing
and holding t he breat h, including breat hing t hrough a mout hpiece or int o a
f ace mask.

2. I nt erpret t est out come and monit or appropriat ely f or post procedural signs of
aspirat ion.
ORTHOPEDIC STUDIES
Bone Imaging
This t est is used primarily t o evaluat e and monit or persons w it h know n or
suspect ed met ast at ic disease. Breast cancers, prost at e cancers, lung cancers,
and lymphomas t end t o met ast asize t o bone. Bone imagings visualize lesions 6
t o 12 mont hs bef ore t hey appear on radiographs. Bone imaging may also be
perf ormed t o evaluat e pat ient s w it h unexplained bone pain, primary bone t umors,
art hrit is, ost eomyelit is, abnormal healing of f ract ures, f ract ures, shin splint s, or
compression f ract ures of t he vert ebral column; t o evaluat e pediat ric pat ient s
w it h hip pain (Legg-Calv-Pert hes disease); and t o assess child abuse, bone
grow t h plat es, sport s injuries, and st ress f ract ures. I t is also perf ormed t o
det ermine t he age and met abolic act ivit y of t raumat ic injuries and inf ect ions.
O t her indicat ions are evaluat ion of candidat es f or knee and hip prost heses,
diagnosis of asept ic necrosis and vascularit y of t he f emoral head, presurgical
and post surgical assessment of viable bone t issue, and evaluat ion of prost het ic
joint s and int ernal f ixat ion devices t o rule out loosening of prost hesis or
inf ect ion.
Bone imaging has great er sensit ivit y in t he pediat ric pat ient t han in t he adult and
is used f or early det ect ion of t rauma. Normally, t here is increased act ivit y in t he
grow t h plat es of t he long bones. The child's hist ory is signif icant f or correlat ion
and diagnost ic diff erent iat ion. I n older children w it h unexplained pain, w ho
part icipat e in sport s, st ress f ract ures are of t en f ound on bone imaging.
A bone-seeking radiopharmaceut ical is used t o image t he skelet al syst em. An
example is 99m Tc-labeled phosphat e inject ed int ravenously. I maging usually
begins 2 t o 3 hours af t er inject ion.
Abnormal pat hology, such as increased blood f low t o bone or increased
ost eocyt ic act ivit y, concent rat es t he radiopharmaceut ical at a higher or low er
rat e t han t he normal bone does. The radiopharmaceut ical mimics calcium
physiologically; t heref ore, it concent rat es more heavily in areas of increased
met abolic act ivit y.
Reference Values
Normal
Homogenous dist ribut ion of radiopharmaceut ical
Procedure
1. I nject radioact ive 99m Tc met hylenediphosphonat e (MDP) int ravenously.
2. Be aw are t hat a 2- t o 3-hour w ait ing period is necessary f or t he

radiopharmaceut ical t o concent rat e in t he bone. During t his t ime, t he pat ient
may be asked t o drink 4 t o 6 glasses of w at er.
3. Bef ore t he imaging begins, ask t he pat ient t o void because a f ull bladder
masks t he pelvic bones.
4. Remember t hat imaging t akes about 30 t o 60 minut es t o complet e. The
pat ient must be able t o lie st ill during t he imaging.
5. Be aw are t hat addit ional spot view s of a specif ic area or 3-dimensional
SPECT imaging may be request ed by t he physician.
Clin ical Alert

For ost eomyelit is, images are acquired during t he inject ion of t he
radiopharmaceut ical, t hus giving t he image of t he blood f low t o t he bone.
Abnormal concent rat ions indicat e t he f ollow ing:
1. Very early bone disease and healing is det ect ed by nuclear medicine bone
images long bef ore it is visible on radiographs. Radiographs are posit ive f or
bone lesions only af t er 30% t o 50% decalcif icat ion (decrease in bone
calcium) has occurred.
2. Many disorders can be det ect ed but not diff erent iat ed by t his t est (eg,
cancer, art hrit is, benign bone t umors, f ract ures, ost eomyelit is, Paget 's
disease, asept ic necrosis). The f indings must be int erpret ed in light of t he
w hole clinical pict ure because any process inducing an increased calcium
excret ion rat e w ill be ref lect ed by an increased upt ake in t he bone.
3. I n pat ient s w it h breast cancer, t he likelihood of a posit ive bone image f inding
in t he preoperat ive period depends on t he st aging of t he disease, and
imaging t est s are recommended bef ore init ial t herapy. Stages 1 and 2: 40%
have a posit ive bone image. Stage 3: 19% have a posit ive bone image.
Yearly nuclear medicine bone imaging should be done f or f ollow -up.
4. Mult iple myeloma is t he only t umor t hat show s bet t er det ect abilit y w it h a
plain radiograph t han a radionuclide bone procedure.
5. Mult iple f ocal areas of increased act ivit y in t he axial skelet on are commonly
associat ed w it h met ast at ic bone disease. The report ed percent age of
solit ary lesions due t o met ast asis varies on a sit e-by-sit e basis. Wit h a
single lesion in t he spine or pelvis, t he cause is more likely t o be met ast at ic
disease t han w it h a single lesion occurring in t he ext remit ies or ribs.
Clin ical Alert

The f lare phenomenon occurs in pat ient s w it h met ast at ic disease w ho are
receiving a new t reat ment . The bone imaging may show increased act ivit y or
new lesions in pat ient s w it h clinical improvement . This is caused by a healing
response in pat ient s w it h prost at e or breast cancer w it hin t he f irst f ew mont hs
of st art ing a new t reat ment . These lesions should show marked improvement
on imagings t aken 3 t o 4 mont hs lat er.
2. Radiographic correlat ion is necessary t o rule out a benign process w hen
solit ary areas of increased or decreased upt ake occur.
Interfering Factors
1. False-negat ive bone images occur in mult iple myeloma of t he bone. When
t his condit ion is know n or suspect ed, t he bone image is an unreliable
indicat or of skelet al involvement .
2. Pat ient s w it h f ollicular t hyroid cancer may harbor met ast at ic bone marrow
disease, but t hese lesions are of t en missed by bone scans.
Interventions
1. I nst ruct t he pat ient about t he purpose and procedure of t he t est . Alleviat e
any f ears concerning t he procedure. Advise t he pat ient t hat f requent drinking
of f luids and act ivit y during t he f irst 6 hours help t o reduce excess radiat ion
t o t he bladder and gonads.
2. Remember t hat t he pat ient can be up and about during t he w ait ing period.
There are no rest rict ions during t he day bef ore imaging.
3. Remind t he pat ient t o void bef ore t he imaging. I f t he pat ient is in pain or
debilit at ed, off er assist ance t o t he rest room.
4. O rder and administ er a sedat ive t o any pat ient w ho w ill have diff icult y lying
quiet ly during t he imaging period.
5. Ref er t o st andard nuclear scan pretest precaut ions on page 655. See
Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest care .

1. Advise t he pat ient t o empt y t he bladder w hen imaging is complet ed, t o
decrease radiat ion exposure t ime.
Bone Mineral Density (Bone Densitometry;

Osteoporosis Imaging) Bone densitometry enables the
clinician to obtain a diagnosis of osteoporosis or
osteopenia, often before fractures occur, by measuring
bone mineral density. No radiopharmaceuticals are
used in this procedure, but special imaging techniques
are used. X-ray absorptiometry for measuring bone
mineral density includes these special modalities:
1. Dual-energy absorpt iomet ry (DEXA or DXA) t o measure spine, hip, and
f orearm densit y
2. Peripheral dual-energy absorpt iomet ry (pDXA) t o measure f orearm densit y
3. Single-energy x-ray absorpt iomet ry (SXA) t o measure t he heel and f orearm
densit y
4. Radiographic absorpt iomet ry (RA) t o measure t he densit y of t he phalanges
DEXA is t he most common and pref erred met hod of measuring bone mineral
densit y because of it s precision and low radiat ion exposure. Wit h t he use of
laser x-ray imaging and specif ic comput er sof t w are, DEXA can assess f ract ure
risk w it h relat ive ease and pat ient comf ort . Fract ure risk is measured in st andard
deviat ions (SDs) by comparing t he pat ient 's bone mass t o t hat of healt hy 25- t o
35-year-old persons. Test scores are print ed out and report ed w it h a T-score
and a Z-score. The T-score is t he number of SDs f or t he pat ient compared w it h
normal young adult s w it h mean peak bone mass. Fract ure risk increases about
1. 5 t o 2. 5 t imes f or every SD. According t o t he World Healt h O rganizat ion, Tscores of less t han 2. 5 may conf irm a diagnosis of ost eoporosis; scores of 2. 5
t o 1. 0 are associat ed w it h ost eopenia; and scores of 1. 0 or great er are
considered normal. The Z-score is def ined as t he number of SDs f or t he pat ient
compared w it h normal persons in t he same age cat egory. The T-score is t he

score most commonly report ed and current ly is t he pref erred ref erence point f or
diagnosing ost eoporosis.
Reference Values
Normal
Absence of ost eoporosis or ost eopenia T-score: <1. 0 SD below normal (>-1. 0)
O st eopenia 1. 0 t o 2. 5 SD below normal (-1. 0 t o -2. 5) O st eoporosis >2. 5 SD
below normal (<-2. 5)
Procedure
1. Posit ion t he pat ient in such a w ay as t o keep t he area being imaged
immobile.
2. Place a f oam block under bot h knees during t he spine imaging. Use a leg
brace immobilizer during t he f emur imaging, and use an arm brace w hen
imaging t he f orearm.
3. Be aw are t hat DEXA images of t he spine and hip t ake approximat ely 20
minut es t o complet e. An addit ional 15 minut es is needed t o image t he
f orearm.
Abnormal imagings may be associat ed w it h t he f ollow ing:
1. Est rogen def iciency in post menopausal w omen
2. Vert ebral abnormalit ies
3. Pat ient s w it h radiographic ost eopenia
4. Hyperparat hyroidism
5. Pat ient s receiving long-t erm cort icost eroid t herapy
Interfering Factors
False readings may occur w it h t he f ollow ing:
1. Nuclear medicine imagings w it hin t he previous 72 hours (longer f or gallium or
indium imagings) may cause residual emission t hat can be misint erpret ed.
2. Barium st udies w it hin t he previous 7 t o 10 days may int erf ere w it h t he spine
imaging.
3. Prost het ic devices or met allic object s surgically implant ed in areas of
int erest may int erf ere w it h t he image.
Interventions
1. Explain t he purpose and procedure f or measuring bone densit y of spine, hip,
f orearm, heel, and phalanges. No radiopharmaceut icals are administ ered.
2. Encourage pat ient s t o w ear cot t on garment s t hat are f ree of met al or plast ic
zippers or but t ons.

1. I nt erpret abnormal t est out come. I f needed, serial st udies may be ordered t o
measure t he eff ect iveness of t reat ment .
Clin ical Alert

1. Bone densit omet ry t est s use x-rays: t he precaut ions out lined in Chapt er
10 should be not ed.
2. Addit ional means, of measuring bone mineral densit y arcs
a. Q uant it at ive comput ed t omography (Q CT) t o measure spine densit y
b. Peripheral quant it at ive comput ed t omography (pQ C) t o measure
f orearm densit y
TUM OR IM AGING STUDIES

Gallium (67 Ga) Imaging This image is used to detect the
presence, location, and size of lymphoma, to detect
chronic infections and abscesses, to differentiate
malignant from benign lesions, and to determine the
extent of invasion of known malignancies. The entire
body is imaged looking for lymph node involvement. In
both adult and pediatric patients, these studies are
used to help stage bronchogenic cancer, Hodgkin's
lymphomas, and non-Hodgkin's lymphomas. Gallium
imagings may also be used to record tumor regression
after radiation or chemotherapy. The radionuclide used
in this study is gallium citrate (67 Ga).
The underlying mechanism f or t he upt ake of 67 G a is not w ell underst ood. Upt ake
in some neoplasms may depend on t he presence of t ransf errin recept ors in
t umor cells, but t his is only speculat ion. O nce gallium ent ers a t issue, it remains
t here unt il radioact ive decay dissipat es t he isot ope.
Reference Values
Normal
No evidence of t umor-t ype act ivit y or inf ect ion
Procedure
1. G ive a laxat ive t he evening bef ore t he imaging.
2. Be aw are t hat laxat ives, supposit ories, and/ or t ap w at er enemas are of t en
ordered bef ore imaging. The pat ient may eat breakf ast on t he day of
imaging.
3. I nject t he radionuclide 24 t o 96 hours bef ore imaging.
4. Have t he pat ient lie quiet ly w it hout moving during t he imaging procedure.
Take ant erior and post erior view s of t he ent ire body.
5. Remember t hat addit ional imaging may be done at 24-hour int ervals t o
diff erent iat e normal bow el act ivit y f rom pat hologic concent rat ions.
1. Abnormal gallium concent rat ion usually implies t he exist ence of underlying
pat hology:
a. Malignancy, especially lung, t est es, and mesot helioma
b. St ages of lymphoma, Hodgkin's disease, melanoma, hepat oma, sof t
t issue sarcoma, primary t umor of bone or cart ilage, neuroblast oma, and
leukemia
c. Abscesses
d. Tuberculosis
e. Thrombosis
f. Abscessed sarcoidosis
g. Chronic inf ect ion
h. I nt erst it ial pulmonary f ibrosis
2. Furt her diagnost ic st udies usually are perf ormed t o dist inguish benign f rom
malignant lesions.
3. Tumor upt ake of 67 G a varies w it h t umor t ype, among persons w it h t umors of
t he same hist ologic t ype, and even among t umor sit es of a given pat ient .
4. Tumor upt ake of 67 G a may be signif icant ly reduced af t er eff ect ive t reat ment .
5. Alt hough 111 I n-labeled leukocyt e imaging is more specif ic f or acut e abscess
localizat ion, gallium imaging may be used as a mult ipurpose screening
procedure f or chronic inf ect ion.
Interfering Factors
1. A negat ive st udy cannot be def init ely int erpret ed as ruling out t he presence
of disease. (The rat e of f alse-negat ive result s in gallium st udies is 40%. )
2. I t is diff icult t o det ect a single, solit ary nodule (eg, adenocarcinoma).
Lesions smaller t han 2 cm can be det ect able. Tumors near t he liver are
diff icult t o det ect , and int erpret at ion of iliac nodes is diff icult .
3. Because gallium does collect in t he bow el, t here may be an abnormal
concent rat ion in t he low er abdomen. For t his reason, laxat ives and enemas
may be ordered.
4. Degenerat ion or necrosis of t umor and use of ant ineoplast ic drugs
immediat ely bef ore imaging cause f alse-negat ive result s.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he gallium imaging.
2. Remember t hat usually, no change in eat ing habit s is required bef ore t est ing.
How ever, some depart ment s request t hat t heir pat ient s eat a low -residue
lunch and a clear-liquid supper t he day bef ore t he examinat ion.
3. See st andard nuclear scan pretest precaut ions on page 655.
4. Be aw are t hat t he usual preparat ion includes oral laxat ives t aken on t he night
bef ore t he f irst imaging session and again on t he night bef ore each imaging
session. Enemas or supposit ories may also be given. These preparat ions
clean normal gallium act ivit y f rom t he bow el.
5. Be aw are t hat act ual imaging t ime is 45 t o 90 minut es per imaging session.

Clin ical Alert

Breast f eeding should be discont inued f or at least 4 w eeks af t er t est ing.
OVERVIEW OF M ONOCLONAL ANTIBODY TUM OR

IM AGING (ONCOSCINT, PROSTASCINT,
CARCINOEM BRYONIC ANTIGEN, OCTREOTIDE AND
OTHER PEPTIDES) These classes of tumor imaging
have revolutionized the foundation of
radiopharmaceutical production. Like other
radiopharmaceuticals, monoclonal antibodies (M ABs)
and peptides have tw o parts: a radioisotope linked to a

substance specific to a target organ. In the case of
M ABs, that substance is an antibody that has been
cloned and mass produced. Because all the daughter
antibodies are identical, a high yield of very specific
antibodies can be produced.
1. O ncoScint MAB. This w as t he f irst monoclonal ant ibody radiopharmaceut ical
t o be approved by t he U. S. Food and Drug Administ rat ion and mass
market ed. O ncoScint w as approved f or t he det ect ion of ovarian and colon
cancer. O ncoScint is an ant ibody linked t o 111 I n.
2. Prost aScint MAB. Prost aScint is a monoclonal ant ibody approved f or t he
det ect ion of lymph node met ast asis f rom prost at e cancer.
3. Carcinoembryonic ant igen (CEA) MAB. This monoclonal ant ibody is similar t o
O ncoScint in t hat an ant ibody t o CEA is used. The radioisot ope, how ever, is
99m Tc pert echnet at e. This ant i-CEA ant ibody produces a diff erent pat t ern of
biodist ribut ion t han O ncoScint does. Each radiopharmaceut ical has it s ow n
indicat ions.
4. O ct reot ide-pept ide. This radiopharmaceut ical pept ide is used f or localizing
neuroendocrine t umors.
Antibody and Peptide Tumor Imagings Antibody and

peptide tumor imaging is used to detect the location
and size of known extrahepatic malignancies. These
procedures are not screening techniques.
Reference Values
Normal
Dist ribut ion occurs in t he normal liver, spleen, bone marrow, and bow el.
Procedure
1. I nject t he pat ient w it h t he radioisot ope over a period of 5 minut es. O bserve
t he pat ient f or any react ion t o t he radiopharmaceut ical.
2. Remember t hat opt imal w hole-body images are obt ained bet w een 2 and 4
days af t er inject ion; addit ional images may be obt ained at 24 hours and at 5
days.
3. Perf orm SPECT imaging if necessary.
1. Abnormal dist ribut ions are f ound in t umors. Any change in t he dist ribut ion
provides inf ormat ion regarding t he eff ect iveness of surgery or t herapy.
2. Abnormal result s have been observed in nonspecif ic areas such as
inf lammat ory bow el disease, colost omy sit es, and post operat ive bow el
adhesions.
3. The pat ient 's medical hist ory should be review ed caref ully.
Interfering Factors
Radioact ivit y in t he bow el may int erf ere w it h colorect al assessment . Follow -up
imaging is usef ul af t er administ rat ion of a cat hart ic t o clarif y equivocal f indings.
Interventions
3. Est ablish an int ravenous line bef ore inject ing t he radiopharmaceut ical.
4. Be aw are t hat a cat hart ic is required t o diff erent iat e bow el act ivit y f rom
abnormal pat hology.

3. O bserve t he pat ient f or 1 hour af t er inject ion of O ncoScint f or ant ibody
react ions (eg, chills, f ever, nausea).
4. Realize t hat some pat ient s develop human ant imouse ant ibody (HAMA) t it ers
af t er O ncoScint inject ion.

Clin ical Alert

Follow ing O ncoScint imaging, HAMA t it ers may result in f alsely elevat ed
immunoassay levels f or CA-125 and CEA.
Iodine-131 Whole-Body (Total-Body) Imaging Wholebody imaging using 131 I can identify functioning thyroid
tissue throughout the body. It is useful to determine the
presence of metastatic thyroid cancer and the amount
and location of residual tissue after thyroidectomy. The
procedure is routinely performed in conjunction with
thyroid therapy using 131 I for thyrocarcinoma.
Reference Values
Normal
No f unct ioning ext rat hyroid t issues out side of t he t hyroid gland
Procedure
1. Administ er radionuclide orally in a capsule f orm.
2. Perf orm imaging 24 t o 72 hours af t er administ rat ion of t he
radiopharmaceut ical. I maging may t ake as long as 2 hours t o perf orm.
3. Remember t hat somet imes, t hyrot ropin (t hyroid-st imulat ing hormone, or TSH)
is administ ered int ravenously bef ore t he radionuclide is given. This st imulat es
any residual t hyroid t issue and enhances 131 I upt ake.
Abnormal upt ake of iodine reveals:
1. Areas of ext rat hyroid t issue such as:
a. St roma ovarii
b. Subst ernal t hyroid

c. Sublingual t hyroid
2. Residual t issue af t er t hyroidect omy
3. Met ast at ic t hyroid cancer
Clin ical Alert

1. I f possible, t his t est should be perf ormed bef ore any ot her radionuclide
procedures and bef ore use of ant iiodine cont rast medium, surgical
preparat ion, or ot her f orm of iodine.
2. The t est is most eff ect ive w hen endogenous TSH levels are high, so as t o
st imulat e radionuclide upt ake by met ast at ic neoplasms.
Interventions
2. Advise t he pat ient t hat t he imaging process may t ake several hours. I f iodine
allergies are suspect ed, observe t he pat ient f or possible react ions.
3. Ref er t o st andard nuclear scan, pretest precaut ions on page 655.

Breast Imaging (Scintimammography); Lymph Node

Imaging (Lymphoscintigraphy) Although x-ray
mammography is the preferred examination for routine
breast screening, scintimammography is often used in
cases of indeterminate mammography. Other

indications for performing breast imaging include
follow-up to surgery, biopsy, radiation therapy, or
chemotherapy. The radiopharmaceutical used for
scintimammography is 99m Tc miraluma. The test is more
specific than x-ray mammography and may differentiate
between benign and malignant lesions. The test is also
used to detect any axillary lymph node involvement
from breast cancer and decreases the number of
unnecessary breast biopsies. Sentinel and satellite
node identification and staging in early breast cancer
using lymphoscintigraphy and intraoperative gamma
node and tissue biopsy show micrometastasis more
frequently than standard dissection.
Lymphoscintigraphy assesses the lymphatic drainage
of tumors.
Reference Values
Normal Breast
Unif orm dist ribut ion of radiopharmaceut ical upt ake in t he breast s w it hout f ocal
point s of concent rat ion No f ocal upt ake in lymphat ic t issue
Normal Lymph Node

No abnormal nodes (indicat ed by obst ruct ion t o t racer).
(The f irst node t he t racer goes t o is ident if ied. )
Procedure for Breast Imaging

1. I nject t he radiopharmaceut ical int ravenously in t he opposit e arm f rom t he
breast of concern.
2. Have t he pat ient lie prone on a special t able w it h a cut out sect ion t hat
allow s t he breast s t o hang t hrough t he t able unobst ruct ed.
3. Place t he pat ient in t he supine posit ion w it h t he arms raised f or obt aining
images of t he axillary lymph nodes.
4. Be aw are t hat t he t ot al pat ient t ime is approximat ely 45 t o 60 minut es. The
act ual scan t ime is 25 t o 30 minut es.
5. For sent inel node ident if icat ion, see Chapt er 11 f or a complet e discussion of
t he procedure.
6. Remember t hat an opt ional SPECT examinat ion may be request ed by t he
nuclear medicine physician. This examinat ion may t ake an addit ional 30 t o 40
minut es.
Procedure for Lymph Node Imaging

1. Special posit ioning is required. (See sent inel node evaluat ion in Chapt er 11. )
2. The t racer is inject ed by int radermal met hod f or melanoma evaluat ion or
subcut aneously f or breast cancer evaluat ion. Massage af t er inject ion f or at
least 30 seconds, moving t he breast t o opt imally clear t he overlying sof t
t issue.
3. I mages are obt ained immediat ely and 24 hours af t er inject ion.
4. Sent inel lymph node ident if icat ion may also be perf ormed t o evaluat e
met ast at ic spread of cancer t o penis, vulva, ut erus, head, and neck.
Clinical Implications of Breast Imaging

1. Abnormal increased f ocal upt ake is f ound in cases of a f ibroadenoma and
adenocarcinoma.
2. Nonunif orm increased diff use upt ake of act ivit y is associat ed w it h f ibrous
dysplasia, w hich may be unilat eral or bilat eral.
3. Several areas of increased f ocal upt ake are of t en seen in cases of mult if ocal
breast cancer.
4. I n pat ient s w it h a breast prost hesis, a f ocal decrease in act ivit y is observed
in relat ion t o t he size and shape of t he prost hesis.
5. Axillary met ast asis is det ect ed as f ocal areas of increased upt ake in t he
axillary nodes.
6. This scan is used t o evaluat e radiat ion t herapy and chemot herapy.
Clinical Implications of Lymph Node Imaging
1. Abnormal nodes show leaks int o adjacent t issue, a blush around t he aff ect ed
node, and unusual collat eral lymph drainage pat hw ays.
2. The f irst lymph node t o drain t he t umor invariably cont ains t he t umor.
3. I t has been f ound t hat t here are more t han one lymphat ic channels draining
t he t umor, and t hat t here are one, t w o, or t hree sent inel lymph nodes (SLNs)
as w ell as sat ellit e nodes.
4. Micromet ast asis of biopsied t issue is f ound more f requent ly t han st andard
axillary node dissect ion.
Interfering Factors
1. There should not be any ot her det ect able amount of radioact ivit y in t he
pat ient .
2. The pat ient should be lying supine f or t he inject ion of t he
radiopharmaceut ical (f or breast imaging) t o prevent a st reaking art if act
f ound on t he result ing image in t he breast region, w hich corresponds t o t he
arm t hat received t he inject ion.
3. To eliminat e a f alse-posit ive appearance, t he pat ient should be inject ed on
t he side opposit e of a know n lymphat ic lesion. I f t he pat ient is know n t o have
bilat eral breast cancer, a f oot vein may be used f or inject ion.
4. Ext ravasat ion of t he radiopharmaceut ical can result in hot spot s of
radioact ivit y in t he locat ion of t he axillary lymph nodes.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he nuclear scan. See
Chapt er 11 f or more inf ormat ion on sent inel node biopsy.
2. Have t he pat ient remove all clot hing and jew elry f rom t he w aist up. The
pat ient w ears a hospit al gow n w it h t he opening of t he gow n in t he f ront .
There are no diet ary or medicat ion rest rict ions. For lymph node imaging,
posit ion pat ient as she w ould be placed f or surgical int ervent ion.
4. See st andard nuclear scan pretest precaut ions on page 655.

1. I nt erpret t est out come, monit or, and counsel appropriat ely about need f or
f urt her t est s (eg, biopsy and possible immediat e surgery).
INFLAM M ATORY PROCESS IM AGING

Leukocyte (WBC) Imaging (Indium- or Ceretec-Labeled
WBCs) The leukocyte imaging test, in which a sample
of the patient's own white blood cells (WBCs) are
isolated, labeled with indium oxine (111 In) or 99m Tc
exametazime, and reinjected, is used for localization of
acute abscess formation. The study is indicated in both
adults and children with signs and symptoms of a
septic process, fever of unknown origin, osteomyelitis,
or suspected intraabdominal abscess. It is also helpful
in determining the cause of complications of surgery,
injury, or inflammation of the gastrointestinal tract and
pelvis. The test results are based on the fact that any
collection of labeled WBCs outside the liver, spleen,
and functioning bone marrow indicates an abnormal
area to which the cells localize. This procedure is 90%
sensitive and 90% specific for acute inflammatory
disease or acute abscess formation.
Reference Values
Normal
Normal leukocyt e concent rat ion and radiopharmaceut ical dist ribut ion in liver,
spleen, and bone marrow No signs of leukocyt e localizat ion out side of t he
ret iculoendot helial syst em
Procedure
1. O bt ain a venous blood sample of 60 mL f or t he purpose of isolat ing and
labeling t he WBCs. The laborat ory process t akes about 2 hours t o complet e.
The pat ient 's WBC count needs t o be at least 4. 0 so t hat t here are enough
cells t o label f or t his procedure.
2. Label t he WBCs w it h radioact ive 111 I n, oxine, or 99m Tc examet azime and
inject int ravenously.
3. Have t he pat ient ret urn f or imaging af t er 4 hours w it h Ceret ec and af t er 24

or 48 hours w it h indium.
4. Be aw are t hat imaging t ime is about 1 hour each session.
Abnormal concent rat ions indicat e:
1. Acut e abscess f ormat ion
2. Acut e ost eomyelit is and inf ect ion of ort hopedic prost heses
3. Act ive inf lammat ory bow el disease
4. Post surgical abscess sit es and w ound inf ect ions
Interfering Factors
1. False-negat ive react ions are know n t o occur w hen t he chemot act ic f unct ion
of t he WBC has been alt ered, as in hemodialysis, hyperglycemia,
hyperaliment at ion, st eroid t herapy, and long-t erm ant ibiot ic t herapy.
2. G allium scans up t o 1 mont h bef ore t he t est can int erf ere.
3. False-posit ive scans occur in t he presence of gast roint est inal bleeding and in
upper respirat ory inf ect ions and pneumonit is w hen pat ient s sw allow purulent
sput um.
NOTE
See Clinical Considerat ions, Pret est Pat ient Care, and Post t est Pat ient
Af t ercare f or nuclear scans on pages 654655.
Clin ical Alert

I f t he pat ient does not have an adequat e number of WBCs, addit ional blood
may have t o be draw n. G allium imaging may be necessary if t oo f ew WBCs
are present , or donor cells can be used.
Part 2 Radionuclide Laboratory Procedures

(Nonradioimmunoassay Studies)
OVERVIEW OF LABORATORY
PROCEDURES
Very small amount s of radioact ive subst ances may be administ ered t o pat ient s,
and subsequent ly t heir body f luids and glands may be examined in t he laborat ory
f or concent rat ions of radioact ivit y. Minut e quant it ies of radioact ive mat erials may
be det ect ed in blood, f eces, urine, ot her body f luids, and glands.
Some procedures (eg, Schilling t est ) check t he abilit y of t he body t o absorb t he
administ ered radioact ive compound. O t hers, such as blood volume
det erminat ions, t est t he abilit y of t he body t o localize or dilut e t he administ ered
radioact ive subst ance.
Part 2 of t his chapt er includes a sampling of t est s t hat employ t he use of
radionuclides in t he st udy of disease. I maging may or may not be required as
part of t hese procedures, w hich are all a f orm of t racer chemist ry.
Schilling Test
The Schilling t est is a 24-hour urine t est t hat is used t o diagnose pernicious
anemia (one f orm of macrocyt ic anemia) and malabsorpt ion syndromes. I t is an
indirect t est of int rinsic f act or def iciency. This t est evaluat es t he body's abilit y t o
absorb vit amin B1 2 f rom t he gast roint est inal
t ract and is based on t he ant icipat ed urinary excret ion of radioact ive vit amin B1 2 .
The procedure may be done in t w o st ages: stage I, w it hout int rinsic f act or; and
stage II, w it h int rinsic f act or. The second st age is perf ormed only w hen an
abnormal f irst st age occurs.
I n st age I , t he f ast ing pat ient is given an oral dose of vit amin B1 2 t agged w it h
radioact ive cobalt (5 7 Co). An int ramuscular inject ion of vit amin B1 2 is given t o
sat urat e t he liver and serum prot ein-binding sit es, w hich allow s radioact ive
vit amin B1 2 t o be excret ed in t he urine. A 24-hour urine specimen is t hen
collect ed.
The amount of t he excret ed radioact ive B1 2 is det ermined and expressed as a
percent age of t he given dose. Normal persons absorb (and t heref ore excret e) as
much as 25% of t he radioact ive B1 2 . Pat ient s w it h pernicious anemia absorb lit t le
of t he oral dose and t heref ore excret e lit t le radioact ive mat erial in t he urine.
Reference Values
Normal
Excret ion of 10% or more of t he dose of cobalt -t agged vit amin B1 2 in t he urine
w it hin 24 hours Normal values assume near-normal kidney f unct ion
Procedure
1. Have t he pat ient f ast f or 12 hours bef ore t he t est . (Fast ing is cont inued f or 3
hours af t er t he vit amin B1 2 doses have been administ ered. )
2. Administ er a t ast eless capsule of radioact ive B1 2 labeled w it h 5 7 Co orally by
a nuclear medicine t echnologist .
3. Have a regist ered nurse or nuclear medicine t echnologist inject
nonradioact ive B1 2 int ramuscularly. This is done 2 hours lat er.
4. Collect a small sample of urine bef ore t he st udy begins. The pat ient also
voids just bef ore inject ion w it h nonradioact ive B1 2 (called a f lushing dose).
Collect all urine f or 24 or 48 hours af t er t he t ime t he pat ient receives t he
inject ion of vit amin B1 2 .
a. O bt ain a special 24-hour urine cont ainer f rom t he laborat ory. No
preservat ive is required.
b. Ensure t hat t here is no cont aminat ion of t he urine w it h st ool.
c. Cont inue collect ing t he urine f or 24 hours (see Chapt er 3).
d. I n t he presence of renal disease, a 48-hour urine collect ion may be
necessary.
1. An abnormally low value (eg, <5%) or borderline (5. 0%9. 9%) allow s t w o
int erpret at ions:
a. Absence of int rinsic f act or
b. Def ect ive absorpt ion in t he ileum
2. When t he absorpt ion of radioact ive vit amin B1 2 is low f rom t he f irst st age,
t he t est must be repeat ed w it h int rinsic f act or (st age I I ) t o rule out int est inal
malabsorpt ion (conf irmat ory Schilling t est ).
a. I f urinary excret ion t hen rises t o normal levels, it indicat es a lack of
int rinsic f act or, suggest ing t he diagnosis of pernicious anemia.
b. I f t he urinary excret ion does not rise, malabsorpt ion is considered t o be
t he cause of t he pat ient 's anemia.
NOTE
A dual -radi onucl i de test i s an al ternati ve method i n whi ch both stages are
perf ormed at the same ti me.
Interfering Factors
1. Renal insuff iciency may cause reduced excret ion of radioact ive vit amin B1 2 . I f
renal insuff iciency is suspect ed, a 48- t o 72-hour urine collect ion is advised
because event ually almost all of t he absorbed mat erial w ill be excret ed, and
urine specif ic gravit y and volume are checked.
2. The pat ient should not undergo diagnost ic procedures t hat int erf ere w it h B1 2
absorpt ion.
3. The single most common source of error in perf orming t he t est i s i ncompl ete
col l ecti on of uri ne. Some laborat ories may require a 48-hour collect ion t o
allow f or a small margin of error.
4. Urinary excret ion of B1 2 is depressed in elderly pat ient s, diabet ic pat ient s,
pat ient s w it h hypot hyroidism, and pat ient s w it h ent erit is.
5. Fecal cont aminat ion in t he urine leads t o f alse result s and invalidat es t he
t est .
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he t est .
2. Ref er t o general procedures, descript ion of benef it s, risks, clinical
considerat ions, and st andard nuclear scan pretest precaut ions on page 655.
3. O bt ain a random urine sample bef ore t he vit amin B1 2 doses are administ ered.
4. G ive a w rit t en reminder t o t he pat ient about f ast ing and collect ion of a 24hour urine specimen. Wat er is permit t ed during t he f ast ing period.
5. Permit f ood and drink 3 hours af t er t he doses of vit amin B1 2 are given.
Encourage t he pat ient t o drink as much as can be t olerat ed during t he ent ire
t est .
6. Be cert ain t he pat ient receives t he nonradioact ive B1 2 . I f t he int ramuscular
dose of vit amin B1 2 is not given, t he radioact ive vit amin B1 2 w ill be f ound in
t he liver inst ead of t he urine.

Clin ical Alert

1. No laxat ives are t o be used during t he t est .
2. Bone marrow aspirat ion should be done bef ore t he Schilling t est because
t he vit amin B1 2 administ ered in t he t est dest roys t he diagnost ic
charact erist ics of t he bone marrow.

1. Assess f or compliance w it h 24-hour urine collect ion prot ocols (see Chapt er
3).
Total Blood Volume; Plasma Volume; Erythrocyte (RBC)

Volume The purposes of the blood volume test are to
determine circulating blood volume, to help evaluate
the bleeding or debilitated patient, and to determine the
origin of hypotension in the presence of anuria or
oliguria w hen dehydration may be the cause. This
determination is one w ay to monitor blood loss during
surgery; it is used as a guide in replacement therapy
after blood or body fluid loss and in the determination
of w hole-body hematocrit. The results are useful in
choosing the most appropriate blood component for
replacement therapy (w hole blood, plasma, or packed
RBCs).
Tot al blood volume det erminat ions are of value in t he f ollow ing sit uat ions:
1. To evaluat e gast roint est inal and ut erine bleeding
2. To aid in t he diagnosis of hypovolemic shock

3. To aid in t he diagnosis of polycyt hemia vera
4. To det ermine t he required blood component f or replacement t herapy, as in
persons undergoing surgery
These t est s reveal an increased or decreased volume of RBC mass. A sample of
t he pat ient 's blood is mixed w it h a radioact ive subst ance, incubat ed at room
t emperat ure, and reinject ed. Anot her blood sample is obt ained 15 minut es lat er.
The most commonly used t racers in blood
volume det erminat ions are serum albumin t agged w it h 1 3 1 I or 1 2 5 I and pat ient or
donor RBCs t agged w it h chromium-51 (5 1 Cr). The combinat ion of procedures
(t ot al blood volume) is t he only t rue blood volume. O t her volume st udies are
plasma volume and RBC volume, w hich may be done separat ely.
The plasma volume is used t o est ablish a vascular baseline, t o det ermine
changes in plasma volume bef ore and af t er surgery, and t o evaluat e f luid and
blood replacement in pat ient s w it h gast roint est inal bleeding, burns, or t rauma.
The 5 1 Cr RBC volume st udy is done t o see w hat percent age of t he circulat ing
blood is composed of RBCs. This procedure is perf ormed in connect ion w it h
evaluat ion of RBC survival or gast roint est inal blood loss and in f errokinet ic
st udies. These t est s can be done simult aneously.
Reference Values
Normal
Tot al blood volume: 5580 mL/ kg or 0. 0550. 080 L/ kg Eryt hrocyt e volume: 20
35 mL/ kg or 0. 0200. 035 L/ kg (great er in men t han in w omen) Plasma volume:
3045 mL/ kg or 0. 0300. 045 L/ kg
NOTE
Because adi pose ti ssue has a sparser bl ood suppl y than l ean ti ssue, the
pati ent's body type can af f ect the proporti on of bl ood vol ume to body wei ght; f or
thi s reason, test f i ndi ngs shoul d al ways be reported i n mi l l i l i ters per ki l ogram
of body wei ght.
Procedure
1. Record t he pat ient 's height and current w eight .
2. O bt ain venous blood samples, and mix one blood sample w it h a radionuclide.
3. Fif t een t o 30 minut es lat er, reinject t he blood radiopharmaceut ical.
4. About 15 minut es lat er, obt ain anot her venous blood sample and have it
examined in t he laborat ory.
1. A normal t ot al blood volume w it h a decreased RBC cont ent indicat es t he
need f or a t ransf usion of packed red cells.
2. Polycyt hemia vera may be diff erent iat ed f rom secondary polycyt hemia.
a. I ncreased t ot al blood volume due t o an increased RBC mass suggest s
polycyt hemia vera. The plasma volume most of t en is normal.
b. Normal or decreased t ot al blood volume due t o a decreased plasma
volume suggest s secondary polycyt hemia. The RBC most of t en is normal.
Clin ical Alert

I f int ravenous blood component t herapy is ordered f or t he same day, t he blood
volume det erminat ion should be done bef ore t he int ravenous line is st art ed.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he t est . Blood
samples and int ravenous inject ion are part of t his t est . No imaging or
scanning t akes place.
2. Weigh t he pat ient just bef ore t he t est if possible.


Red Blood Cell (RBC) Survival Time Test The RBC

survival time test has its greatest use in the evaluation
of know n or suspected hemolytic anemia and is also
indicated w hen the cause for anemia is obscure
(abnormal sequestration of RBCs in the spleen), to
identify accessory spleens, and to determine abnormal
RBC production or destruction. A sample of the
patient's erythrocytes is mixed w ith a radioactive
substance (51 Cr), incubated at room temperature, and
reinjected. Blood specimens are draw n after 24 hours
and at regular intervals for at least 3 w eeks. After
counting the specimens, the results are plotted, and
the RBC survival time is calculated. Results are based
on the fact that disappearance of radioactivity from the
circulation corresponds to disappearance of the RBCs,
thereby determining overall erythrocyte survival.
Scanning of t he spleen is of t en done as part of t his t est . The RBC survival t est
usually is ordered in conjunct ion w it h a blood volume det erminat ion and
radionuclide iron upt ake and clearance t est s. When st ool specimens are
collect ed f or 3 days, t he t est is of t en ref erred t o as t he gast roint est inal blood
loss t est .
Reference Values
Normal
Normal half -t ime f or survival of 5 1 Cr-labeled red blood cells is approximat ely 25
t o 35 days.
51
Cr in st ool: <3 mL/ 24 hours
Procedure
1. O bt ain a venous blood sample of 20 mL.
2. Ten t o 30 minut es lat er, reinject t he blood af t er being t agged w it h a
radionuclide, 5 1 Cr.
3. Remember t hat blood samples are usually obt ained on t he f irst day; again
af t er 24, 48, 72, and 96 hours; and t hen at w eekly int ervals f or 3 w eeks.
Time may be short ened depending on t he out come of t he t est . As part of t his
procedure, a radioact ive det ect or may be used over t he spleen, st ernum,
and liver t o assess t he relat ive concent rat ions of radioact ivit y in t hese areas.
This ext ernal count ing helps t o det ermine w het her t he spleen is t aking part in
excessive sequest rat ion of RBCs as a causat ive f act or in anemia.
4. Be aw are t hat in some inst ances, a 72-hour st ool collect ion may be ordered
t o det ect gast roint est inal blood loss. O bt ain special collect ion cont ainers
labeled f or radiat ion hazard. At t he end of each 24-hour collect ion period,
t he t ot al st ool is t o be collect ed by t he depart ment of nuclear medicine. This
t est can be complet ed in 3 days.
1. Short ened RBC survival may result f rom blood loss, hemolysis, or removal of
RBCs by t he spleen, as in:
a. Chronic granulocyt ic leukemia
b. Hemolyt ic anemia
c. Hemoglobin C disease
d. Heredit ary spherocyt osis
e. Pernicious anemia
f. Megaloblast ic anemia of pregnancy
g. Sickle cell anemia
h. Uremia
2. Prolonged RBC survival t ime may result f rom an abnormalit y in RBC

product ion, as in t halassemia minor, and f alse-negat ive result s w hen
t ransf usion is given during t he procedure.
3. I f hemolyt ic anemia is diagnosed, f urt her st udies are needed t o est ablish
w het her t he RBCs have int rinsic abnormalit ies or w het her anemia result s
f rom immunologic eff ect s of t he pat ient 's plasma.
4. Result s are normal in:
a. Hemoglobin C t rait
b. Sickle cell t rait
5. Half of t he radioact ivit y in t he plasma may not disappear f or 7 t o 8 hours.
Interventions
1. Explain t he purpose and procedure of t he t est . Emphasize t hat t his t est
requires a minimum of 2 w eeks of t he pat ient 's t ime, w it h t rips t o t he
diagnost ic f acilit y f or venipunct ures.
2. I f st ool collect ion is required, advise t he pat ient of t he import ance of saving
all st ool and t hat st ool must be f ree of urine cont aminat ion.
Clin ical Alert

1. The t est usually is cont raindicat ed in a pat ient w ho is act ively bleeding.
2. Record and report signs of act ive bleeding.
3. Transf usions should not be given w hile t he t est is in progress. I f it is
necessary t o do so, not if y t he nuclear medicine depart ment t o t erminat e
t he t est .

2. I nt erpret t est out come and monit or appropriat ely. Explain need f or f urt her
t est ing and possible t reat ment (spleenect omy).
Part 3 Positron Emission Tomography
Positron Emission Tomography (PET)

Imaging PET imaging involves the
combined use of positron-emitting
radionuclides and emission CT. PET
technology generates high-resolution
images of body function and metabolism.
PET uses radiopharmaceuticals that are
the basic elements of biologic substances.
In this way, normal and abnormal biologic
function of cells and organs can be
determined. It produces images of
molecular-level physiologic function,
including glucose metabolism, oxygen
utilization, blood flow, and tissue
perfusion. The radiopharmaceutical dose
is injected and emits radioactivity in the
form of positrons, which are detected and
transformed into a visual display by
computer.
A broad spect rum of radiopharmaceut icals is current ly used in PET imaging. A
main advant age of PET derives f rom t he posit ron-emit t ing isot opes t hemselves:
carbon-11 (11 Ca), nit rogen-13 (1 3 N), and oxygen-15 (1 5 O ), w hich are present in
organic molecules, and f luorine-18 (1 8 F), w hich can be subst it ut ed f or hydrogen.

Typically, radionuclides used in PET imaging have very short half -lives (2 minut es
t o 2 hours).
18
F is used f or several purposes. I t s half -lif e is long enough t o t race biochemical

react ions. I t can be used t o label a glucose compound, permit t ing imaging of a
variet y of t issues. 1 8 F is administ ered primarily in a glucose f orm called
f luorodeoxyglucose (FDG ). FDG is highly sensit ive. Neoplast ic cells are
hypermet abolic and appear t o have an FDG aff init y t hat result s in high cont rast .
FDG has great er t han 90% specif icit y f or myocardial viabilit y, neoplast ic
processes, and inf ect ion. FDG is an out st anding t racer t hat can be used in many
areas of t he body. I t is a glucose analogue and has a broad applicat ion because
every cell uses glucose as f uel.
Indications for PET

Clinical PET is a usef ul diagnost ic t ool aiding diagnosis of many disease st at es,
primarily in oncology, neurology, and cardiology. How ever, t he t echnique is
applicable t o all part s of t he body f or diagnosis, disease st aging, and monit oring
of t herapy. Unlike MRI or CT, PET provides physiologic, anat omic, and
biochemical dat a.
Alt hough PET is more sensit ive t han gamma SPECT, it is considerably more
expensive. The use of FDG imaging w it h specially equipped gamma cameras has
been an alt ernat ive t o exclusive PET imaging syst ems. The pat ient preparat ion
f or nuclear medicine use of FDG in gamma SPECT imaging is similar t o t hat f or
PET imaging of FDG . Because of t he physics of 1 8 F, only mult iheaded cameras
can be used f or gamma SPECT acquisit ions. Current ly, t here are cert ain
limit at ions w it h gamma SPECT imaging w hen compared w it h t rue PET imaging.
I n oncology, FDG -PET has proved usef ul in several areas, including t he
diagnosis of pulmonary nodules, t he diff erent iat ion of pancreat ic cancer f rom
mass-f orming pancreat it is, and t he diagnosis of breast cancer in select ed cases
of mammography and biopsy f ailure. PET imaging is used f or t he init ial
preoperat ive st aging of cancer involving t he lung, liver, colon, breast , head, and
neck as w ell as in melanomas and lymphomas. For example, in lung cancer, PET
is usef ul in det ermining t he degree of operabilit y. Wit h ext ensive met ast asis in
t he mediast inum, surgery is cont raindicat ed. St aging, det ect ion of recurrence,
and response t o t herapy also can be det ermined.
I n cardiology, PET has demonst rat ed excellent ut ilit y f or measuring myocardial
blood f low and perf usion and f or det ect ing coronary art ery disease. The highenergy phot ons of PET t racers produce high-qualit y images even in obese
pat ient s. I n t hese cases, PET can provide import ant inf ormat ion f or det ermining
w hich pat ient s w ill benef it f rom t he more invasive procedures.
I n neurology, FDG -PET imaging is a noninvasive aid in predict ing prognosis and
f or surgical planning in epilepsy. By revealing areas of increased and decreased
glucose ut ilizat ion, PET helps surgeons pinpoint t he surgical sit e. PET is being
used t o diagnose a w ide variet y of dement ias, including Alzheimer's disease,
w hich show s a dist inct pat t ern of glucose consumpt ion in t he t emporal and
pariet al regions of t he brain. Also, dist inct brain pat t erns can be seen in t he
involunt ary movement disorders, such as Parkinson's disease, Hunt ingt on's
disease, and Touret t e's syndrome.
Reference Values
Normal
Normal pat t erns of t issue met abolism based on oxygen, glucose, and f at t y acid
ut ilizat ion and prot ein synt hesis Normal blood f low and t issue perf usion
Procedure
1. Remember t hat t he act ual imaging t ime required f or a single scan is 1 t o 2
hours. The act ual t ime involved w it h t he pat ient may be several hours and
occurs bef ore and during radiopharmaceut ical inject ion. Delayed imaging may
produce diff erent result s t han early imaging af t er inject ion (af t er 45 minut es
f or body t umor and 30 minut es f or brain t umor).
2. Posit ion t he pat ient on a t able, t hen w it hin t he scanner. Bef ore administ rat ion
of t he radiopharmaceut ical, perf orm a background t ransmission scan. I n
cert ain procedures, t his preliminary scan is opt ional. A number of posit ions
are assumed, 26 minut es at each posit ion.
3. Administ er t he radioact ive drug int ravenously. The pat ient w ait s 30 t o 45
minut es in t he depart ment , usually remaining on t he t able, and t hen t he area
of int erest is scanned.
4. Be aw are t hat pat ient s undergoing PET procedures f or colon cancer,
suspect ed pelvic pat hology, or kidney st udies may require a urinary cat het er.
5. Remember t hat cardiac pat ient s do not require f ast ing, and glucose
monit oring may be part of t he pat ient preparat ion bef ore t he scan. Elevat ed
glucose result s in decreased FDG upt ake in cancer cells. Hydrat e pat ient
bef ore and af t er FDG inject ion t o minimize bladder upt ake.
6. Combined PET and CT scans result in more sensit ive, improved images.
Interventions
Pat ient preparat ion f or FDG -PET imaging varies among inst it ut ions. How ever,
some generalizat ions can be made.

1. Explain t est purpose and procedure. Fast ing is required f or all t est s (except
cardiac). Somet imes, f ast ing blood glucose levels are obt ained. I f blood
glucose levels are t oo high, insulin may be ordered and administ ered by t he
physician. Caut ion must be t aken if insulin is given because it suppresses
glucose t issue upt ake. I nsulin also suppresses FDG t issue upt ake, w hich
aff ect s t he qualit y of t he result ing scan.
2. Administ er t he FDG radiopharmaceut ical int ravenously. Blood pressure is
monit ored.

1. I nt erpret t est out come and monit or appropriat ely f or side eff ect s.
Brain Imaging
1. Epi l epsy. Focal areas w it h increased met abolism have been seen during
act ual episodes of epilepsy, w it h decreased oxygen ut ilizat ion and blood f low
during int erict al episodes. (PET becomes an alt ernat ive t o dept h elect rode
implant s. )
2. Stroke. An ext remely complex pat hophysiologic pict ure is being revealed,
including anaerobic glycolysis, depressed oxygen ut ilizat ion, and decreased
blood f low.
3. Coronary artery di sease. Excellent images of decreased myocardial blood
f low and perf usion are observed.
4. Dementi a. Decreased glucose consumpt ion (hypomet abolic act ivit y) is
revealed by PET imaging. PET is used t o diff erent iat e Alzheimer's disease
f rom ot her t ypes of dement ia, such as Hunt ingt on's disease and Parkinson's
disease.
5. Schi zophreni a. Some st udies using labeled glucose indicat e reduced
met abolic act ivit y in t he f ront al region. The PET scans can also dist inguish
t he development al st ages of cranial t umors and give inf ormat ion about t he
operabilit y of such t umors.
6. Brai n tumors. Dat a have been collect ed concerning oxygen use and blood
f low relat ions f or t hese t umors. G liomas have relat ively good perf usion
compared w it h t heir decreased oxygen ut ilizat ion. The high upt ake of
radiopharmaceut ical in gliomas is report ed t o correlat e w it h t he t umor's
hist ologic grade.
Interfering Factors
Excessive anxiet y can alt er t he t est result s w hen brain f unct ion is being t est ed.
Tranquilizers cannot be given bef ore t he t est because t hey alt er glucose
met abolism.
Interventions
1. I nst ruct t he pat ient about t he purpose, procedure, and special requirement s
of t he PET scan (see page 700). Ref er t o st andard nuclear scan pretest
precaut ions on page 655.
2. Advise t he pat ient t hat lying as st ill as possible during t he scan is necessary.
How ever, t he, pat ient is not t o f all asleep nor count t o pass t he t ime.
3. Remember t hat during t he scan, it is import ant t o maint ain a quiet
environment .

Cardiac Imaging
1. I n cardiology, PET imaging provides measurement s of blood f low, myocardial

perf usion, and myocardial viabilit y. These measurement s are used t o det ect :
a. Coronary art ery disease, w hich is charact erized by areas of decreased
blood f low, decreased perf usion, or bot h.
b. Transient ischemia (bot h st ress and rest images are perf ormed).
2. A high rat e of glucose consumpt ion is required t o meet t he energy needs of
t he heart . Low glucose met abolism in areas of decreased blood f low
indicat es nonviable myocardial t issue.
Interventions
1. I nst ruct t he pat ient about t he purpose, procedure, and special requirement s
of t he PET scan (see page 700). Ref er t o st andard nuclear scan pretest
precaut ions on page 655.
2. Be aw are t hat an int ravenous line may be necessary. Cardiac pat ient s do not
require f ast ing and may be given glucose as part of pat ient preparat ion.
Smoking and medicat ion rest rict ions may be required bef ore imaging.
Consult w it h t he ref erring physician or t he nuclear imaging depart ment .
3. I t may be necessary t o place ECG leads on t he pat ient .

Tumor Imaging
1. Measurement s of glucose (FDG ) met abolism are used t o det ermine t umor
grow t h. Because small amount s of FDG can be visualized, early t umor
det ect ion is possible bef ore st ruct ural changes det ect able by MRI or CT
occur. Tumor grading can be assessed by t he rat e of increase in glucose

met abolism. I n cases of suspect ed t umor recurrence af t er t herapy, PET
diff erent iat es any new grow t h f rom necrot ic t issue.
2. PET is used t o dist inguish bet w een recurrent , act ive t umor grow t h and
necrot ic masses in sof t t issue; t his diff erent iat ion is diff icult t o make by MRI
or CT.
Interventions
1. Explain t he purpose, procedure, and special requirement s of t he PET scan
(see page 700). Ref er t o st andard nuclear scan pretest precaut ions on page
655.
2. Usually, no special preparat ion is needed. Somet imes, a urinary cat het er
may have t o be insert ed f or colon or kidney t umor det ect ion.

BIBLIOGRAPHY
Alazraki N, St yblo T, G rant s, et al: Sent inel node: St aging of early breast
cancer using lymphoscint igraphy and int raoperat ive gamma det ect ing probe.
Seminars in Nuclear Medicine 30: 5664, 2000
Arnold SE. Cardiac st ress t est ing. Nursing 97 January: 5861, 1997
Baum S, et al. : At las of Nuclear Medicine I maging. New York, Applet on &
Lange, 1993
Bernier DR, Christ ina PE, Langa JK, et al. : Nuclear Medicine Technology and
Techniques, 4t h ed. St Louis, Mosby, 1997
Daw son-Hughes B, et al. : Eff ect of calcium and vit amin D supplement at ion on
bone densit y in men and w omen 65 years of age or older. N Engl J Med
337: 670676, 1997
DePuey EG , G arcia EV, Berman DS: Cardiac SPECT I maging, 2nd ed.
Philadelphia, Lippincot t Williams & Wilkins, 2001
Early PJ, Sodee DB: Principles and Pract ice of Nuclear Medicine, 2nd ed. St
Louis, Mosby, 1995
Frohlich JM, Schubergn AP, von Schult hess G K: Cont rast agent s and
radiopharmaceut icals. I n von Schult hess G K, Hennig J (eds): Funct ional
I maging. Philadelphia, Lippincot t -Raven, 1998
Hudok CM, G allo BM: Q uick review of neurodiagnost ic t est ing. Am J Nurs
97(7): 16CC16FF, 1997
Kirks DR, G riscom NT (eds): Pract ical Pediat ric I maging. 3rd ed.
Kumar D: PET scanning applicat ions f or t reat ing epilepsy. Am J Nut r 98(7):
16G 17G , 1998
O 'Connor MK (ed): The Mayo Clinic Manual of Nuclear Medicine. New York,
Churchill Livingst one, 1996
Put nam CE, Ravin CE: Text book of Diagnost ic I maging, 2nd ed. , vols 1 and 2.
Sandler MP, Coleman RE, Pat t on JA, Wackers FJT, G ot t schalk A: Diagnost ic
Nuclear Medicine, 4t h ed. Philadelphia, Lippincot t Williams & Wilkins, 2003
Taylor A, Schust er D, Alazraki N: A Clinician's G uide t o Nuclear Medicine,
Societ y of Nuclear Medicine, I nc. , Rest on, VA, 2000
Treves ST (ed): Pediat ric Nuclear Medicine, 2nd ed. New York, SpringerVerlag, 1995
von Schult hess G K, Hennig J (eds): Funct ional I maging. Philadelphia,
Lippincot t -Raven, 1998
Wilson MA (ed): Text book of Nuclear Medicine. Philadelphia, Lippincot t Raven, 1998

Wilkins
> Table of C ontents > 10 - X- R ay S tudies
10
X-Ray Studies
OVERVIEW OF X-RAY STUDIES

X-ray st udies, also know n as radi ographs or roentgenograms, are used t o
examine sof t and bony t issues of t he body. X-rays are short -w avelengt h
elect romagnet ic vibrat ions produced w hen f ast -moving elect rons collide w it h
subst ances in t heir pat hw ays. X-rays t ravel in st raight lines at t he speed of light
(186, 000 miles/ second). When an x-ray beam passes t hrough mat t er, some of it s
int ensit y is absorbed; t he more dense t he mat t er, t he great er t he degree of x-ray
absorpt ion. The composit e image produced represent s t hese varying degrees of
t issue densit y in shades of black, w hit e, and gray. I mages may be capt ured on
phot ographic f ilm, displayed on a video screen, or recorded on digit al media.
The basic principle of radiography is t hat diff erences in densit y among various
body st ruct ures produce images of varying light or dark int ensit y, much like t he
negat ive print of a phot ograph. Dense st ruct ures appear w hit e, w hereas air-f illed
areas are black.
USE OF CONTRAST AGENTS

Many radiographic t echniques use t he nat ural cont rast s and varying densit ies
t hat exist in body t issues represent ing air, w at er (in sof t t issue), f at , and bone.
The lungs and gast roint est inal (G I ) t ract normally cont ain air or gases. O t her
body st ruct ures are encased in a f at t y envelope. Bone cont ains nat urally
occurring mineral salt s. How ever, diagnosis of cert ain pat hologic condit ions
requires visualizat ion of det ails t hat cannot be revealed t hrough plain x-rays. I n
t hese cases, det ails can be highlight ed by t he presence of contrast medi a in t he
area. These cont rast subst ances can be administ ered t hrough oral, rect al, or
inject ion administ rat ion.
The ideal cont rast agent should be relat ively harmless (low t oxicit y, nonant igenic,
nonallergenic, and inert ), should not int erf ere w it h any physiologic f unct ions, and
should allow high and repeat ed dosing at a moderat e cost . A cont rast medium
may be classif ied as eit her radi opaque (not permit t ing t he t ransmission of xrays) or radi ol ucent (permit t ing part ial t ransmission of x-rays). The adverse
pharmacodynamics of cont rast media causes deat h in an est imat ed 1 of every
20, 000 t o 40, 000 administ rat ions. The most commonly used cont rast agent s are
water-sol ubl e iodine agent s f or G I examinat ions and int ravascular procedures.
Ult imat ely, one must alw ays be alert t o t he possibilit y of an adverse react ion t o
cont rast media. Consequent ly, emergency supplies and equipment should be
readily available w hen using t hese agent s.
The f ollow ing cont rast agent s are used rout inely in x-ray st udies:
1. Aliment ary canal cont rast agent s
a. Wat er-soluble agent s (eg, G ast rograf in, G ast roview, oral Hypaque)
b. Wat er-insoluble agent s (eg, BaSO4 , Polibar Plus, Esophot rast , Anat rast )
c. G ases (CO2 gas, gas-producing calcium cit rat e and magnesium cit rat e)
2. I nject able cont rast agent s
a. Nonionic iodinat ed cont rast (low osmolar agent s, eg, O mnipaque, I sovur,
O pt iray)
b. I onic iodinat ed cont rast (high osmolar agent s, eg, Renavest , Hypaque,
Conray)
3. Specif ic-use agent s
a. Bile agent s (Cholebin, Bilivist )
b. I odized oil cont rast agent s
ADVERSE REACTIONS TO CONTRAST AGENTS

All cont rast agent s have t he pot ent ial f or causing allergic react ions t hat can
range f rom mild (eg, nausea and vomit ing) t o severe anaphylaxis (eg,
cardiovascular collapse and cent ral nervous syst em depression leading t o deat h
if unt reat ed). Table 10. 1 list s t he range
of possible adverse react ions t o iodine cont rast media. React ions happen quickly
and usually occur w it hin minut es of administ rat ion of t he cont rast agent . Such
react ions can occur in anyone.
Table 10.1 Signs, Symptoms, and Incidence of R
Cardiovascular
Respiratory
Cutaneous
Gastro
Pallor
Sneezing
Erythema
Nausea
Diaphoresis
Coughing
Feeling of
warmth
Vomitin
Tachycardia
Rhinorrhea
Parotitis
Metallic
Bradycardia
W heezing
Urticaria
Abdomi
cramps
Palpitations
Acute asthma
attack
Pruritus
Diarrhe
Pain at the
Arrhythmia
Laryngospasm
injection site
Acute
pulmonary
edema
Cyanosis
Angioneurotic
edema
Shock
Laryngeal
edema
Swelling of
eyes
Congestive
heart failure
Apnea
Cardiac arrest
Respiratory
arrest
Paralyti
Dyspnea
All Iodine Contrast Reactions
Minor reactions requiring no treatment: sensation of heat, n

vomiting, local urticaria, rash, dizziness, light-headedness,
arrhythmia, pain at injection site, mild pallor, pruritus, facial
Intermediate reactions that require treatment but no hospita

and are not life-threatening: vomiting, extensive urticaria,
bronchospasm, faintness, dyspnea, mild chest pain, headac
chills, and fever
Severe reactions that require hospitalization and are life-thr
syncope, laryngeal and pulmonary edema, hypotension, con

circulatory collapse, pulmonary edema, severe angina, myo
infarction, cardiac arrhythmia, coma, respiratory arrest
Cardiac arrest
Death
Clinical Considerations When Iodine Contrast Agents

Are Used
1. Know t he pat ient 's age and healt h st at us. Children and elderly people,
especially t hose w it h medical problems, may be especially sensit ive t o
cont rast agent s. This sensit ivit y may increase t he chance f or side eff ect s.
2. The presence of ot her medical problems may increase t he risk f or side
eff ect s.
a. Those w it h ast hma or hay f ever are at a great er risk f or having an
allergic react ion t o t he cont rast agent .
b. Those w it h diabet es have a great er risk f or developing kidney problems.
c. Those w it h severe hypert ension may experience a dangerous rise in
blood pressure and t achycardia.
d. Those w it h kidney and liver disease may experience exacerbat ion of t heir
disease.
e. Those w it h mult iple myeloma may develop severe kidney problems.
f. Those w it h overact ive t hyroid may experience a sudden increase in
sympt oms or t hyroid st orm.
g. Those w it h sickle cell disease may experience t he f ormat ion of abnormal
blood cells.
h. Those using bet a blockers may have a higher risk f or developing
anaphylact oid react ions.
i. Those w it h chronic obst ruct ive pulmonary disease (CO PD) have an
increased risk f or post inject ion dyspnea.
3. Pat ient s w ho are allergic t o iodine cont rast media must have t his inf ormat ion
document ed in t heir healt h care records. The risk f or subsequent react ions
increases t hree t o f our t imes af t er t he f irst react ion; how ever, subsequent
react ions w ill not necessarily be more severe t han t he f irst . The pat ient must
be made aw are of t he implicat ions of t he sit uat ion. Assess f or and document
allergies t o iodine-cont aining subst ances (eg, seaf ood, cabbage, kale, raw
leaf y veget ables, t urnips, iodized salt ). Also det ermine each person's
react ions t o penicillin or t o skin t est f or allergies because t hese pat ient s
have a great er chance of having a react ion.
4. Check t he pat ient 's f ast ing st at us bef ore t he x-ray procedure has begun.
Except in an ext reme emergency, iodine cont rast media should never be
administ ered int ravenously sooner t han 90 minut es af t er t he pat ient has
eat en. I n most inst ances, t he pat ient should f ast t he night bef ore undergoing
any x-ray procedure using an iodine cont rast agent .
5. Deat h f rom an allergic react ion can occur if severe sympt oms go unt reat ed.
St aff in at t endance must be qualif ied t o administ er cardiopulmonary
resuscit at ion should it be necessary. Emergency equipment and supplies
must be readily available.
6. Prompt ly administ er ant ihist amines per physician's order if mild t o moderat e
react ions t o iodine cont rast subst ances occur (see Table 10. 1).
7. When coordinat ing x-ray t est ing w it h a cont rast agent , keep in mind t hat
st udies using iodine and t hose using barium should be scheduled at diff erent
t imes.
8. Some physiologic change can be expect ed w hen an iodine cont rast
subst ance is inject ed, as during an int ravenous pyelogram (I VP). Physiologic
responses t o iodine given int ravenously include hypot ension, t achycardia,
and arrhyt hmias. For t his reason,
alw ays check blood pressure, pulse, and respirat ion bef ore and af t er t hese
t est s are perf ormed.
9. I f appropriat e f or t he pat ient , encourage int ake of large amount s of oral
f luids af t er t he t est t o promot e f requent urinat ion. This f lushes t he iodine out
of t he body.
10. Possible cont raindicat ions t o t he administ rat ion of iodine cont rast subst ances
include t he f ollow ing condit ions:
a. Hypersensit ivit y t o iodine
b. Sickle cell anemia (use may increase sickling eff ect )
c. Syphilis (use may lead t o nephrot ic syndrome)
d. Long-t erm st eroid t herapy (iodine subst ances may render part of t he
drug inact ive)
e. Pheochromocyt oma (may produce sudden, pot ent ially f at al rise in blood
pressure)
f. Hypert hyroidism
g.
COPD
h. Mult iple myeloma

i. Acut e ast hma
j. Hist ory of renal f ailure
k. Pregnancy
l. Diabet es mellit us
m. Severe dehydrat ion
n. Congest ive heart f ailure
o. Drug t herapy know n t o be nephrot oxic (eg, cisplat in)
11. Nonionic cont rast agent s t end t o produce f ew er side eff ect s t han do ionic
mat erials.
12. Pat ient s w it h renal f ailure may develop acidosis w hen iodine cont rast is
administ ered.
Clin ical Alert

1. Caref ul pat ient preparat ion considers pat ient saf et y, prevent s
complicat ions, and can prevent repeat procedures. Assess f or t he
f ollow ing risk f act ors associat ed w it h a higher incidence of undesirable
cont rast agent react ions:
a. Allergy
b. Ast hma
c. Previous react ions t o cont rast media
d. Repeat and high dosages administ ered
e. Diabet es mellit us
f. Renal f ailure (preexist ing); many laborat ories require preprocedural
assessment of creat inine levels in older adult s
g. Liver insuff iciency
h. Mult iple myeloma
i. Dehydrat ion
j. O lder adult (>65 yr)
k. New borns
l. Hist ory of seizures
m. Pheochromocyt oma
2. No cont rast agent is w it hout risk f or causing react ions. Benef it versus risk
must be considered. For example, in a w ork-up t o det ect cancer, t he
benef it s of early det ect ion f ar out w eigh t he dangers of cumulat ive xirradiat ion exposure. The pat ient must be inf ormed of t he risk-t o-benef it
rat io; t he pat ient has a legal right t o t his know ledge.
P.
3.
4.
5.
6.
7.
8.
I n inst ances in w hich cont rast must be delivered t o high-risk pat ient s,
prophylact ic premedicat ion w it h prednisone may be ordered. Consult t he
radiology depart ment f or f urt her inf ormat ion.
Never inject iodized oils or barium int o t he bloodst ream.
Cont rast agent induced acut e renal insuff iciency is a rare and dangerous
complicat ion t hat occurs 1 t o 5 days f ollow ing int ravenous inject ion of a
cont rast medium. Dehydrat ed pat ient s and t hose w it h serum creat inine
levels >1. 4 mg/ dL (>123. 8 mol/ L) are at great est risk.
I nt ravascular iodinat ed cont rast may int eract w it h cert ain I V medicat ions.
These int eract ions produce insoluble precipit at es t hat may lead t o
embolism. For t hat reason, exist ing I V lines should be f lushed w it h saline
bef ore using t his line as t he mechanism f or delivering cont rast .
Special at t ent ion is necessary f or diabet ic pat ient s because of t heir
increased pot ent ial f or renal f ailure and development of lact ic acidosis.
Diabet ic persons t aking oral hypoglycemic G lucophage/ met f ormin should
have t his drug w it hheld t he day of and 48 hours f ollow ing t he inject ion of
iodinat ed cont rast . I n addit ion, advise t he pat ient t hat his or her serum
creat inine level be rechecked 24 t o 48 hours af t er he or she has received
parent eral cont rast . Examinat ions requiring ext remely small volumes of
cont rast (myelography, art hrography) may not require such st ringent
precaut ions. Check w it h t he radiology depart ment f or specif ic inst ruct ions.
Test s f or t hyroid f unct ion (serum t est s as w ell as nuclear medicine
st udies) are adversely aff ect ed f or several w eeks t o mont hs f ollow ing
iodinat ed cont rast inject ion.
Lat e react ions (23 days af t er procedure) most of t en occur w it h t he use
of agent s such as iot rolan and iodoxane f or int ravascular procedures such
as angiography.
Clinical Considerations When Barium Contrast Is Used

There is always some risk when introducing barium
sulfate or a similar contrast agent into the GI tract.
1. Barium radiography may int erf ere w it h many ot her abdominal examinat ions. A
number of st udies, including ot her x-rays, t est s using iodine, ult rasound
procedures, radioisot ope st udies, t omograms, comput ed t omography (CT),
and proct oscopy, must be scheduled bef ore or several days f ollow ing barium
st udies. Consult w it h t he radiography depart ment f or t he proper sequencing
of st udies.
2. Emphasize t hat a laxat ive should be t aken af t er a barium sulf at e procedure
is complet ed. I ncreased consumpt ion of f luids w ill help t o clear t he bow el of
barium.
3. Elderly, inact ive persons should be checked f or st ool impact ion if t hey f ail t o
def ecat e w it hin reasonable lengt h of t ime af t er a barium procedure. The f irst
sign of impact ion in an elderly person is f aint ing.
4. O bserve and record f indings regarding st ool color and consist ency f or at
least 2 days t o det ermine w het her barium has been evacuat ed. St ools w ill be
light in color unt il all barium has been expelled. O ut pat ient s should be given
a w rit t en reminder t o inspect t heir st ools f or at least 2 days f ollow ing barium
administ rat ion.
5. I f possible, avoid giving narcot ics, especially codeine, w hen barium x-rays
are ordered because t hese drugs can cause decreased bow el mot ilit y t hat
can compound possible barium-associat ed const ipat ion.
Clin ical Alert

1. Rare inst ances of severe allergic react ions t o barium sulf at e have been
report ed. All pat ient s should be quest ioned regarding t heir allergic hist ory
bef ore administ rat ion of any t ype of cont rast agent . A hist ory of hay f ever,
ast hma, and ot her allergies places t he pat ient at higher risk f or react ions
t o all t ypes of cont rast agent s.
2. The risk f or post procedure const ipat ion or blockage of t he bow el is
increased in pat ient s w it h t he f ollow ing condit ions:
a. Cyst ic f ibrosis
b. Dehydrat ion
c. Acut e ulcerat ive colit is
3. Barium should not be used f or int est inal st udy in t he f ollow ing
circumst ances:
a. When a bow el perf orat ion is suspect ed
b. Follow ing sigmoidoscopy or colonoscopy, especially if a biopsy w as
perf ormed, because leakage of barium f rom t he aliment ary canal can
cause perit onit is. I odinat ed cont rast should be used in t hese cases.
There are special clinical considerat ions f or ost omy pat ient s undergoing bow el
preparat ion f or G I st udies; exam preparat ion and procedure should be t ailored
by t he primary care provider and t he radiology depart ment t o achieve t he most
opt imal out comes. I n most cases, st andard diet ary and medicat ion rest rict ions
apply, but modif icat ions involving mechanical bow el cleansing w it h enemas and
physiologic cleansing w it h laxat ives may be necessary.
Clin ical Alert for Patien ts w ith Ostomies

1. Enemas and laxat ives should not be given t o a person w it h an ileost omy in
preparat ion f or x-rays or endoscopy (Chap. 12) because t his put s t he
person at risk f or dehydrat ion and elect rolyt e imbalance. Conversely, a
person w it h a sigmoid colost omy requires enemas bef ore x-ray st udies or
endoscopy is perf ormed. Consequent ly, it is import ant t o ident if y t he t ype
of surgical procedure t he pat ient has undergone. Moreover, not all
colost omies need irrigat ion. For example, a person w it h an ascending
right -sided colost omy w ill usually pass a liquid, past y st ool high in w at er
cont ent and digest ive enzymes; such a pat ient may only require laxat ives.
2. Not if y t he radiology depart ment t hat t he person has an ost omy.
3. Advise all pat ient s t o bring ext ra ost omy supplies and pouches f or use
af t er t he procedure is complet ed.
RISKS OF RADIATION
Exposure of t he human body t o radiat ion carries cert ain risks. The biologic
eff ect s of ionizing radiat ion change t he chemical makeup of cells, causing cell
damage and mut at ion and promot ing carcinogenesis. How ever, not all f orms of
radiat ion are equal in t he pot ent ial f or causing damage, and of t en no percept ible
or long-last ing damage occurs. G enerally speaking, t he higher t he dose (as
det ermined by t he st rengt h of t he radiat ion and t he durat ion of t he exposure),
t he great er t he risk.
Det erminist ic eff ect s (ie, early eff ect s), such as eryt hema, acut e radiat ion
syndrome, and induced f ert ilit y, occur af t er t he person has received massive
doses of radiat ion. St ochast ic or lat e eff ect s of radiat ion (ie, t hose in w hich t he
risk f or damage rises w it h increasing exposure levels and consequent ly are of
most concern in diagnost ic radiology) include radiocarcino-genesis and genet ic
eff ect s. Because t he most radiosensit ive human is t he embryo during t he f irst
t rimest er of pregnancy, special precaut ions must be t aken t o prevent or minimize
radiat ion exposure t o t he pregnant ut erus (Table 10. 2, Table 10. 3, Table 10. 4
and Table 10. 5).
Table 10.2 Principal Early Effects of Radiation

Exposure on Humans and Approximate Minimum
Radiation Dose Necessary to Produce Them
Effect
Anatom ic
Site
Minim um Dose
(Gray)
Death
W hole body
Hematologic
depression
W hole body
0.25
Skin erythema
Small field
Epilation
Small field
Chromosome
aberration
W hole body
0.05
Gonadal
dysfunction
Local tissue
0.1
From Bushong SC: Radiologic Science for

Technologists, 7th ed. St. Louis, CV Mosby, 2001.
Table 10.3 Relative Risk for Childhood Leukemia

After Irradiation in Utero by Trimester
Tim e of X-Ray Exam ination
Relative Risk
First trimester
8.3
Second trimester
1.5
Third trimester
1.4
Total
1.5
From Bushong SC: Radiologic Science for

Table 10.4 Summary of Effects After 10-rad in

Exposure in Utero
Tim e of
Exposure
Type of
Response
Natural
Occurrence
Radiation
Response
02 wk
Spontaneous
abortion
25%
0.1%
210 wk
Congenital
abnormalities
5%
1%
215 wk
Mental
retardation
6%
0.5%
09 mo
Malignant
disease
8/10,000
12/10,000
09 mo
Impaired
growth and
development
1%
Nil
Genetic
09 mo
mutations
10%
Nil
From Bushong SC: Radiological Science for

Table 10.5 Representative Radiation Quantities from

Various Diagnostic X-Ray Procedures
Exam ination
Technique
(kVp/m As)
Entrance
Skin
Exposure
(m rad)
Mean
Marrow
Dose
(m rad)
Gonad
Dose
(m rad)
Skull
76/50
200
10
<1
Chest
110/3
10
<1
Cervical
spine
70/40
150
10
<1
Lumbar
spine
72/60
300
60
225
Abdomen
74/60
400
30
125
Pelvis
70/50
150
20
150
Extremity
60/5
50
<1
Head CT
125/300
3000
20
50
Pelvis CT
124/400
4000
100
3000
From Bushong SC: Radiological Science for Technologists,

7th ed. St. Louis, CV Mosby, 2001.
Safety Measures
Cert ain precaut ions must be t aken t o prot ect pat ient s, visit ors, and st aff f rom
unnecessary exposure t o radiat ion.
General Precautions
1. The pat ient 's medical records should be review ed f or radiat ion t herapy
hist ory and t o minimize t he pot ent ial f or unw arrant ed repeat st udies.
2. Fast f ilm and high-resolut ion screens produce qualit y result s. Filmless
comput ed radiography may reduce radiat ion exposure and ret akes.
3. The size or area irradiat ed must be caref ully adjust ed so t hat no more t issue
t han necessary is exposed t o t he x-irradiat ion. Collimat ors (shut t ers), cones,
or lead diaphragms can assure proper sizing and x-ray exposure area.
4. Fluoroscopy yields a higher dose t han st at ic radiographs or CT st udies.
Signif icant dose reduct ion is achieved by employing pulsed digit al
f luoroscopy.
5. The gonads should be shielded in bot h f emale and male pat ient s of
childbearing age unless t he examinat ion involves t he abdomen or gonad
areas.
6. The primary x-ray beam should pass t hrough layers of aluminum adequat e t o
f ilt er out excess radiat ion w hile st ill providing det ailed images.
7. St aff in t he radiology depart ment should w ear lead aprons (and gloves if
indicat ed) w hen not w it hin a shielded boot h during x-ray exposures. Pat ient s
should be shielded appropriat ely insof ar as t he procedure allow s.
8. The x-ray t ube housing should be checked periodically t o det ect radiat ion
leakage and t o indicat e w hen repairs or adjust ment s are necessary.
Precautions to Be Used with Pregnant Patients

1. Women of childbearing age w ho could possibly be in t he f irst t rimest er of
pregnancy should not have x-ray examinat ions involving t he t runk or pelvic
regions. A brief menst rual hist ory should be obt ained t o det ermine w het her a
possible pregnancy exist s. I f pregnancy is possible, a pregnancy t est should
be done bef ore proceeding w it h x-ray examinat ion.
2. All pregnant pat ient s, regardless of t rimest er, should avoid radiographic,
f luoroscopic, and serial f ilm st udies of t he pelvic region, lumbar spine, and
abdomen if at all possible.
3. Should x-ray st udies be necessary f or obst et ric regions, repeat f ilms should
be avoided.
4. I f x-ray st udies of nonreproduct ive t issues are necessary (eg, dent al x-rays),
t he abdominal and pelvic region should be shielded w it h a lead apron.
Responsibilities in Ordering, Scheduling, and

Sequencing X-Ray Examinations Correct and complete
information should be entered into the computer or on
the x-ray requisition. An appropriate order w ill include
the name of the exam, the ordering physician's name,
and the clinical indication for the exam. Explain to the
patient the purpose and procedure of the x-ray
examination. Written patient instructions may be
helpful.
When a complet e genit ourinary-gast roint est inal (G I / G U) w orkup is scheduled, t he
sequence of x-ray procedures should f ollow a def init e order:
1. First day: I VP and barium enema
2. Second day (or subsequent day): upper G I [ UG I ] series
Barium st udies should be scheduled af t er t he f ollow ing procedures:
1. Abdominal or pelvic ult rasound examinat ion
2. Lumbar-sacral spine x-rays

3. Pelvic x-rays
4. Hyst erosalpingogram
5.
IVP
As a general rule, examinat ions t hat do not require cont rast should precede
examinat ions t hat do require cont rast . All examinat ions t hat require iodine
cont rast should be complet ed bef ore t hose t hat require barium cont rast . I n
addit ion, examinat ions t hat require iodine cont rast must precede nuclear
medicine examinat ions t hat require radioact ive iodine administ rat ions (eg, t hyroid
scans).
O t her x-ray examinat ions t hat do not require preparat ion can be perf ormed at
any t ime. Such examinat ions include t he f ollow ing:
1. X-rays of t he head, spine, and ext remit ies
2. Noncont rast abdominal x-rays (eg, kidney, uret ers, bladder [ KUB] , abdomen
series)
3. Mammograms
Clin ical Alert for Nu rsin g Home Patien ts All n u rsin g h ome
patien ts sh ou ld be accompan ied by an oth er adu lt to th e x-ray
testin g site. If a n on fastin g patien t w ill be in th e x-ray
departmen t over lu n ch time, th e facility sh ou ld sen d a bag lu n ch
or mon ey for lu n ch w ith th e patien t.
PLAIN (CONVENTIONAL) X-RAYS/RADIOGRAPHY

Chest X-Ray
The chest x-ray is t he most f requent ly request ed radiograph. I t is used t o
diagnose cancer, t uberculosis and ot her pulmonary diseases, and disorders of
t he mediast inum and bony t horax. The chest x-ray provides a record of t he
sequent ial progress or development of a disease. I t can also provide valuable
inf ormat ion about t he condit ion of t he heart , lungs, G I t race, and t hyroid gland. A
chest x-ray must be done af t er t he insert ion of chest t ubes or subclavian
cat het ers t o det ermine t heir anat omic posit ion as w ell as t o det ect possible
pneumot horax relat ed t o t he insert ion procedure. A post bronchoscopy chest xray is done t o ensure t here is no pneumot horax f ollow ing a biopsy. I n addit ion,
t he posit ion of ot her devices such as nasogast ric or ent eric f eeding t ubes can be
det ermined and adjust ed if necessary.
Reference Values
Normal
Normal-appearing and normally posit ioned chest , bony t horax (all bones present ,
aligned, symmet rical, and normally shaped), sof t t issues, mediast inum, lungs,
pleura, heart , and aort ic arch
Procedure
1. Remember t hat rout ine chest radiography consist s of t w o images: a f ront al
view (post eroant erior [ PA] ) and a lef t lat eral view. Upright chest f ilms are
pref erred and are of ut most import ance because f ilms t aken in t he supine
posit ion do not demonst rat e f luid levels. This observat ion is especially
import ant w hen t est ing pat ient s on bed rest .
2. St reet clot hing t hat is covering t he chest is removed t o t he w aist . Allow only
clot h or paper hospit al gow ns f ree of but t ons and snaps t o be w orn during
t he x-ray. Remove jew elry on or adjacent t o t he chest .
3. Ensure t hat monit oring cables and pat ches do not obscure t he chest area, if
possible.
4. I nst ruct t he pat ient t o t ake a deep breat h and t o exhale; t hen t o t ake anot her
deep breat h and t o hold it w hile t he x-ray image is t aken. Af t er t he x-ray is
complet ed, t he pat ient may breat he normally.
5. Be aw are t hat t he procedure t akes only a f ew minut es.
6. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, inf ormed i ntratest
care.
1. Abnormal chest x-ray result s indicat e t he f ollow ing lung condit ions:
a. Presence of f oreign bodies
b. Aplasia
c. Hypoplasia
d. Cyst s
e. Lobar pneumonia
f. Bronchopneumonia
g. Aspirat ion pneumonia
h. Pulmonary brucellosis
i. Viral pneumonia
j. Lung abscess
k. Middle lobe syndrome
l. Pneumot horax
m. Pleural eff usion
n. At elect asis
o. Pneumonit is
p. Congenit al pulmonary cyst s
q. Pulmonary t uberculosis
r. Sarcoidosis
s. Pneumoconiosis (eg, asbest osis)
t. Coccidioidomycosis
u. West ermark's sign (indicat es decreased pulmonary vascularit y,
somet imes t hought t o suggest pulmonary embolus)
2. Abnormal condit ions of t he bony t horax include t he f ollow ing:
a. Scoliosis
b. Hemivert ebrae
c. Kyphosis
d. Trauma
e. Bone dest ruct ion or degenerat ion
f. O st eoart hrit is
g. O st eomyelit is
3. Cardiac enlargement
Interfering Factors
An import ant considerat ion in int erpret ing chest radiographs is t o ask w het her
t he f ilm w as t aken in f ull inspirat ion. Cert ain disease st at es do not allow t he
pat ient t o inhale f ully. The f ollow ing condit ions may alt er t he pat ient 's abilit y t o
breat he properly and should be considered w hen evaluat ing radiographs:
1. O besit y
2. Severe pain
4. Scarring of lung t issues
Interventions
1. No special preparat ion is required. How ever, t he pat ient should be given a
brief explanat ion of t he purpose of and procedure f or t he t est and assured
t hat t here w ill be no discomf ort . Screen f or pregnancy st at us of f emale
pat ient s. I f posit ive, advise t he radiology depart ment .
2. Remove all jew elry and ot her ornament at ion in t he chest area bef ore t he xray.
3. Remind t he pat ient of t he need t o remain mot ionless and t o f ollow all
breat hing inst ruct ions during t he procedure.
care.
Clin ical Alert

A port able x-ray machine may be brought t o t he nursing unit if t he pat ient
cannot be t ransport ed. The nurse may need t o assist x-ray personnel in
posit ioning t he pat ient and f ilm. I t is t he x-ray t echnologist 's responsibilit y t o
clear all unnecessary personnel f rom t he radiat ion f ield bef ore x-ray exposure.

1. I nt erpret t est out comes and monit or f or pulmonary disease and chest
disorders. Explain changes in t herapy based on chest x-ray result s (eg,
diuret ics f or pulmonary edema, endot racheal t ube reposit ioning, st art ing or
st opping mechanical vent ilat ion, f urt her t est ing t o det ermine new chest
inf ilt rat es).
care.
Mammography (Breast X-Ray) Soft tissue

mammography visualizes the breast to detect small
abnormalities that could warn of cancer. Its primary
use is to screen for and discover cancers that escape
detection by other means such as palpation. Typically,

cancers <1 cm cannot be detected by routine clinical or
self-examinations. Because the average breast cancer
has probably been present for some time before it
reaches the clinically palpable 1-cm size, the
prognosis for cure is excellent if detected in this
preclinical or presymptomatic phase.
The low -energy x-ray beam used f or t his procedure is applied t o a t ight ly
rest rict ed area and consequent ly does not produce signif icant radiat ion exposure
t o ot her areas of t he body. Theref ore, it is quit e accept able f rom a radiat ion
saf et y st andpoint t o recommend rout ine screenings. Diagnosis by mammography
is based on t he radiographic appearance of gross anat omic st ruct ures. Benign
lesions t end t o push breast t issue aside as t hey expand, w hereas malignant
lesions may invade surrounding breast t issue. Alt hough f alse-negat ive and f alseposit ive readings can occur, mammography is highly accurat e.
Most breast lumps are not malignant ; many are benign cyst s. For w omen >40
years of age, t he benef it s of using low -dose mammography t o f ind early, curable
cancers out w eigh possible risks f rom radiat ion exposure (Table 10. 6).
Table 10.6 Likelihood of Breast Cancer
Age (yr)
Odds
25
1:19,608
30
1:2525
35
1:622
40
1:217
45
1:93
50
1:50
55
1:33
60
1:24
65
1:17
70
1:14
75
1:11
80
1:10
85
1:9
95
1:8
Source: National Cancer Institute, 2000.

The American College of Radiology (ACR) accredit s mammography machines,
and t he Food and Drug Administ rat ion (FDA) cert if ies mammographic f acilit ies.
To earn accredit at ion, mammograms must be perf ormed by specially t rained and
credent ialed radiographers, and t he
result ing images must be int erpret ed by radiologist s w ho meet crit eria f or
cont inuing educat ion in mammography. Addit ionally, t he ACR has st ringent
st andards f or equipment , image qualit y, and radiat ion dose. Healt h insurers,
including Medicare, require mammographic services t o be perf ormed at an
accredit ed inst it ut ion. Recent ly, t he FDA has approved cert ain digit al syst ems;
t hese syst ems record breast anat omy on a comput er rat her t han on f ilm.
Indications for M ammography
1. To det ect clinically nonpalpable breast cancers in w omen >40 years of age,
younger w omen at high risk, or t hose having a hist ory of breast cancer
2. When signs and sympt oms of breast cancer are present
a. Skin changes (eg, orange peel skin associat ed w it h inf lammat ory t ype
cancer)
b. Nipple or skin ret ract ion
c. Nipple discharge or erosion
3. Breast pain
4. Lumpy breast ; mult iple masses or nodules
5. Pendulous breast s t hat are diff icult t o examine
6. Survey of opposit e breast af t er mast ect omy
7. Pat ient s at risk f or having breast cancer (eg, f amily hist ory of breast cancer)
8. Adenocarcinoma of undet ermined origin
9. Previous breast biopsy
10. Tissue samples removed f rom t he breast may be radiographed using det ailed
mammography t echniques.
11. Follow -up st udies f or quest ionable mammographic images
NOTE
The American Cancer Societ y recommends a baseline mammogram f or all
w omen at 40 years of age, an annual or biannual mammogram f or t hose 40 t o
49 years of age, and a yearly mammogram f or t hose >50 years of age.
Reference Values
Normal
Essent ially normal breast t issue: calcif icat ion, if present , should be evenly
dist ribut ed; normal duct s w it h gradual narrow ing duct al syst em branches
Procedure
1. Mammogram
a. Perf orm mammograms w it h t he person in an upright posit ion, pref erably
st anding. Make accommodat ions f or pat ient s using w heelchairs.
b. Expose t he breast and lif t ont o a f ilm holder or digit al plat e. Adjust t he
breast t issue by hand, smoot hing out all skin f olds and w rinkles. Low er a
movable paddle ont o t he breast , rigorously compressing t he breast
t issue.
c. Make an x-ray exposure quickly, and immediat ely lif t t he compression.
d. Typically, t ake t w o view s (craniocaudal and mediolat eral) of each breast .
e. Be aw are t hat bef ore or af t er t he x-ray examinat ion, t he t echnologist
visually observes and manually palpat es t he breast s.
f. Tell pat ient t hat t he complet e examinat ion t akes about 30 minut es.
g. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, inf ormed
i ntratest care .
2. X-rayguided biopsy (st ereot act ic t echnique)
a. Administ er a local anest het ic and a sedat ive.
b. Have t he pat ient lie on her abdomen, allow ing her breast t o prot rude
t hrough an opening in a special t able.
c. Take t w o st ereoview mammograms, allow ing precise posit ioning of
hollow -core needle.
d. I nsert t he needle int o t he breast at precise locat ions using st erile
lacerat ions. Take mult iple core t issue samples because t umors have bot h
benign and malignant areas.

e. Cleanse t he breast , and apply a st erile dressing.
Comparison of Core Needle vs. Vacuum-Assisted
Core
Needle
Biopsy
ABB1
Site-select
Centrica
Technique
Automated
gun
Large core
needle
Disadvantages
Adva
Requires
multiple passes
into tissue
Exce
dens
lesio
Rela
inexp
equip
Vacuum -Assisted Biopsy (VAB)
M1BB
Mammotome
ATEC
Dual lumen
needle/probe
with rotating
cutter
Increased
potential for
postprocedural
bleeding
Expensive
equipment
Sing
into
yield
multi
samp
Larg
tissu
samp
3. Needle x-ray localizat ion and surgical biopsy

a. Administ er a local anest het ic and sedat ive. I n some inst ances, general
anest hesia is used.
b. I nsert a needle t hat holds a f ine w ire, clip, or biodegradable marker int o
t he breast t issue, using breast x-ray f ilms as a guide. When t he needle
point is at t he t ip of t he x-raydef ined abnormalit y, t he device is
released. I t st ays t here unt il t he surgeon, guided by t he w ire, removes a
specimen of t he abnormal t issue.
NOTE
Rigorous compression is a brief and uncomf ort able but crit ical st ep in ensuring
a high-qualit y mammogram. I t low ers dose and improves image qualit y.
Clin ical Alert

1. Comput er-assist ed diagnosis (CAD) recent ly became a reimbursable
procedure f or Medicare pat ient s. Comput er sof t w are scans t he image and
not es suspicious areas t hat a radiologist could miss, t hus act ing as a
second opinion.
2. Many radiologist s double-read all mammograms.
3. Comparison w it h old mammograms is very import ant . Consequent ly,
pat ient s are advised t o have all mammograms perf ormed at t he same
f acilit y or ret rieve old mammograms and bring t hem along w hen having a
new st udy perf ormed.
4. Mammographic examinat ion of augment ed breast s requires addit ional
view s t hat add t o procedure t ime. The presence of implant s should be
communicat ed t o t he radiology depart ment w hen scheduling t he
procedure.
Abnormal mammogram f indings reveal t he f ollow ing condit ions:
1. Breast mass
a. Benign breast masses (eg, cyst s, f ibroadenomas) are usually round and
w ell demarcat ed.
b. Malignant breast masses are of t en irregularly shaped w it h ext ensions
int o adjacent t issue, generally w it h an increased number of blood vessels
(Fig. 10. 1).
FI G URE 10. 1 Half of all breast cancers develop in t he upper out er

sect ion. (Source: Depart ment of Healt h and Human Services, 1994. )
c. When a mass is det ect ed, addit ional st udies are perf ormed t o help
diff erent iat e t he nat ure of t he mass. These st udies may include t he
f ollow ing:
1. Special x-ray magnif icat ion view s of t he area in quest ion
2. Spot compression view s perf ormed using a special paddle t hat
isolat es t he suspicious t issue (Fig. 10. 2)
FI G URE 10. 2 Examples of (A) w hole breast compression and (B)

spot compression.
3. Ult rasound of t he area t o help diff erent iat e a cyst ic (f luid-f illed) mass
f rom a solid lesion
2. Calcif icat ions present in t he malignant mass (duct carcinoma) or in adjacent
t issue (lobular carcinoma) are described as innumerable punct at e
calcif icat ions resembling f ine grains of salt or rod-like calcif icat ions t hat
appear t hin, branching, and curvilinear. Macrocalcif icat ions (large mineral
deposit s) generally represent benign degenerat ive processes.
Microcalcif icat ions (<1/ 50 inch) are of more concern and require close
examinat ion.
3. The likelihood of malignancy increases w it h a great er number of
calcif icat ions in a clust er. How ever, a clust er w it h as f ew as t hree
calcif icat ions, part icularly if t hey are irregular in shape or size, can occur in
cancer.
4. Typical parenchymal pat t erns are as f ollow s:

a. N1: normal
b. P1: mild duct prominence on less t han one f ourt h of t he breast
c. P2: marked duct prominence
d. DY: dysplasia (some diagnost icians believe t hat t he person w ho exhibit s
dysplasia is 22 t imes more likely t o develop breast cancer t han t he
person w it h normal result s)
5. Findings of breast cancer w hen cont rast is inject ed are associat ed w it h
ext ravasat ion of cont rast , f illing def ect s, obst ruct ion or irregular narrow ing
of duct s (Chart 10. 1) (see Fig. 10. 1 and Fig. 10. 2).
Ch art 10.1 Clinical Note

1. Contrast mammography (duct ogram, galact ogram) is a valuable aid f or
diagnosing int raduct al papillomas. Mammary duct inject ion is used w hen
cyt ologic examinat ion of breast f luid or discharge is abnormal. I n cont rast
mammography, af t er caref ul cannulat ion of a discharging duct , about 1 mL
of a radiopaque subst ance (eg, 50% sodium diat rizoat e) is inject ed int o
t he breast duct w it h a blunt , 25-gauge needle.
2. Ductal l avage is a new t echnique in w hich t he milk duct s are cannulized.
Saline is inject ed and, w hen w it hdraw n, w ill w ash out duct al cells. These
cells are examined in t he laborat ory, in much t he same w ay as a Pap
smear is review ed. (See Chap. 11 f or addit ional inf ormat ion. )
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of mammograms.
Mammography is t he single best met hod f or det ect ing breast cancer w hile it
is st ill in a curable st age (Fig. 10. 3). Some discomf ort is t o be expect ed
w hen t he breast is compressed.
FI G URE 10. 3 Size of t umors f ound by mammography and breast self exam. (Source: I maginisG uidelines Women Should Follow f or Early
Det ect ion of Breast Cancer, sponsored by Siemens. )
2. Assess pregnancy st at us of f emale pat ient s. I f posit ive, advise radiology

depart ment .
3. I nst ruct t he pat ient not t o apply deodorant , perf ume, pow ders, or oint ment t o
t he underarm area on t he day of t he examinat ion. Residue f rom t hese
preparat ions can obscure opt imal visualizat ion.
4. Advise t he pat ient t o w ear separat es rat her t han a dress because clot hing
must be removed f rom t he upper body.
5. Suggest t hat pat ient s w ho have painf ul breast s ref rain f rom caff einat ed
f oods and beverages (eg, coff ee, t ea, cola, chocolat e) f or 5 t o 7 days
bef ore t est ing.
care.
NOTE
Pat ient s in t he reproduct ive age group are advised t o have mammograms
perf ormed in t he 2 w eeks t hat f ollow t heir last menst rual period.

1. I nt erpret t est out comes and counsel appropriat ely. I f a biopsy is necessary,
see procedures f or biopsy using x-ray t echnology.
care.
Clin ical Alert

1. A mammogram det ect s abnormalit ies t hat could w arn of cancer. The act ual
diagnosis of cancer is made by biopsy. O nly one in f ive biopsies t est
posit ive f or cancer.
2. Several met hods can be used t o provide a breast t issue sample necessary
f or cancer diagnosis. These include core-needle biopsy, surgical biopsy,
and vacuum-assist ed biopsy. Any of t hese met hods can ut ilize eit her x-ray
mammography or ult rasound f or image guidance.
Orthopedic X-Ray: Bones, Joints, and Supporting

Structures Orthopedic radiography examines a
particular bone, group of bones, or joint. The bony or
osseous system presents five functions of radiologic
significance: structure support of the body,
locomotion, red marrow storage, calcium storage, and
protection of underlying soft tissue and organ
structures. Orthopedic radiography is performed on the
following structures:
1. The ext remit ies (eg, hand, w rist , shoulder, f oot , knee, hip)
2. The bony t horax (eg, ribs, st ernum, clavicle)
3. The spine (eg, cervical, t horacic, lumbar, sacrum, coccyx)
4. The head and skull (eg, f acial bones, mast oids, sinuses)
O pt imal result s f rom ort hopedic x-ray examinat ions depend on proper
immobilizat ion of t he area being st udied. To produce a t horough image of t he
body part , at least t w o and somet imes more project ions are required. These are
usually t aken at angles of 90 degrees t o one anot her (eg, ant eropost erior and
lat eral view s).
To examine more complex st ruct ures such as t he spine and skull, or t o examine a
st ruct ure in great er det ail, several project ions f rom various angles may be
required.
Reference Values
Normal
Normal osseous (bone) and support ing t issue st ruct ures
Procedure
1. I nf orm t he pat ient t hat diet ary rest rict ions are not necessary.
2. Have t he pat ient assume t he posit ions most f avorable t o capt uring t he best
images. How ever, t he degree of pat ient mobilit y and physical condit ion may
also need t o be considered. Typically, t he anat omic st ruct ures being st udied
are examined f rom several angles and posit ions. This may require t he
examiner t o manipulat e t he body area physically int o a posit ion t hat w ill allow
opt imal visualizat ion.
3. Be aw are t hat jew elry, zippers, snaps, monit oring cables, and so f ort h
int erf ere w it h proper visualizat ion. These object s must be removed f rom t he
visual f ield if possible. Skull x-rays require removal of dent ures and part ials.
4. Remove surgical-t ype hardw are used t o st abilize a t raumat ized area. This
should be done only under t he direct ion of t he at t ending physician.
care.
Abnormal ort hopedic x-ray result s may reveal t he f ollow ing condit ions:
1. Fract ures
2. Dislocat ions
3. Art hrit is
4. O st eoporosis
5. O st eomyelit is
6. Degenerat ive joint disease
7. Hydrocephalus
8. Sarcoma
9. Abscess and asept ic necrosis
10. Paget 's disease
11. G out
12. Acromegaly
13. Met ast at ic processes
14. Myeloma
15. O st eochondrosis, f or example,
a. Legg-Calv-Pert hes disease
b. O sgood-Schlat t er disease
16. Bone inf arct s
17. Hist iocyt osis X
18. Bone t umors (benign and malignant )
19. Foreign bodies
Interfering Factors
Radiography of t he lumbosacral spine, coccyx, or pelvis must be complet ed
bef ore barium st udies because residual barium may int erf ere w it h proper
visualizat ion. Jew elry and accessories, heavy clot hing, met allic object s, zippers,
but t ons, snaps, cables, and ot her monit oring equipment and supplies can
int erf ere w it h opt imal view s and need t o be removed bef ore t he examinat ion.
Interventions
1. Explain t he purpose and procedure of t he t est . No preparat ion or diet ary
rest rict ions are necessary. Screen f or pregnancy st at us of f emale pat ient s.
I f posit ive, advise t he radiology depart ment .
2. Assure t he pat ient t hat t he procedure in and of it self causes no pain.
How ever, necessary manipulat ion of t he body may cause discomf ort . I f
appropriat e, pain medicat ion may be administ ered bef ore t he procedure.
3. Advise t he pat ient t hat all dent ures, part ials, jew elry, and ot her
ornament at ion w orn in t he anat omic area being examined must be removed
bef ore t he st udy. I f possible, simple clot hing should be w orn, and t he
previously ment ioned it ems should be lef t at home or in t he pat ient 's room.
4. Emphasize t he import ance of not moving during t he procedure unless
specif ically inst ruct ed ot herw ise. Movement dist ort s or blurs t he image and
of t en requires repeat exposures.
care.

1. I nt erpret t est out comes and monit or f or f ract ures, dislocat ions, and ot her
ort hopedic disorders. Counsel about need f or f ollow -up procedures and
t reat ment .
care.
Clin ical Alert

1. O rt hopedic radiography also can provide inf ormat ion about sof t t issue
st ruct ures, such as sw elling or calcif icat ions. How ever, radiography alone
cannot provide dat a about t he condit ion of cart ilage, t endons, or
ligament s.
2. Port able x-ray machines can be t aken t o t he nursing unit if t he pat ient
cannot be t ransport ed t o t he radiology depart ment . Nursing personnel may
need t o assist in t he process. The x-ray t echnologist is responsible f or
clearing all unnecessary personnel f rom t he immediat e radiat ion f ield
bef ore act ivat ing t he exposure.
Abdominal X-Ray: Plain Film or KUB (Kidney, Ureters,

Bladder); Scout Film; Flat Plate, Abdominal Series This
radiographic study does not use contrast media. It is
done to aid in the diagnosis of intraabdominal diseases
such as nephrolithiasis, intestinal obstruction, soft

tissue mass, or ruptured viscus. It may be the
preliminary step in evaluating the GI tract, the
gallbladder, or the urinary tract, and it is done before
IVP or other renal studies. Abdominal films may
provide information on the size, shape, and position of
the liver, spleen, and kidneys.
Reference Values
Normal
Normal abdominal st ruct ures
Procedure
1. Have t he pat ient w ear a hospit al gow n. All met allic object s must be removed
f rom t he abdominal area.
2. Have t he pat ient lie in a supine posit ion on t he x-ray t able.
3. Take mult iple images (including upright and lef t decubit us) f or an abdominal
series t o assess air-f luid levels.
care.
Abnormal abdominal x-ray result s reveal t he f ollow ing condit ions:
1. Calcium deposit s in blood vessels and lymph nodes; cyst s, t umors, or st ones
2. Uret ers are not clearly def ined, alt hough calculi may be visualized w it hin t he
uret ers.
3. The urinary bladder can of t en be ident if ied by t he shadow it cast s, especially
in t he presence of urine w it h high specif ic gravit y.
4. Abnormal kidney size, shape, and posit ion
5. Appendicolit hiasis
6. Foreign bodies
7. Abnormal f luid; ascit es
8. Large t umors and masses, (eg, bladder, ovarian, or ut erine), if t hey displace
normal bow el conf igurat ions
9. Abnormal gas dist ribut ion associat ed w it h bow el perf orat ion or obst ruct ion
10. Fusion anomalies
11. Horseshoe-shaped kidneys
Interfering Factors
1. Barium may int erf ere w it h opt imal visualizat ion. Theref ore, t his examinat ion
should be done bef ore barium st udies.
2. A f lat plat e of t he abdomen does not det ect f ree air.
Interventions
1. Explain t he purpose and procedure of t he t est . Normal diet is allow ed unless
cont raindicat ed. Assure t he pat ient t hat t he procedure in it self is not painf ul.
2. Remove belt s, zippers, jew elry, and ot her ornament at ion f rom t he abdominal
area.
3. I nst ruct t he pat ient t o remain st ill and t o f ollow breat hing inst ruct ions.
care.
Clin ical Alert

1. Abdominal plain f ilms are not diagnost ic f or cert ain condit ions, such as
esophageal varices or bleeding pept ic ulcer.
2. A port able x-ray machine may be brought t o t he nursing unit if t he pat ient
cannot be moved. Assist w it h posit ioning as necessary. The x-ray
t echnologist is responsible f or clearing all unnecessary personnel f rom t he
radiat ion f ield bef ore t he x-ray is t aken.
1. I nt erpret t est out comes and monit or f or int raabdominal disease.

care.
Dental X-Rays
Dent al x-rays screen and diagnose causes of pain and ot her sympt oms relat ed
t o t he t eet h, jaw s, and t emporomandibular joint s and are also used as f ollow -up
f or dent al t herapy. Many diff erent t ypes of dent al radiographs are available
because of t he complex t issue densit y f ound w it hin t he human mast icat ory
syst em. The x-rays are cat egorized by t he locat ion at w hich t he f ilm is placed
during t he procedure (i ntraoral versus extraoral ). The most common x-rays t aken
are t he bit e w ing and t he periapical, bot h of w hich are int raoral. The various
t ypes of dent al x-rays include t he f ollow ing:
1. I nt raoral (f ilm posit ioned inside t he mout h)
a. Bit e w ing: show s coronal port ion of t he t oot h; also done f or caries
det ect ion; show s bit e correlat ion bet w een upper and low er t eet h
b. Peripheral: show s x-ray of t he w hole t oot h and immediat e surrounding
area
c. O cclusal: show s chew ing surf aces and curve of mandibular molar t eet h
2. Ext raoral (f ilm posit ioned out side t he mout h)
a. Show s various project ions of t he skull, maxilla, sinuses, or
t emporomandibular joint s
b. Panorex (f ull-mout h x-ray)
c.
CT
d. Art hrography of t he t emporomandibular joint
Reference Values
Normal
Normal mandible, maxilla, t emporomandibular joint s, maxillary sinuses, and
primary or permanent dent it ion
Procedure
1. Have t he pat ient sit upright and place t he f ilm and holder in t he mout h f or
int raoral st udies. The pat ient may bit e on t he holder or may anchor it w it h a
f inger t o keep it in place. Drape a lead apron w it h a cervical collar over t he
pat ient 's t orso and neck area.
2. Remember t hat diff erent designs of f ilm holders f acilit at e proper alignment
f or correct x-ray t ube orient at ion. There are also many diff erent t ypes of
ext raoral f ilms t hat can be t aken, each w it h t heir ow n procedures. For
example, w it h t he lat eral skull project ion, t he pat ient sit s upright , and t he
f ilm packet is placed on one side of t he head w hile t he x-ray source is
placed on t he opposit e side. I n ot her inst ances, such as Panorex imaging,
rot at e t he x-ray machine around t he f ace.
care.
Clin ical Alert

Previous ext ensive radiat ion t herapy or a current st at e of pregnancy may
present cont raindicat ions t o dent al x-rays. Consult t he pat ient 's physician if in
doubt .
1. Abnormal dent al x-ray result s reveal t he f ollow ing condit ions:
a. Dent it ion
1. Changes in number of t eet h
2. Changes in shape of t eet h
3. Changes in pulp canal

4. Miscellaneous ot her t oot h lesions
b. Radiolucent lesions of t he jaw and t eet h
1. Lesions at t he t oot h apex or it s midline
2. Lesions in place of a missing t oot h
3. Lesions around t he crow n of an impact ed t oot h
4. Bubble-like radiolucencies
5. O t her mult iple but diff erent radiolucent lesions
6. Lesions t hat dest roy t he cort ical plat e of t he t oot h
c. Mixed lesions (radiopaque and radiolucent )
d. Salivary gland lesions
e. Sof t t issue lesions
f. Temporomandibular joint abnormalit ies
Interfering Factors
The f ollow ing f act ors can int erf ere w it h proper visualizat ion:
1. Braces and ret ainers
2. Part ials and dent ures
3. Rest orat ions
4. Jew elry (eg, earrings)
5. Bony grow t hs on t he inside of t he mandible and t he midline of t he hard
palat e (t orus) or excess deposit s of bone
Interventions
1. Explain purpose, procedure, benef it s, and risks (minimum radiat ion
exposure). St ress t he import ance of holding st ill and breat hing t hrough t he
nose t o lessen t he gag ref lex.
2. Assist t he pat ient t o rinse his or her mout h bef ore t he procedure.
3. Assess f or cont raindicat ions and int erf ering f act ors.
care.

1. Evaluat e x-ray f ilms and explain abnormalit ies. Comparison w it h a normal xray f ilm may be helpf ul.
care.
CONTRAST X-RAYS/RADIOGRAPHY
To visualize hollow int ernal viscera, cont rast media is administ ered t o highlight
t he st ruct ure. Ref er t o pages 706711 f or special care w hen using cont rast
media. Caref ul sequencing of mult iple examinat ions is necessary. As a general
rule, t he f ollow ing inst ruct ions f or sequencing should be f ollow ed:
1. Perf orm abdominal pelvic plain f ilm or CT, ult rasound, and nuclear medicine
st udies bef ore cont rast st udies of t he int est ines.
2. Perf orm examinat ions of t he low er int est ine (barium enema) 1 or 2 days
bef ore UG I examinat ions.
3. Perf orm examinat ions requiring an inject ion of iodinat ed cont rast , such as an
I VP, bef ore any barium st udies (eg, barium enema, UG I ).
4. Consult t he radiology depart ment f or specif ic sequencing inf ormat ion.
5. Take special caut ion w hen administ ering cont rast agent s t o diabet ic persons
and persons w it h kidney problems (see page 710).
6. See caut ions on eff ect s of concurrent use of codeine and barium cont rast
agent s as explained on page 710.
7. Use f luoroscopy f or imaging of diagnost ic (moving) st ruct ures such as t hose
of t he aliment ary canal. Use f luoroscopy t o localize t umors f or biopsy and
drainages, guide cat het er, or f ilt er st ent placement and monit or vascular
f illing f or bot h diagnost ic and t herapeut ic purposes (angioplast y).
Fluoroscopic radiat ion dose is higher t han convent ional x-rays. Dose is direct ly
relat ed t o t ime of exposure. The use of digit al f luorography t ends t o reduce dose
by pulsing t he x-ray beam.
Contrast X-Ray of the Stomach: Gastric X-Ray

Including Upper Gastrointestinal Examination (Upper GI
[UGI] Series, Barium Swallow, Esophagram)

G ast ric radiography visualizes t he f orm, posit ion, mucosal f olds, perist alt ic
act ivit y, and mot ilit y of t he st omach and upper G I t ract . A UG I series includes
t he esophagus, duodenum, and upper port ion of t he jejunum.
Preliminary f ilms w it hout t he use of a cont rast medium are usef ul in det ect ing
perf orat ion, presence of radiopaque f oreign subst ances, gast ric w all t hickening,
and displacement of t he gast ric air bubble, w hich may indicat e a mass ext ernal
t o t he st omach.
O ral cont rast subst ances, such as barium sulf at e or diat rizoat e meglumine
(G ast rograf in), highlight condit ions such as hiat al hernia, pyloric st enosis,
gast ric divert iculit is, presence of undigest ed f ood, gast rit is, congenit al anomalies
(eg, dext roposit ion, duplicat ion), or diseases of t he st omach (eg, gast ric ulcer,
cancer, st omach polyps).
Reference Values
Normal
Normal st omach size, cont our, mot ilit y, and perist alt ic act ivit y Normal esophagus
NOTE
A video-esophagram is t ypically perf ormed t o evaluat e sw allow ing disorders,
part icularly in post st roke pat ient s, and af t er head and neck surgery w it h
plast ic repair. This examinat ion generally includes evaluat ion by a speech
pat hologist .
Procedure
1. Have pat ient change f rom st reet clot hing int o a hospit al gow n. Neck and
t orso jew elry and ot her ornament at ion must be removed.
2. I nst ruct t he pat ient t o sw allow t he barium af t er t he pat ient is properly
posit ioned in f ront of t he f luoroscopy machine. Some changes in posit ion may
be necessary during t he procedure. A mot orized t ablet op shif t s t he pat ient
f rom an upright t o a supine posit ion w hen appropriat e. Fluoroscopy allow s
visualizat ion and f ilming of act ual act ivit y t aking place in real t ime.
3. Take several convent ional x-ray f ilms f ollow ing f luoroscopic examinat ion. The
pat ient w ill need t o hold his or her breat h during each exposure.
4. Tell pat ient t hat examinat ion t ime may be 20 t o 45 minut es.
care.
Abnormal UG I x-ray result s reveal t he f ollow ing condit ions:
1. Congenit al anomalies
2. G ast ric ulcer
3. Carcinoma of st omach
4. G ast ric polyps
5. G ast rit is
6. Foreign bodies
7. G ast ric divert icula
8. Pyloric st enosis
9. Ref lux and hiat al hernia
10. Volvulus of t he st omach
NOTE
Normal cont ours may be def ormed by int rinsic t umors or consist ent f illing
def ect s as w ell as by st enosis in conjunct ion w it h dilat ion.
Interfering Factors
1. I f t he pat ient is debilit at ed, proper examinat ion may be diff icult ; it may be
impossible t o visualize t he st omach adequat ely.
2. Ret ained f ood and f luids int erf ere w it h opt imal f ilm clarit y.
Interventions
1. Explain purpose and procedure (consult barium cont rast t est precaut ions on
pages 710711). Writ t en inst ruct ions on pret est preparat ion are helpf ul f or
t he pat ient . Screen f emale pat ient s f or pregnancy st at us. I f posit ive, inf orm
t he radiology depart ment .
2. I nf orm pat ient t hat complet e f ast ing f rom f ood and f luids is required f or a
minimum of 8 hours bef ore t he procedure. Necessary oral medicat ions (ot her
t han G lucophage/ met f ormin) may be t aken w it h a t iny sip of w at er. I nf orm
radiology depart ment because pills may be visualized during t he st udy.
3. I nst ruct t he pat ient t o hold st ill and f ollow breat hing inst ruct ions during t he
procedure.
care.
Clin ical Alert

1. I f t he pat ient has diabet es, alert t he radiology depart ment and schedule
examinat ion f or early morning. I f diabet ic pat ient is t aking
G lucophage/ met f ormin, special considerat ions may be necessary. Consult
w it h radiology depart ment t o det ermine w het her t his medicat ion regimen
must be suspended f or t he day of and several days af t er t he st udy.
2. Det ermine w het her t he pat ient is allergic t o barium. Alt hough rare,
presence of t his allergy must be communicat ed t o t he radiology
depart ment so t hat alt ernat e cont rast can be used.
3. All f emale pat ient s of reproduct ive age must be screened f or pregnancy
bef ore perf orming t his st udy.

1. Pret est diet and act ivit y may be resumed. Provide f ood and ample f luids.
2. Administ er laxat ives as ordered. I f barium sulf at e or diat rizoat e meglumine
has been administ ered, a laxat ive should be t aken.
3. O bserve and record st ools f or color and consist ency. Monit or evacuat ion of
barium. Counsel t hat f ollow -up procedures may be necessary.
care.
Small Bowel X-Ray; Intestinal Radiography and

Fluoroscopy These small intestine studies, usually
scheduled in conjunction with UGI series, are done to
diagnose small bowel diseases (eg, ulcerative colitis,
tumors, active bleeding, obstruction). A contrast
material such as barium sulfate or meglumine
diatrizoate highlights Meckel's diverticulum, congenital
atresia, obstruction, filling defects, regional enteritis,
lymphoid hyperplasia, tuberculosis of small intestine
(malabsorption syndrome), sprue, Whipple's disease,
intussusception, and edema.
The mesent eric small int est ine begins at t he duodenojejunal valve and ends at
t he ileocecal valve. The mesent eric small int est ine is not rout inely included as
part of a UG I st udy.
Reference Values
Normal
Normal small int est ine cont our, posit ion, and mot ilit y
Procedure
1. Have t he pat ient change int o a hospit al gow n af t er removing st reet clot hes
and accessories. Perf orm a preliminary plain-f ilm st udy w it h t he pat ient on
t he examining t able.
2. Have t he pat ient sw allow t he prescribed amount of cont rast media w hile t he
pat ient is st anding in f ront of t he f luoroscopy machine.
3. Take t imed f ilms af t er cont rast mat erial is sw allow ed, usually every 30
minut es.
4. Remember t hat t he examinat ion is not complet e unt il t he ileocecal valve has
f illed w it h cont rast mat erial. This may t ake several minut es (f or t hose
pat ient s w it h a bypass) t o several hours.
care.
Abnormal small bow el x-ray result s indicat e t he f ollow ing condit ions:
1. Anomalies of small int est ine
2. Errors of rot at ion
3. Meckel's divert iculum
4. At resia
5. Neoplasms
6. Regional ent erit is (Crohn's disease)
7. Tuberculosis
8. Malabsorpt ion syndrome
9. I nt ussuscept ion
10. Roundw orms (ascariasis)
11. I nt raabdominal hernias
Interfering Factors
1. Delays in small int est ine mot ilit y can be due t o t he f ollow ing circumst ances:
a. Morphine use
b. Severe or poorly cont rolled diabet es
2. I ncreases in mot ilit y in t he small int est ine can be due t o t he f ollow ing
circumst ances:
a. Fear or anxiet y
b. Excit ement
c. Nausea
d. Pat hogens
e. Viruses
f. Diet (eg, very high f iber)
Interventions
1. Explain t he purpose and procedure of t he t est . Ref er t o barium cont rast t est
precaut ions (see pages 710711). Writ t en reminders f or pret est inst ruct ions
are helpf ul, especially f or diet limit at ions. Screen f emale pat ient s f or
pregnancy st at us. I f posit ive, advise t he radiology depart ment .
2. Maint ain t ot al f ast f rom midnight unt il t he examinat ion is complet ed.
3. Do not administ er laxat ives or enemas t o a pat ient w it h an ileost omy.
4. I nst ruct t he pat ient regarding t he need t o hold st ill and t o f ollow breat hing
inst ruct ions during t he procedure.
care.
Clin ical Alert

1. I f t he pat ient has diabet es, alert t he radiology depart ment and schedule
examinat ion f or early morning. I f t he diabet ic pat ient is t aking
G lucophage/ met f ormin, special considerat ions may be necessary. Consult
w it h t he radiology depart ment t o det ermine w het her t his medicat ion
regimen must be suspended during and f or several days af t er st udy.
2. Det ermine w het her t he pat ient is hypersensit ive t o barium. Alt hough rare,
presence of t his allergy must be communicat ed t o t he radiology
depart ment so alt ernat e cont rast can be used.
3. All f emale pat ient s of reproduct ive age must be screened f or pregnancy
bef ore perf orming t his st udy.

1. Resume pret est diet and act ivit y. Assist pat ient if necessary.
2. Administ er laxat ives if ordered. I f a barium sulf at e sw allow has been done, a
laxat ive should be t aken. How ever, do not give laxat ives t o a pat ient w it h an
ileost omy unless specif ically ordered.
3. Monit or st ools f or color and consist ency.
4. Counsel pat ient about mot ilit y disorders and ot her small int est ine
abnormalit ies. Follow -up procedures may be necessary.
care.
Colon X-Ray: Defecography (DEF); Barium Enema; Air

Contrast Study (Evacuative Portography) This
fluoroscopic and filmed examination of the large
intestine (colon) allows visualization of the position,
filling, and movement of contrast medium through the
colon. It can reveal the presence or absence of
diseases such as diverticulitis, mass lesions, polyps,
colitis, obstruction, or active bleeding. Barium or
diatrizoate meglumine (Hypaque) is instilled into the
large intestine through a rectal tube inserted into the
colon. The radiologist, with the aid of a fluoroscope,
observes the barium as it flows through the large
intestine. X-ray films are taken concurrently.
Edu cation Alert
A pret est preparat ion is vit al f or t his exam. For a sat isf act ory examinat ion, t he
colon must be t horoughly cleansed of f ecal mat t er. This is most import ant .
Accurat e ident if icat ion of small polyps is possible only in a clean bow el. The
presence of st ool can also make t he search f or bleeding sources much more
diff icult .
I f polyps are suspect ed, an air-cont rast colon examinat ion may be done. The
procedure is basically t he same as t hat f or t he barium enema; how ever, more
complex radiographs need t o be t aken w it h t he pat ient in several diff erent
posit ions. A double-cont rast mixt ure of air and barium is inst illed int o t he colon
under f luoroscopic visualizat ion.
Reference Values
Normal
Normal colon posit ion, cont our, f illing, movement t ime, and pat ency
Procedure
1. Have t he pat ient lie on his or her back w hile a preliminary x-ray f ilm is made;
t his st ep may be omit t ed at some inst it ut ions.
2. Have t he pat ient t hen lie on his or her side w hile barium is administ ered by
rect al enema (ie, t hrough t he rect um and up t hrough t he sigmoid,
descending, t ransverse, and ascending colon t o t he ileocecal valve).
3. Take convent ional x-ray f ilms f ollow ing f luoroscopy, w hich includes several
spot f ilms. Af t er t hese are complet ed, t he pat ient is f ree t o expel t he barium.
Af t er evacuat ion, anot her f ilm is made.
4. Be aw are t hat def ecography and evacuat ive port ography are cont rast enhanced st udies of t he anus and rect um f unct ion during evacuat ion. O f t en
used in young pat ient s t o evaluat e rect oceles, rect al prolapse, or rect al
int ussuscept ion, t his examinat ion requires t he pat ient t o evacuat e int o a
specially designed commode w hile being evaluat ed f luoroscopically.
care.
1. Abnormal colon x-ray result s indicat e t he f ollow ing condit ions:
a. Lesions or t umors (benign)
b. O bst ruct ions
c. Megacolon
d. Fist ulas
e. I nf lammat ory changes
f. Divert icula
g. Chronic ulcerat ive colit is
h. St enosis
i. Right -sided colit is
j. Hernias
k. Polyps
l. I nt ussuscept ion
m. Carcinoma
2. Appendix size, posit ion, and mot ilit y can also be evaluat ed; how ever, a
diagnosis of acut e or chronic appendicit is cannot be made f rom x-ray
f indings. I nst ead, t ypical signs and sympt oms of appendicit is provide t he
most accurat e dat a f or t his diagnosis.
Interfering Factors
A poorly cleansed bow el is t he most common int erf ering f act or. Fecal mat t er
int erf eres w it h accurat e and complet e visualizat ion. Theref ore, it is imperat ive
t hat proper bow el cleansing be conscient iously carried out , or t he procedure may
need t o be repeat ed.
Interventions
Preparat ion involves a t hree-st ep process over a 1- t o 2-day period and includes
diet rest rict ions, physiologic cleansing of t he large bow el by means of oral
laxat ives, and mechanical cleansing w it h enemas. Tw elve- t o 18-hour prot ocols
are common. Follow inst it ut ional prot ocols.
1. Explain t he purpose and procedure of t he t est . Pat ient s may be apprehensive
or embarrassed. I nclude a f amily member in t his process if it appears likely
t hat t he pat ient w ill need assist ance w it h preparat ion. Explain t he need t o
cooperat e t o expedit e t he procedure. Emphasize t hat t he act ual t ime f rame
w hen t he colon is f ull is quit e brief . Screen f emale pat ient s f or pregnancy
st at us. I f posit ive, advise t he radiology depart ment .
2. A w rit t en reminder about t he f ollow ing may be helpf ul t o t he pat ient :
a. O nly a clear liquid diet should be t aken bef ore t est ing (according t o
prot ocols).
b. St ool sof t eners, laxat ives, and enemas need t o be t aken t o ensure bow el
cleanliness necessary f or opt imal visualizat ion. Agent s such as X-Prep,
cit rat e of magnesia, and bisacodyl assist in empt ying t he ascending and
right t o midt ransverse colon (proximal large bow el). Enemas cleanse t he
lef t t ransverse, descending, and sigmoid colon and t he rect um.

Supposit ories also empt y t he rect um.
c. Fast ing f rom f ood and f luids is prescribed bef ore t he t est . Not hing should
be eat en or drunk f rom midnight unt il t he t est is complet ed. O ral
medicat ions should also be t emporarily discont inued unless specif ically
ordered ot herw ise. Check w it h t he clinician w ho orders t he t est .
3. Ref er t o barium cont rast t est precaut ions on pages 710711.
care.

1. Resume pret est act ivit y and diet . Assist t he pat ient if necessary. This bow el
examinat ion can be very exhaust ing. Pat ient s may be w eak, t hirst y, hungry,
and t ired. Provide a calm, rest f ul environment t o promot e ret urn t o normal
st at us.
2. Administ er laxat ives f or at least 2 days af t er t hese st udies or unt il st ools
ret urn t o normal. I nst ruct t he pat ient t o assess st ools during t his t ime. St ools
w ill be light colored unt il all barium has been expelled. O ut pat ient s should be
given a w rit t en reminder t o inspect st ools f or 2 days.
care.
Clin ical Alert

1. Mult iple enemas given bef ore t he procedure, especially t o a person at risk
f or elect rolyt e imbalances, could induce a rat her rapid hypokalemia.
Enema f luid, if not expelled w it hin a reasonable t ime, can be absorbed
t hrough t he bow el w all and deposit ed int o t he int est inal spaces and
event ually w it hin ext racellular spaces.
2. Caut ion should dict at e administ rat ion of cat hart ics or enemas in t he
presence of acut e abdominal pain, act ive bleeding, ulcerat ive colit is, or
obst ruct ion. Consult w it h t he physician or radiology depart ment and
consider t he f ollow ing point s:
a. I nt roducing large quant it ies of w at er int o t he bow el of a pat ient w it h
megacolon should be avoided because of t he pot ent ial danger of w at er
int oxicat ion. I n general, pat ient s w it h t oxic megacolon should not
receive enemas.
b. I n t he presence of colon obst ruct ion, large volumes of w at er f rom
enemas may be reabsorbed, and impact ion may occur.
c. Rect al obst ruct ion makes it diff icult or impossible t o give cleansing
enemas because t he solut ion w ill not be able t o ent er t he colon.
Consult t he physician or radiology depart ment .
3. St rong cat hart ics administ ered in t he presence of obst ruct ive lesions or
acut e ulcerat ive colit is can present hazardous or lif e-t hreat ening
sit uat ions.
4. Be aw are of complicat ions t hat can occur w hen barium sulf at e or ot her
cont rast media are int roduced int o t he G I t ract . For example, barium may
aggravat e acut e ulcerat ive colit is or cause a progression f rom part ial t o
complet e obst ruct ion. Barium also should not be given as cont rast f or
int est inal st udies w hen a bow el perf orat ion is suspect ed because leakage
of barium t hrough t he perf orat ion may cause perit onit is. I odinat ed cont rast
subst ances should be used if perf orat ion is suspect ed.
P.
5. Det ermine w het her t he pat ient is hypersensit ive t o barium. Alt hough rare,
t he presence of t his allergy must be communicat ed t o t he radiology
depart ment so t hat alt ernat e cont rast media can be used.
6. Fast ing orders include oral medicat ions except w hen specif ied ot herw ise.
7. I f pat ient has diabet es, alert t he radiology depart ment and schedule
examinat ion f or early morning. I f diabet ic pat ient is t aking
G lucophage/ met f ormin, special considerat ion may be necessary. Consult
w it h t he radiology depart ment t o det ermine w het her t his medicat ion
regimen must be suspended t he day of and several days af t er t he st udy.
8. Det ermine w het her pat ient is allergic t o lat ex. Lat ex product s are t ypically
used t o administ er t he cont rast agent ; alt ernat e mat erials must be used if
t he pat ient is hypersensit ive. I nf orm t he radiology depart ment of any
know n or suspect ed lat ex allergies.
9. I nf orm t he radiology depart ment if t his procedure is t o f ollow a
sigmoidoscopy or colonoscopy, part icularly if a biopsy w as perf ormed. I n
t he case of biopsy, an iodinat ed cont rast agent , rat her t han barium, is
used.
Clin ical Alert

Colon ic Tran sit Time
This examinat ion is perf ormed on pat ient s w it h suspect ed colonic mot ilit y
disorder. The pat ient must not t ake any laxat ives, enemas, or supposit ories
bef ore beginning t his t est or during t he 47 days it t akes t o perf orm t his t est .
The procedure is quit e simple:
1. The pat ient receives several pills t hat cont ain radiopaque markers (sit z
markers).
2. A KUB or series of KUBs are perf ormed at f ixed t imes several days lat er.
3. The passage of or ret ent ion of t hese markers is not ed and recorded.
4. Ret ent ion of a signif icant port ion of markers 5 days af t er administ rat ion is
considered abnormal and is evidence of dysmot ilit y or an out let
obst ruct ion.
1. Children or elderly pat ient s receiving barium enemas
a. Because a successf ul examinat ion of t he large int est ine depends on t he
abilit y of t he bow el t o ret ain cont rast medium during visualizat ion and
f ilming, special t echniques are used f or inf ant s and young children and
t he inf irm or uncooperat ive adult pat ient .
b. Af t er insert ing a small enema t ip int o t he rect um, t he inf ant 's but t ocks
are gent ly t aped t oget her t o prevent leakage of cont rast mat erial during
t he st udy.
c. For t he older pat ient , a special ret ent ion enema t ip may by used. This
device resembles a regular enema t ip, but it can be inf lat ed, much like an
indw elling urinary cat het er, af t er insert ion int o t he rect um. When t he
examinat ion is done, t he ret ent ion balloon is def lat ed and t he t ip
removed.
2. Barium enema in t he presence of a colost omy
a. See page 711 f or assessment crit eria.
b. Laxat ives can be t aken.
c. Supposit ories are of no value.
d. Follow physician's diet orders.
e. I f irrigat ion is necessary, a preassembled colost omy irrigat ion kit or a
sof t , no. 28, st andard-t ip Foley cat het er at t ached t o a disposable enema
bag may be used.
f. Advise t he pat ient t hat a Foley cat het er is used t o int roduce t he barium
int o t he st oma.
g. The pat ient should bring addit ional colost omy supplies t o t he radiology
depart ment f or posttest use.
3. Pat ient s w it h st omas
a. Pat ient s w it h descending or sigmoid colost omies may need a normal
saline or t ap-w at er irrigat ion t o w ash out t he barium.
b. Advise t hose w ho normally irrigat e t heir colost omy t o w ear a disposable

pouch f or several days unt il all t he barium has passed.
Bile Duct X-Ray (Cholangiography), T-Tube

Cholangiogram, Operative Cholangiogram,
Percutaneous Transhepatic Cholangiogram A
cholangiogram visualizes the bile ducts by enhancing
them with an iodinated contrast agent. Often performed
on the postcholecystectomy patient, the cholangiogram
is used to identify intraductal mass lesions and calculi.
A number of approaches may be used to opacify and
image the bile ducts:
1. T-tube chol angi ogram: Follow ing cholecyst ect omy, a self -ret aining T-shaped
drainage t ube may be surgically insert ed int o t he common bile duct . Bef ore
removal, pat ency is verif ied by inject ing iodinat ed cont rast int o t he T-t ube t o
f ill t he biliary t ree.
2. Chol angi ogram wi th stone removal : This st udy combines diagnost ic
visualizat ion of t he bile duct s w it h t herapeut ic capt ure and removal of duct al
calculi.
3. Intravenous chol angi ography: This st udy allow s radiographic visualizat ion of
t he large hepat ic duct s and t he common duct s by means of int ravenous
inject ion of a cont rast medium. I t is rarely perf ormed.
4. O perati ve chol angi ography: Cannulat ion and inject ion of cont rast medium
int o t he exposed cyst ic duct or common bile duct is perf ormed during
surgery.
5. Percutaneous transhepati c chol angi ography: A needle or small-diamet er
cat het er is percut aneously int roduced int o t he liver and t he bile duct .
Follow ing inject ion of t he cont rast agent , t he hepat ic and common duct s
should be visualized. The dilat ed biliary t ree can be show n up t o t he point of
obst ruct ion, w hich is usually in t he common duct . This procedure is
f requent ly done f or jaundiced pat ient s w hose liver cells are unable t o
t ransport oral or int ravenous cont rast agent s properly.
6. Intravenous chol ecystography: Radiographic visualizat ion of t he gallbladder
is perf ormed af t er int ravenous inject ion of a cont rast agent . I t is rarely
perf ormed.
7. O ral chol ecystography: Radiographic visualizat ion of t he gallbladder is
perf ormed af t er oral administ rat ion of an opaque medium. This t est is of t en
combined w it h or replaced by gallbladder sonography.

8. Endoscopi c retrograde chol angi opancreatography (ERCP): This endoscopic
procedure uses an inject ion of a cont rast agent t o evaluat e t he pat ency of
pancreat ic and common bile duct s, t he duodenal papilla, and t he normalcy of
t he gallbladder (see Chap. 12). O f t en, t he ERCP is perf ormed
t herapeut ically, involving st one ext ract ion, st ent placement , or ot her
t reat ment s.
Reference Values
Normal
Pat ent bile duct s
Procedure for T-Tube Cholangiogram

1. Have t he pat ient lie on t he x-ray t able as an iodine cont rast medium is
inject ed int o t he T-t ube.
2. Be aw are t hat no pain or discomf ort should be f elt ; how ever, some persons
may f eel pressure during t he inject ion.
3. Unclamp t he T-t ube af t er t he procedure and allow it t o drain f reely unless
ot herw ise ordered. This minimizes prolonged, irrit at ing cont act of residual
cont rast in t he bile duct .
care.
Abnormal duct and gallbladder x-ray result s reveal st enosis obst ruct ion or
choledocholit hiasis (bile duct calculi of t he common bile duct ).
Interventions
1. Explain t he purpose and procedure of t he t est . Assure t he pat ient t hat t he
procedure is not painf ul, but some discomf ort or pressure may be f elt w hen
t he cont rast is inject ed. I f t he pat ient is diabet ic, special precaut ions may be
necessary (see page 710).
2. I nst ruct pat ient t o remove st reet clot hing and accessories such as jew elry
bef ore t he st udy. Provide a gow n f or pat ient use.
3. St ress t he import ance of remaining st ill and f ollow ing breat hing inst ruct ions
during t he procedure.
4. Ref er t o iodine t est precaut ions. Assess f emale pat ient s f or pregnancy
st at us. I f posit ive, advise t he radiology depart ment .
5. O mit f ood and f luid bef ore t he examinat ion. Check inst it ut ional prot ocols f or
spe-cif ic diet ary and f luid rest rict ions. A laxat ive may be ordered t he evening
bef ore t he examinat ion.
6. I nf orm t he pat ient and f amily t hat a cholangiogram can be a lengt hy
procedure last ing > 2 hours.
care.

1. Be aw are t hat posttest nausea, vomit ing, and t ransient elevat ed t emperat ure
may occur as a react ion t o t he iodine cont rast .
2. Document observat ions and not if y physician if necessary.
care.
Clin ical Alert

1. Persist ent f ever, especially if associat ed w it h chills, may indicat e bile duct
inf lammat ion.
2. I f t he pat ient has diabet es, assess w het her he or she is t aking
G lucophage/ met f ormin. Due t o an increased risk f or renal f ailure, t his
medicat ion regimen must be discont inued t he day of and several days
af t er administ rat ion of cont rast media. Consult t he radiology depart ment
f or specif ic inst ruct ions.
3. Assess pat ient f or allergies t o all subst ances, specif ically lat ex, and
inf orm t he radiology depart ment of any know n or suspect ed sensit ivit ies
bef ore st udy.
4. Assess w het her pat ient is allergic t o iodine. I f iodine cont rast sensit ivit ies
are know n or suspect ed, inf orm t he radiology depart ment bef ore st udy.
5. Monit or f or hemorrhage, pneumot horax, or perit onit is af t er percut aneous
t ranshepat ic cholangiography. Unusual pain or t enderness, diff icult y
breat hing, or change in vit al signs may signal t hese complicat ions. I f t hese
side eff ect s occur, t ake immediat e act ion t o t reat .
Intravenous Urography (IVU); Excretory Urography or

Intravenous Pyelography (IVP) IVU is one of the most
frequently ordered tests in cases of suspected renal
disease or urinary tract dysfunction.
NOTE
I VU is indicat ed during t he init ial invest igat ion of any suspect ed urologic
problem, especially t o diagnose kidney and uret er lesions and impaired renal
f unct ion.
An int ravenous radiopaque iodine cont rast subst ance is inject ed and
concent rat es in t he urine. Follow ing t his inject ion, a series of x-ray f ilms are
made at predet ermined int ervals over t he next 20 t o 30 minut es. A f inal post void
f ilm is t aken af t er t he pat ient empt ies t he bladder.
These f ilms demonst rat e t he size, shape, and st ruct ure of t he kidneys, uret ers,
and bladder and t he degree t o w hich t he bladder can empt y. Renal f unct ion is
ref lect ed by t he lengt h of t ime it t akes t he cont rast mat erial f irst t o appear and
t hen t o be excret ed by each kidney. Kidney disease, uret eral and bladder
st ones, and t umors can be det ect ed w it h I VU.
CT also may be done in conjunct ion w it h I VU t o obt ain bet t er visualizat ion of
renal lesions. This increases examinat ion t ime. I f kidney t omography or
nephrot omograms are ordered separat ely, t he procedure and preparat ion are t he
same as f or I VU.
Reference Values
Normal
1. Normal size, shape, and posit ion of t he kidneys, uret ers, and bladder.
Normal kidneys are approximat ely as long in dimension as t hree and one half
vert ebral bodies. Theref ore, kidney size is est imat ed in relat ion t o t his rule
of t humb.
2. Normal renal f unct ion
a. Tw o t o 5 minut es af t er t he inject ion of cont rast mat erial, t he kidney
out line appears on an x-ray f ilm. Threadlike st rands of cont rast mat erial
appear in t he calyces.
b. When t he second f ilm is t aken several minut es af t er cont rast inject ion,
t he ent ire renal pelvis can be visualized.
c. Lat er f ilms show t he uret ers and bladder as t he cont rast mat erial makes
it s w ay int o t he low er urinary t ract .
d. No evidence of residual urine should be f ound on t he post void f ilm.
Procedure
1. Take a preliminary x-ray (KUB) w it h t he pat ient in a supine posit ion t o ensure
t hat t he bow el is empt y and t he kidney locat ion can be visualized.
2. I nject t he int ravenous cont rast mat erial, usually int o t he ant ecubit al vein.
3. Alert t he pat ient t hat during and f ollow ing t he int ravenous cont rast inject ion
t hey may experience w armt h, f lushing of t he f ace, salt y t ast e, and nausea.
a. I nst ruct t he pat ient t o t ake slow, deep breat hs should t hese sensat ions
occur. Have an emesis basin and t issue w ipes available. Use st andard
precaut ions w hen handling secret ions.
b. Assess f or ot her unt ow ard signs, such as respirat ory diff icult y,
diaphoresis, numbness, palpit at ions, or urt icaria. Be prepared t o respond
w it h emergency drugs, equipment , and supplies. These it ems should be
readily available w henever t his procedure is perf ormed.
4. Take at least t hree x-ray f ilms at predet ermined int ervals f ollow ing inject ion
of t he cont rast mat erial.
5. Af t er t hese t hree f ilms are t aken, inst ruct t he pat ient t o void bef ore t he f inal
f ilm is made t o det ermine t he abilit y of t he bladder t o empt y.
care.
1. Abnormal I VU f indings may reveal t he f ollow ing condit ions:
a. Alt ered size, f orm, and posit ion of t he kidneys, uret ers, and bladder
b. Duplicat ion of t he pelvis or uret er
c. Presence of only one kidney
d. Hydronephrosis
e. Supernumerary kidney
f. Renal or uret eral calculi (st ones)
g. Tuberculosis of t he urinary t ract
h. Cyst ic disease
i. Tumors
j. Degree of renal injury subsequent t o t rauma
k. Prost rat e enlargement in males
l. Enlarged kidneys suggest ing obst ruct ion or polycyst ic disease kidney
m. Evidence of renal f ailure in t he presence of normal-sized kidneys

suggest ing an acut e rat her t han chronic disease process
n. I rregular scarring of t he renal out lines, suggest ing chronic pyelonephrit is
2. A t ime delay in radiopaque cont rast visualizat ion is indicat ive of renal
dysf unct ion. No cont rast visualizat ion may indicat e very poor or no renal
f unct ion.
Interfering Factors
1. Feces or int est inal gas w ill obscure urinary t ract visualizat ion.
2. Ret ained barium can obscure opt imal view s of t he kidneys. For t his reason,
barium t est s should be scheduled af t er I VU w hen possible.
Interventions
1. Explain t he purpose and procedure of t he t est . A w rit t en reminder may be
helpf ul t o t he pat ient . Screen pat ient s f or pregnancy st at us. I f posit ive,
advise t he radiology depart ment . I f pat ient has diabet es, special precaut ions
may be necessary (see page 710).
2. O bserve iodine cont rast t est precaut ions. Assess f or all allergies and
det ermine prior allergic react ion t o cont rast subst ances. Many radiology
depart ment s require a recent creat inine level f or all pat ient s >40 years of
age bef ore perf orming t his procedure in order t o ensure t he absence of renal
insuff iciency.
3. Because a relat ive st at e of dehydrat ion is necessary f or cont rast mat erial t o
concent rat e in t he urinary t ract , inst ruct t he pat ient t o abst ain f rom al l f ood,
liquid, and medicat ion (if possible) f or 12 hours bef ore examinat ion. Fast ing
af t er t he evening meal t he day bef ore t he t est w ill meet t his crit erion.
4. I nst ruct t he pat ient t o t ake a laxat ive t he evening bef ore t he examinat ion,
and alert t he pat ient t hat he or she may receive an enema t he morning of t he
t est .
a. Pat ient s w it h int est inal disorders such as ulcerat ive colit is should be
given a cat hart ic only w hen specif ied by t he physician.
b. Elderly pat ient s may need assist ance t o t he bat hroom. Be alert f or signs
of w eakness and st ress.
5. Do not give children <7 years of age pret est cat hart ics or enemas. Should
t he preliminary x-ray f ilm show int est inal gas obscuring t he kidneys, a f ew
ounces of inf ant f ormula or carbonat ed beverage may relieve t he
concent rat ion of gas at t hat part icular locat ion.
6. Evaluat e st ool and check f or abdominal dist ent ion t o evaluat e f or possible
barium ret ent ion if it has been used in previous st udies. Addit ional bow el
preparat ion may be necessary.
care.
NOTE
Elderly or debilit at ed pat ient s w it h poor renal reserves may not t olerat e t hese
de-hydrat ion prot ocols (f ast ing, laxat ives, enemas). I n such inst ances, consult
w it h t he radiologist or t he pat ient 's physician t o ascert ain t he proper
procedure. For inf ant s and small children, f ast ing t ime usually varies f rom 6 t o
8 hours pret est . I f in doubt , verif y prot ocols w it h t he radiologist or at t ending
physician.

1. Resume prescribed diet and act ivit y af t er t he examinat ion.
2. Teach and encourage t he pat ient t o drink suff icient f luids t o replace t hose
lost during t he pretest phase.
3. Encourage rest , as needed, f ollow ing t he examinat ion. I nst ruct pat ient s t o
let t heir body t ell t hem about rest needs.
4. O bserve and document mild react ions t o t he iodine mat erial, w hich may
include hives, skin rashes, nausea, or sw elling of t he parot id glands (iodism).
Not if y t he physician if t he signs and sympt oms persist . O ral ant ihist amines
may relieve more severe sympt oms.
care.
Clin ical Alert

1. Cont raindicat ions t o an I VU or I VP include t he f ollow ing condit ions:
a. Hypersensit ivit y or allergy t o iodine preparat ions
b. Combined renal and hepat ic disease
c. O liguria or anuria
d. Renal f ailure: most radiology depart ment s require recent creat inine
t est levels t o det ermine w het her t o administ er cont rast mat erials.
G enerally, creat inine levels >1. 5 mg/ dL (>133 mol/ L) raise suspicion
and signal t he need f or repeat laborat ory w ork. A blood urea nit rogen
(BUN) level > 40 mg/ dL (>14 mmol/ L) also may cont raindicat e t he use
of iodine cont rast .
e. Mult iple myeloma, unless t he pat ient can be adequat ely hydrat ed
during and af t er t he st udy
f. Advanced pulmonary t uberculosis
g. Pat ient s receiving drug t herapy f or chronic bronchit is, emphysema, or
2.
3.
4.
5.
ast hma
h. Congest ive heart f ailure (increased f luid load)
i. Pheochromocyt oma (increased blood pressure)
j. Sickle cell anemia (accelerat ion of sickling pot ent ial, renal f ailure)
k. Diabet es, especially diabet es mellit us
I f pat ient has diabet es, assess w het her he or she is t aking
G lucophage/ met f ormin. Due t o an increased risk f or renal f ailure and lact ic
acidosis, t his medicat ion regimen must be discont inued t he day of and
several days af t er administ rat ion of cont rast media. Consult t he radiology
depart ment f or specif ic inst ruct ions.
Some physiologic changes can be expect ed af t er radiopaque iodine
inject ions. Hypert ension, hypot ension, t achycardia, arrhyt hmias, or ot her
elect rocardiographic (ECG ) changes may occur.
An iodine-based cont rast medium is given w it h caut ion in t he presence of
hypert hyroidism, ast hma, hay f ever, or ot her allergies.
O bserve f or anaphylaxis or severe react ions t o iodine, as evidenced by
shock, respirat ory dist ress, precipit ous hypot ension, f aint ing, convulsions,
or act ual cardiopulmonary arrest . Resuscit at ion supplies and equipment
should be readily available.
P.
6. I n all cases except emergencies, a cont rast medium should not be inject ed
sooner t han 90 minut es af t er eat ing.
7. I nt ravenous iodine can be highly irrit at ing t o t he int imal layer of t he veins
and may cause painf ul vascular spasm. I f t his occurs, a 1% procaine
int ravenous inject ion may relieve vascular spasm and pain. Somet imes
local vascular irrit at ion is severe enough t o induce t hrombophlebit is. Warm
or cold compresses t o t he area may relieve pain; how ever, t hese do not
prevent sloughing. The at t ending physician should be not if ied.
Ant icoagulant t herapy may need t o be inst it ut ed.
8. Local react ions t o iodine may be evidenced by ext ensive redness,
sw elling, and pain at t he inject ion sit e. Even a small amount of iodine
cont rast ent ering subcut aneous t issues can cause t issue sloughing, w hich
may require skin graf t ing. Radiographic evidence of iodine cont rast
leakage w it hin sof t t issues surrounding t he inject ion sit e conf irms
ext ravasat ion. Treat ment may include a local inf ilt rat ion of hyaluronidase.
9. Assess f or lat ex allergy and inf orm t he radiology depart ment of any know n
or suspect ed sensit ivit ies bef ore st udy.
Other Tests Used to Examine the Urinary System
1. Excreti on urography or i ntravenous pyel ography (IVP): Af t er inject ion of an

int ravenous cont rast agent , t he collect ing syst em (ie, calyces, pelvis, and
uret er) of each kidney is progressively opacif ied. Radiographs are made at
5- t o 15-minut e int ervals unt il t he urinary bladder is visualized.
2. Dri p i nf usi on pyel ography: This is a modif icat ion of convent ional
pyelography. An increased volume of cont rast agent is administ ered by
cont inuous int ravenous inf usion.
3. Cystography: The urinary bladder is opacif ied by means of a cont rast agent
inst illed t hrough a uret hral cat het er. Af t er t he pat ient voids, air may be
int roduced int o t he bladder t o obt ain a double-cont rast st udy.
4. Retrograde cystourethrography: Af t er cat het erizat ion, t he bladder is f illed t o
capacit y w it h a cont rast agent , and radiography is used t o visualize t he
bladder and uret hra.
5. Voi di ng cystourethrography: Af t er cont rast mat erial has been inst illed int o
t he urinary bladder, f ilms are made of t he bladder and uret hra during t he
process of voiding.
Retrograde Pyelography and Other Tests to Examine

the Urinary System Retrograde pyelography generally
confirms IVU findings and is indicated when IVU yields
insufficient results because of kidney nonvisualization
(congenital kidney absence), decreased renal blood
flow that impairs renal function, obstruction, kidney
dysfunction, presence of calculi, or patient allergy to
intravenous contrast material. This x-ray examination
of the upper urinary tract begins with cystoscopy to
introduce ureteral catheters up to the level of the renal
pelvis. Following this, iodine contrast is injected into
the ureteral catheter, and x-ray films are then taken.
The chief advantage of retrograde pyelography lies in
the fact that the contrast substance can be indirectly
injected under controlled pressure so that optimal
visualization is achieved. Renal function impairment
does not influence the degree of visualization.
Reference Values
Normal
Normal cont our and size of uret ers and kidneys
Procedure
1. This examinat ion is usually done in t he surgical depart ment in conjunct ion
w it h cyst oscopy (see Chap. 12).
2. Sedat ion and analgesia may precede insert ion of a local anest het ic int o t he
uret hra (see Cyst oscopy in Chap. 12). G eneral anest hesia may be required if
t he pat ient is not able t o cooperat e f ully w it h t he procedure.
care.
Urinary syst em x-ray result s may reveal t he f ollow ing condit ions:
1. I nt rinsic abnormalit y of uret ers and kidney pelvis (eg, congenit al def ect s)
2. Ext rinsic abnormalit y of t he uret ers (eg, obst ruct ive t umor or st ones)
Interfering Factors
Because barium may int erf ere w it h t est result s, t hese st udies must be done
bef ore barium x-rays are perf ormed.
Interventions
1. Explain t he purpose and procedure of t he t est . Screen f emale pat ient s f or
pregnancy st at us. I f posit ive, advise t he radiology depart ment .
2. Be aw are t hat t he pat ient or ot her aut horized person must sign and have
w it nessed a legal consent f orm bef ore examinat ion in t he operat ing room.
3. Follow iodine cont rast t est precaut ions. A recent creat inine level may be
required by t he radiology depart ment t o evaluat e t he kidney's abilit y t o clear
t he cont rast .
4. Have t he pat ient f ast f rom f ood and f luids af t er midnight bef ore t he t est .
5. Administ er cat hart ics, supposit ories, or enemas as ordered.

care.

1. O bserve pat ient f or signs of allergic react ion t o iodine cont rast .
2. Check vit al signs f requent ly f or t he f irst 24 hours f ollow ing t he t est . Follow
inst it ut ional prot ocols if general anest het ics w ere administ ered.
3. Record accurat e urine out put and appearance f or 24 hours f ollow ing t he
procedure. Hemat uria or dysuria may be common af t er t he examinat ion. I f
hemat uria does not clear and dysuria persist s or w orsens, not if y t he
physician. I nst ruct t he pat ient t o do t he same.
4. Administ er analgesics as necessary. Discomf ort may be present immediat ely
f ollow ing t he examinat ion and may require a prescript ive analgesic (eg,
codeine).
care.
Clin ical Alert

1. Renal f unct ion t est s of blood and urine must be complet ed bef ore t his
examinat ion is done.
2. Assess w het her t he pat ient is allergic t o iodine. I f iodine cont rast
sensit ivit ies are know n or suspect ed, inf orm t he radiology depart ment
bef ore st udy.
3. Ref er t o Clinical Alert s post ed in t he t ext f or Cyst oscopy in Chapt er 12.
Arthrography (Joint X-Ray) Arthrography involves

multiple x-ray examinations of encapsulated joint
structures following injection of contrast agents into
the joint capsular space. Arthrography is done in cases
of persistent, unexplained joint discomfort. Although
the knee is the most frequently studied joint, the
shoulder, hip, elbow, wrist, temporomandibular joint,
and other joints may also be examined. Local

anesthetics are used, and aseptic conditions are
observed.
Reference Values
Normal
Normal f illing of encapsulat ed joint st ruct ures, joint space, bursae, menisci,
ligament s, and art icular cart ilage
Procedure
1. Posit ion t he pat ient on t he examining t able.
2. Surgically prepare and drape t he skin around t he joint .
3. I nject a local anest het ic int o t issues around t he joint . I t is usually
unnecessary t o anest het ize t he act ual joint space.
4. Aspirat e any eff usion f luids present in t he joint . I nject t he cont rast agent s
(eg, gas, w at er, soluble iodine). Remove t he needle, and manipulat e t he joint
t o ensure even dist ribut ion of t he cont rast mat erial. I n some cases, ask t he
pat ient t o w alk or exercise t he joint f or a f ew minut es.
5. Remember t hat during t he examinat ion, several posit ions are assumed t o
obt ain various x-ray view s of t he joint .
6. Be aw are t hat a special f rame may be at t ached t o t he ext remit y t o w iden t he
joint space f or a bet t er view. Pillow s and sandbags also may be used t o
posit ion t he joint properly.
care.
Abnormal joint x-ray result s reveal t he f ollow ing condit ions:
1. Art hrit is
2. Dislocat ion
3. Ligament t ears
4. Rot at or cuff rupt ure
5. Synovial abnormalit ies
6. Narrow ing of joint space

7. Cyst s
Interventions
1. Explain t he purpose and procedure of t he t est . Advise t he pat ient t hat some
discomf ort is normal during cont rast inject ion and joint manipulat ion.
2. Remember t hat in most inst ances, a properly signed and w it nessed consent
f orm is required.
3. Ref er t o iodine t est precaut ions on pages 707710. Check f or know n
allergies t o iodine, ot her cont rast subst ances, and lat ex.
4. Advise pat ient t o bring any prior x-ray f ilms of t he joint in quest ion t o t he
art hrogram appoint ment .
care.

1. The joint should be rest ed f or 12 hours.
2. An elast ic bandage may be applied t o t he knee joint f or several days af t er
t he examinat ion.
3. I ce can be applied t o t he area if sw elling occurs. Pain can usually be
cont rolled w it h a mild analgesic.
4. Cracking or clicking noises in t he joint may be heard f or 1 or 2 days
f ollow ing t he t est . This is normal. Not if y t he physician if crepit ant noises
persist or if increased pain, sw elling, or rest lessness occurs.
care.
Clin ical Alert

I f diabet ic pat ient is t aking G lucophage/ met f ormin, special considerat ions may
be necessary. Consult w it h t he radiology depart ment t o det ermine w het her
t his medicat ion regimen must be discont inued t he day of and several days
af t er t he st udy.
Myelography, Myelogram, Spinal Cord X-Ray

Myelography is a radiographic study of the spinal
subarachnoid space in which iodine contrast material
is introduced into that space so that the spinal cord
and nerve roots are outlined and dura mater distortions
can be detected.
This st udy is done t o det ect neoplasms, rupt ured int ravert ebral disks, or
ext raspinal lesions such as art hrit ic st enosis or ankylosing spondyloses. This
examinat ion is also indicat ed w hen compression of t he spinal or post erior f ossa
neural st ruct ure or nerve root s is suspect ed. The t est is f requent ly done bef ore
surgical t reat ment f or a rupt ured vert ebral disk or release of st enosis.
Sympt oms may include unrelieved back pain, pain radiat ing dow n t he leg, absent
or abnormal ankle and knee ref lexes, claudicat ion of neurospinal origin, or past
hist ory of cancer w it h loss of mobilit y or bladder cont rol.
Myelograms f all int o t hree cat egories: posit ive cont rast s using w at er-soluble
iodine, iodized oil cont rast , and negat ive air cont rast . Wat er-soluble iodine
cont rast is t he most commonly used medium f or myelograms and is of t en
f ollow ed by CT scanning t o improve visualizat ion. I n low -dose myelograms,
inject ion of a very small amount of w at er-soluble cont rast is immediat ely
f ollow ed by scanning.
Reference Values
Normal
Normal lumbar, cervical, or t horacic myelogram
Procedure
1. The t est is usually done in t he radiography depart ment w it h t he pat ient
posit ioned on his or her abdomen during t he procedure.
2. Prepare and drape t he punct ure area.
3. The procedure is t he same as t hat f or lumbar punct ure (see Chap. 5), except
f or t he inject ion of t he cont rast subst ance and f luoroscopic x-ray f ilms. Wit h
t he use of w at er-soluble cont rast , a narrow -bore needle (22-gauge) may be
used. A lumbar punct ure is done w hen a lumbar def ect is suspect ed; a
cervical punct ure is done f or a suspect ed cervical lesion. I n children, t he
level at w hich t he lumbar punct ure is perf ormed is much low er t han t he level
in adult s t o
avoid punct uring t he spinal cord. Depending on t he cont rast subst ance used,
it may be removed (oil) or lef t t o be absorbed (w at er or air).
4. Tilt t he t able during t he procedure t o achieve opt imal visualizat ion. Use
shoulder and f oot braces t o maint ain correct posit ion.
care.
Abnormal myelogram result s reveal dist ort ed out lines of t he subarachnoid space
t hat indicat e t he f ollow ing condit ions:
1. Rupt ured int ervert ebral disk
2. Compression and st enosis of spinal cord
3. The exact level of int ravert ebral t umors
4. Spinal canal obst ruct ion
5. Avulsion of nerve root s
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he t est . Explain t hat
some discomf ort may be f elt during t he procedure. Disadvant ages of w at er
and air cont rast include poor visualizat ion and painf ul headache (air cont rast )
because of t he diff icult y in cont rolling t he gas int roduced int o t he area. O il
cont rast subst ances can cause t issue irrit at ion or can be poorly absorbed
f rom t he subarachnoid space. O il may remain visible on x-ray examinat ion f or
up t o 1 year f ollow ing t he original examinat ion. For t hese reasons, oil and air
cont rast are rarely used. Ref er t o iodine cont rast t est precaut ions if iodine is
used (see pages 707710).
2. Be aw are t hat a legal consent f orm must be properly signed and w it nessed
3. Assess pregnancy st at us of f emale pat ient s. Advise t he radiology
depart ment if posit ive.
4. Explain t hat t he examinat ion t able may be t ilt ed during t he t est but t hat t he
pat ient w ill be securely f ast ened and w ill not f all off t he t able.
5. Most diagnost ic depart ment s require t he pat ient t o ref rain f rom eat ing f or
about 4 hours bef ore t est ing. Clear liquids may be permit t ed and even
encouraged t o low er t he incidence of headaches af t er t he t est . Check w it h
t he radiology depart ment and physician f or specif ic orders.
6. I nf orm t he pat ient t hat a myelogram usually produces some discomf ort . I f t he
pat ient has t rouble moving, a pain reliever may be necessary t o allow easier
posit ioning and movement during t he t est .
care.

1. Bed rest is necessary f or 4 t o 24 hours af t er t est ing. I f a w at er-soluble
cont rast is used, t he head of t he bed should be elevat ed at 45 degrees f or 8
t o 24 hours af t er t he procedure. The pat ient is also advised t o lie quiet ly.
This posit ion reduces upw ard dispersion of t he cont rast medium and keeps it
out of t he head, w here it may cause headache. I f oil cont rast dye is used,
t he pat ient usually must lie prone f or 2 t o 4 hours and t hen remain on his or
her back f or anot her 2 t o 4 hours. I f t he ent ire amount of oil cont rast is not
w it hdraw n at t he end of t he procedure, t he head must be elevat ed t o prevent
t he oil f rom f low ing int o t he brain.
2. Encourage f luid int ake t o hast en absorpt ion of residual cont rast mat erial, t o
replace cerebrospinal f luid, and t o reduce risk f or headache and unusual or
met allic t ast e.
3. Check f or bladder dist ent ion and adequat e voiding, especially if met rizamide
has been used.
4. Check vit al signs f requent ly (at least every 4 hours) f or t he f irst 24 hours
af t er t he examinat ion.
care.
Clin ical Alert

1. O bserve t he pat ient f or possible complicat ions such as cont inued nausea
and vomit ing, headache, f ever, seizure, paralysis of one side of t he body
or bot h arms or legs (rare), arachnoidit is (inf lammat ion of t he spinal cord
coverings), change in level of consciousness, hallucinat ions, drow siness,
st upor, neck st iff ness, and st erile meningit is react ion (severe headache,
sympt oms of arachnoidit is, slow -w ave pat t erns on elect roencephalogram).
2. Alt erat ion of cerebrospinal f luid pressure may cause an acut e
3.
4.
5.
6.
7.
8.
exacerbat ion of sympt oms t hat may require immediat e surgical

int ervent ion. Lumbar punct ures should not be done unless absolut ely
necessary.
This t est is t o be avoided unless t here is a reason t o suspect a lesion.
Mult iple sclerosis, f or example, may be w orsened by t his procedure.
Det ermine w het her w at er-soluble, oil, or air cont rast w as used f or t he
procedure because posttest int ervent ions diff er.
I f nausea or vomit ing occurs af t er t he procedure and a w at er-soluble
cont rast has been used, do not administ er phenot hiazine ant iemet ics such
as prochlorperazine (Compazine).
Assess w het her t he pat ient is allergic t o lat ex or iodine and inf orm t he
radiology depart ment of any know n or suspect ed sensit ivit ies bef ore
st udy.
I f pat ient has diabet es, assess w het her pat ient is t aking
G lucophage/ met f ormin. Because of an increased risk f or renal f ailure and
lact ic acidosis, t his medicat ion regimen may need t o be discont inued t he
day of and several days af t er administ rat ion of cont rast media. Consult
t he radiology depart ment f or specif ic inst ruct ions.
Many radiology depart ment s require t he discont inuat ion of w arf arin sodium
(Coumadin) t herapy f or several days bef ore perf ormance of a myelogram.
O f t en, a prot hrombin t ime is required bef ore beginning t he examinat ion.
Hysterosalpingography (Uterine and Fallopian Tube XRays) Hysterosalpingography involves radiographic

visualization of the uterine cavity and the fallopian
tubes to detect abnormalities that may be the cause of
infertility or other problems. Normally, a contrast agent
introduced into the uterine cavity will travel through
the fallopian tubes and spill into the peritoneal
cavity, where it will be naturally reabsorbed.
Reference Values
Normal
Normal int raut erine cavit y Pat ent f allopian t ubes
Procedure
1. Have t he pat ient remove all clot hing and put on a hospit al gow n. The bladder
should be empt ied bef ore t he st udy begins.
2. Have t he pat ient lie supine on t he x-ray t able in a lit hot omy posit ion.
Preliminary pelvic x-ray f ilms may be t aken.
3. The radiologist or gynecologist int roduces a speculum int o t he pat ient 's
vagina and insert s a cannula t hrough t he cervical canal. Administ er t he
iodinat ed cont rast agent int o t he ut erus t hrough t his cannula.
4. Remove t he speculum (unless it is radiolucent ), and perf orm bot h
f luoroscopic and convent ional f ilms.
care.
Abnormal ut erine and f allopian t ube x-ray f indings include t he f ollow ing
condit ions:
1. Bicornuat e ut erus or ot her ut erine cavit y anomalies
2. Tubal t ort uosit y
3. Tubal obst ruct ion evidenced by f ailure of t he cont rast dye t o spill int o t he
perit oneal cavit y on one or bot h sides (bilat eral t ubal obst ruct ion causes
inf ert ilit y).
4. Scarring and evidence of old pelvic inf lammat ory disease.
Interventions
1. Explain t est purpose and procedure. Some inst it ut ions require a properly
signed and w it nessed inf ormed consent .
2. Ref er t o iodine cont rast t est precaut ions on pages 707710.
3. Verif y dat e of last menst rual period t o ensure t hat t he pat ient is not
pregnant .
4. Advise pat ient t hat some discomf ort may be experienced but subsides
quickly.
5. Suggest t hat t he pat ient bring along sanit ary napkins t o w ear because some
spot t ing and cont rast dye discharge may occur.
care.
Clin ical Alert

1. Pregnancy, act ive vaginal bleeding, and act ive pelvic inf lammat ory disease
are cont raindicat ions t o hyst erosalpingography. I t is best t o perf orm t his
t est 710 days af t er t he onset of menses.
2. I f pat ient has diabet es and is t aking G lucophage/ met f ormin, special
considerat ions may be necessary. Consult w it h t he radiology depart ment
t o det ermine w het her t his medicat ion regimen must be discont inued t he
day of and several days af t er t he st udy.
3. Assess w het her pat ient is allergic t o lat ex, and inf orm t he radiology
depart ment of any know n or suspect ed sensit ivit ies bef ore st udy.
4. Assess w het her pat ient is allergic t o iodine. I f iodine cont rast sensit ivit ies
are know n or suspect ed, inf orm t he radiology depart ment prior t o st udy.

1. Monit or pat ient f or discomf ort and administ er analgesics as ordered.
2. I nst ruct t he pat ient t o report heavy vaginal bleeding, abnormal discharge,
unusual pain, or f ever t o t he ref erring physician.
3. I nt erpret t est out comes and counsel about inf ert ilit y problems.
care.
Angiography (Digital Subtraction Angiography [DSA],

Transvenous Digital Subtraction, Vascular X-Ray)
Digital angiography is a computer-based imaging
method of performing vascular studies that require
catheterization of certain venous or arterial vessels.
Vasculature studies include the carotid vessels;
intracranial vessels; those vessels originating from the
aortic arch; abdominal vessels,
including the celiac, renal, and mesenteric branches;

and other peripheral vessels. Digital subtraction
angiography began as an intravenous technique, but
because of its limitations, other methods of iodine
contrast administration may be employed. Although
carrying a greater complication risk, intraarterial
injection can be used for detailed visceral studies. The
presence of the contrast material blocks the path of xrays and makes blood vessels visible. An image taken
just before contrast injection is subtracted from that
taken when the contrast material is actually within the
vascular system. The resulting image shows only the
distribution of the contrast substance. Digital
subtraction is used to isolate a clinically relevant
subset of information and is particularly useful in
preoperative and postoperative evaluations for
vascular and tumor surgery.
Visualizat ion of t he carot id and vert ebral vasculat ure is possible in pat ient s w it h
a hist ory of st roke, t ransient ischemic at t acks, bruit , or subarachnoid
hemorrhage. The procedure may be used as an adjunct t o CT or magnet ic
resonance scanning and may be perf ormed just bef ore t hese st udies in persons
w ho have evidence of an aneurysm, vascular malf ormat ion, or hypervascular
t umor. O f t en, a bi-plane imaging device is used, producing simult aneous
images 90 degrees apart .
The st udy names are derived f rom t he vascular st ruct ure st udied and t he st udy
met hod used. Arteri ography ref ers t o cont rast agent st udies of art erial vessels.
Venous st ruct ures may also be visualized as t hese procedures progress.
Venography is t he cont rast agent st udy of peripheral or cent ral veins.
Lymphography st udies lymph vessels and nodes. Angi ocardi ography invest igat es
t he int erior of t he heart and adjacent great vessels such as t he pulmonary
art eries. Aortography ref ers t o a cont rast st udy of aort ic segment s such as t he
t horacic aort a (thoraci c aortography), t he abdominal aort a (abdomi nal
aortography), or t he lumbar aort a (l umbar aortography).
Angiographic examinat ions also can be named f or t he rout e used t o inject t he
cont rast subst ance. For example, renal arteri ography is perf ormed by insert ing a
cat het er int o t he abdominal aort a and t hen direct ing it int o t he renal art ery.
During peri pheral arteri ography, t he cont rast is inject ed direct ly int o t he vessel
being st udied (eg, f emoral art ery). I f done t hrough t he venous rout e, a large
bolus of cont rast medium is direct ly inject ed int o a peripheral vein (eg, venous
aort ography). X-ray f ilms are t aken t o t rack t he f low of cont rast t hrough t he
right side of t he heart , t he lungs, and t he lef t side of t he heart .
Reference Values
Normal
Normal carot id art eries, vert ebral art eries, abdominal aort a and it s branches,
renal art eries, and peripheral art eries
Procedure
1. Cleanse, prepare, and inject t he vascular access area w it h a local
anest het ic, using t he st erile t echnique. Depending on t he t ype of st udy and
pat ient f act ors, t his is commonly t he groin or t he ant ecubit al area of t he arm.
Follow st andard precaut ions.
2. Advance t he cat het er cont aining a guide w ire int o t he desired vessel or right
at rium of t he heart . Remove t he guide w ire, and connect t he cat het er t o a
pow er inject or t hat administ ers iodine under pressure in def ined quant it ies
and at prescribed int ervals. Take x-ray images and st ore on digit al or f ilm
media. Therapeut ic procedures such as angioplast y, ablat ions, and st ent
placement may be done in concert w it h t his examinat ion.
3. Remove t he cat het er af t er t he procedure is t erminat ed.
4. Place a dressing over t he insert ion sit e, and apply manual pressure t o t he
punct ure sit e f or about 5 minut es or unt il bleeding st ops. Tape a more
permanent pressure dressing in place; t his usually can be removed in 24
hours.
5. Monit or t he pat ient f requent ly f or hemorrhage or hemat oma f ormat ion.
care.
Abnormal digit al subt ract ion angiography result s reveal t he f ollow ing condit ions:
1. Art erial st enosis
2. Large aneurysms
3. I nt ravascular or ext ravascular t umors or ot her masses
4. Tot al occlusion of art eries

5. Thoracic out let syndrome
6. Large or cent ral pulmonary emboli
7. Ulcerat ive plaque
8. Tumor circulat ion
Interfering Factors
1. Because t his examinat ion is very sensit ive t o physical movement , mot ion
art if act w ill produce poor images. Consequent ly, uncooperat ive or agit at ed
pat ient s cannot be st udied. Even t he act of sw allow ing result s in
unsat isf act ory images. Measures t o reduce sw allow ing, such as breat h
holding, using a bit e block, or exhaling t hrough a st raw, do not alw ays yield
sat isf act ory result s.
2. Vessel overlap of ext ernal and int ernal carot id art eries makes it almost
impossible t o obt ain a select view of a specif ic carot id art ery because
cont rast f ills bot h art eries almost simult aneously.
Clin ical Alert

1. These t est s should be used caut iously in pat ient s w it h renal insuff iciency
or unst able cardiac disease. Assess f or cont raindicat ions t o iodinat ed
cont rast drugs list ed on page 709.
2. I n t he presence of diabet es, assess w het her t he pat ient is t aking
G lucophage/ met f ormin. Due t o an increased risk f or renal f ailure and lact ic
acidosis, t his medicat ion regimen must be discont inued t he day of and
several days af t er administ rat ion of cont rast media. Consult t he radiology
depart ment f or specif ic inst ruct ions.
Interventions
1. Explain t est purpose and procedure and document inst ruct ions given.
Reinf orce explanat ion of t est benef it s and risks.
2. Ensure t hat t he pat ient is coherent and cooperat ive and able t o hold his or
her breat h and remain absolut ely st ill w hen so inst ruct ed.
3. Be aw are t hat a legal consent f orm must be properly signed and w it nessed.
4. Ref er t o iodine cont rast t est precaut ions (see pages 707710).
5. Det ermine w het her t he pat ient has any know n allergies, especially t hose t o
iodine, cont rast media, or lat ex. See pages 706711 f or addit ional
assessment crit eria.
6. Assess pregnancy st at us of f emale pat ient s. I f posit ive, advise t he radiology
depart ment .
7. Ensure t hat preprocedure laborat ory w ork is perf ormed in accordance w it h
depart ment al st andards. This generally w ill include t he f ollow ing t est s:
a. Prot hrombin t ime draw n on day of procedure f or any pat ient s on
ant icoagulat ion t herapy (eg, w arf arin sodium [ Coumadin] )
b. Creat inine levels f or all pat ient s
c. Recent prot hrombin t ime and part ial t hromboplast in t ime (PT/ PTT) and
plat elet count (generally w it hin 30 days)
8. I n many inst ances, administ er glucagon int ravenously just bef ore abdominal
examinat ions. This serves t o reduce mot ion art if act s by st opping perist alsis.
9. Remember t hat t he f ew risks include venous t hrombosis and inf ect ion. When
cont rast is administ ered t hrough t he venous rout e, t he art eriesw hich are
normally under higher pressure t han t he veinscan clear t he cont rast agent
t hrough t he process of normal circulat ion. For t he same reason, t here is less
risk f or loosening plaques.
10. Advise pat ient t hat no f ood or f luids should be t aken w it hin 2 hours bef ore
t he st udy t o minimize vomit ing if an iodine cont rast react ion occurs.
11. Be aw are t hat all art eries in a specif ic area can be visualized during one
series of exposures. This overview gives t he advant age of being able t o
evaluat e t he ent ire blood supply t o a given area at one t ime. I n cont rast ,
during rout ine angiography, only one specif ic art ery at a t ime can be
visualized.
care.

1. Check vit al signs f requent ly. Report unst able signs t o t he physician.
2. O bserve t he cat het er insert ion sit e f or signs of inf ect ion, hemorrhage, or
hemat oma. Use st erile asept ic t echnique at all t imes. Monit or neurovascular
st at us of t he ext remit y. Report problems t o t he physician prompt ly.
3. O bserve f or allergic react ions t o iodine. Mild side eff ect s include nausea,
vomit ing, dizziness, and urt icaria. Also w at ch f or ot her complicat ions such as
abdominal pain, hypert ension, congest ive heart f ailure, angina, myocardial
inf arct ion, and anaphylaxis. I n suscept ible persons, renal f ailure may occur
because higher doses of cont rast mat erials are given compared w it h
convent ional art eriograms. Resuscit at ion equipment and emergency supplies
should be readily available. I mmediat ely report t hese condit ions t o t he
physician.
4. I nst ruct t he pat ient t o increase f luid int ake t o at least 2000 mL during t he 24
hours f ollow ing t he procedure t o f acilit at e excret ion of t he iodine cont rast
subst ance.
care.
Clin ical Alert

1. The cat het er punct ure sit e must be observed f requent ly and closely f or
hemorrhage, pseudoaneurysm, or hemat oma f ormat ion. These can be
serious complicat ions and require immediat e at t ent ion should t hey occur.
Many such pat ient s received ant icoagulant s bef ore t he procedure.
2. Vit al sign assessment , punct ure sit e assessment , and neurovascular
assessment s may need t o be done as f requent ly as every 15 minut es f or
t he f irst f ew hours af t er t he procedure. Neurovascular assessment s
include evaluat ion of color, mot ion, sensat ion, capillary ref ill t ime, pulse
qualit y, and t emperat ure (w arm or cool) of t he aff ect ed ext remit y.
Compare t he aff ect ed ext remit y w it h t he nonaff ect ed ext remit y.
3. Review t he chart or quest ion t he pat ient or physician regarding def icit s
t hat w ere present bef ore t he procedure t o est ablish baseline levels of
circulat ory f unct ion. Report post procedure changes immediat ely.
4. I f an art erial punct ure w as perf ormed, t he aff ect ed ext remit y must not be
bent f or several hours, and t he pat ient must lie f lat ot her t han a pillow
under t he head. Do not raise t he head of t he bed or cart because t his can
put a st rain on a f emoral punct ure sit e. The pat ient may t urn if t he
aff ect ed ext remit y is maint ained in a st raight posit ion w it hout
P.
put t ing st rain on t he f emoral punct ure sit e. I f needed, a f ract ure bedpan
can lessen st rain on a groin punct ure sit e.
5. I f bleeding or hemat oma occurs, apply pressure t o t he sit e. Somet imes
sandbags may be applied t o t he punct ure sit e as a rout ine part of
post procedure prot ocols.
6. Maint ain a f unct ional int ravenous access sit e. Usually, t he pat ient w ill
ret urn t o t he nursing unit w it h an I V in place.

7. A Doppler device may reveal audible pulse sounds if pulses are
nonpalpable.
8. Sudden onset of pain, numbness or t ingling, great er degree of coolness,
decreased or absent pulses, and blanching of ext remit ies are alw ays cues
t o not if y t he physician immediat ely. These signs can indicat e art erial
occlusion, w hich may require rapid surgical int ervent ion.
Lymphangiography (X-Rays of Lymph Nodes and

Vessels) Lymphangiography examines the lymphatic
channels and lymph nodes by means of radiopaque
iodine contrast injected into the small lymphatics of
the foot. This test is commonly ordered for patients
with Hodgkin's disease or cancer of the prostate to
check for nodal involvement. Lymphangiography is
also indicated to evaluate edema of an extremity
without known cause, to determine the extent of
adenopathy, to stage lymphomas, and to localize
affected nodes as part of surgical or radiotherapeutic
treatment.
Reference Values
Normal
Normal lymphat ic vessels and nodes
Procedure
1. Place t he pat ient in t he supine posit ion on t he x-ray t able.
2. I nject a blue cont rast int radermally bet w een each of t he f irst t hree t oes of
each f oot t o st ain t he lymphat ic vessels.
3. Make a 1- t o 2-inch incision on t he dorsum of each f oot af t er t he sit e is
inf ilt rat ed w it h local anest het ic.
4. I dent if y and cannulat e t he lymphat ic vessel t o f acilit at e ext remely low pressure inject ion of t he iodine cont rast medium.
5. Discont inue t he inject ion w hen t he cont rast medium reaches t he level of t he
t hird and f ourt h lumbar vert ebrae as seen on f luoroscopy.

6. O bserve t hat abdominal, pelvic, and upper body f ilms demonst rat e t he
lymphat ic vessels f illing.
7. O bt ain a second set of f ilms 12 t o 24 hours lat er t o demonst rat e f illing of t he
lymph nodes.
8. View t he nodes in t he inguinal, ext ernal iliac, common iliac, and periaort ic
areas, as w ell as t he t horacic duct and supraclavicular nodes, using t his
procedure.
9. Be aw are t hat w hen a lymphat ic of t he hand is inject ed, t he axillary and
supraclavicular nodes should be visible.
10. Because t he cont rast dye remains present in t he nodes f or 6 mont hs t o 1
year af t er lymph-angiography, repeat st udies can be done t o t rack disease
act ivit y and t o monit or t reat ment w it hout t he need t o repeat cont rast
inject ion. The pat ient may need t o have addit ional f ilms t aken.
care.
Abnormal lymph node and vessel x-ray result s indicat e t he f ollow ing condit ions:
1. Ret roperit oneal lymphomas associat ed w it h Hodgkin's disease
2. Met ast asis t o lymph nodes
3. Abnormal lymphat ic vessels
Interventions
1. Explain t est purpose and procedure. O bt ain a signed, w it nessed consent
f orm.
2. See iodine cont rast t est precaut ions on pages 707710.
depart ment .
4. Tell pat ient t hat no f ast ing is necessary. Usual medicat ions can be t aken.
5. I nst ruct t he pat ient t hat he or she may f eel some discomf ort w hen t he local
anest het ic is inject ed int o t he f eet .
6. Administ er oral ant ihist amines per physician orders if allergy t o t he iodized
cont rast agent s is suspect ed.
care.

1. Check and record t he pat ient 's t emperat ure every 4 hours f or 48 hours af t er
t he examinat ion.
2. Provide a rest f ul environment .
3. I f ordered, elevat e t he legs t o prevent sw elling.
4. Wat ch f or complicat ions such as delayed w ound healing, inf ect ion, ext remit y
edema, allergic dermat it is, headache, sore mout h and t hroat , skin rashes,
t ransient f ever, lymphangit is, and oil embolism.
care.
Clin ical Alert

1. Lymphangiography is usually cont raindicat ed in t he f ollow ing condit ions:
a. Know n iodine hypersensit ivit y
b. Severe pulmonary insuff iciency
c. Cardiac disease
d. Advanced renal or hepat ic disease
2. The major complicat ion of t his procedure relat es t o cont rast media
embolizat ion int o t he lungs. This w ill diminish pulmonary f unct ion
t emporarily and, in some pat ient s, may produce lipid pneumonia. The
pat ient may require aggressive respirat ory management if t his
complicat ion is lif e-t hreat ening.
4. Assess w het her pat ient is allergic t o l atex, and inf orm radiology
depart ment of any know n or suspect ed sensit ivit ies bef ore st udy.
5. Assess w het her pat ient is allergic t o i odi ne. I f iodine cont rast sensit ivit ies
are know n or suspect ed, inf orm t he radiology depart ment bef ore st udy.
COM PUTED TOM OGRAPHY (CT) Computed tomography

(CT), also called CT scanning, computerized
tomography, or computerized axial tomography (CAT),
produces x-rays similar to those used in conventional
radiography; how ever, CT scans are taken w ith a
special scanner system. Conventional x-rays pass
though the body and produce an image of bone, soft
tissues, and air. With CT scans, a computer provides
rapid complex calculations that determine the extent to
w hich tissues absorb multiple x-ray beams. CT is
unique because it can produce cross-sectional images
(ie, slices) of anatomic structures w ithout
superimposing tissues on each other. Additionally, CT
can discern the different characteristics of tissue
structures w ithin solid organs. Agents may be used for
delineation of blood vessels, the opacification of
certain tissue (eg, kidneys), demonstration of bow el,
and blood flow patterns.
The pat ient lies on a mot orized t able posit ioned inside a doughnut -shaped f rame
called t he gantry. The gant ry cont ains t he x-ray t ubes, w hich rot at e around t he
pat ient during t he scan. By rot at ing t he narrow -beamed x-ray source around t he
pat ient 's body, mult iple at t enuat ion readings are gat hered and processed by t he
comput er. The display, similar t o a convent ional radiograph, demonst rat es
varying densit ies t hat correspond t o t he absorpt ion of x-rays by t he pat ient 's
anat omy. As w it h t radit ional x-ray t echniques, bones appear w hit e, and gas and
f at appear black. How ever, w it h CT, discret e diff erences in at t enuat ion can be
quanti f i ed. This means a CT scan can demonst rat e minor diff erences in densit y
and composit ion in shades of gray. A CT scan can diff erent iat e t umors f rom sof t
t issues, air space f rom cerebrospinal f luid, and normal blood f rom clot t ed blood.
By int erpret ing t he scan, st ruct ures are ident if ied by appearance, shape, size,
symmet ry, and posit ion. Usually, space-occupying lesions show charact erist ic
displacement of surrounding viscera. Scans can be perf ormed at diff erent levels
and planes and in diff erent slice t hicknesses t o isolat e small lesions. O f t en,
hollow viscera (eg, int est ines) and blood vessels need t o be accent uat ed w it h
t he use of cont rast media.
Spiral CT scanners, also know n as helical CT scanners, are a modif icat ion of t he
convent ional CT t echnique. A spiral scan employs a cont inuous, corkscrew scan
pat t ern t hat produces a t hree-dimensional raw dat a set . This allow s f or t hreedimensional reconst ruct ion and CT angiography. Mult i-row scanners are capable
of producing up t o 16 image slices simult aneously.
Follow ing image acquisit ion on a mult i-row or spiral CT scanner, several
post processing t echniques can be applied t o t he dat a set s. This comput er
manipulat ion allow s f or:
1. CT angi ographyallow ing t he vascular syst em t o be view ed in t hree
dimensions w it hout t he visualizat ion of overlying st ruct ures. Considered a
complement t o t rue angiography, t he CT t echnique does have t he advant age
of requiring only an int ravenous st ick rat her t han an art erial punct ure.
2. Shaded surf ace di spl aya comput er-generat ed surf ace rendering. The
result ant images have t he percept ion of dept h, w hich may be of part icular
value t o surgeons, especially during reconst ruct ion (eg, post t rauma)
procedures.
CT scans can be perf ormed on virt ually any body part and can isolat e virt ually
any abdominal organ. Typical CT applicat ions include t he f ollow ing st udies:
1. Abdomen: t o include liver, pancreas, gallbladder, kidneys, adrenals, spleen,
ret roperit oneum, and abdominal blood vessels
2. Pelvis: t o include urinary bladder, ut erus, ovaries, dist al colon, and prost at e
3. Spine
4. Head, sinuses, orbit s, mast oids, int ernal audit ory canals, f acial bones, neck
5. Chest : t o include lungs, mediast inum, and heart
6. Joint s and specif ic bones
7. CT-guided biopsy
8. Fee-f or-service screening t est may be available t o evaluat e t he heart , lungs,
colon, or t he ent ire body.
Computed Tomography (CT) of the Head and Neck;

Brain, Eyes, and Sinus Computerized Axial Tomography
(CAT) CT of the head is a relatively simple x-ray
examination done by means of a special scanning
machine to evaluate for suspected intracranial lesions
(see pages 753754 for CT explanation). The results

form a cross-sectional picture of the anatomic
structure of the head that includes the internal cranial
structure, brain tissue, and surrounding cerebrospinal
fluid. This axial image of the head is similar to a view
looking down through the top of the head.
Reference Values
Normal
No evidence of t umor, ot her pat hology, or f ract ure Typically, low -densit y t issue
areas appear black, w hereas higher-densit y t issues appear as shades of gray.
The light er t he shading, t he higher t he densit y of t he t issue or st ruct ure.
Procedure
1. During t he t est , have t he pat ient lie perf ect ly st ill on a mot orized t able w it h
his or her head comf ort ably immobilized. The t able is moved int o a doughnut shaped f rame called a gantry. X-ray t ubes sit uat ed w it hin t his gant ry move
around t he pat ient in a circular f ashion.
2. I nject an iodinat ed radiopaque cont rast subst ance if t issue densit y
enhancement is desired because a quest ionable area needs f urt her
clarif icat ion. Some pat ient s experience nausea and vomit ing af t er receiving
t his cont rast agent .
3. Take addit ional images during cont rast inject ion.
4. Be aw are t hat during and af t er t he int ravenous inject ion, t he pat ient may
experience w armt h, f lushing of t he f ace, salt y t ast e, or nausea. Encourage
t he pat ient t o breat he deeply. An emesis basin should be readily available.
5. Wat ch f or ot her unt ow ard signs such as respirat ory diff icult y, diaphoresis,
numbness, or palpit at ions.
care.
Abnormal CT head and neck scan result s reveal t he f ollow ing condit ions:
1. Bony and sof t t issue t umor masses such as meningiomas, ast rocyt omas,
angiomas, and cyst s
2. I nt racranial bleeding or hemat oma

3. Aneurysm
4. I nf arct ion
5. I nf ect ion
6. Sinusit is
7. Foreign bodies
Interfering Factors
1. A f alse-negat ive CT scan can occur in t he presence of hemorrhage. As
hemat omas age, t heir appearance on CT scans changes f rom high-int ensit y
t o low -int ensit y levels, part ly because older hemat omas become more
t ransparent t o x-rays.
2. Pat ient movement s negat ively aff ect image qualit y and accuracy.
Interventions
1. Explain t est purpose and procedure. Provide w rit t en inst ruct ions. Reinf orce
know ledge regarding possible adverse eff ect s such as radiat ion exposure or
allergy t o iodine cont rast media. The amount of x-ray exposure f or t his
examinat ion is about t he same as t hat received during a rout ine skull x-ray.
depart ment .
3. Ref er t o iodine cont rast t est precaut ions on pages 706710. A creat inine
level may be required bef ore t he st udy.
4. G enerally, t he pat ient should f ast 2 t o 3 hours bef ore t he t est if a cont rast
st udy is planned. I n most cases, prescribed medicat ions can be t aken bef ore
CT st udies.
5. Reassure t he pat ient t hat scanning produces no great er radiat ion t han
convent ional x-ray st udies.
6. Check f or pat ient allergies. Nausea and vomit ing, w armt h, and f lushing of t he
f ace may signal a possible iodine allergy. See pages 706710 f or addit ional
assessment crit eria.
7. Reassure t he pat ient w ho is prone t o claust rophobia t hat claust rophobic f ear
of t he scanner is common. Pict ures of t he scanner or int roduct ion t o t he

scanner may alleviat e t hese f ears.
8. Administ er analgesics and sedat ives, especially t o minimize pain and
unnecessary movement .
care.

1. Det ermine w het her an iodine cont rast subst ance w as used. I f used, observe
and record inf ormat ion about react ions if t hey occur. React ions may include
hives, skin rashes, nausea, sw elling of parot id glands (iodism), or, most
serious of all, anaphylaxis.
2. Not if y t he physician immediat ely if allergic react ions occur. Ant ihist amines
may be necessary t o t reat sympt oms.
3. Document at ion should include assessment of inf ormat ion needs, inst ruct ions
given, t ime examinat ion w as complet ed, pat ient response t o t he procedure,
and any allergic react ions.
care.
Clin ical Alert

2. Assess w het her pat ient is allergic t o iodine or lat ex. I f iodine cont rast or
lat ex sensit ivit ies are know n or suspect ed, inf orm t he radiology
depart ment bef ore st udy.
Computed Tomography (CT) of the Body; Computerized

Axial Tomography (CAT) Body Scan; Chest, Spine,
Extremities, Abdomen, and Pelvis Computed
Tomography
Body CT imaging provides det ailed cross-sect ional images of t he chest ,
abdomen, pelvis, spine, and ext remit ies. When used t o evaluat e neoplast ic and
inf lammat ory disease, CT dat a acquisit ion can be rapidly sequenced t o evaluat e
blood f low and t o det ermine vascularit y of a mass. This t echnique, know n as
dynami c CT scanni ng, requires t he administ rat ion of int ravenous cont rast . I n
addit ion, CT can be used t o det ect int ervert ebral disk disease, herniat ion, and
sof t t issue damage t o ligament s w it hin joint spaces.
Convent ional x-ray machines produce a f lat pict ure, w it h organs in t he f ront of
t he body appearing t o be superimposed over organs t ow ard t he back of t he
body. The result is a t w o-dimensional image of t he t hree-dimensional body part .
CT imaging produces many cross-sect ional anat omic view s w it hout
superimposing st ruct ures. Spiral scanners allow CT angiography and t hreedimensional reconst ruct ion t echniques.
Reference Values
Normal
No apparent t umor or pat hology O n CT scans, air appears black, bone appears
w hit e, and sof t t issue appears in various shades of gray. Shade pat t erns and
t heir correlat ion t o diff erent t issue densit ies, t oget her w it h t he added dimensions
of dept h, allow ident if icat ion of normal body st ruct ures and organs.
Procedure
1. Have t he pat ient drink a special cont rast preparat ion several minut es bef ore
t he CT abdominal examinat ion. This cont rast mat erial out lines t he bow el so
t hat it can be more readily diff erent iat ed f rom ot her st ruct ures.
2. Have t he pat ient lie supine on a mot orized couch t hat moves int o a doughnut shaped f rame called a gantry. X-ray t ubes w it hin t he gant ry move around t he
pat ient as t he pict ures are t aken. These f ilms are concurrent ly project ed
ont o a monit or screen.
3. Have t he pat ient lie w it hout moving, and give breat hing inst ruct ions.
4. I nject iodine cont rast subst ance and t ake more pict ures if a quest ionable
area requires f urt her clarif icat ion. Pat ient s having pelvic CT scans are given
a barium cont rast enema. Furt hermore, f emale pat ient s undergoing pelvic CT
scans may require insert ion of a cont rast enhanced vaginal t ampon t o
delineat e t he vaginal w all. Anot her indicat ion f or cont rast is blood vessel
delineat ion, t he opacif icat ion of w ell-vascularized t issue, and evaluat ion of
blood f low pat t erns (as f or diff erent ial diagnosis of hemangioma).
5. Be aw are t hat t he pat ient may experience w armt h, f lushing of t he f ace, salt y
t ast e, and nausea w it h int ravenous inject ion of t he cont rast mat erial. Slow,
deep breat hs may alleviat e t hese sympt oms. Have an emesis basin readily
available. Wat ch f or ot her unt ow ard signs such as respirat ory diff icult y,
heavy sw eat ing, numbness, palpit at ions, or progression t o an anaphylact ic
react ion. Resuscit at ion equipment and drugs should be readily available.
Not if y t he physician immediat ely should any of t hese side eff ect s occur.
care.
Abnormal body CT scan f indings reveal t he f ollow ing condit ions:
1. Tumors, nodules, and cyst s
2. Ascit es
3. Fat t y liver
4. Aneurysm of abdominal aort a
5. Lymphoma
6. Enlarged lymph nodes
7. Pleural eff usion
8. Cancer of pancreas
9. Ret roperit oneal lymphadenopat hy
10. Abnormal collect ion of blood, f luid, or f at
11. Skelet al bone met ast asis
12. Cirrhosis of liver
13. Fract ures
14. Sof t t issue or ligament damage
15. Abscess
Interfering Factors
1. Ret ained barium can obscure organs in t he upper and low er abdomen.
Barium t est s should be scheduled af t er CT scans w hen possible.
2. I nabilit y of t he pat ient t o lie quiet ly produces less-t han-opt imal pict ures.
Interventions

1. Explain t est purpose and procedure. Writ t en explanat ions may be helpf ul.
Benef it s and risks of t he t est should be explained t o t he pat ient bef ore t he
procedure.
depart ment .
3. Ref er t o iodine and barium cont rast t est precaut ions on pages 706711.
4. I n most cases, allow pat ient t o t ake usual prescribed medicat ions bef ore CT
st udies.
5. I nf orm t he pat ient t hat an iodine cont rast subst ance may be administ ered
bef ore and during t he examinat ion. Det ermine w het her t he pat ient is allergic
t o iodine. See pages 706710 f or addit ional assessment crit eria. Pelvic CT
examinat ions usually require bot h int ravenous and rect al administ rat ion of
cont rast mat erial. A creat inine level may be required bef ore t he st udy.
6. Be aw are t hat abdominal cramping and diarrhea may occur; t heref ore, drugs
such as glucagon, Lipomul, or Donnat al may be ordered t o decrease t hese
side eff ect s.
7. I nf orm t he pat ient t hat solid f oods are usually w it hheld on t he day of t he
examinat ion unt il af t er t est complet ion. Clear liquids may be t aken up t o 2
hours bef ore examinat ion. I f in doubt , check w it h t he diagnost ic depart ment
f or specif ic prot ocols. A pat ient w it h diabet es may need t o adjust his or her
insulin dose and diet bef ore t he t est (see Clinical Alert on next page). For CT
of t he abdomen, t he pat ient usually can t ake not hing by mout h.
8. I nst ruct t he pat ient t hat he or she may experience w armt h, f lushing of t he
f ace, a salt y met allic t ast e, and nausea or vomit ing if int ravenous iodine is
administ ered.
9. Claust rophobic sensat ions w hile in t he CT scanner are common. Show t he
pat ient a pict ure of t he scanner bef ore t he procedure t o alleviat e anxiet y.
10. Remember t hat sedat ion and analgesics may help t he pat ient lie quiet ly
during t he t est t o achieve opt imal result s.
care.

1. O bserve and document react ions t o iodine cont rast mat erial such as hives,
skin rashes, nausea, sw elling of parot id glands (iodism), or anaphylact ic
react ion.
2. Not if y t he physician immediat ely if sympt oms are serious.

3. Administ er ant ihist amines t o relieve t he more severe sympt oms.
4. Document preparat ion and inst ruct ions given t o t he pat ient or signif icant
ot hers, t he t ime t he procedure w as complet ed, pat ient 's response t o t he
procedure, any allergic react ions, and subsequent t reat ment .
care.
Clin ical Alert

2. Assess w het her t he pat ient is allergic t o iodine. I f iodine cont rast
sensit ivit ies are know n or suspect ed, inf orm t he radiology depart ment
bef ore st udy.
CT Screening
Typically perf ormed as a f ee-f or-service exam, CT screening is receiving much
media at t ent ion. Pract it ioners are divided as t o t he eff icacy and value of t hese
screens. G enerally not covered by medical insurance, t hese procedures are
available w it hout a prescript ion t o t hose w ho are able t o pay. Furt her
cont roversy exist s as t o t he t ype of scanner used f or t he screening st udies. No
def init ive dat a exist t o show superiorit y of one t echnique over anot her. Scanners
used f or t his purpose may be a spiral, mult i-row CT scanner or an elect ron-beam
scanner (EBT). The most common screening CT exams are:
1. Calcium scoring (cardiac scoring, heart scan)used t o det ect and measure
t he amount of calcium plaque w it hin t he coronary art eries. Considered
predict ive f or t he pot ent ial f or coronary event s.
2. Lung screeningused t o det ect t he presence of lung masses f or pat ient s
w it h a signif icant risk (smoking hist ory, t oxin exposure).
3. Whole-body screeninga head-t o-t oe scan t o det ect t he presence of
lesions.
4. CT colonographya new t echnique t hat may pot ent ially serve as a subst it ut e
t o colonoscopy.
I n CT colonography, a small amount of CO2 gas is administ ered t hrough a rect al

cat het er. Rapid scans are t aken w it h t he pat ient in a prone and supine posit ion.
Using complex post processing sof t w are, images of t he ent ire colon are laid out ,
present ed in a f ilet f ormat , or t hey can be f low n t hrough w it h comput er
animat ion. Alt hough t he preparat ion f or CT colonography is t he same as f or
t radit ional colonoscopy, pat ient discomf ort is lessened, and accept ance of t he
process appears t o be enhanced.
BIBLIOGRAPHY
Adler AM, Carlt on RR: I nt roduct ion t o Radiographic Sciences and Pat ient
Care, 3rd ed. Philadelphia, WB Saunders, 2003
Ballinger PW: Merrill's At las of Roent genographic Posit ions and St andard
Radiologic Procedures, Vols. 13, 10t h ed. St . Louis, CV Mosby, 2003
Bier V: Healt h Eff ect s of Exposure t o Low Levels of I maging Radiat ion.
Washingt on, DC, Nat ional Academy Press, 1990
Bont rager KL: Text book of Radiographic Posit ioning and Relat ed Anat omy, 5t h
ed. St . Louis, CV Mosby, 2001
Bushong SC: Radiologic Science f or Technologist s, 7t h ed. St . Louis, CV

Mosby, 2001
Bushong SC: Radiat ion Prot ect ion. New York, McG raw -Hill, 1998
Carlt on R: Principles of Radiographic I maging, an Art and a Science, 3rd ed.
Delmar Thomson, Albany, NY, 2001
Cochran ST: Det erminat ion of serum creat inine levels prior t o administ rat ion
of radiographic cont rast media. JAMA 277(7): 517518, 1997
Jensen SC, Peppers MP: Pharmacology and Drug Administ rat ion f or I maging
Technologist s. St . Louis, CV Mosby, 1998
Seeram EL: Radiat ion Prot ect ion. Philadelphia, Lippincot t Raven, 1997
St at kiew icz-Sherer MA, Viscont i PJ, Rit enour ER: Radiat ion Prot ect ion in
Medical Radiography, 4t h ed. St . Louis, CV Mosby, 2002
INTERNET SITES
int elihealt h. com
diabet esmonit or. com
epa. gov/ radiat ion
post gradmed. com
imaginis. com
acr. org
breast cancer. org
cancernew s. com
emedicine. com
aunt minnie. com

Wilkins
> Table of C ontents > 11 - C ytologic , His tologic , and Genetic S tudies
11
Cytologic, Histologic, and Genetic Studies
CYTOLOGIC AND HISTOLOGIC STUDIES
Overview of Cytologic (Cells) Studies Exfoliated cells
in body tissues and fluid are studied to determine the
types of cells present and to diagnose malignant and
premalignant conditions. The staining technique
developed by Dr. George N. Papanicolaou has been
especially useful in diagnosis of malignancy and is
now used routinely in the cytologic study of the female
genital tract as well as in many types of
nongynecologic specimens.
Some cyt ologic (cells) specimens (eg, smears of t he mout h, genit al t ract , nipple
discharge) are relat ively easy t o obt ain f or st udy. O t her samples (eg, amniot ic
f luid, pleural eff usions, cerebrospinal f luid [ CSF] ) are f rom less accessible
sources, and special t echniques, such as f ine-needle aspirat ion, are required f or
collect ion. Tissue (hist ologic) samples may be obt ained by biopsy during surgery
or during out pat ient diagnost ic procedures such as endoscopy. I n all st udies, t he
source of t he sample and it s met hod of collect ion must be not ed so t hat t he
evaluat ion can be based on complet e inf ormat ion.
Specimens f or cyt ologic and hist ologic st udy usually consist of many diff erent
cells. Some are normally present , w hereas ot hers indicat e pat hologic condit ions.
Cells normally observed in one sample may, under cert ain condit ions, be
indicat ive of an abnormal st at e w hen observed elsew here. All specimens are
examined f or t he number of cells, cell dist ribut ion, surf ace modif icat ions, size,
shape, appearance and st aining propert ies, f unct ional adapt at ions, and
inclusions. The cell nucleus is also examined. Any increases or decreases f rom
normal values are not ed.
G ynecologic specimens may be smeared and f ixed in 95% alcohol. Some t ypes
of spray f ixat ive are also available. (G ynecologic specimens collect ed using t he
liquid-based t echnique are collect ed in special [ ie, PreservCyt ] solut ion. )

Nongynecologic specimens are generally collect ed w it hout preservat ive. They
may be placed in saline, and t hey must be handled caref ully t o prevent drying or
degenerat ion. Check w it h your individual laborat ory f or collect ion requirement s.
I t is import ant t hat all cyt ology specimens be sent t o t he laborat ory as soon as
t hey are obt ained t o prevent disint egrat ion of cells or any ot her process t hat
could cause alt erat ion of t he mat erial f or st udy.
Clin ical Alert

1. The t est is only as good as t he specimen received.
2. Specimens collect ed f rom pat ient s in isolat ion should be clearly labeled on
t he specimen cont ainer and requisit ion f orm w it h appropriat e w arning
st ickers. The specimen cont ainer should t hen be placed inside t w o sealed,
prot ect ive biohazard bags bef ore it is t ransport ed t o t he laborat ory.
3. The U. S. O ccupat ional Saf et y and Healt h Administ rat ion (O SHA) requires
t hat all specimens be placed in a secondary cont ainer bef ore
t ransport at ion t o t he laborat ory. Most laborat ories pref er plast ic biohazard
bags. Requisit ions should be kept on t he out side of t he bag or in a
separat e compart ment in t he biohazard bag, if available.
I n pract ice, result s of cyt ologic st udies are commonly report ed as:
1. I nf lammat ory
2. Benign
3. At ypical
4. Suspicious f or malignancy
5. Posit ive f or malignancy (in sit u versus invasive)
Overview of Histologic (Tissue) Studies Material

submitted for tissue examination may be classified
according to its histologic or cellular characteristics. A
basic method for classifying cancers according to the
histologic or cellular characteristics of the tumor is
Broder's classification of malignancy:
1. G rade I : t umors show ing a marked t endency t o diff erent iat e; 75% or more of
cells diff erent iat ed

2. G rade I I : 75% t o 50% of cells diff erent iat ed, slight t o moderat e dysplasia
and met aplasia
3. G rade I I I : 50% t o 25% of cells diff erent iat ed, marked dysplasia, marked
at ypical f eat ures, and cancer in sit u
4. G rade I V: 25% t o 0% of cells diff erent iat ed
The t umor-node-met ast asis (TNM) syst em is a met hod of ident if ying t umor st age
according t o spread of t he disease. This syst em evolved f rom t he w ork of t he
I nt ernat ional Union Against Cancer and t he American Joint Commit t ee on Cancer.
I n addit ion, t he TNM syst em f urt her def ines each specif ic t ype of cancer, (eg,
breast , head, neck). This st aging syst em (Chart 11. 1) is employed f or previously
unt reat ed and t reat ed cancers and classif ies t he primary sit e of cancer and it s
ext ent and involvement , such as lymphat ic and venous invasion.
Ch art 11.1 TNM System T h ree capital letters are u sed to

describe th e exten t of th e can cer:
T: Primary t umor
N: Regional lymph nodes
M: Dist ant met ast asis
Low er-case let t ers are used t o indicat e t he chronology of classif icat ion:
c: Clinicaldiagnost ic
p: Post surgical t reat ment pat hologic
r: Ret reat ment
a: Aut opsy
This classif icat ion is ext ended by t he f ollow ing designat ions:
T Su bclasses (Exten t of Primary Tu mor)

TX: Tumor cannot be adequat ely assessed
T0: No evidence of primary tumor

Tis: Carcinoma in sit u
T1, T2, T3, T4: Progressive increase in t umor size and involvement
N Su bclasses (In volvemen t of Region al Lymph Nodes)

NX: Regional lymph nodes cannot be assessed clinically
N0: Regional lymph node metastasis

N1, N2, N3, N4: I ncreasing degrees of demonst rable abnormalit y of
regional lymph nodes
HISTOPAT HOLOGY
G X: G rade cannot be assessed
G1: Well-differentiated grade

G2: Moderately w ell-differen tiated grade
G3: Poorly differentiated grade

G4: Un differen tiated
Metastasis
MX: The minimum requirement s t o assess t he presence of dist ant
met ast asis cannot be met
M 0: No evidence of distant metastasis

M1: Dist ant met ast asis present (specif y sit es of met ast asis)
The cat egory M1 may be subdivided according t o t he f ollow ing not at ions:
Pulmonary:
PUL
Hepatic:
HEP
Osseous:
OSS
Brain:
BRA
Lymph nodes:
LYM
Skin:
SKI
Bone marrow:
MAR
Peritoneum:
PER
Pleura:
PLE
Other:
OTH
I n cert ain sit es, f urt her inf ormat ion regarding t he primary t umor may be
recorded under t he f ollow ing headings:
LYMPHAT IC INVASION (L)

LX: Lymphat ic invasion cannot be assessed
L0: No evidence of lymphatic invasion

L1: Lymph atic in vasion
VENOUS INVASION (V)
VX: Venous invasion cannot be assessed
V0: No venous invasion

V1: Microscopic ven ou s in vasion
V2: M acroscopic venous invasion

I nf ormat ion on residual t umor does not ent er int o est ablishing t he st age of t he
t umor but should be recorded f or use in considering addit ive t herapy. When
t he cancer is t reat ed by def init ive surgical procedures, residual cancer, if any,
is recorded.
RESIDUAL T UMOR (R)

RX: Residual t umor at primary sit e cannot be assessed
R0: No residual tumor

R1: Microscopic residu al tu mor
R2: M acroscopic residual tumor

(M): Symbol in parent heses indicat es mult iple t umors
Y: SymbolY pref ix indicat es classif icat ion occurring w it h int ense
mult imodalit y t herapy
Z: SymbolZ pref ix indicat es recurrent t umors af t er a disease-f ree
int erval
Adapt ed f rom Beahrs O H, Myers MH (eds): Manual f or St aging of Cancer, 4t h
ed. Philadelphia, JB Lippincot t , 1992
Fine-Needle Aspirates: Cell (Cytologic) and Tissue

(Histologic) Study Fine-needle aspiration is a method of
obtaining diagnostic material for cytologic (cell) and
histologic (tissue) study that causes a minimal amount
of trauma to the patient. Aspirates may be obtained
from all parts of the body, including the mouth, breast,
liver, genital tract, respiratory tract, urine,
cerebrospinal fluid, and thyroid. Bacteriologic studies
may also be done on material obtained during fineneedle aspiration. Unfixed material, left in the syringe
or on a needle rinsed in sterile saline, may be taken to
the microbiology department for study.
Reference Values
Normal
Benign or negat ive: no abnormal cells or abnormal t issue present No pat hogenic
organisms
Procedure
1. Use local anest hesia in most cases. Aspirat e superf icial or palpable lesions
w it hout radiologic aid, but aspirat e nonpalpable lesions using radiographic
imaging as an aid f or needle placement . Use st erile t echnique.
2. Posit ion t he needle properly, t hen ret ract t he plunger of t he syringe t o creat e
negat ive pressure. Move t he needle up and dow n, and somet imes at several
diff erent angles. Release t he plunger of t he syringe and remove t he needle.
3. Express mat erial obt ained ont o glass slides, w hich must eit her be f ixed
immediat ely in 95% alcohol, spray f ixed, or air dried, depending on t he
st aining procedure used by t he laborat ory. The remaining mat erial may be
placed in a preservat ive solut ion, such as 50% alcohol. Check w it h your
laborat ory f or recommended f ixat ion requirement s. Mat erial may also be sent
t o t he laborat ory in t he syringe.
4. Record t he source of t he sample and met hod of collect ion so t hat evaluat ion
can be based on complet e inf ormat ion.
5. Clearly label specimens collect ed f rom pat ient s in isolat ion on t he specimen
cont ainer and on t he requisit ion f orm w it h an appropriat e w arning st icker.
Place t he specimen cont ainer inside t w o sealed, prot ect ive biohazard bags
bef ore t ransport .
6. See Chapt er 1 guidelines f or i ntratest care.
Abnormal result s report ed as at ypical, suspicious f or malignancy, and posit ive
f or malignancy (in sit u versus invasive) are helpf ul in ident if ying:
1. Inf ecti ous processes. The inf ect ious agent may be seen, or charact erist ic
cellular changes may indicat e t he inf ect ious agent t hat is present .
2. Beni gn condi ti ons. Some charact erist ic cellular changes may be present ,
indicat ing t he presence of a benign process.
3. Mal i gnant condi ti ons, ei ther pri mary or metastati c. I f t he disease is
met ast at ic, t he f indings may be report ed as consist ent w it h t he primary
malignancy.
Interventions
1. Explain t he purpose and procedure, benef it s, and risks of t he t est . Even
t hough a local anest het ic is used, t he procedure causes some discomf ort ,
and t his should not be minimized. I f t he approach involves passing near a rib,
t he pain may be great er because of t he sensit ivit y of t he bone; t his is not a
cause f or alarm. Unexpect ed pain may induce a vasovagal or ot her
undesirable response. O t her risks include inf ect ion and hemat oma or
hemorrhage, depending on t he sit e aspirat ed.

1. Monit or f or signs of inf lammat ion and use sit e care inf ect ion cont rol
measures. Treat pain, w hich may be common in sensit ive areas such as t he
breast , nipple, prost at e, and scrot um.
Monit or f or specif ic problems, w hich vary depending on t he sit e aspirat ed
(eg, hemopt ysis af t er a lung aspirat ion).
2. Counsel about f ollow -up procedures f or inf ect ions and malignant condit ions.
Sentinel Node Location Before Biopsy (Breast,

M elanoma); Special Prebiopsy Study The concept of
identifying and localizing the sentinel node or nodes
before biopsy is that these nodes receive initial
lymphatic drainage and are the first filter to remove
metastatic cells; thus, if this sentinel node is free of
disease, then the rest of the nodes in the patient w ill be
free of disease, also. Three methods (along w ith
marking of the skin) are used: (1) lymphoscintigraphy
(preoperative), (2) nuclear probe localization
(intraoperative), and (3) blue dye injection
(intraoperative). Often, all three techniques are used
together, the lymph nuclear scan being the most
common (see Procedures).
These special prebiopsy procedures are done bef ore biopsies t o diagnose
cancer of breast or melanoma. I ndicat ions f or lymph nuclear scan
lymphoscint igraphy include det ect ion of met ast asis, mapping of all sent inel
nodes, and st aging and monit oring cancers, such as melanoma, breast , head,
neck, and skin. I ndicat ions f or using t he nuclear gamma-radiat ion probe include
det ect ing t he most sent inel nodes and providing audit ory conf irmat ion. Also, see
Chapt er 9 f or more inf ormat ion on nuclear scans. I ndicat ions f or blue dye
st aining include t o provide visual conf irmat ion of nodes and t o map t umor rout e
(urine w ill t urn blue and skin w ill st ain).
Clin ical Alert

O nly w hen t he sent inel node is posit ive is a complet e nodal dissect ion
perf ormed.
Reference Values
Normal
No evidence of t umor act ivit y No blocked lymphat ic drainage
Procedure
1. Lymph nucl ear scan (l ymphosci nti graphy)
a. For t he breast , inject t he radiopharmaceut ical (large volume)
subcut aneously int o t he breast and adjacent t o suspect ed breast t umor;
and f or lymphedema, int o w ebs of f ingers and t oes.
b. For melanoma, make f our t o six int radermal inject ions around t he t umor
or excision sit e, avoiding scar t issue.
c. Perf orm immediat e imaging w it h t he pat ient in t he posit ion expect ed
during surgery.
2. Nucl ear radi ati on (gamma) probe (w hich produces sound)
a. Remember t hat a previously administ ered radiopharmaceut ical and t he
sound radiat ion det ect or permit node det ect ion and localizat ion t o
det ermine w here t he init ial operat ive incisions can be made.
b. Use t he sound-radiat ion gamma probe t o locat e t he area of radioact ivit y,
not associat ed w it h t he inject ion sit es. O f t he t hree procedures, t he
probe is t he most sensit ive.
3. Bl ue dye (not ext ernally visible)
a. I n order t o ident if y t he nodes t o undergo biopsy, inject t he f eet in t he
w eb bet w een t he t oes and t he hands bet w een t he second and t hird
f ingers (allergic react ion t o t he dye may occur).
b. Remember t hat an operat ive biopsy procedure f ollow s.
1. Abnormal f indings reveal met ast at ic nodes and rout es of spread.
2. Asymmet ry may indicat e lymph f low obst ruct ion.
Interventions
1. Explain purpose of sent inel node ident if icat ion procedures.
2. I nf orm t he pat ient t hat if t he result s are posit ive, surgery usually f ollow s
soon af t er.
In tratest Patien t Care

1. Be aw are t hat usually sedat ion or analgesia is not ordered.
2. Mark t he sit e of lymph nodes w it h indelible pen.
3. Provide support , assist w it h posit ioning, and assure t he pat ient t hat t est ing
is proceeding as expect ed.

1. Monit or inject ion sit e (breast , t oes, f ingers, or around t umor excision sit e).
Check f or signs of inf lammat ion or bleeding.
2. I f surgery is planned, prepare according t o est ablished prot ocol. Also, see
Biopsies O verview in alphabet ical list ing.
3. When surgery is scheduled, t ake images just bef ore t ransf er t o t he operat ing
room (2 hours lat er or next morning).
4. Counsel about out comes and possible need f or f urt her t est ing or t reat ment .
Tissue (Histologic) Biopsy Studies: Overview ;

Prognostic and Predictive M arkers Tissue biopsies
from many body sites (ie, breast, liver, kidney, lymph
nodes, skin, bone, muscle, lung, bladder, prostate,
thyroid, cervix) may be examined for the presence of
benign, toxic, or malignant cells and conditions. The
amount of tissue obtained and submitted to the
laboratory depends on the specimen site and disease
process (eg, in liver biopsy, at least tw o to three liver
cores > 2 cm in length). These procedures may be

performed in outpatient or inpatient settings. Some
specimens should be collected early in the day. For
ultrasound-guided prostate specimens (ie, transrectal
ultrasound [TRUS]), 6 to 12 threadlike sections of
tissue are obtained, ranging from 0.5 to 1.5 cm in
length. Pain and bloody urine are common after.
Depending on the body site sampled, anesthetic (ie,
local or general) or conscious sedation and analgesia
(see Appendix C) is necessary.
Tissue obt ained f or rout ine hist ologic (t issue st udy) and pat hologic examinat ion
requires special handling (eg, place in 10% f ormalin or send f resh and int act ).
Tissue needed f or f rozen-sect ion examinat ion must be delivered t o t he laborat ory
immediat ely w it h no f ixat ive added. Tissue needed f or special st udies (eg,
special st ains f or microorganisms, hormonal st udies, DNA ploidy, bone biopsies)
may need special handling. A f rozen sect ion is done upon t he pat hologist 's
recommendat ion. Tissue f reezing (f rozen sect ion) may act ually be
cont raindicat ed and not in t he pat ient 's best int erest . Cont act your individual
laborat ory f or specif ic inst ruct ions.
Af t er t he biopsy specimen is sent t o t he laborat ory, various t est s are done t o
ident if y t he unique charact erist ics of t he pat ient 's t umor cells and t o select
correct chemot herapy based on resist ance t o specif ic drugs. Mult iple and
complex genet ic changes result f rom loss of cont rol over normal cell grow t h, and
t hese alt erat ions may inf luence t he t umor's response t o chemot herapy. To
measure t hese changes, f our major t est ing groups are used and include t he
f ollow ing:
1. Extreme drug resi stance (EDR) assay t est s of solid t umors and malignant
f luids (blood, bone marrow eff usions), w hich det ermine t he probabilit y of a
t umor's resist ance t o specif ic chemot herapeut ic drugs (eg, 5-f luorouracil [ 5FU] f or colon cancer). I f t he t umor cells grow in t he presence of ext reme
exposures t o a specif ic drug, t his indicat es t he presence of signif icant drug
resist ance and, by ident if ying inact ive agent s, avoids exposing pat ient s t o
t he t oxicit y of drugs t hat are likely t o be ineff ect ive, saves valuable
t reat ment t ime, and decreases t he possibilit y of cross-resist ance t o ot her
eff ect ive agent s.
2. Di f f erenti al stai ni ng and cytotoxi ci ty (Di SC) assay uses special st ains and
t echniques t o det ect drug resist ance in leukemia, lymphoma, blood, and bone
marrow specimens.
3. Prognosti c markers measure t he t umor's grow t h pot ent ial or abilit y t o invade
ot her t issues (met ast asis). Tumor cells release prot eases and angiogenic
f act ors t o break dow n basement membranes and induce new vascularizat ion
of t he t umor, w hich delivers oxygen and nut rient s t o t he t umor and allow s
micromet ast asis t o dist ant sit es.
4. Predi cti ve markers ident if y specif ic mechanisms of drug resist ance and
provide inf ormat ion on how eff ect ive clinically indicat ed chemot herapy agent s
w ill be in t reat ing t he pat ient 's t umor cells. Prognost ic and predict ive
markers use molecular probes t o det ermine t he genet ic charact erist ics,
amount of prot ein, prolif erat ion index, resist ance mechanisms, recept or
st at us, and ot her def ining f act ors of t he pat ient 's malignant t umor. To obt ain
t he most comprehensive analysis of t he pat ient 's unique t umor biology, drug
resist ance t est ing is done in combinat ion w it h oncoprof iles and prognost ic
and predict ive markers f or t he specif ic cancer t ype. A radi ati on resi stance
assay can also be done bef ore t he t reat ment act ually begins.
These combined st udies ident if y cervical cancer resist ive t o int ernal and ext ernal
radiat ion plus chemot herapy (t he st andard t reat ment is prognost ic indicat ors of
progression-f ree survival). Also included are p53, t hrombospondin-1 (Tsp-1),
CD31, and angiogenesis index (AI ). Prognost ic and predict ive markers are as
f ollow s:
1. Androgen receptor. This recept or predict s prost at e cancer's response t o
hormone t herapy.
2. Angi ogenesi s i ndex (p53, Tsp-1, CD31). The AI def ines a pat ient 's risk f or
occult met ast at ic disease and is composed of f act ors t hat charact erize t he
capacit y f or new blood vessel f ormat ion: p53, Tsp-1, and CD31 (vessel
count ). The p53 gene cont ribut es t o t umor grow t h suppression by slow ing
cell cycle progression and promot ing apopt osis in damaged t umor cells. I t
also suppresses t umor angiogenesis. Tsp-1 levels have been f ound t o
decrease af t er t he t umor sust ains mut at ions in p53. CD31 is expressed on
t he membrane of endot helial cells, allow ing f or microvessel count in t he
t umor.
3. BAX. I ncreased levels of BAX, a 21-kd prot ein and amino acid, indicat e
accelerat ed programmed cell deat h induced by apopt ot ic st imulus.
4. Proto-oncoprotei n bc12 (apoptosi s regul ator). The t ranslocat ion of t he bc12
gene, occurring in f ollicular lymphomas, is brought under cont rol of t he
immunoglobulin gene promot er, result ing in increased int racellular levels of
bc12 prot ein. This prot ein suppresses programmed cell deat h (apopt osis).
I nduct ion of cell deat h is an import ant mechanism f or many chemot herapeut ic
agent s. An abnormal expression of bc12 prot ein can render t umor cells
resist ant t o chemot herapeut ic agent s.
5. Cathepsi n D (i nvasi on potenti al ). Cat hepsin D, a lysosomal acid prot ease,

has been associat ed w it h met ast at ic pot ent ial. Elevat ed levels of cat hepsin
D are predict ors of early recurrence and deat h in node-negat ive cancer and
breast cancer.
6. CD31 (component of tumor angi ogenesi s i ndex). CD31 st ains microvessels,
allow ing f or count ing, and helps t o predict more aggressive disease,
met ast ases, poor survival, and new vascularizat ion of t he t umor mass.
7. DNA pl oi dy and S phase (f l ow cytometry). DNA ploidy and prolif erat ive index
are independent indicat ors of prognosis. Pat ient s w it h aneuploid t umors or
high S-phase f ract ions have poor disease-f ree survival compared w it h
pat ient s w it h diploid or low S-phase f ract ion t umors. DNA ploidy (image
analysis) (Feulgen st ain) is an indicat or of prognosis in select ed t umor t ypes
in f resh specimens.
8. Epi dermal growth f actor receptor (EG F-R). This grow t h f act or recept or is a
glycoprot ein t yrosine kinase, eit her EG F or t ransf orming grow t h f act or-
(TG F- ). When high levels occur in breast , prost at e, ovarian, lung, and
squamous cell carcinomas, t here is an associat ion w it h poorer prognosis and
poor disease-f ree survival.
9. Endogl i n (CD105). Endoglin normally occurs in vascular endot helial cells of
capillaries, art erioles, small art eries, and venules. I ncreased levels are
f ound in t umor vessels and prolif erat ing endot helial cells. Endoglin has been
f ound in non-T/ non-B and pre-B acut e lymphoblast ic leukemia (ALL) and
acut e myelocyt ic and myelomonocyt ic leukemia cells.
10. Estrogen receptor (ER) and progesterone receptor (PR). ER and PR
posit ivit y is associat ed w it h a 70% response rat e t o ant ihormonal t herapy. I n
cont rast , t he response rat e is less t han 10% among pat ient s w hose t umors
are ER and PR negat ive. Pat ient s w hose t umors are ER and PR posit ive
generally achieve superior disease-f ree survival.
11. G l utathi one S-transf erase (G ST); al kyl ator resi stance. G ST is an enzyme
t hat inact ivat es cert ain ant icancer agent s by linking glut at hione t o t he drug.
I ncreased G ST levels are associat ed w it h drug resist ance t o chlorambucil
and melphalan.
12. HER2/ neu c-erbB2 oncoprotei ns. The presence of HER2/ neu, a prot ein t hat
f unct ions as an oncogene, is associat ed w it h poorer prognosis. HER2/ neu
det ect ion also provides inf ormat ion on t he pot ent ial t reat ment response t o
Hercept in.
13. Ki -67 (prol i f erati ve i ndex). This is a st aining t echnique. Monoclonal ant ibody
Ki-67 is associat ed w it h increased cell prolif erat ive act ivit y in t umors and is
associat ed w it h more aggressive t umors and poor disease-f ree survival.
14. MDR-1 (P170 gl ycoprotei n: mul ti drug resi stance). The presence of MDR-1
cancer cells is associat ed w it h resist ance t o nat urally produced

chemot herapeut ic agent s such as paclit axel (Taxol), doxorubicin, and
et oposide and plays a crit ical role in t he select ion of a t reat ment regimen.
15. O 6-methyl guani ne-DNA methyl transf erase (MG MT) (ni trosourea resi stance).
MG MT, a repair prot ein, occurring af t er DNA damage caused by
nit rosoureas, such as BCNU. Brain cancer pat ient s w it h high levels of t he
MG MT gene and alkylt ransf erase (AT) have short er disease-f ree and overall
survival.
16. Mul ti drug resi stance protei n (MRP). This prot ein is similar t o, but dist inct
f rom, MDR-1, and is st rongly associat ed w it h resist ance t o cisplat in drugs in
ovarian cancer.
17. p21. A prot ein-like t umor suppressor like p53, p21 cont rols w hen and how
t he cell replicat es. Low levels of p21 are associat ed w it h increased risk f or
t umor occurrence, and no p21 cont ribut es t o aggressive grow t h in some
t umors.
18. p53 (cel l cycl e and Tsp-1 regul ator). The t umor suppressor gene p53
regulat es cell cycle progression, cellular prolif erat ion, DNA repair, apopt osis
(cell deat h), and angiogenesis. I ncreased levels of mut at ed p53 prot ein in
t umor cell nuclei are associat ed w it h t umor progression and a poorer
prognosis.
19. PCNA (prol i f erati ve i ndex). Presence of PCNA prot ein is associat ed w it h cell
prolif erat ion and w it h increased levels occurring w it h more aggressive t umors
and poor disease-f ree survival.
20. Thymi dyl ate synthase (TS; 5-FU resi stance). Drug resist ance t est s of
t hymidylat e synt hase (TS), a cellular enzyme essent ial f or DNA biosynt hesis
and cell prolif erat ion t hat is a t arget f or 5-FU, is an import ant component of
some breast cancer and colon cancer t reat ment regimens. I ncreased TS
expression correlat es w it h poorer response rat es t o 5-FU and w it h short er
survival in breast and colon cancer.
21. Thrombospondi n-1 (Tsp-1). This ext racellular mat rix prot ein is involved in
w ound healing. Low value is associat ed w it h increased t umor neovascularit y
and mut ant p53 expression.
22. UIC-2 (MDR-1) shi f t assay. This st aining t echnique can be perf ormed on
solid t umors. The UI C-2 shif t assay can be perf ormed on blood and bone
marrow specimens f rom pat ient s w it h acut e myelogenous leukemia (AML),
mult iple myeloma, or lymphoma and, if t he sample cont ains an adequat e
amount of viable t umor cells, on solid t umors.
23. Vascul ar endothel i al growth f actor (VEG F). Vascular endot helial grow t h
f act or, or vascular permeabilit y f act or (VPF), plays an import ant role in
angiogenesis, w hich promot es t umor progression and met ast asis.
O ncoprof iles provide t he maximum usef ul inf ormat ion f rom a single biopsy
specimen. These disease-specif ic marker st udies include t est s t hat have been
associat ed w it h clinical out comes f or each cancer t ype. O ncoprof iles ident if y
relat ive risk f or relapse and assist in planning t herapy t o each pat ient 's specif ic
t umor. Table 11. 1 show s an example of oncoprof iles off ered by O ncot ech, I nc. ,
of I rvine, Calif ornia.
Table 11.1 Useful Information From a Single Biopsy

Specimen*
Oncoprofile
Basic
Profile
Com prehensive
Profile
Bladder cancer
DNA, p53,
HER2/neu
DNA, p53,
HER2/neu, CD31
Brain cancer
DNA, p53,
HER2/neu
DNA, p53,
HER2/neu, CD31
Breast cancer
DNA, ER/PR,
HER2/neu
DNA, ER/PR,
HER2/neu, p53,
CD31
Colon cancer
DNA, p53
DNA, p53, TS,

MDR-1, CD31
Endometrial cancer
DNA, ER/PR,
Ki-67
DNA, ER/PR, Ki67, CD31,
MDR-1, p53
DNA, MDR-1
DNA, MDR-1,
p53, CD31
Leukemia/nonHodgkin's
lymphoma
DNA, Ki-67
DNA, Ki-67,
bc12, p53, MDR1
Lung cancer
DNA, p53
DNA, p53, MDR1, bc12
Melanoma
DNA, MDR-1
DNA, MDR-1,
p53, CD31
Ovarian cancer
DNA, ER/PR,
HER2/neu,
DNA, ER/PR,
HER2/neu,
EGF-R
EGF-R, p53,
MDR-1
Prostate cancer
DNA, AR
DNA, AR, p53,

CD31
Sarcoma
DNA, p53
DNA, p53, MDR1
Unknown primary
site
DNA, p53,
HER2/neu
DNA, p53,
HER2/neu, MDR1
Kidney cancer
*The laboratory report from these tumor studies should
provide answers to questions such as Is tumor

malignant?, Is type of cancer identified?, How
aggressive is the cancer?, Is the cancer likely to
recur?, and To which drugs is the tumor resistant?
Interventions
1. Explain t he purpose and biopsy procedure, and obt ain a signed, w it nessed
consent f orm.
2. Remember t hat pat ient preparat ion depends on t he predet ermined biopsy
sit e. Complet e blood count (CBC), prot hrombin t ime (PT), and ot her bleeding
t ime det erminant s may be required. O bt ain a pert inent hist ory (eg, prior
radiat ion t herapy, ot her cancer, current medicat ions, pregnancy).
3. Follow Chapt er 1 guidelines f or saf e, eff ect ive, and inf ormed pretest care.
Clin ical Alert

Cont raindicat ions t o t issue biopsy depend on t he body sit e sampled: bleeding
diat hesis (uncont rolled), ant icoagulant t herapy, highly vascular lesions, sepsis,
seriously impaired lung f unct ion, an uncooperat ive pat ient , or local inf ect ion
near t he biopsy sit e.

1. Monit or f or signs of bleeding, inf lammat ion, inf ect ion, lacerat ion of t issue
and organs, and perf orat ion. Treat pain, w hich may be experienced t o
various degrees depending on t he body sit e sampled.
2. Counsel t he pat ient about f ollow -up procedures and t reat ment f or inf ect ions
and malignant condit ions.
3. Follow t he guidelines in Chapt er 1 f or saf e, eff ect ive, and inf ormed posttest
care.
Breast Biopsy: Cell (Cytologic) and Tissue (Histologic)

Study and Prognostic M arkers Breast biopsies are
among the most common type of biopsy done. The

cells and tissue obtained by breast biopsy establish the
presence of breast disease, diagnose histopathology,
and classify the process. They also confirm and
characterize calcifications noted in prebiopsy
mammograms. The breast tissue is examined to
determine surgical margins, presence or absence of
vesicular invasion, tumor type, staging, and grading.
Secondary studies relevant to survival may include
imaging procedures, along w ith the follow ing
prognostic markers. (Also see Tumor M arkers in
Chapter 8 for more information.)
1. ER and PR. These hormone recept ors are indicat ors of prognosis and are
used t o manage hormonal t herapy in breast and endomet rial cancer.
I mmunohist ochemical (I HC) st aining aids recognit ion of met ast at ic breast
cancer.
2. DNA pl oi dy. This t est measures cell t urnover or replicat ion; it is used t o
predict prognosis and short er survival t imes by t he presence of aneuploid
(rapidly replicat ing cells) f or cert ain t umor t ypes, breast , prost at e, and
colon; less clear f or ovarian, lung, kidney, and bladder (urine) (66% of
breast cancers are aneuploid).
3. S-phase f racti on (SPF)t o predict survival and reduced chance of relapse.
Low levels of SPF appear t o have longer survival and reduced chance or
relapse. SPF is t he DNA synt hesis phase obt ained by a st at ist ical met hod.
4. Cathepsi n Ddone t o det ermine prognosis. The presence of t his lysosomal
prot ease is est rogen relat ed and may promot e t umor spread. Prognost ic
signif icance remains ambiguous.
5. EG F recepti ondone t o predict survival t ime. Presence is correlat ed w it h
ER negat ivit y, aneuploidy, increased S-phase f act ors, and lymph node
met ast ases. I ncreased EG F recept ion may be associat ed w it h w orse relapse
f ree and survival t ime.
6. p53 geneused t o predict prognosis. This t umor suppression gene regulat es
cell cycles. Some clinicians believe t hat t he p53 gene's prognost ic value is
second only t o lymph node st at us.
7. c-erbB2 (HER-2) oncogenedet ermines w hich pat ient s are most likely t o
benef it f rom high doses of chemot herapy. High levels of t his oncogene
recept or are associat ed w it h poor response t o convent ional chemot herapy

and may be a marker f or pat ient s likely t o benef it f rom high doses of
chemot herapy. HER-2/ neu levels may also be det ermined in a blood
specimen.
Reference Values
Normal
Negat ive f or malignant or ot her abnormal cells and t issue Prognost ic markers: of
no signif icance or negat ive No vascular invasion
DNA index: 0. 81. 2 on t he diploid scale Prolif erat ive ant igen index of 10% S
phase: 7% = amount of cells on t he S phase
Procedure
1. See Chapt er 10 (mammography) f or image guided t umor localizat ion st udy
bef ore biopsy.
2. Be aw are t hat breast t issue specimens may be obt ained by open surgical
t echnique by x-rayguided core biopsy or by needle biopsy. Place t hese
specimens in a biohazard bag, t ake direct ly t o t he laborat ory, and give t o t he
pat hologist or hist ot echnologist . The breast t issue is examined and t he
ext ent of t he t umor det ermined. React ion margins and t he grade and st age
of disease are ident if ied.
1. Af t er breast t issue is examined, t he ext ent of t he t umor is det ermined.
Resect ion margins are evaluat ed, and grade and st age of disease are
ident if ied. The f urt her dediff erent iat ed a t umor becomes, t he f urt her it
deviat es f rom t he normal diploid st at e. This may be expressed as a
t et raploid or aneuploid st at e according t o t he amount of DNA on t he st ained
t issue = DNA index of bet w een 1. 0 and 2. 0. The more cells in t he S or DNA
phase, t he more aggressive t he t umor.
2. Favorable prognost ic indicat ors include t umor size of less t han 1 cm, a low
hist ologic grade, negat ive axillary lymph nodes, and posit ive ER and PR.
3. Fibroplasia and f ibroadenophasia are benign condit ions.
Interventions
1. Explain biopsy purpose and procedure. O bt ain and record relevant f amily or
personal hist ory of prior biopsy, t rauma, recent or current pregnancy, nipple
discharge, locat ion of lump, and how lesion w as det ect ed. O bt ain inf ormed
consent .
2. Be aw are t hat open breast biopsies are perf ormed under local or general
anest hesia. Sedat ion may be used w it h local anest het ics. NPO is required
w hen general anest hesia is used (see Appendix C).
3. Provide inf ormat ion and support , recognizing t he f ear t he pat ient experiences
about t he procedure.

1. I f general anest hesia is used, f ollow t he recovery prot ocols. See analgesia
precaut ions in Appendix C f or conscious sedat ion.
2. I nt erpret biopsy out come and counsel appropriat ely about possible f urt her
t est ing and t reat ment (surgery, radiat ion, and medicat ion [ chemot herapy] ).
Ductal Lavage of Breast Cells (Cytologic) Study; Gail

Index of Breast Cancer Risk Ductal lavage collects
cells from the milk ducts of the nipple w here most
breast cancers begin. If cytologic study show s
abnormal cells, this is an indication of increased risk
for breast cancer development. Ductal lavage is used to
assess breast cancer risk and for ongoing surveillance.
A statistical model computes a Gail Index Score in a
w oman of a given age and w ith the presence of certain
risk factors that indicates risk for developing breast
cancer over a specified interval. The Gail Index Score
is based on risk factors (eg, late age at menarche, late

age at first live birth, number of previous biopsies, and
number of first-degree relatives w ith breast cancer).
Reference Values
Normal
No at ypical or abnormal cells G ail I ndex of breast cancer risk = odds rat io 1. 7.
For more inf ormat ion, see G ail, Brint on, Byar, et al. , 1989.
Procedure
1. Apply a local anest het ic cream t o t he nipple area using a special kit ; use a
suct ion device t o draw t iny amount s of f luid droplet s f rom t he milk duct s t o
t he nipple surf ace. These droplet s locat e t he milk duct s' nat ural opening on
t he surf ace of t he nipple.
2. I nsert a very f ine (hair-t hin) cat het er (Fig. 11. 1) int o t he periareolar duct .
Administ er local anest het ic int o t he duct . Use a saline w ash t o separat e t he
cells. Place t he specimen in a special collect or vial and send f or examinat ion
in a biohazard bag.
FI G URE 11. 1 A duct al lavage microcat het er. (Source: CAP Today [ College of
American Pat hologist s] ; 16 (2), February 2002)
1. Abnormal f indings include at ypical hyperplasia and evidence of prolif erat ive
breast disease. The presence of at ypical cells increases t he risk f or breast
cancer by 4 t o 5 t imes as compared w it h w omen w ho do not have at ypical
cells.
2. Relat ive risk is increased even f urt her in presence of a f amily hist ory of
breast cancer (mot her, daught er, sist er, or t w o or more close relat ives w it h
hist ory of breast cancer), specif ic genet ic change (BRCA1 and BRCA2
mut at ions), and a G ail I ndex Score of at least 1. 7.
3. The age-specif ic composit e evidence rat e of t he G ail Model increases
rapidly w it h age, alt hough t he conversion model changes l i ttl e w it h age.
4. Lat er relat ive risk (%) or est imat e of developing breast cancer w it hin 10, 20,
or 30 years of f ollow -up is based on project ed probabilit y.
Interventions
1. Explain t he lavage purpose, procedure, benef it s, and risks.
2. Be aw are t hat relat ive high-risk w omen of any age may be good candidat es
f or duct al lavage. O bt ain appropriat e hist ory of risk.
3. Describe sensat ions t hat might be f elt ; f eelings of f ullness, pinching and
gent ly t ugging on t he breast , uncomf ort able, but not usually painf ul.

1. I nt erpret t est result s and counsel appropriat ely about chance of breast
cancer development , f ollow -up, close monit oring (yearly examinat ions), and
prevent ive drug t reat ment (eg, t amoxif en) or surgery (oophorect omy or
bilat ery mast ect omy).
2. Remember t hat t est out comes are int erpret ed in conjunct ion w it h
mammogram and physical examinat ion f indings.
Liver Biopsy: Cell (Cytologic) and Tissue (Histologic)

Study Liver needle biopsy is an invasive procedure and
is done to confirm diagnosis of chronic hepatitis and
liver cirrhosis, evaluate disease severity, and establish
etiology. Cellular material from the liver may be useful
in evaluating the status of the liver in diffuse disorders
of the parenchyma and in the diagnosis of spaceoccupying lesions. Liver biopsy is especially useful
w hen the clinical findings and laboratory test results
are not diagnostic (eg, an aspartate aminotransferase
[AST] level 10 to 20 times less than the upper defined
limit w ith an alkaline phosphatase [ALP] level less than
3 times the limit) and w hen the diagnosis or cause
cannot be established by other means (enlarged liver of
unknow n cause or systemic disease affecting the liver,
such as miliary tuberculosis). Other indications for
liver biopsy include evaluation of chronic hepatitis,
portal hypertension, and fever of unknow n origin
(tuberculosis and brucellosis) and to confirm alcoholic
liver disease.
Reference Values
Normal
Negat ive f or malignant or ot her abnormal cells and abnormal t issue No evidence
of local or diff use liver disease No evidence of t oxic react ion t o drugs or
inf lammat ory react ions No pat hogenic organisms present
Procedure
1. See Fine-Needle Aspirat es: Cell (Cyt ologic) and Tissue (Hist ologic) St udy.
2. Be aw are t hat in most cases t he pat ient is hospit alized overnight .
3. Remember t hat t he t est may be done at t he bedside in a special area,
usually under local anest hesia. O bt ain specimens w it h ult rasound or
comput ed t omography (CT) x-ray guidance and
a t issue core biopsy needle, such as t he Menghini needle, t hat provides

hist ologic and cyt ologic mat erial; or use a f ine-needle aspirat ion needle,
w hich obt ains cyt ologic mat erial only and is usef ul f or cancer diagnosis but
not diagnosis of ot her liver diseases.
4. Place t issue specimens in 10% f ormalin f or f ixat ion. Do not place specimens
f or cult ure in a f ixat ive. Check w it h your laborat ory f or specif ic inst ruct ions
f or handling special cases (eg, liver biopsies f or copper levels).
5. Express cyt ology specimens on glass slides and f ix immediat ely in 95%
alcohol. Needle rinses may provide helpf ul diagnost ic mat erial as w ell.
6. See Chapt er 1 f or saf e, eff ect ive, inf ormed i ntratest care . See Chapt er 12 on
endoscopic examinat ion and liver biopsy.
Abnormalit ies in t est result s of liver biopsies may be helpf ul in det ect ing t he
f ollow ing liver diseases:
1. Benign disorders, such as t hose causing liver cirrhosis, and presence of
pat hogenic organisms in liver abscess
2. Met abolic disorders:
a. Fat t y met amorphosis
b. Hemosiderosis
c. Accumulat ion of bile (hepat it is, obst ruct ive jaundice, malignancy)
d. Diabet ic pat hology and Wilson's disease (t issue copper is elevat ed per
dry t issue w eight )
e. Hepat ic cyst s (congenit al or hydat id)
f. Malignant processes such as end-st age of lymphomas
Interfering Factors
The report ed eff ect iveness of liver aspirat es or biopsies varies in t he limit ed
published inf ormat ion. Because a very small f ragment of t issue, of t en part ially
dest royed, is t aken in a random manner f rom a large organ, localized disease is
easily missed.
1. False-negat ive result s may be caused by:
a. Sampling error. Det ect ion rat e of liver met ast ases is approximat ely 50%
t o 70% w it h blind biopsy and about 85% (range, 67%96%) w it h t he use
of ult rasound guidance. Also, many diseases produce nonspecif ic

changes t hat may be spot t y, healing, or minimal.
b. Degenerat ion or dist ort ion caused by f ault y preparat ion of specimen.
2. False-posit ive result s may be caused by misint erpret at ion of markedly
react ive hepat ocyt es.
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he t est . O bt ain
properly signed, inf ormed consent . The procedure usually causes minimal
discomf ort , but only f or a short w hile. Explain t hat a local anest het ic w ill be
inject ed int o t he skin. Remember t o ask w het her t he pat ient has ever had a
react ion t o any numbing medicines. Discont inue all aspirin and NSAI Ds f or at
least 7 days bef ore t he procedure. PT, part ial t hromboplast in t ime (PTT),
blood urea nit rogen (BUN), bleeding t ime, and t ype L screen cross-mat ch f or
possible t ransf usion are usually ordered bef ore biopsy.
2. Ensure t hat t he pat ient t akes not hing by mout h (NPO ) f or 4 t o 6 hours bef ore
t he procedure. Ask t he pat ient t o lie supine w it h t he right arm above t he
head. During t he biopsy, t he pat ient should t ake a deep breat h in, blow t he
air out , and t hen hold t he breat h.
3. Be aw are t hat risks include a small but def init e risk f or int raabdominal
bleeding and bile perit onit is. Percut aneous liver biopsy result s in
complicat ions in only about 1% of cases.
Clin ical Alert

Cont raindicat ions include:
1.
2.
3.
4.
Bleeding diat hesisant icoagulant t herapy

Highly vascular lesions
Uncooperat ive pat ient
A prot hrombin t ime in t he ant icoagulant range, PTT more t han 20 seconds
over cont rol
5. Severe anemia (Hb < 9. 5 g/ dL or < 95 g/ L) or marked prolonged bleeding
t ime
6. I nf ect ion
7. A plat elet count of >50, 000/ mm3 (50 109 / L)

8. Marked or t ense ascit es (risk f or leakage)
9. Sept ic cholangit is

1. Remember t hat st rict bed rest f or at least 6 hours is usually ordered, w it h
observat ion f or 24 hours.
2. Monit or in a recovery area. Assess pulse, blood pressure, and respirat ion
every 15 minut es f or t he f irst hour, every 30 minut es f or t he next 2 hours,
once in each of t he next 4 hours, and t hen every 4 hours unt il t he pat ient 's
condit ion is st able.
3. Not if y t he surgeon if t he blood pressure diff ers markedly f rom baseline or if
t he pat ient is in severe pain.
4. Maint ain NPO st at us f or 2 hours; previous diet can t hen be resumed. Take
act ion immediat ely if a bleeding episode occurs. Assess f or pain and t reat as
ordered.
5. Af t er 6 hours, a blood specimen f or hemat ocrit t est ing is usually ordered t o
rule out int ernal bleeding. A small number of pat ient s need t ransf usion f or
int raperit oneal bleeding.
6. Warn t he pat ient not t o cough hard or st rain f or 2 t o 4 hours af t er t he
procedure. Heavy lif t ing and st renuous act ivit ies should be avoided f or about
1 w eek.
7. Follow t he guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed posttest care .
Clin ical Alert

The most common complicat ions include uncont rolled pain, hemorrhage (cause
of deat h f rom liver biopsy), perit onit is, bile leakage, lacerat ions of ot her
organs, sepsis, and bact eremia.
Kidney Biopsy: Cell (Cytologic) and Tissue (Histologic)

Study Kidney biopsy is used to establish a diagnosis in
the presence or renal dysfunction, evaluate severity
and extent of disease, guide therapy, and identify
candidates for kidney transplantation.
Reference Values
Normal
No pat t erns of abnormalit y or abnormal glomeruli No evidence of drug t oxicit y,
inf ect ion, or inf lammat ion
Procedure
1. O bt ain a specimen of kidney t issue (cont aining 810 glomeruli) by needle
biopsy or open surgical t echnique using x-ray or ult rasound as a guide.
2. Place in normal saline unt il f rozen or place in a f ixat ive or saline and send
immediat ely t o t he laborat ory. Check w it h your laborat ory f or specif ic
handling inst ruct ions. Proper handling is crit ical t o ensure t hat t he specimen
is properly preserved f or necessary t est ing.
3. See sect ion on of Fine-Needle Aspirat es: Cyt ologic St udy f or inf ormat ion
regarding obt aining kidney mat erial f or cyt ologic st udy.
Abnormal pat t erns reveal int erst it ial f ibroses and scleroses, diabet ic nephrot ic
pat hology syndrome, chronic renal f ailure, kidney t ransplant react ions, reject ion
or f ailure, past inf ect ions, glomerulonephrit is, and renal pat hology in syst emic
diseases.
Interventions
1. Explain purpose and procedure, benef it s, and risks of kidney biopsy.
2. Use sedat ion and local or general anest hesia if necessary (see Appendix C).
3. O bt ain signed, w it nessed consent .
4. Be aw are t hat cont raindicat ions include uncont rolled bleeding, cancer, large
cyst s, abscess, pregnancy, acut e pyelonephrit is, aneurysm, and renal art ery.

1. I n counsel w it h ot her clinicians, counsel pat ient and int erpret t est out comes,
discussing f urt her t est ing and possible t reat ment .
2. Monit or f or complicat ions, w hich include hemat uria (more common in

uncont rolled hypert ension and uremia), hemat omas (presence of a local
mass), inf ect ion, and lacerat ion of ot her organs.
Clin ical Alert

Deat h (alt hough very rare) has occurred in 0. 12% of pat ient s.
Respiratory Tract: Cell (Cytologic) and Tissue

(Histologic) Study The lungs and the passages that
conduct air to and from the lungs form the respiratory
tract, w hich is divided into the upper and low er
respiratory tracts. The upper respiratory tract consists
of the nasal cavities, the nasopharynx, and the larynx;
the low er respiratory tract consists of the trachea and
the lungs.
Sput um is composed of mucus and cells. I t is t he secret ion of t he bronchi, lungs,
and t rachea and is t heref ore obt ained f rom t he low er respirat ory t ract (bronchi
and lungs). Sput um is eject ed t hrough t he mout h but originat es in t he low er
respirat ory t ract . Saliva produced by t he salivary glands in t he mout h is not
sput um. A specimen can be correct ly ident if ied as sput um in microscopic
examinat ion by t he presence of dust cells (carbon dust laden macrophages).
Alt hough t he glands and secret ory cells in t he mucous lining of t he low er
respirat ory t ract produce up t o 100 mL of f luid daily, t he healt hy person normally
does not cough up sput um.
Cyt ologic st udies of sput um and bronchial specimens are import ant as diagnost ic
aids because of t he f requency of cancer of t he lung and t he relat ive
inaccessibilit y of t his organ. Also det ect able are cell changes t hat may be
relat ed t o t he f ut ure development of malignant condit ions and t o inf lammat ory
condit ions.
Reference Values
Normal
Negat ive f or abnormal cells or t issue No pat hogenic organisms
Procedures
1. Procedure f or obt aining sput um

a. Be aw are t hat t he pref erred mat erial is an early-morning specimen.
Usually, t hree specimens are collect ed on 3 separat e days.
b. Have t he pat ient inhale air t o t he f ull capacit y of t he lungs and t hen
exhale t he air w it h an expulsive deep cough.
c. Have t he pat ient cough t he specimen direct ly int o a w ide-mout hed, clean
cont ainer cont aining 50% alcohol. (Some cyt ology laborat ories pref er t he
specimen t o be f resh if it w ill be delivered t o t he laborat ory immediat ely. )
I f microbiologic st udies are also ordered, t he cont ainer must be st erile
and no f ixat ive should be added.
d. Cover t he specimen w it h a t ight -f it t ing, clean lid.
e. Label t he specimen w it h t he pat ient 's name, age, dat e, diagnosis, and
number of specimens (one, t w o, or t hree) and send immediat ely t o t he
laborat ory.
2. Procedure f or obt aining bronchial secret ions
a. O bt ain bronchial secret ions during bronchoscopy (see Chapt er 12).
Diagnost ic bronchoscopy involves removal of bronchial secret ions and
t issue f or cyt ologic and microbiologic st udies.
b. Collect secret ions obt ained in a clean cont ainer and t ake t o t he cyt ology
laborat ory. I f microbiologic st udies are ordered, t he cont ainer must be
st erile.
3. Procedure f or obt aining bronchial brushings
a. O bt ain bronchial brushings during bronchoscopy.
b. Smear t he mat erial collect ed direct ly on all-f rost ed slides and
immediat ely f ix, or place t he act ual brush in a cont ainer of 50% et hyl
alcohol or saline and deliver t o t he cyt ology laborat ory (check w it h t he
laborat ory f or t heir pref erence).
4. Procedures f or bronchopulmonary lavage
a. Use bronchopulmonary lavage t o evaluat e pat ient s w it h int erst it ial lung
disease.
b. I nject saline int o t he dist al port ions of t he lung and aspirat e back t hrough
t he bronchoscope int o a specimen cont ainer. This essent ially w ashes
out t he alveoli.
c. Take t he f resh specimen direct ly t o t he laborat ory. A t ot al cell count and
a diff erent ial cell count are perf ormed t o det ermine t he relat ive numbers
of macrophages, neut rophils, and lymphocyt es.
For all procedures, see Chapt er 1 guidelines f or i ntratest care.
Abnormalit ies in sput um and bronchial specimens may somet imes be helpf ul in
det ect ing t he f ollow ing:
1. Benign at ypical changes in sput um, as in:
a. I nf lammat ory diseases
b. Ast hma (Curschmann's spirals and eosinophils may be f ound, but t hey
are not diagnost ic of t he disease. )
c. Lipid pneumonia (Lipophages may be f ound, but t hey are not diagnost ic
of t he disease. )
d. Asbest osis (f erruginous or asbest os bodies)
e. Viral diseases
f. Benign diseases of lung, such as bronchiect asis, at elect asis,
emphysema, and pulmonary inf arct s.
2. Met aplasia (t he subst it ut ion of one adult cell t ype f or anot her); severe
met aplast ic changes are f ound in pat ient s w it h:
a. Hist ory of chronic cigaret t e smoking
b. Pneumonit is
c. Pulmonary inf arct s
d. Bronchiect asis
e. Healing abscess
f. Tuberculosis
g. Emphysema (Met aplasia of t en adjoins a carcinoma or a carcinoma in
sit u. )
3. Viral changes and t he presence of virocyt es (viral inclusions) may be seen in:
a. Viral pneumonia
b. Acut e respirat ory disease caused be adenovirus
c. Herpes simplex
d. Measles
e. Cyt omegalic inclusion disease
f. Varicella
4. Degenerat ive changes, as seen in viral diseases of t he lung
5. Fungal and parasit ic diseases (I n parasit ic diseases, ova or parasit e may be
seen. )
6. Tumors (benign and malignant )
Interfering Factors
1. False-negat ive result s may be caused by:
a. Delays in preparat ion of t he specimen, causing a det eriorat ion of t umor
cells
b. Sampling error (Diagnost ic cells may not have exf oliat ed int o t he mat erial
examined. )
2. The f requency of f alse-negat ive result s is about 15%, in cont rast t o about
1% in st udies f or cervical cancer. This high incidence occurs even w it h
caref ul examinat ion of mult iple deep cough specimens.
Selection of Medications and Media for All Respiratory

Cell and Tissue Procedures
1. Mild sedat ive and analgesia or local anest het ic (or all) may be used during
bronchoscopy. Analgesia is indicat ed f or pain af t er bronchoscopy. See
Chapt er 12 f or bronchoscopy care and Appendix C f or sedat ive and analgesia
precaut ions.
2. Sput um specimens are collect ed in a w ide-mout hed cont ainer; 50% alcohol
may be added if t ransport at ion t o t he laborat ory w ill be delayed.
3. Bronchial w ashings may be collect ed in a t rap t ube or w ide-mout hed
cont ainer.
4. Bronchial brushes may be smeared direct ly on glass slides, w hich are t hen
f ixed immediat ely in 95% alcohol or spray f ixat ive. Brushes may be placed in
a f ixat ive solut ion such as 50% alcohol.
Clin ical Alert

The uncooperat ive pat ient is a cont raindicat ion.
Interventions
1. Explain t he purpose and procedure of t he t est . Tell t he pat ient not t o drink
f ixat ive liquid in specimen cont ainer.
2. Emphasize t hat sput um is not saliva. I f a pat ient is having diff icult y producing
sput um, a hot show er bef ore obt aining a specimen may improve t he yield.
3. Advise t he pat ient t o brush t he t eet h and rinse t he mout h w ell bef ore
obt aining t he sput um specimen t o avoid int roduct ion of saliva int o t he
specimen. The specimen should be collect ed bef ore t he pat ient eat s
breakf ast .
4. I f a bronchoscopy is perf ormed, maint ain NPO f or 6 hours bef ore t he
procedure.
5. Manage pain w it h sedat ion as indicat ed.
6. Provide emot ional support .
7. I nst ruct t he pat ient t o breat he in and out of t he nose w it h t he mout h open
during t he procedure. The f iberopt ic bronchoscope is insert ed t hrough t he
nose or mout h; t he rigid bronchoscope is insert ed t hrough t he mout h.

1. I f t he specimen is obt ained by bronchoscopy, check t he pat ient 's blood
pressure and respirat ions every 15 minut es f or 1 hour, t hen every 2 hours f or
4 hours, t hen as ordered.
2. Assist and t each t he pat ient t o not eat or drink unt il t he gag ref lex ret urns.
3. Maint ain bed rest and elevat e t he head of t he bed 45 degrees.
4. Manage pain as indicat ed.
5. Auscult at e t he chest f or breat h sounds every 2 t o 4 hours and t hen as
ordered.
6. Perf orm post ural drainage and oropharyngeal suct ioning as ordered. (Ref er
t o bronchoscopy care in Chapt er 12. )
8. I nt erpret t est out comes and provide support f or abnormal out comes.
Gastrointestinal Tract: Cell (Cytologic) and Tissue

(Histologic) Study Exfoliative cytology of the
gastrointestinal tract is useful in the diagnosis of
benign and malignant diseases. It is not, how ever, a
specific test for these diseases. M any benign diseases,

such as leukoplakia of the esophagus, esophagitis,
gastritis, pernicious anemia, and granulomatous
diseases, may be recognized because of their
characteristic cellular changes. Response to radiation
may also be noted from cytologic studies.
Reference Values
Normal
Negat ive f or abnormal cells
Squamous epit helial cells of t he esophagus may be present .
Procedure
1. G ive a sedat ive bef ore t he procedure. For esophageal st udies, pass a
nasogast ric Levin t ube approximat ely 40 cm (t o t he cardioesophageal
junct ion) w it h t he pat ient in a sit t ing posit ion.
2. For st omach st udies, pass a Levin t ube int o t he st omach (approximat ely 60
cm) w it h t he pat ient in a sit t ing posit ion.
3. For pancreat ic and gallbladder drainage, pass a special double-lumen gast ric
t ube orally 45 cm, w it h t he pat ient in a sit t ing posit ion. Then place t he
pat ient on his or her side and
pass t he t ube slow ly 8. 5 cm. I t t akes about 20 minut es f or t he t ube t o reach
t his dist ance. Conf irm t he t ube locat ion by biopsy. Lavage w it h physiologic
salt solut ion is done during all upper gast roint est inal cyt ology procedures.
4. Be aw are t hat specimens can also be obt ained during endoscopy
procedures.
5. Remember t hat mat erial obt ained w it h t he use of brushes may be smeared
direct ly on glass slides, w hich are f ixed immediat ely in 95% alcohol or spray
f ixat ive. Brushes may also be placed in a f ixat ive such as 50% alcohol. See
Chapt er 12 f or endoscopic biopsy procedures. Washings must be delivered
immediat ely t o t he laborat ory and may need t o be placed on ice. Check w it h
your individual laborat ory f or specif ic inst ruct ions on handling of w ashings
f rom t he gast roint est inal t ract .
1. The charact erist ics of benign and malignant cells of t he gast roint est inal t ract
are t he same as f or cells of t he rest of t he body.
2. Abnormal result s in cyt ologic st udies of t he esophagus may be a nonspecif ic
aid in t he diagnosis of :
a. Acut e esophagit is, charact erized by increased exf oliat ion of basal cells
w it h inf lammat ory cells and polymorphonuclear leukocyt es in t he
cyt oplasm of t he benign squamous cells
b. Vit amin B12 and f olic acid def iciencies, charact erized by giant epit helial
cells
c. Malignant diseases, charact erized by t ypical cells of esophageal
malignancy
3. Abnormal result s in st udies of t he st omach may be a nonspecif ic aid in t he
diagnosis of :
a. Pernicious anemia, charact erized by giant epit helial cells. An inject ion of
vit amin B12 causes t hese cells t o disappear w it hin 24 hours.
b. G ranulomat ous inf lammat ions seen in chronic gast rit is and sarcoidosis of
t he st omach, w hich is charact erized by granulomat ous cells
c. G ast rit is, charact erized by degenerat ive changes and an increase in t he
exf oliat ion of clust ers of surf ace epit helial cells
d. Malignant diseases, most of w hich are gast ric adenocarcinomas.
Lymphoma cells can be diff erent iat ed f rom adenocarcinoma. The ReedSt ernberg cell, a mult inucleat ed giant cell, is t he charact erist ic cell f ound
along w it h abnormal lymphocyt es in Hodgkin's disease.
4. Abnormal result s in st udies of t he pancreas, gallbladder, and duodenum may
reveal malignant cells (usually adenocarcinoma), but it is somet imes diff icult
t o det ermine t he exact sit e of t he t umor.
5. Abnormal result s in examinat ion of t he colon may reveal:
a. I leit is, charact erized by large, mult inucleat ed hist ocyt es (Bovine
t uberculosis commonly manif est s it self in t his area. )
b. Ulcerat ive colit is, charact erized by hyperchromat ic nuclei surrounded by
a t hin cyt oplasmic rim
c. Malignant cells (usually adenocarcinoma)
Interfering Factors
The barium and lubricant used in Levin t ubes int erf ere w it h good result s because
t hey dist ort t he cells and prevent accurat e evaluat ion.
Interventions
1. Tell t he pat ient t he purpose of t his t est , t he nat ure of t he procedure, and t o
ant icipat e some discomf ort .
2. Be aw are t hat a liquid diet usually is ordered f or t he 24 hours bef ore t est ing.
Encourage t he pat ient t o t ake f luids t hroughout t he night and in t he morning
bef ore t he procedure.
3. Do not administ er oral barium f or t he preceding 24 hours.
4. Remember t hat laxat ives and enemas are ordered f or colon cyt ologic
st udies.
5. Because insert ion of t he nasogast ric t ube can cause considerable
discomf ort , devise a syst em (eg, raising a hand) t o indicat e discomf ort w it h
t he pat ient . (See gast ric analysis procedure in Chapt er 16. )
6. I nf orm t he pat ient t hat pant ing, mout h breat hing, or sw allow ing can help t o
ease insert ion of t he t ube.
7. Tell pat ient t hat sucking on ice chips or sipping t hrough a st raw also makes
insert ion of t he t ube easier.
8. Remember t hat ballot t ement and massage of t he abdomen are needed t o
release cells w hen a gast ric w ash t echnique is used.
Clin ical Alert

1. The uncooperat ive pat ient is a cont raindicat ion.
2. I mmediat ely remove t he t ube if t he pat ient show s signs of dist ress:
coughing, gasping, or cyanosis.

1. I nt erpret t est result s and monit or appropriat ely. The pat ient should be given
f ood, f luids, and rest af t er t he t est s are complet ed.
2. Provide rest . Pat ient s having colon st udies w ill be f eeling quit e t ired.
3. Be aw are t hat pot ent ial complicat ions of endoscopy include respirat ory
dist ress and esophageal, gast ric, or duodenal perf orat ion. Complicat ions of
proct osigmoidoscopy include possible bow el perf orat ion. Decreased blood
pressure, pallor, diaphoresis, and bradycardia are signs of vasovagal
st imulat ion and require immediat e not if icat ion of t he physician.
Papanicolaou (Pap) Smear: Cell (Cytologic) Study of

the Female Genital Tract, Vulva, Vagina, and Cervix;
DNA Test for Human Papilloma Virus (HPV)
Charact erist ic physiologic cellular changes occur in t he genit al t ract f rom birt h
t hrough t he post menopausal years. Three major cell t ypes occur in a
charact erist ic pat t ern in normal vaginal smears:
1. Superf icial squamous cells (mat ure squamous, usually polygonal, cont aining
a pyknot ic [ t hick, compact , dense] nucleus)
2. I nt ermediat e squamous cells (mat ure squamous, usually polygonal,
cont aining a clearly st ruct ured vesicular nucleus, w hich may be eit her w ell
preserved or changed as a result of bact erial cyt olysis)
3. Parabasal cells (immat ure squamous, usually round or oval, cont aining one
or, rarely, more t han one) as a result of degenerat ion or necrosis)
Findings indicat e t hat presence of human papilloma virus (HPV) may be
associat ed w it h t he development of cervical cancer.
Clin ical Alert

Deviat ion f rom normal physiologic cell pat t erns may be indicat ive of a
pat hologic condit ion.
The Papanicolaou (Pap) cyt ologic smear is used principally f or early det ect ion of
cervical cancer and diagnosis of precancerous and cancerous condit ions of t he
vulva and vagina. This t est is also used f or diagnosis of inf lammat ory and
inf ect ious diseases. Because t he Pap smear is of great import ance in t he early
det ect ion of cervical cancer, it is recommended t hat all w omen older t han 20
years of age have t he t est at least once a year. HPV t est ing is recommended f or
all w omen w it h a Pap cyt ologic diagnosis of at ypical squamous cells of
undet ermined signif icance (ASCUS).
The value of t he Pap smear depends on t he f act t hat cells readily exf oliat e (or
can be easily st ripped) f rom genit al cancers. Cyt ologic st udy can also be used
f or assessing response t o administ ered sex hormones. The microbiologic
examinat ion on cyt ology samples is not as accurat e as bact erial cult ure, but it
can provide valuable inf ormat ion.

Specimens f or cyt ologic examinat ion of t he genit al t ract are usually obt ained by
vaginal speculum examinat ion or by colposcopy w it h biopsy. Mat erial f rom t he
cervix, endocervix, and post erior f ornix is obt ained f or most smears. Smears f or
hormonal evaluat ion are obt ained f rom t he vagina.
Clin ical Alert

1. Cyt ologic f indings alone do not f orm t he basis of a diagnosis of cancer or
ot her diseases. O f t en t hey are used t o just if y f urt her procedures, such as
biopsy.
2. The Pap smear has been FDA approved f or diagnosis of cancer and human
papilloma virus (HPV).
3. The Bet hesda Syst em2001 recommends delet ing hormonal evaluat ion.
Hormonal evaluat ion is a crude measure of est rogen-like eff ect s on
squamous cells. I t is not reproducible and does not correlat e w it h
sympt oms or plasma est rogen levels (St one, 1975).
I n an eff ort t o st andardize report ing of cervical-vaginal cyt ology specimens, t he

Bet hesda Syst em f or report ing cervical-vaginal diagnoses w as developed by a
1977 Nat ional Cancer I nst it ut e w orkshop and slight ly modif ied af t er a second
w orkshop in 1991 and revised in 2001. This report ing syst em is being adapt ed
by numerous laborat ories nat ionw ide. The t erminology of t his report ing syst em
appears in Table 11. 2.
Table 11.2 Bethesda System for Reporting CervicalVaginal Diagnoses
Bethesda System 2001

(Specim en type:
Bethesda System
1991
Conventional [Pap] vs. liquid

vs. other)
SPECIMEN
ADEQUACY
SPECIMEN ADEQUACY
Satisfactory for
evaluation
Satisfactory but
limited by
Satisfactory for evaluation

(describe presence or absence of
endocervical/ transformation
zone component and any other
quality indicators)
Unsatisfactory
Unsatisfactory for evaluation

(specify reason):
(1) Specimen rejected but
processed (specify reason)
(2) Specimen processed and
examined but unsatisfactory for
evaluation of epithelial
abnormality because of (specify
reason)
GENERAL
CAT EGORIZAT ION
GENERAL CAT EGORIZAT ION
W ithin normal
limits
Epithelial cell
abnormality
(followed by
interpretation)
Benign cellular
changes
Other
Negative for intraepithelial lesion

or malignancy
Epithelial cell abnormality
(followed by interpretation)
Other: see interpretation/result
GENERAL
CAT EGORIZAT ION
INT ERPRETAT ION/RESULT
W ithin normal
limits
Benign cellular
changes:
(1) Trichomonas
vaginalis
(2) Fungal
organisms
morphologically
consistent with
Candidaspecies
(3) Shift in flora
suggestive of
bacterial vaginosis
(coccobacillus)
(4) Actinomyces
species
(5) Herpes simplex
virus
(6) Reactive
changes
associated with
inflammation or
atrophic vaginitis
or radiation or
intrauterine device
(IUD)
Negative for intraepithelial lesion

or malignancy
Organisms:
(1) Trichomonas vaginalis
(2) Fungal organisms
morphologically consistent with
Candida species
(3) Shift in flora suggestive of
bacterial vaginosis
(coccobacillus)
(4) Bacteria morphologically
consistent with Actinomyces
species
(5) Cellular changes consistent
with herpes simplex virus
Other nonneoplastic findings:
(1) Reactive changes associated
with inflammation (includes
repair), radiation, IUD, atrophy,
glandular cells status after
hysterectomy, or endometrial
cells (in women >40 years of
age)
EPIT HELIAL CELL

ABNORMALIT IES
EPIT HELIAL CELL

ABNORMALIT IES
SQUAMOUS CELL
T YPE
SQUAMOUS CELL T YPE
Atypical squamous
cells of
undetermined
significance
(ASCUS), qualify
Low-grade
squamous
intraepithelial
lesion (LSIL)
HSIL
HSIL
encompassing
moderate, severe,
carcinoma in situ
(CIS)
Squamous cell
carcinoma
Squamous cell:
ASCUS, cannot exclude highgrade squamous intraepithelial
lesion (HSIL)(ASC-H)
LSIL encompassing human
papilloma virus (HPV), mild
dysplasia, cervical intraepithelial
neoplasm (CIN) grade 1 (lowgrade precursor)
HSIL encompassing moderate,
severe, CIS/CIN 2 and CIN 3
(grades 2 and 3 are high-grade
precursors)
Squamous cell carcinoma
GLANDULAR
CELL LESIONS
GLANDULAR CELL LESIONS
Endometrial cells,
cytologically
benign in a
postmenopausal
woman
ASCUS, qualify
Endocervical
adenocarcinoma
Atypical
(1) Endocervical cells (NOS or
specify in comments)
(2) Endometrial cells (NOS or
(3) Glandular cells (NOS or
(4) Endocervical cells, favor
neoplastic
Endometrial
adenocarcinoma
Extrauterine
adenocarcinoma
Adenocarcinoma
NOS (not otherwise
specified)
(5) Glandular cells, favor

neoplastic
Endocervical adenocarcinoma in
situ
Adenocarcinoma
(1) Endocervical
(2) Endometrial
(3) Extrauterine
(4) NOS (not otherwise specified)
The Aut oPap Syst em received preliminary approval f rom t he U. S. Food and Drug
Administ rat ion in early 1998 and is t he f irst device of it s kind t o receive a
recommended approval f or aut omat ed init ial Pap smear screening. Wit h t he
Aut oPap Syst em, approximat ely 25% of submit t ed Pap smears w ould receive
Aut oPap review only and w ould not need t o be seen by a t echnologist .
Cyt yc has t aken a diff erent approach t o creat e a bet t er Pap smear: ThinPrep.
The Pap smear collect ion device f or ThinPrep is rinsed in a special solut ion (ie,
PreservCyt ) and sent t o t he lab. A special machine prepares a unif orm
monolayer Pap smear. These slides are t hen manually screened in t he usual
manner. St udies have show n t hat t hese ThinPrep smears have a higher rat e of
det ect ion of biopsy-proven high-grade lesions and a low er rat e of f alse-negat ive
result s t han convent ional Pap smears.
Human papilloma virus (HPV) has been ident if ied as t he primary causal f act or in
cervical cancer. The Digene Hybrid Capt ure HPV Test is approved in t he U. S. f or
HPV DNA det ect ion. Primarily, t his t est is usef ul t o t riage or manage w omen w it h
an ASCUS or equivocal cyt ology
result . I t is an eff icient , rapid t est t hat is able t o diff erent iat e pat ient s w it h highrisk versus low -risk HPV and can be perf ormed f rom t he same pat ient specimen
w hen t he ThinPrep Pap Test is used. I n addit ion, t he FDA has approved t est ing
f or Chl amydi a trachomati s and Nei sseri a gonorrhoeae direct ly f rom t he ThinPrep
sample vial. I f t he ThinPrep Pap Test is not used, a collect ion kit is available
f rom Digene. Clinicians should check w it h t heir laborat ories f or ordering and
collect ion inst ruct ions f or any of t hese t est s.
Reference Values
Normal Pap
No abnormal or at ypical cells No inf lammat ion, no inf ect ion, no part ially
obscuring blood Major cell t ypes w it hin normal limit s Negat ive f or int raepit helial
cell abnormalit y of malignancy Negat ive f or HPV
Procedure
1. Ask t he pat ient t o remove clot hing f rom t he w aist dow n.
2. Place t he pat ient in a lit hot omy posit ion on an examining t able.
3. G ent ly insert an appropriat ely sized bivalve speculum, lubricat ed and
w armed only w it h w at er, int o t he vagina t o expose t he cervix.
4. O bserve st andard universal precaut ions (see Appendix A).
5. I f a convent ional Pap smear, as opposed t o liquid base, is being t aken,
scrape t he post erior f ornix and t he ext ernal os of t he cervix w it h a w ooden
spat ula, a cyt obrush, or a cyt obroom. Smear mat erial obt ained on glass
slides and place immediat ely in 95% alcohol or spray f ixat ive bef ore airdrying occurs.
6. I f a ThinPrep Pap smear is being t aken, use a broomlike collect ion device.
I nsert t he cent ral brist les of t he broom int o t he endocervical canal deep
enough t o allow t he short brist les t o cont act t he ect ocervix f ully. Push gent ly
and rot at e t he broom in a clockw ise direct ion f ive t imes. Rinse t he broom
w it h a PreservCyt solut ion vial by pushing t he broom int o t he bot t om of t he
vial 10 t imes, f orcing t he brist les apart . As a f inal st ep, sw irl t he broom
vigorously t o release mat erial. Discard t he collect ion device. Tight en t he cap
on t he solut ion cont ainer so t hat t he t orque line on t he cap passes t he t orque
line on t he vial.
7. Label t he specimen properly w it h t he pat ient 's name and ident if ying number
(if appropriat e) and t he area f rom w hich t he specimen w as obt ained, and
send it t o t he laborat ory w it h a properly complet ed inf ormat ion sheet ,
including dat e of collect ion, pat ient 's dat e of birt h, dat e of last menst rual
period, and pert inent clinical hist ory.
8. Examinat ion t akes about 5 minut es.
Clin ical Alert

1. The best t ime t o t ake a Pap smear is 2 w eeks af t er t he f irst day of t he
last menst rual period, def init ely not w hen t he pat ient is menst ruat ing or
bleeding, unless bleeding is a cont inuous condit ion.
2. Cyt ologic specimens should be considered inf ect ious unt il f ixed w it h a
germicidal f ixat ive. O bserve st andard precaut ions w hen handling

specimens f rom all pat ient s.
1. Abnormal Pap cyt ologic responses include at ypical squamous cells of
undet ermined signif icance (ASCUS) and can be classif ied as prot ect ive,
dest ruct ive, reparat ive (regenerat ive), or neoplast ic.
2. I nf lammat ory react ions and microbes (Tri chomonas vagi nal i s and Moni l i a,
Coccobaci l l a, Candi da, and Acti nomyces species, cells indicat ive of herpes
simplex virus [ HSV] ) can be ident if ied t o help in t he diagnosis of vaginal
diseases, and evidence of Chl amydi a trachomati s and Nei sseri a
gonorrhoeae.
3. React ive cells associat ed w it h inf lammat ion, t ypical surgical repair, radiat ion,
int raut erine cont racept ion devices (I UDs), post -hyst erect omy glandular cells,
at rophy, and endomet rial cells in a w oman 40 years of age or older
4. Posit ive DNA t est f or HPV
5. Precancerous and cancerous lesions of t he cervix can be ident if ied.
Clin ical Alert

1. A cyt obrush should not be used t o obt ain a cervical specimen f rom a
pregnant pat ient .
2. Some nonpregnant pat ient s experience heavy bleeding af t er a cyt obrush is
used.
Interfering Factors
1. Medicat ions such as t et racycline and digit alis, w hich aff ect t he squamous
epit helium, alt er t est result s.
2. The use of lubricat ing jelly in t he vagina or recent douching int erf eres w it h
t est result s by dist ort ing t he cells and prevent ing accurat e evaluat ion.
3. Heavy menst rual f low and blood may make t he int erpret at ion of t he result s
diff icult and may obscure at ypical cells.
Figure. No capt ion available.
Interventions
1. Explain t he Pap cyt ology t est purpose and procedure. I n rape cases, vaginal
sw abs f or f orensic evidence require a chain-of -cust ody prot ocol (see
Appendix L).
2. I nst ruct t he pat ient not t o douche f or 2 t o 3 days bef ore t he t est because
douching may remove t he exf oliat ed cells.
3. I nst ruct t he pat ient not t o use vaginal medicat ions or vaginal cont racept ives
during t he 48 hours bef ore t he examinat ion. I nt ercourse is not recommended
t he night bef ore t he examinat ion.
4. Have t he pat ient empt y bladder and rect um bef ore examinat ion.
5. Ask t he pat ient t o give t he f ollow ing inf ormat ion:
a. Ageindicat e if adolescent , pregnant , or post menopausal
b. Use of hormone t herapy, birt h cont rol pills, or cont racept ive devices
c. Past vaginal surgical repair or hyst erect omy
d. All medicat ions t aken, including prescribed, over-t he-count er, and herbal
medicat ions
e. Any radiat ion t herapy
f. Any ot her pert inent clinical hist ory (eg, previous abnormal Pap smear,
signs of inf lammat ion or bleeding)

1. G ive t he pat ient a perineal pad af t er t he procedure t o absorb any bleeding
or drainage.
2. I nt erpret t est result s and counsel appropriat ely regarding repeat cyt ology
t est ing if at ypical or abnormal cells are present .
3. Explain t hat monit oring and management of w omen w it h at ypical or abnormal
cells f ollow s ASCCP consensus guidelines. Repeat HPV DNA t est s and
repeat cyt ology Pap smears are st andard.
4. Counsel t hat t reat ment may include int ravaginal est rogen t herapy, diagnost ic
excisional procedures, and/ or ref erral t o an expert . Management opt ions may
vary if t he w oman is an adolescent , pregnant , or post menopausal (see Table
11. 2, t he Bet hesda Syst em, and Chapt er 12, Endoscopic St udies f or t ypical
procedures).
Further Testing After Abnormal Results of Pap

Testing*
P. 7
Adolescents
LSIL
Postm enopausal
Wom enASCUS
Wom en With
HSIL
Repeat Pap
at 6 and 12
months.
Intravaginal
estrogen therapy
Colposcopy with
endocervical
assessment
Colposcopy
if repeat Pap
is ASC or
above, or
HPV DNA at
12 months
After treatment,
repeat PAP cytology
in one week.
If no CIN, review
cytology,
colposcopy, and
histology. If
necessary, a
revised report is
issued.
If positive for
high-risk
HPV, refer
for
colposcopy.
If Pap is negative,
repeat at 46
months.
If no change
found upon
review, biopsy to
confirm CIN.
If positive,
perform
another
colposcopy
If repeat is
negative, return to
regular screening
schedule. If either
Pap is ASC or
above, refer for
Manage and
treat per ASCCP.
colposcopy.
Footn ote
*For complet e recommendat ions, ref er t o 2001 ASCCP Consensus G uidelines.
LSI L, low -grade squamous int raepit helial lesions; ASCUS, at ypical squamous
cells of undet ermined signif icance; HSI L = high-grade squamous int raepit helial
lesions; CI N = cervical int raepit helial neoplasm; ASCCP = American Societ y f or
Colposcopy and Cervical Pat hology (Source: 2001 Consensus G uidelines f or t he
Management of Women w it h Cervical Cyt ological Abnormalit ies, JAMA 287: 2120
2129, 2002)
Anal Smears: Cell (Cytologic) Study The incidence of

anal squamous neoplasms has been increasing,
especially in homosexual and bisexual men and in
w omen w ith multicentric genital tract squamous
lesions. When evaluating high-risk populations, the rate
of anal cancer has been reported to be as high as 70
cases per 100,000. The etiology and pathogenesis of
anal squamous neoplasia are similar to that of cervical
squamous neoplasia, including an association w ith
human papilloma virus, w hich has been identified in
90% of anal squamous cancers in reported studies.
Clin ical Alert
Anoscopic and hist ologic assessment of anal lesions is crit ical t o classif y
lesions accurat ely. Any cyt ologic abnormalit y should be f ollow ed up w it h highresolut ion anoscopy and any lesion should be biopsied t o conf irm t he grade of
dysplasia.
While t here are no off icial guidelines regarding anal cyt ology screening f or anal
squamous int raepit helial lesions (ASI L), smears of t he anorect al junct ion are
being done w it h increasing f requency on high-risk pat ient s. Taking an anal Pap
is a f airly simple procedure, and samples are handled in a similar f ashion t o
cervical/ vaginal Pap smears. Clinicians should check w it h t heir laborat ories f or
specif ic handling inst ruct ions.
Reference Values
Normal
Negat ive f or int raepit helial cell abnormalit y or malignancy Negat ive f or HPV
Procedure
1. Ask t he pat ient t o remove clot hing f rom t he w aist dow n.
2. Place t he pat ient on t he side w it h t he knees draw n up t o t he chest .
3. G ent ly insert a Dacron sw ab or cyt obrush int o t he anus t o a dist ance of 2 t o
3 cm, ensuring sampling of t he anorect al junct ion by passing and including
t he dent at e line.
4. Rot at e t he sw ab or cyt obrush 360 degrees w hile gent ly pulling back and
f ort h.
5. Transf er t he sample by insert ing t he sw ab or brush int o a vial of f ixat ive f luid
and gent ly agit at e, or if t he laborat ory pref ers, direct ly apply t he sample t o
a glass slide, w hich is t hen placed in 95% alcohol or spray f ixed.
6. Seal t he sample vial in a biohazard bag and f orw ard t o t he laborat ory w it h a
properly complet ed requisit ion.
Abnormal result s are indicat ive of abnormal cyt ology, anal squamous
int raepit helial lesions (ASI L) and malignancy.
Interventions
Pretest Patien t Preparation
1. Explain t he purpose of t he t est and t he collect ion procedure. No rect al
supposit ories bef ore day of obt aining smear.
2. Advise t hat t here may be a slight discomf ort (eg, pressure sensat ion) during
insert ion and rot at ion of sw ab.
3. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, and inf ormed pretest care.
Posttest Patien t Care

1. G ive t he pat ient a perineal pad af t er t he procedure t o absorb any bleeding
or drainage.
2. I nt erpret t est result s and counsel appropriat ely regarding subsequent t est ing
(anoscopy and biopsy) if an abnormal result is received and possible need
f or t reat ment (ie, excisional procedures).
Aspirated Breast Cysts and Nipple Discharge: Cell

(Cytologic) Study, Fine Needle Aspiration (FNA) and
Cytologic Study of Breast Aspirate and Biomarkers of
Cancer Risk Nipple discharge usually is normal only
during the lactation period. Any other nipple discharge
is abnormal, and w hen it occurs, the breasts should be
examined for mastitis, duct papilloma, and intraductal
cancer. (How ever, certain situations increase the
possibility of finding a normal nipple discharge, such
as pregnancy, perimenopausal state, and use of birth
control pills.) About 3% of breast cancers and 10% of
benign lesions of the breast are associated w ith
abnormal nipple discharge. The contents of the
identified breast cyst are obtained by fine-needle
aspiration biopsy and are examined to detect malignant
cells. Fine needle perioareolar breast aspiration, along
w ith the Gail Risk M odel and certain biomarkers, is
used to predict cancer development in high-risk
individuals.
Reference Values
Normal
Negat ive f or neoplasia or hyperplasia w it h at ypia No evidence of high-risk result s
No expression of select biomarkers as predict ors of f ut ure cancer development
Procedure for Nipple Discharge

1. Limit t his procedure t o pat ient s w ho have no palpable masses in t he breast
or ot her evidence of breast cancer.

2. Wash t he nipple w it h a cot t on pledget and pat dry.
3. G ent ly st rip, or milk, t he nipple t o obt ain a discharge. Express f luid unt il a
pea-sized drop appears. The pat ient may assist by holding a bot t le of
f ixat ive beneat h t he breast so t hat t he slide may be dropped in immediat ely.
4. Spread t he nipple discharge direct ly on glass slides and t hen drop int o t he
f ixat ive bot t le cont aining 95% alcohol or spray f ixed.
5. I dent if y t he specimen w it h pert inent dat a, including f rom w hich breast it w as
obt ained, and send w it hout delay t o t he laborat ory.
6. For all procedures, see Chapt er 1 guidelines f or i ntratest care.
Procedure for FNA

1. Administ er buff ered lidocaine (1%) as a local anest het ic. Use a 1. 5 inch-21
G A needle w it h at t ached 1012 mL syringe pre-w et t ed w it h t issue cult ure
medium. Posit ion needle direct ly adjacent t o areola, avoiding superf icial
blood vessels. A number of aspirat ions may be perf ormed in upper, out er,
and inner quadrant s of breast .
2. All cells if f rom mult iple aspirat ions may be pooled in 5 mL of an ice-cold
medium in an ice bat h and f ixed in acet one, met hanol, and/ or f ormalin unt il
st ained. Part of specimen is used f or cyt ology (cell) st udy, t he rest f or
expression of biomarkers.
3. Use st erile measures and st andard precaut ions.
Abnormal result s are helpf ul in ident if ying:
1. Benign breast condit ions, such as mast it is or int raduct al papilloma
2. Malignant breast condit ions, such as int raduct al cancer or int racyst ic
inf ilt rat ing cancer
3. FNA result s of hyperplasia w it h at ypia are associat ed w it h a great er risk of
f ut ure development of breast cancer.
4. Expression of DNA aneuploidy (2+ int ensit y), p53 expression (2+
int ensit y), HER2/ neu expression (2+ int ensit y), nER expression (1+
int ensit y), and EG F-R expression (2+ int ensit y).
5. Also see breast biopsy prognost ic markers and ER, PR, and DNA ploidy.
Interfering Factors
Use of drugs t hat alt er hormone balance (eg, phenot hiazines, digit alis, diuret ics,
st eroids) of t en result s in a clear nipple discharge.
Interventions
1. Explain t he purpose and procedure of t he nipple discharge procedure. O ral
lorazepam may be given f or anxiet y.
2. The nipple should be w ashed w it h a cot t on pledget and pat t ed dry.
Clin ical Alert

The only cont raindicat ion is an uncooperat ive pat ient .

1. No special inst ruct ions are needed f or nipple discharge af t ercare because
t his is not an invasive procedure. The pat ient should be inst ruct ed t o cont act
t he clinician.
2. I nt erpret t est result s and counsel appropriat ely about possible f urt her t est ing
(eg, biopsy) and t reat ment (eg, t amoxif en, w hich reduces breast cancer risk,
or ant ibiot ics f or inf ect ion).
3. Af t er FNA, monit or f or hemat oma f ormat ion and inf ect ion. Apply cold packs
f or approximat ely 10 minut es, bind breast and chest w all w it h gauze, and
inst ruct pat ient t o w ear a t ight -f it t ing sport s bra.
Clin ical Alert

1. Any nipple discharge, regardless of color, should be report ed and
examined. A bloody or blood-t inged discharge is especially signif icant .
2. Af t er FNA, a large hemat oma may require surgery, and inf ect ion may
require ant ibiot ics.
Urine: Cell (Cytologic) Study Cells from the epithelial

lining of the urinary tract exfoliate readily into the
urine. Urine cytology is most useful in the diagnosis of
cancer and inflammatory diseases of the bladder, the
renal pelvis, the ureters, and the urethra. This study is
also valuable in detecting cytomegalic inclusion
disease and other viral diseases and in detecting
bladder cancer in high-risk populations, such as
w orkers exposed to aniline dyes, smokers, and patient
previously treated for bladder cancer. A Pap stain of
smears prepared from the urinary sediment, filter
preparations, or cytocentrifuged smears is useful to
identify abnormalities.
Reference Values
Normal
Negat ive
Epit helial and squamous cells are normally present in urine.
(See also Chapt er 3, especially Microscopic Examinat ion of Urine Sediment. )
Procedure
1. O bt ain a clean-voided urine specimen of at least 180 mL f or an adult or 10
mL f or a child.
2. O bt ain a cat het erized specimen, if possible, if cancer is suspect ed.
3. Deliver t he specimen immediat ely t o t he cyt ology laborat ory. Urine should be
as f resh as possible w hen it is examined. I f a delay is expect ed, an equal
volume of 50% alcohol may be added as a preservat ive.
4. Collect urine specimens or bladder w ashings in w ide-mout hed cont ainers;
add 50% alcohol if laborat ory t ransport w ill be delayed. Check w it h your
1. Findings possibly indicat ive of inf lammat ory condit ions of t he low er urinary
t ract include:
a. Epit helial hyperplasia
b. At ypical cells
c. Abundance of red blood cells
d. Leukocyt es
2. Findings indicat ive of viral disease include t he f ollow ing:
a. Cyt omegalic inclusion disease: large int ranuclear inclusions
1. Cyt omegaloviruses or salivary gland viruses are relat ed t o t he herpes
varicella agent s.
2. I nf ect ed people may excret e virus in t he urine or saliva f or mont hs.
3. About 60% t o 90% of adult s have experienced inf ect ion.
4. I n closed populat ions (eg, inst it ut ionalized ment ally disabled persons,
household cont act s), high inf ect ion rat es may occur at an early age.
b. Measles: charact erist ic cyt oplasmic inclusion bodies may be f ound in t he
urine bef ore t he appearance of Koplik's spot s.
3. Findings possible indicat ive of malacoplakia and granulomat ous disease of
t he bladder or upper urinary t ract include:
a. Hist ocyt es w it h mult iple granules in an abundant , f oamy cyt oplasm
b. Michaelis-G ut mann bodies in malacoplakia
4. Cyt ologic f indings possibly indicat ive of mal i gnancy. I f t he specimen show s
evidence of any of t he changes associat ed w it h malignancy, cancer of t he
bladder, renal pelvis, uret ers, kidney, or uret hra may be suspect ed.
Met ast at ic t umor should be ruled out as w ell.
NOT E
I nf lammat ory condit ions could be caused by benign prost at ic hyperplasia,
adenocarcinoma of t he prost at e, kidney st ones, divert icula of bladder,
st rict ures, or malf ormat ions.
NOT E
Cyt omegalic inclusion disease is a viral inf ect ion t hat usually occurs in
childhood but is also seen in cancer pat ient s t reat ed w it h chemot herapy and in
t ransplant at ion pat ient s t reat ed w it h immunosuppressive drugs. The renal
t ubular epit helium is usually involved.
Interventions
1. Be aw are t hat pat ient preparat ion depends on t he t ype of procedure being
done. Explain t he purpose, procedure, benef it s, and risks t o t he pat ient .
2. I f cyst oscopy is done, give t he pat ient anest hesia (general, spinal, or local).
Ref er t o Chapt er 12 f or cyst oscopy care.
3. I f voided urine is required, inst ruct t he pat ient in t he procedure f or collect ion
of a clean-cat ch specimen.
Clin ical Alert


1. I nt erpret t est result s and monit or appropriat ely. I f cyst oscopy is perf ormed
gent ly and w it h adequat e lubricat ion, t he pat ient should experience only
minimal discomf ort af t er t he procedure.
2. Be aw are t hat af t ereff ect s may include mild dysuria and t ransient hemat uria,
but t hese should disappear w it hin 48 hours af t er t he procedure. The pat ient
should be able t o void normally af t er a rout ine cyst oscopic examinat ion.
Ref er t o Chapt er 12 f or cyst oscopy care.
Cerebrospinal Fluid (CSF): Cell (Cytologic) Study CSF

obtained by lumbar puncture is examined for the
presence of abnormal cells and for an increase or
decrease in the normally present cell population. M ost
of the usual laboratory procedures for study of CSF
involve an examination of the leukocytes and a
leukocyte count; chemical and microbiologic studies
are also done. Cell studies of the CSF also have been
used
to identify neoplastic cells. These studies have been

especially helpful in diagnosis and treatment of the
different phases of leukemia. The nature of neoplasia is
such that for tumor cells to exfoliate, they must
actually invade the CSF circulation and enter such
areas as the ventricle w all, the choroid plexus, or the
subarachnoid space.
Reference Values
Normal
Tot al cell count , adult : 010/ mm 3 or 010 109 cells/ L (all mononuclear cells)
Tot al cell count , inf ant : 020/ mm 3 or 020 109 cells/ L
Negat ive f or neoplasia
A variet y of normal cells may be seen. Large lymphocyt es are most common.
Small lymphocyt es are also seen, as are element s of t he monocyt omacrophage
series.
The CSF of a healt hy person should be f ree of all pat hogens.
Negat ive f or blood
Procedure
1. O bt ain f our specimens of at least 1 t o 3 mL each by lumbar punct ure (see
Chapt er 5).
2. Remember t hat generally, only one specimen of 1 t o 3 mL goes t o t he
cyt ology laborat ory. O t her t ubes are sent t o diff erent laborat ories f or
examinat ion.
3. Label t he specimen w it h t he pat ient 's name, dat e, and t ype of specimen.
4. Send t he sample immediat ely t o t he cyt ology laborat ory f or processing.
Clin ical Alert

The laborat ory should be given adequat e w arning t hat a CSF specimen is
being delivered. Time is a crucial f act or; cells begin t o disint egrat e if t he
sample is kept at room t emperat ure f or more t han 1 hour.
1. CSF abnormalit ies may indicat e:
a. Malignant gliomas t hat have invaded t he vent ricles or cort ex of t he brain:
leukocyt es, 150/ mm3 or 150 109 cells/ L (The samples may be normal in
75% of pat ient s. )
b. Ependymoma (neoplasm of diff erent iat ed ependymal cells) and
medulloblast oma (a cerebellar t umor) in children
c. Seminoma and pineoblast oma (t umors of t he pineal gland)
d. Secondary carcinomas:
1. Secondary carcinomas met ast asizing t o t he cent ral nervous syst em
have mult iple avenues t o t he subarachnoid space t hrough t he
bloodst ream
2. The breast and lung are common sources of met ast at ic cells
exf oliat ed in t he CSF. I nf ilt rat ion of acut e leukemia is also common.
e. Cent ral nervous syst em leukemia
f. Fungal f orms:
1. Congenit al t oxoplasmosis: leukocyt es, 50 t o 500/ mm3 or 50500
10 9 cells/ L (most ly monocyt es present )
2. Coccidiodomycosis: leukocyt es, 200/ mm3 (200 109 cells/ L)
g. Various f orms of meningit is:
1. Crypt ococcal meningit is: leukocyt es, 800/ mm3 or 800 109 cells/ L
(lymphocyt es are more abundant t han polynuclear neut rophilic
leukocyt es)
2. Tuberculous meningit is: leukocyt es, 25 t o 1000/ mm3 or 251000
10 9 cells/ L (most ly lymphocyt es present )
3. Acut e pyogenic meningit is: leukocyt es, 25 t o 1000/ mm3 or 251000
10 9 cells/ L (most ly polynuclear neut rophilic leukocyt es present )
h. Meningoencephalit is (primary amebic meningoencephalit is):
1. Leukocyt es, 400 t o 21, 000/ mm3 (40021, 000 109 cells/ L)
2. Red blood cells are also f ound.
3. Wright 's st ain may reveal amebas.
i. Hemosiderin-laden macrophages, as in subarachnoid hemorrhage
j. Lipophages f rom cent ral nervous syst em dest ruct ive processes
2. Charact erist ics of neoplast ic cells:

a. Somet imes marked increase in size, most likely sarcoma and carcinoma
b. Exf oliat ed cells t end t o be more polymorphic as t he neoplasm becomes
increasingly malignant
Interfering Factors
The lumbar punct ure can occasionally cause cont aminat ion of t he specimen w it h
squamous epit helial cells or spindly f ibroblast s.
Interventions
1. Explain t he procedure t o t he pat ient (see Chapt er 5). A local anest het ic w ill
be used. Remember t o ask w het her t he pat ient has a hist ory of react ing t o
local anest het ic. CSF is collect ed in t ubes and delivered immediat ely t o t he
laborat ory. No f ixat ive is added t o t he specimen. I nst ruct t he pat ient t hat t he
procedure may be uncomf ort able and t hat immobilizat ion is ext remely
import ant . The pat ient should be inst ruct ed t o breat he normally and not t o
hold t he breat h. Provide t he pat ient w it h physical and emot ional support
during t he procedure.
Clin ical Alert


1. Place t he pat ient in a supine posit ion. Keep t he head of t he bed f lat f or 4 t o
8 hours as ordered; if headache occurs, elevat e t he f eet 10 t o 15 degrees
above t he head. Assist and t each t he pat ient t o t urn and deep breat he every
2 t o 4 hours. Blood pressure, pulse, and respirat ion should be checked every
15 minut es f our t imes, t hen every hour f our t imes, t hen as ordered. Cont rol
pain as ordered and observe t he sit e of punct ure f or redness, sw elling, or
drainage; report any sympt oms t o physician.
3. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, and inf ormed posttest
care.
Effusions (Thoracentesis and Paracentesis): Cell

(Cytologic) Study Effusions are accumulations of
fluids. They may be exudates, w hich generally
accumulate as a result of inflammation (tuberculosis,
abscess, pancreatitis), lung infarct or embolus, trauma,
systemic lupus erythematosus (SLE), or transudates,
w hich are fluids not associated w ith inflammation (ie,
cirrhosis, congestive heart failure, and nephrotic
syndromes). Table 11.4 compares these tw o effusions.
Table 11.4 Comparison of Exudate and Transudate
Effusions
Exudate
1.
Accumulates in body
cavities and tis-
Transudate
1.
sues because of
malignancy or
Accumulates in body
cavities from
impaired circulation
inflammation
2.
Associated with an
inflammatory
process
2.
Not associated with

an inflammatory
process
3.
Viscous; opaque to
purulent
4.
High content of
protein, cells, and
3.
Highly fluid
4.
Low content of
protein (<2.53.0
g/dL
solid materials
derived from cells
or <2530 g/L), cells,

or solid materials
derived from cells
5.
May have high W BC

content
5.
Has low W BC content
6.
Clots spontaneously
(contains high
6.
W ill not clot
7.
Malignant cells may

be present
8.
Specific gravity
<1.016
concentration of
fibrinogen)
7.
Malignant cells as
well as bacteria
may be detected
8.
Specific gravity
>1.016
Fluid cont ained in t he pleural, pericardial, perit oneal, or abdominal cavit y is a

serous f luid. Accumulat ion of f luid in t he perit oneal cavit y is called ascit es.
Cyt ologic st udies of eff usions (exudat e or t ransudat es) are helpf ul in det ermining
t he cause of t hese abnormal collect ions of f luids. The eff usions are f ound in t he
pericardial sac, t he pleural cavit ies, and t he abdominal cavit ies. The chief
problem in diagnosis is in diff erent iat ing malignant cells f rom react ive mesot helial
cells.
Reference Values
Normal
Negat ive f or abnormal cells
Procedure
1. G eneral procedure
a. O bt ain mat erial f or cyt ologic examinat ion of eff usions by eit her
t horacent esis or paracent esis.
b. Remember t hat bot h of t hese procedures involve surgical punct ure or a
cavit y aspirat ion of a f luid.
c. Fluid may be obt ained in syringes, vacuum bot t les, or ot her cont ainers,
depending on t he volume of accumulat ed f luid. Heparin may be added t o
prevent clot t ing. Check w it h your laborat ory f or specif ic inst ruct ions.
2. Thoracent esis procedure
a. Ensure t hat chest x-rays are available at t he pat ient 's bedside so t hat
t he locat ion of f luid may be det ermined.
b. G ive t he pat ient a sedat ive if necessary.
c. Expose t he chest . The physician insert s a long t horacent esis needle w it h
a syringe at t ached.
d. Wit hdraw at least 40 mL of f luid. I t is pref erable t o w it hdraw 300 t o
1000 mL of f luid.
e. Collect t he specimen in a clean cont ainer and add heparin if necessary,
part icularly if t he specimen is very bloody (5 t o 10 U of heparin per
millilit er of f luid). Do not add alcohol.
f. Label t he specimen w it h t he pat ient 's name, t he dat e, t he source of t he
f luid, and t he diagnosis.
g. Send t he covered specimen immediat ely t o t he laborat ory. (I f t he
specimen cannot be sent at once, it may be ref rigerat ed).
3. Paracent esis (abdominal) procedure
a. Ask t he pat ient t o void.
b. Place t he pat ient in Fow ler's posit ion.

c. G ive a local anest het ic.
d. I nt roduce a No. 20 needle int o t he pat ient 's abdomen and w it hdraw f luid,
50 mL at a t ime, unt il 300 t o 1000 mL has been w it hdraw n.
e. Follow t he same procedure f or collect ion and t ransport of t he specimen
as f or t horacent esis.
f. For all procedures, see Chapt er 1 guidelines f or i ntratest care.
Clin ical Alert

Paracent esis can precipit at e hepat ic coma in a pat ient w it h chronic liver
disease. The pat ient must be w at ched const ant ly f or indicat ions of shock:
pallor, cyanosis, or dizziness. Emergency st imulant s should be ready.
1. All eff usions cont ain some mesot helial cells. (Mesot helial cells make up t he
epit helial layer covering t he surf ace of all serous membranes. ) The more
chronic and irrit at ing t he condit ion, t he more numerous and at ypical are t he
mesot helial cells. Hist iocyt es and lymphocyt es are common.
2. Evidence of abnormalit ies in serous f luids is charact erized by:
a. Degenerat ing red blood cells, granular red cell f ragment s, and
hist iocyt es cont aining blood. Presence of t hese st ruct ures means t hat
injury t o a vessel or vessels is part of t he condit ion causing f luid t o
accumulat e.
b. Mucin, w hich is suggest ive of adenocarcinoma
c. Large numbers of polymorphonuclear leukocyt es, w hich is indicat ive of
an acut e inf lammat ory process such as perit onit is
d. Prevalence of plasma cells, w hich suggest parasit ic inf est at ion,
Hodgkin's disease, or hypersensit ive st at e
e. Presence of many react ive mesot helial cells t oget her w it h hemosiderin
hist iocyt es, w hich may indicat e:
1. Leaking aneurysm
2. Rheumat oid art hrit is
f. Malignant cells
3. Abnormal cells may be indicat ive of :
a. Malignancy (The most import ant crit erion of cancer is t he arrangement of

chromat in w it hin t he nuclei. )
b. I nf lammat ory condit ions
Interfering Factors
Vigorous shaking and st irring of specimens causes alt ered result s.
Interventions
1. Explain t he purpose of t he t est and t he procedure. The procedure varies
depending on t he sit e of f luid accumulat ion. G eneral pat ient preparat ion
includes measuring blood pressure, t emperat ure, pulse, and respirat ion;
administ ering sedat ion as ordered; preparing local anest het ic as ordered;
providing emot ional support ; and obt aining a signed consent f orm.
2. Be aw are t hat local anest het ic and sedat ive may be ordered t o achieve a
st at e of conscious sedat ion (see Appendix C).
Clin ical Alert


1. Monit or according t o agency prot ocols.
2. Check blood pressure, pulse, and respirat ions every 15 minut es f or 1 hour,
t hen every 2 hours f or 4 hours, and as ordered. Check t emperat ure every 4
hours f or 24 hours. Apply adhesive bandage or dressing t o sit e of punct ure.
Check dressing every 15 t o 30 minut es. Turn pat ient ont o t he unaff ect ed side
f or 1 hour, t hen t o a posit ion of comf ort . Manage pain as indicat ed. Measure
and record t he t ot al amount of f luid removed; not e it s color and charact er.
Skin/Cutaneous Immunofluorescence Biopsy: Cell

(Cytologic) Study and Tissue (Histologic) Study Biopsy
of the skin for direct epidermal fluorescent studies is

indicated in the investigation of certain disorders such
as lupus erythematosus, blistering disease, and
vasculitis. Skin biopsies are also used to confirm the
histopathology of skin lesions, to rule out other
diagnoses (ie, herpes simplex and psoriasis), and to
monitor the results of treatment.
Reference Values
Normal
A descript ive int erpret at ive report of t he skin biopsy is made.
Procedure
1. O bt ain a 3- t o 6-mm punch biopsy or shave biopsy, excisional biopsy, or
incisional biopsy specimen of involved or uninvolved skin. Scraping smears
and/ or aspirat es also may be obt ained. Take care not t o crush t he specimen.
2. Check w it h your laborat ory f or specif ic guidelines f or specimen handling.
1. Biopsy of skin show s t he lesions of discoid lupus eryt hemat osus as a
bandlike immunof luorescence of immunoglobulins and complement
component s. Similar f indings in a biopsy of normal skin are consist ent w it h
SLE and may be used t o monit or t he result s of t reat ment .
2. I n blist ering diseases such as pemphigus and pemphigoid, in w hich
circulat ing ant ibodies may not be present , a lesion may show int ercellular
epidermal ant ibody or pemphigus or basement membrane ant ibody of
pemphigoid.
Interventions
1. Explain t he purpose and procedure of t he skin biopsy. Local anest hesia w ill
be used.
Clin ical Alert

1. An uncooperat ive pat ient
2. Bleeding diat hesis t endencyant icoagulant t herapy

1. Monit or biopsy sit e f or inf ect ion or bleeding. Counsel and int erpret out comes
and need f or possible t reat ment .
2. See Chapt er 1 f or saf e, eff ect ive, inf ormed posttest care .
Estrogen/Estradiol Receptor (ER), Progesterone

Receptor (PR) Tissue (Histologic) Study and DNA Ploidy
(Tumor Aneuploidy) Cancers have abnormal amounts of
nuclear DNA. The higher the grade of tumor cells, the
more likely the DNA content w ill be abnormal. The
determination of tumor ploidy (the number of
chromosome sets in a cell; ie, diploid, tw o sets,
triploid, three sets) by various methods: flow cytometry
(Fc), histograms, and image analysis divide cells into
triploid/diploid (slow ly replicating cells) or aneuploid
(rapidly replicating cells).
ER and PR in t he cells of breast and endomet rial cancer t issues are measured t o
det ermine w het her t he cancer is likely t o respond t o endocrine t herapy or t o
removal of t he ovaries. DNA ploidy measures cell t urnover (replicat ion) in a
specimen ident if ied as cancer and predict s progress, short er survival, and
relapse in some pat ient s w it h cancer: bladder, breast , colon, endomet rial,
prost at e, kidney, and t hyroid. The predict ive value is great er f or breast ,
prost at e, and colon.
Reference Values
Normal
ER: negat ive; <3 f emt omoles (f mol)/ mg (<3. 0 nmol/ kg) of prot ein PR: negat ive;
<5 f mol/ mg (<5. 0 nmol/ kg) of prot ein DNA index (DI ): 0. 91. 0 is normal DNA
ploidy (cont ent ) or t he diploid st at e.
An int erpret ive hist ogram by f low cyt omet ry classif ies t he st ained nucleic as DNA
diploid, DNA aneuploid, DNA t et raploid, or DNA unint erpret able.
Procedure
1. O bt ain a f resh specimen by biopsy, keep on ice, and deliver immediat ely t o
t he hist ology laborat ory.
2. Examine a 1-g specimen of quickly f rozen t umor f or sat urat ion and express in
a Scat chard's plot . Do not place t he specimen in f ormalin. Some laborat ories
can perf orm ERA/ PRA st udies on paraff in-embedded t issue. Check w it h your
3. Classif y specimens f or DNA ploidy on t he basis of t he percent age of
epit helial cells t hat cont ain diploid (2n) DNA cont ent and nondiploid DNA
(aneuploid). DNA cont ent is calculat ed as t he DNA index.
1. A posit ive t est f or ER occurs at levels 10 f mol (10 nmol/ kg) and f or PR
binding at levels of 10 f mol (10 nmol/ kg). The f requency of posit ive ER and
PR occurs more of t en in post menopausal w omen.
2. Approximat ely 50% of ER-posi ti ve t umors respond t o ant iest rogen t herapy,
and 60%70% respond in pat ient s w it h bot h ER- and PR-posit ive t umors.
3. ER-negati ve t umors rarely respond t o ant iest rogen t herapy.
4. The f inding of posit ive progest erone increases t he predict ive value of
select ing pat ient s f or hormonal t herapy. There is some evidence t o suggest
t hat progest erone recept or synt hesis is est rogen dependent .
5. The presence of aneuploid peaks in t he replicat ive act ivit y of neoplast ic cells
may be prognost ically signif icant , independent of t umor grade and st age.
6. The great er t he amount of cells in S phase (DNA synt hesis) of t he cell cycle,
t he more aggressive t he t umor.
7. Posit ive aneuploidy point s t o a f avorable prognosis in some condit ions, such
as acut e lymphoblast ic lymphoma and neuroblast oma and perhaps
t ransit ional cell bladder cancer.
Interventions
1. Explain purpose and procedure of t est ing. See Tissue (Hist ologic) Biopsy
St udies: O verview ; Prognost ic and Predict ive Markers; and Breast Biopsy:
Cell (Cyt ologic) and Tissue (Hist ologic) St udy and Prognost ic Markers on
pages 766 and 770. O bt ain appropriat e clinical hist ory so t hat t his
inf ormat ion can be provided w it h t he specimen.
2. Be aw are t hat posit ive ER and PR means t hat ant iest rogen drug t herapy may
be benef icial.
3. See Chapt er 1 f or saf e, eff ect ive, inf ormed pretest care .
Clin ical Alert

1. An uncooperat ive pat ient
2. Bleeding diat hesis (t endency t o spont aneous bleeding due t o coagulat ion
def ect )ant icoagulant t herapy

1. I nt erpret t est result s and counsel appropriat ely about possible t reat ment .
GENETIC STUDIES
Overview of Genetic Studies
G enet ics is concerned w it h t he component s and f unct ion of biologic inherit ance.
G enet ic t est ing invest igat es t he presence, absence, or act ivit y of genes t hrough
direct and indirect means and by chemical analysis, microscopic met hods,
submicroscopic t echniques, and molecular biology st udies.
I nsight int o causes of development al problems, birt h def ect s, and herit able
disorders of t en involves genet ic st udies. Basic t echnology count s t he
chromosomes in a person's cells or measures t he amount of specif ic prot eins
and enzymes. At t he ot her end of t he spect rum, cellular
DNA can be assayed w it h molecular probes designed t o ident if y a unique genet ic

sequence. G enet ic t est ing is a rapidly evolving f ield t hat has show n expanding
possibilit ies, an ever-increasing number of t est s, and a unique set of limit at ions
and dilemmas.
Many disease st at es ref lect heredit ary component s even t hough general clinical
st udies usually f ocus on t he disorder it self rat her t han on it s genet ic
component s. This sect ion addresses circumst ances t hat may require biochemical
analysis (enzymes, organic acids, amino acids) and DNA t est s of cyt ogenet ic
(chromosome) st udies f or proper diagnosis and/ or management .
Test ing may be done bef ore birt h, neonat ally, during childhood or adult lif e, or
post mort em.
Clin ical Alert

1. Cyt ogenet ics is t he part of genet ics concerned w it h t he st ruct ure and
f unct ions of cells, especially chromosomes. G enet ic t est s are done t o
ident if y inborn errors of met abolism, t o det ermine sex w hen ambiguous
genit alia are present as w ell as t o det ect chromosome aberrat ions such
as Dow n syndrome.
2. Biochemical analysis and t est s t o det ect carrier st at us of inborn errors of
met abolism are being done more and more of t en, primarily t hrough
det ect ion of abnormal accumulat ion in body f luids and t issue. Advances in
t he st udy of molecular genet ics has been aff ect ed by t he complet ion of t he
Human G enome Project . Test s in t his cat egory include diagnosis of
neoplast ic disease (eg, Philadelphia chromosome in chronic myelocyt ic
leukemia and N-MY C gene in neuroblast oma) and inherit ed disorders (eg,
cyst ic f ibrosis, spinal cerebellar at axia).

1. Prenat al care: medical management of pot ent ially problemat ic pregnancies
ident if ied t hrough abnormal mat ernal screening, ult rasound, or f amily hist ory
may include specif ic genet ic t est ing and realist ic inf ormat ion about f et al
abnormalit ies t o allow parent s t o make inf ormed decisions about pregnancy
cont inuat ion.
2. New born screening, t o det ect prevent able, common, or t reat able disease
3. I nvest igat ion of f et al deat h, st illbirt h, or miscarriage
4. Decisive diagnosis: diagnost ic and/ or presympt omat ic st udies may be done
t o invest igat e cert ain syndromes or diseases relat ed t o chromosomal or
single gene disorders; f or gene st at us in t he diagnosis of cancer; f or

inherit ed diseases in carrier st at us; and t o t est asympt omat ic relat ives at
risk f or developing signif icant medical or reproduct ive problems. As a
general rule, presympt omat ic t est ing is not off ered t o minors.
5. Cyt ogenet ic analysis or DNA probes are used t o st udy bone marrow and t o
check f or diagnost ic t ranslocat ions, part icularly in leukemias (cells w it h
genet ic changes).
6. Assignment of gender in t he presence of ambiguous genit alia
7. G enet ic counseling: t o address prognosis and diagnosis as w ell as causes
and recurrence risks in t he cont ext of t he f amily as w ell as individuals.
G enet ic counseling of t en depends on precise t est ing or chromosomal
analysis.
Clin ical Alert

1. Test s are not perf ormed purely f or inf ormat ion's sake; inst ead t hey are
ordered f or diagnost ic purposes in sympt omat ic individuals af t er t est ing
implicat ions are
P.
2.
3.
4.
5.
6.
explained f or condit ions f or w hich t reat ment is available or in sit uat ions in
w hich t reat ment w ould be useless.
G enet ic counseling ideally should be available bef ore and af t er t est ing and
linked t o management (proper medicat ions, diet s, hormone replacement )
and t o educat ional and age-appropriat e t herapy programs.
Pat ient s should be able t o use t est result s t o make t heir ow n inf ormed
decisions about issues such as child-bearing and medical t reat ment .
Privacy may be an issue in genet ic t est ing.
Everyone carries genes t hat are pot ent ially harmf ul or def ect ive t o some
degree; genet ic counseling can put t hese risks int o perspect ive.
Family hist ory, along w it h t he medical and personal healt h records, is a
major t ool in ident if ying genet ic disorders.
Recognize and document signs of possibly genet ic disorders:
a. Birt h def ect s: clef t palat e, congenit al heart disease
b. Dysmorphic f eat ures: abnormally shaped or low -set ears, ext ra
f ingers/ t oes, large t ongue, upw ard slant ing of eyes, f lat t ened f ace,
charact erist ic f eat ures of Dow n syndrome, hypopigment at ion of skin,
abnormal color of urine, brit t le hair
c. G row t h problems: short st at ure (f ound in Dow n syndrome and Turner's
syndrome); t all st at ure (f ound in Marf an's syndrome)
d. Development al delay: f ailure t o t hrive, lat e achievement of w alking or
t alking, hypot onia
e. Sensory def icit s: early onset hearing loss or visual impairment ;

vomit ing w it h hypoglycemia (suggest s galact osemia); also, many
met abolic disorders only become apparent during recurrent f ever and
inf ect ions
f. Adult ret ardat ion: f ragile X syndrome, long f ace, prominent ears, jaw,
and f orehead in persons (usually male) w it h undiagnosed ment al
ret ardat ion
Inheritance in Human Disorders Genetic information is

coded within DNA. This information is packaged into
chromosomes that are present in cell nuclei. In
humans, 46 chromosomes contain an estimated 30,000
to 50,000 gene pairs. DNA contains four distinct
molecules (base pairs). These four base pairs code the
information that controls growth, development, and
function by providing a template for message
molecules called RNA. RNA molecules are involved in
the process of transcription (changing a DNA message
into a protein) as well as in providing molecules that
regulate expression, make the hardware within the cell
for building proteins (ribosomes), and also perform
many housekeeping functions.
Wit h t he except ion of red blood cells and egg/ sperm cells, t here are 23 pairs of
chromosomes in human cell nuclei. O ne of each pair comes f rom each parent .
Tw ent y-t w o of t hese pairs mat ch up and cont ain copies of t he same genes
(alt hough t he copies may not be ident ical). These chromosomes are assigned
numbers, and t hey are called autosomes. Then, t here are t w o sex chromosomes,
X and Y. Females have t w o X-chromosomes; males have one X-and one Ychromosome. The Y chromosome is unique t o males and cont ains genes t hat
det ermine male st ruct ure and f unct ion and also aff ect f ert ilit y. The Y
chromosome cont ains very f ew genes, but it s presence or absence det ermines
male or f emale development .
G enes, like chromosomes, come in pairs, except f or genes on t he sex
chromosomes.
1. Autosomal domi nant i nheri tance. Wit hin one gene pair, an abnormalit y in a
single copy of t he gene may produce a disorder. A person w it h such a gene
combinat ion w ould have a

t heoret ical 50-50 chance of passing t his gene on t o any off spring. Dominant
disorders may t heref ore be inherit ed f rom a parent , or t hey may arise as a
new mut at ion in an egg or sperm cell t hat part icipat es in f ert ilizat ion. For
many dominant ly inherit ed condit ions, manif est at ions of t he disorder are not
consist ent . This observat ion is know n as vari abl e expressi on. Examples of
dominant ly inherit ed disorders include Hunt ingt on's disease,
neurof ibromat osis, f amilial hypercholest erolemia, and heredit ary colon
cancer (Chart 11. 2).
2. Autosomal recessi ve i nheri tance. Bot h copies of t he gene pair must not
f unct ion correct ly f or a problem t o be apparent . I f bot h parent s carry t he
same nonf unct ional gene, t here is a 1-in-4 chance t hat any child could inherit
t w o nonf unct ional copies, leading t o possible disease. Examples of
aut osomal recessively inherit ed diseases include cyst ic f ibrosis, sickle cell
disease, Tay-Sachs disease, some nonsyndromic early-onset hearing loss,
and recurrent pyogenic inf ect ions.
3. X-l i nked recessi ve i nheri tance. Males have only one X chromosome, so t hat
abnormal genes on t he X chromosome can cause problems. Females have a
second X chromosome, w hich usually masks t he aff ect s of an abnormal
gene, alt hough not alw ays complet ely. A w oman w it h a disease-causing gene
on one X chromosome w ould have a 50-50 chance of passing t his gene t o
any child, and t his is independent of her 50-50 chance of having a son.
Examples of X-linked disorders include hemophilia and Duchenne's muscular
dyst rophy.
4. Mul ti f actori al i nheri tance. Some development al processes, as w ell as some
adult disease st at es, are inf luenced by t he int eract ions of many genes
associat ed w it h environment al f act ors. Examples of mult if act orial disorders
include pyloric st enosis, clef t lip and palat e, spinal bif ida, and schizophrenia.
5. Cytogeni c i nheri tance. Chromosomal abnormalit ies may include abnormal
numbers of chromosomes (eg, Dow n syndrome is caused by t hree copies of
chromosome 21). Chromosomal rearrangement s, called transl ocati ons, can
be unbalanced, causing mult iple congenit al abnormalit ies. A molecular
abnormalit y w it hin a single gene can cause st ruct ural diff erences like f ragileX ment al ret ardat ion syndrome. Submicroscopic delet ions of chromosomes
can be st udied using f luorescent in sit u hybridizat ion. Examples of human
syndromes caused by microdelet ions include Williams' syndrome and
DiG eorge's syndrome.
6. Mi tochondri al i nheri tance. Separat e f rom t he nucleus of t he cell are t he
energy-processing organelles called mi tochondri a. These organelles possess
a unique set of genes on a single chromosome. Mut at ions in t hese genes can
cause a w ide variet y of disorders, including neuromuscular disorders.
Examples include Kearns-Sayre syndrome and Leber's heredit ary opt ic
neuropat hy. Mit ochondria are inherit ed exclusively f rom t he mot her.
7. Nontradi ti onal i nheri tance. Some human genes are sensit ive t o modif icat ion
(know n as i mpri nti ng or methyl ati on) t hat alt ers gene expression, depending
on t he sex of t he parent in w hich t he gene originat es. Some human
syndromes are caused by t he presence of t w o copies of a gene or
chromosome originat ing f rom one parent , and none f rom t he ot her
(called uni parental di somy, or UPD). Examples include Beckw it h-Wiedemann
syndrome and Prader-Willi syndrome.
Ch art 11.2 Types of Genetic Disorders
Autosomal
Dominant
Autosomal
Recessive
X-Linked Recessive
Familial breast
cancer
Sickle cell
anemia
Hemophilia A and B
Huntington's
disease
Thalassemia
and
Duchenne's and
Becker's muscular
dystrophy
Adult polycystic
disease (some
types)
Cystic
fibrosis
Fragile X syndrome
Myotonic
dystrophy
Alpha 1 antitrypsin
deficiency
Ornithene
transcarbamylase
deficiency (OTC)
Tay-Sachs
disease
Direct Detection of Abnormal Genes by DNA Testing

M any genetic diseases continue to be detected by the
effects they produce in abnormal body structure,
function, or chemistry. With the elucidation of gene
structure and the cataloging of human gene mutations,
direct detection of hundreds of mutations is possible.
For know n genetic disorders for w hich specific
mutational analysis is not available, indirect analysis
using varied techniques, including protein expression,
may be applicable.
A dat abase of medical genet ics inf ormat ion resources f or physicians and ot her
healt h care providers and researchers maint ains daily updat es of available
t est ing w orldw ide at w w w. genet est s. org. Regist rat ion is required.
G enet ic t est ing f or diagnost ic purposes requires pat ient educat ion and consent ,
physician request , and coordinat ion of sample collect ions. Diagnost ic t est s must
be done in a Clinical Laborat ory I mprovement Act (CLI A)-approved laborat ory.
Research labs cannot provide t his service and should not be cont act ed f or
clinical t est ing.
Sensit ivit y of t est ing in genet ic disease needs t o be addressed because many
diseases may have diff erent causes, and many genet ic t est s are not capable of
f inding all mut at ions in complex genes. For example, nearly 1000 gene mut at ions
have been linked t o cyst ic f ibrosis, but st ill an est imat ed 3% t o 10% of mut at ions
cannot be f ound. I nt erpret at ion of result s can be a challenge also, especially in
sit uat ions in w hich a gene change can be demonst rat ed but it is not know n
w het her it is a harmless change or not . An example of t his is polymorphism in t he
BRCA1 gene. I n such sit uat ions, int erpret at ion may rely on comparison t o gene
changes f ound in know n aff ect ed relat ives.
A variet y of morbid genet ic changes have been discovered, including gain or loss
of a single base pair or larger group of base pairs as w ell as repet it ive
sequences t hat get copied over and over so many t imes t hat t hey disable t he
f unct ion of t he gene. Det ect ion st rat egies are t ailored t o t he t ype of mut at ion
present or suspect ed.
Procedure
1. Est ablish availabilit y and sensit ivit y of clinical t est ing and inf orm t he pat ient
of t he benef it s, limit at ions and consequences of t est ing (see G enet ic
Counseling, next ). I nf ormed consent may be required. Prepayment may be
required. Test result s may t ake w eeks or mont hs.
2. O bt ain samples or specimens of body f luids or t issues as specif ied by t he

receiving laborat ory. O vernight shipment must usually be arranged.
1. I mproved diagnosis of t ypes of cancer may have t herapeut ic implicat ions.
2. Discovery of heredit ary disease or cancer may have implicat ions f or ot her
f amily members.
3. Precise DNA t est s can be done f or some inherit ed diseases (eg, cyst ic
f ibrosis, Duchenne's and Becker's muscular dyst rophy, some polycyst ic
kidney diseases).
4. Pat ernit y ident it y t est ing and f orensic t est ing
5. I dent if icat ion of microbes in inf ect ious diseases (eg, chlamydia,
cyt omegalovirus)
6. Predict ion of progression in neuromuscular disorders (eg, Hunt ingt on's
disease, myot onic dyst rophy, cerebellar at axia)
7. I dent if icat ion of comorbid disease risks (eg, progressive kidney f ailure in
some hearing-loss syndromes)
8. I dent if icat ion of reproduct ive risks
9. Explanat ion of miscarriage and st illbirt h
10. Pot ent ial associat ions w it h common diseases of aging (eg, cardiovascular
disease, Alzheimer's disease)
Genetic Counseling Genetic counseling is the process

of providing individuals and families with information
on the nature, inheritance, and implications of genetic
disorders in order to help them make informed medical
and personal decisions. Risk assessment, family
history, and genetic testing to clarify genetic status of
family members may be part of the genetic counseling
process.
G enet ic counselors are healt h care prof essionals w it h specialized educat ion,
t raining, and experience in medical genet ics. They f requent ly w ork as part of a
t eam t hat includes physicians and ot her specialist s in biochemist ry and genet ics,
and t hey coordinat e act ivit ies w it h many medical specialt ies, including prenat al
care, pediat rics specialt ies, neurology, hemat ology, and laborat ory t est ing.
G enet ics services are available at or t hrough most major medical cent ers in t he
Unit ed St at es and serve t he medical and lay communit ies as sources of
inf ormat ion, clinical evaluat ion, management of genet ic condit ions and birt h
def ect s, and coordinat ion w it h appropriat e t est ing services. G eographic list ings
of genet ic clinics and genet ic counselors can be f ound online at
w w w. genet est s. org and w w w. nsgc. org.
When t est ing f or genet ic disease is being considered, pret est counseling may
include addit ional at t ent ion t o issues of realist ic usef ulness of current ly available
t est s and considerat ion of personal, f amily, privacy, and insurance implicat ions
of t est ing. Just because a t est is available does not mean it is appropriat e
unw ant ed inf ormat ion can be generat ed by genet ic t est ing, t est s may cost
t housands of dollars, and ambiguous result s are possible.
Post t est counseling not only present s t est result s but review s medical and
psychological implicat ions f or t he f amily and pot ent ially may be expanded t o
include ot her f amily members f or counseling and t est ing. Experience w it h rare
genet ic diseases once ident if ied w ill add t o t he direct ion of specif ic medical care
and t herapy, and pat ient educat ion and counseling can assist t he process of
ident if ying opt ions and resources.
The number of specif ic genet ic t est s is increasing rapidly, alt hough availabilit y
may be limit ed and t he cost may be w ell over $500 and not covered by healt h
insurance. An addit ional dilemma is t he lack of usef ulness of t est ing in many
disorders t o rule out a specif ic diagnosis. (For example, a t all t hin individual w it h
some heart f indings like mit ral valve prolapse may be t hought t o have Marf an's
syndrome. Current ly, t est ing f or t he gene t hat causes Marf an's syndrome can be
done, but it does not f ind many mut at ions, even in individuals w ho are know n t o
have t he syndrome. ) O f t en, it is necessary t o st udy an aff ect ed f amily member
t o det ermine w hat gene mut at ion is present in a f amily. This can be problemat ic
in diseases like breast cancer because t he aff ect ed persons may be deceased,
unavailable, or uncooperat ive because of f amily dynamics. I f a f amily w ishes t o
be st udied but no gene mut at ion is ident if ied, linkage st udies might be
considered t o est imat e risks w it hin a f amily.
Because t he possibilit y of ident if ying gene changes associat ed w it h human
disease now exist s, so does t he expect at ion and challenge of improving
t reat ment and underst anding of bot h rare and common diseases.
CYTOGENETICS
Chromosomal Analysis
The karyot ype, a st udy of chromosome dist ribut ion f or an individual, det ermines
chromosome numbers and chromosome st ruct ure (Chart 11. 3); alt erat ions in
eit her of t hese can produce problems. The st andard karyot ype can be a
diagnost ic precursor t o genet ic counseling. Addit ional
or missing pieces of most chromosomal mat erial cause development al problems.

Despit e much speculat ion, it is not know n exact ly how t hese abnormalit ies
t ranslat e int o st ruct ural or f unct ional anomalies. Predict ions almost alw ays
depend on comparisons w it h clinical f indings f rom ot her similar cases t hat
present t he same evidence.
Ch art 11.3 Definition and Nomenclature of Karyotype

Backgrou n d
The karyot ype is an arrangement of t he chromosomes on a cell int o a specif ic
order, f rom t he largest size t o t he smallest , so t hat t heir number and st ruct ure
can be analyzed. This is rout inely done t hrough banding, a t echnique t hat
permit s det ect ion of t he diff erences in st ruct ure bet w een t he diff erent pairs.
Bef ore banding, it w as of t en impossible t o pair chromosomes correct ly;
inst ead, t hey w ere arranged in groups according t o size and st ruct ure and
labeled A t hrough G . The X chromosomes w ere part of group C, and t he Y
chromosomes belonged t o group E. Now, t hey are usually placed w it h each
ot her, apart f rom t he ot her pairs.
The pairs of chromosomes are diff erent iat ed according t o t he f ollow ing
charact erist ics:
1. Their lengt h
2. The locat ion of t he cent romere, t he const rict ion t hat divides chromosomes
int o long (q) and short (p) arms
3. Rat io of t he long and short arms t o each ot her
4. Secondary const rict ions
5. Sat ellit es, w hich are small, variable pieces of DNA seen at t he ends of t he
arms of some chromosomes
6. St aining or banding pat t erns. A variet y of diff erent st ains and t echniques
can be used. The most common is G iemsa banding. Most of t he ot her
met hods, such as cent romeric or f luorescent st aining, are rest rict ed t o
specif ic sit uat ions.
Nomen clatu re of th e Karyotype T h e stan dard con ven tion s for

listin g karyotypes is as follow s:
1. The f irst number denot es t he t ot al number of chromosomes.
2. Second, t he sex chromosome complement f ollow s (usually XX f or normal
f emales and XY f or normal males).
3. Third, t he missing, ext ra, or abnormal chromosomes are ident if ied.

4. The let t er p ref ers t o t he short arm, q t o t he long arm.
5. Bands are numbered f rom t he cent romere out . As t echniques evolve, t hese
are f urt her subdivided. For example, in t he t w o-digit number 32, t he f irst
number (3) is t he band and t he second number (2) is t he subdivision of
t hat band (band 32). Decimal point s indicat e f urt her division under t he
same syst em; f or example (w orking backw ard), 32. 41 is t he f irst
subdivision (1) of t he f ourt h subdivision (4) of t he second subdivision of
t he t hird band.
6. A t hree-let t er code at t he end designat es t he banding t echnique. The f irst
let t er is t he t ype of banding; t he second let t er denot es t he general
t echnique; t he t hird let t er indicat es t he st ain. Probably t he most common
code is G TG : band t ype G , banding by t rypsin, using G iemsa st ain.
Special or unusual t echniques are used only in select ed circumst ances.
More t han 80 ot her abbreviat ions can be used t o label ot her st ruct ural
f indings. Some of t he more common ones are ment ioned in clinical implicat ions
of chromosome analyses.
St andard chromosome st udies can be helpf ul in evaluat ion of t he f ollow ing
clinical sit uat ions:
1. Mult iple malf ormat ions of st ruct ure and f unct ion
2. Failure t o t hrive
3. Ment al ret ardat ion
4. Ambiguous genit alia or hypogonadism
5. Recurrent miscarriages
6. I nf ert ilit y
7. Primary amenorrhea or oligomenorrhea
8. Delayed onset of pubert y
9. St illbirt hs or miscarriages (part icularly w it h associat ed malf ormat ions)
10. Prenat al diagnosis of pot ent ial or act ual abnormalit ies relat ed t o
chromosome disorders (eg, Dow n syndrome, especially in off spring of
mot hers > 35 years of age)
11. Det ect ion of parent s w it h chromosomal mosaicism or t ranslocat ions, w ho
may be at high risk f or t ransmit t ing genet ic abnormalit ies t o t heir children
12. Sex det erminat ion
13. Select ed cancers and leukemias in w hich abnormalit ies of t he chromosomes
may reveal prognosis or disease st age
Reference Values
Normal
46 chromosomes
Women: 44 aut osomes + 2 X chromosomes (karyot ype 46, XX) Men: 44
aut osomes + 1 X and 1 Y chromosome (karot ype 46, XY ) A phot ograph of
represent at ive karyot ype is included w it h report .
Procedure
Specimens f or chromosome analyses are generally obt ained as f ollow s, using
asept ic procedures and special kit s and cont ainers:
1. Be aw are t hat heparinized venous blood leukocyt es f rom peripheral vascular
blood samples are used most f requent ly because t hey are t he most easily
obt ained. Preparat ion of t he cells t akes at least 3 days. The t ime required is
direct ly proport ional t o t he complexit y of t he analyt ic process.
2. Collect bone marrow in a green-t opped t ube, at least 5 mL in a heparinized
syringe (2025 unit s of heparin). Biopsies can somet imes be complet ed
w it hin 24 hours. Bone marrow analysis is of t en done t o diagnosis cert ain
cat egories of leukemias.
3. Remember t hat f ibroblast s f rom skin or ot her surgical specimens can be
grow n and preserved in long-t erm cult ure mediums f or f ut ure st udies. G row t h
of a suff icient amount of t he specimen f or st udies usually requires at least 1
w eek. These specimens are especially helpf ul in det ect ing mosaicism
(diff erent chromosome const it ut ions in diff erent t issues) and in t he st udy of
st illbirt hs, neonat al deat h, and spont aneous abort ion.
4. Be aw are t hat amniot ic f luid in t he prenat al period obt ained t hrough
amniocent esis st ored in a st erile cont ainer requires at least 1 w eek t o
produce a suff icient amount of cell grow t h f or analysis. These st udies are
of t en done f or prenat al det ect ion of chromosomal abnormalit ies (see Chapt er
15).
5. Remember t hat chorionic villus sampling (CVS) can be done at earlier st ages
of pregnancy (about 9 w eeks) t han can amniocent esis. Some init ial CVS
st udies can be done almost immediat ely af t er concept ion. O ccasional f alseposit ive result s represent mosaicism of t he placent a (t he presence of several
cell lines, some of w hich may not be f ound in t he f et us). These st udies need
conf irmat ion of f indings t hrough long-t erm cult ure (see Chapt er 15).
6. G row cells f rom f et al t issue or f rom early-t rimest er product s of concept ion
t o det ermine causes of spont aneous abort ion. Cells f rom t he f et al surf ace of
t he placent a may be easiest t o grow and are t he most likely t o be
successf ul.
7. Take t he buccal smear, f or det ect ing sex chromosomes, f rom t he inner cheek
and use f luorescent in sit u hybridizat ion w it h probes specif ic f or t he X or Y
chromosome.
8. Take dried blood spot f rom heel of new born.
9. Place specimens of lymph nodes or solid t umors in st erile cont ainers.
10. Remember t hat chromosome analysis is of t en perf ormed using ot her
specimens, such as skin, f ascia, lung t issue, kidney, or t he placent a. At least
2 mm of volume is needed f or an adequat e specimen.
Many chromosomal abnormalit ies can be placed int o one of t w o classes; some
examples f ollow :
1. Abnormalit ies of number
a. Aut osomal:
1. Trisomy 21 (Dow n syndrome)
2. Trisomy 18 (Edw ard's syndrome)
3. Trisomy 13 (Pat au's syndrome)
b. Sex chromosome syndrome:
1. Turner-Ulrect syndrome (45 single X)short st at ure, w ebbed neck,
and renal and C anomalies
2. Klinef elt er's syndrome (47 XXXY )hypogonadism, inf ert ilit y, learning
disabilit ies, undeveloped secondary charact erist ics
3. XXY, 47 XXY t all, increased risk f or behavior problems
4. Triple XXXincreased risk f or inf ert ilit y and behavior problems
2. Abnormalit ies of st ruct ure
a. Delet ions:
1. Cri du chat / cat 's cry syndrome: t he dist al part of t he chromosome 5
short arm is delet ed
2. Missing short arm of chromosome 18: 18p- is delet ed
3. Prader-Willi syndrome: 15 Q is delet ed in some cases
b. Duplicat ions: ext ra mat erial f rom t he second band in t he long arm of t he
t hird chromosome: 3q2 t risomy (Cornelia de Lange's syndrome
resemblance)
c. Translocat ions: t ranslocat ion of chromosomes 11 and 22: t (11; 22) or 14
and 21
d. I sochromosomes: a single chromosome w it h duplicat ion of t he long arm
of t he X chromosome: i(Xq) (a variant of Turner's syndrome)
e. Ring chromosomes: a chromosome 13 w it h t he ends of t he long and short
arms joined t oget her, as in a ring: r(13)
f. Mosaicism: t w o cell lines, 1 normal f emale and t he ot her f or Turner's
syndrome: 46, X, 45, X
Interventions
1. Provide inf ormat ion and ref errals f or appropriat e genet ic counseling and
t reat ment if necessary.
2. Explain t he purpose, procedure, and limit at ions of t he genet ic t est t oget her
w it h t he know n risks and benef it s. This educat ion process should be done by
a genet ic counselor.
3. O bt ain inf ormed, signed, and w it nessed consent . This is required f or most
genet ic t est s.

1. I f an amniot ic f luid specimen or CVS is obt ained f or analysis, f ollow t he
same precaut ions as list ed in Chapt er 15.
2. Provide t imely inf ormat ion and compassionat e support and guidance f or
parent s, children, and signif icant ot hers.
3. See Chapt er 1 f or guidelines f or saf e, eff ect ive, inf ormed posttest care .
Clin ical Alert

1. O ccasionally, it is possible t o line a cert ain chromosomal pat t ern w it h
specif ic genes and t o t hen underst and t he clinical pict ure f rom analyzing
t hese result s. How ever, f or t he most part , t he associat ion bet w een
specif ic chromosomal abnormalit ies and specif ic set s of f indings is not yet
w ell underst ood. I nt erpret at ions f rom karyot ype st udies usually come f rom
correlat ions w it h similar cases rat her t han f rom any t heoret ical
considerat ions. Theref ore, because many variables exist , predict ions must
be made caut iously and judiciously.
2. Most laborat ories provide int erpret at ions of result s. How ever, it may be
necessary t o t alk direct ly w it h laborat ory personnel t o f ully underst and t he
meaning of an unusual karyot ype.
Special Chromosomal Studies

The f ragile-X syndrome is one of t he most common genet ic causes of ment al
ret ardat ion. An X-linked t rait , it is more commonly seen in males. Females may
carry t his gene w it hout exhibit ing any of it s charact erist ics; how ever, t hey can
also be as severely aff ect ed as males. This syndrome t akes it s name f rom t he
small area on t he long arm of t he X chromosome t hat looks like a break in t he
arm (alt hough it act ually is not ). The cells need t o be grow n in a special medium
t o reveal t his pat t ern; a regular karyot ype w ill miss it . Even w it h t he special
medium, not all cells show t he charact erist ic. I n f emale carriers of t his t rait , t he
syndrome becomes harder t o det ect as t he w oman ages. Accurat e det ect ion of
f ragile-X syndrome at a molecular level is now available.
Rare condit ions such as excess chromosome breakage (Fanconi's anemia) or
abnormal cent romeres (Robert s' syndrome) merit special analyt ic processes and
procedures. Chromosome and molecular analyses are done using a venous blood
sample (5 mL w it h EDTA t ube) t o ident if y t he f ragile-X ment al ret ardat ion
syndrome and possible carrier st at us.
Newborn Screening for Congenital Disorders All North

American states and providences and most
industrialized countries of the world require screening
of newborns to detect congenital and metabolic
disorders within the first week of life (eg, before the
baby is discharged from the hospital or maternity
home, or after home birth, specimens are collected by
physicians, nurses, or birth attendant [midwife]).
Providing and performing the testing and following up
on all abnormal results is the responsibility of state
health departments. Some state health departments

also supply required types of formulas. For those
babies with a confirmed congenital disorder, genetic
counseling, treatment, and long-term care are also
provided in most states (eg, special dietary formula for
parents with PKU children is free of charge).
Procedure
1. New born blood is sampled using a heel-st ick procedure in t he f irst w eek of
lif e (see Chapt er 2). A special kit is used.
2. Apply t he blood drops (less t han 0. 5 mL) t o a piece of special f ilt er paper,
w hich usually cont ains t hree t o f ive print ed circles.
3. Fill all t he print ed circles w it h blood, w hich in most cases can be done w it h
one drop of blood per circle.
4. Be sure t he at t ached coverslip does not come int o cont act w it h t he blood
unt il complet ely dry. Do not permit t he blood-soaked port ion of t he collect ion
kit t o come in cont act w it h anot her surf ace (eg, deskt op, absorbent paper).
Proper collect ion procedures are based on t he Nat ional Commit t ee on
Clinical Laborat ory St andard (NCCLS) document LA4-A4: Blood Collect ion on
Filt er Paper f or New born Screening Programs; Approved St andard.
5. I n addit ion t o t he f ilt er paper, t he collect ion kit also cont ains a mult ipart f orm
request ing inf ormat ion regarding t he baby's name, mot her's name, birt h dat e
and t ime, specimen collect ion dat a and t ime, birt h w eight , and so f ort h. I t is
import ant t hat t his f orm be f illed out complet ely because t he inf ormat ion is
crit ical f or t he laborat ory st aff in t he int erpret at ion of t est result s (see
example of f orm used in Appendix H). For example, diff erent iat ing normal
f rom abnormal t hyroid-st imulat ing hormone (TSH) result s f or pot ent ial
hypot hyroidism may be dependent on t he age (in hours) of t he inf ant at t he
t ime of special collect ion.
6. Af t er t he specimen is collect ed, allow t he blood card t o air-dry in a
horizont al posit ion f or a minimum of 3 hours at room t emperat ure. Af t er t he
blood is dried, t he specimen should be f orw arded (mail or courier) t o t he
screening laborat ory w it hin 24 hours.
Processes vary among new born screening laborat ories. Most t est ing begins by
punching a 1/ 8-inch blood spot int o a 96-w ell microplat e (or some ot her vessel
such as a t est t ube or dimple t ray). The t echnology used t o t est t he blood can
be described under general headings.
1. Basic chemist ry procedures, such as measurement of phenylalanine or

galact ose met abolit es
2. Elect rophoresis t echnology, or liquid chemot herapy, is used t o separat e
hemoglobin f ract ions and t o quant if y t he amount of each hemoglobin based
on diff erence in elect rical charge and mobilit y in an elect ric f ield.
3. I mmunochemist ry (eg, ant igen-ant ibody react ions) is used t o measure t hyroid
hormones (hypot hyroidism), 17-hydroxyprogest erone (congenit al adrenal
hyperplasia), and immunoreact ive t rypsinogen enzyme (cyst ic f ibrosis).
4. G ene mut at ion analysis t o det ect t he genet ic mut at ion causing t he disorder's
(cyst ic f ibrosis, hemoglobin) alt ernat e assay, are t est ed using mut at ion
assays.
5. Tandem mass spect romet ry (MS/ MS) has allow ed new born screening
programs t o expand signif icant ly t he number of disorders screened using a
single 1/ 8-inch spot (eg, f at t y acid oxidat ion [ FAO ] , organic acidemia [ O A] ,
urea cycle [ UC] , and aminoacidopat hies [ AA] ). The FAO and O A disorders
are det ect ed by measuring acylcarnit ines (an int ermediat e compound
cont aining f at t y acids or organic acids combined w it h carnit ine t hat occurs
f rom blocked met abolic pat hw ays). At least 20 disorders can be det ect ed by
t his t echnology.
Chart 11. 4 is a list of disorders t hat current ly can be det ect ed t hrough new born
screening. I t should be not ed t hat t he inf ormat ion provided is generally not
considered all-inclusive, and result s are considered presumpt ive (requiring
conf irmat ion bef ore a f ormal diagnosis is made and t reat ment implement ed). The
St at e Public Healt h Laborat ory or Healt h Depart ment in specif ic st at es or
regions w ill provide inf ormat ion about t he st at us of new born screening in a st at e
or region. Abnormal result s are indicat ed by change in paper color, as f ollow s:
bl uepossibly abnormal, gol ddef init ely abnormal. Abnormal values represent
t he absence of expect ed enzyme act ivit y, elevat ed or decreased hormone values,
presence of abnormal or variant hemoglobins, and abnormal levels of amino
acids and evidence of f at t y acid disorders or genet ic mut at ion.
Ch art 11.4 Disorders Currently Detectable Through Newborn

Screeningm
Biotin idase
Prevalence:
Substance
1:100,000
measured:
Biotinidase enzyme activity
Determined by:
Basic chemistry
Abnormal:
No enzyme activity. Birth weight

and age in hours dependent
Interfering
factors:
Transfusions may cause a falsenegative result
Additional
diagnostic
testing:
Serum/plasma enzyme
quantification
Treatment:
Biotindaily supplements
Clinical
symptoms (not
treated):
Seizures, dermatitis, hair loss
Con gen ital Adren al Hyperplasia (CAH)
Prevalence
1:10,000
Substance
measured:
17-Hydroxyprogesterone (17-OHP)
Determined
by:
Immunochemistry
Elevated 17-OHP: typical cutoff range:
Abnormal
(cutoff):
>90 ng/dL (>2.7 nmol/L) are considered

critical in full term babies. Cutoffs will
vary by program in low-birth-weight
babies.
Interfering
factors:
False positives can be expected in lowbirth-weight babies and early sample

collections (<24 hours).
Diagnostic
testing:
Refer to a pediatric endocrinologist for

CAH workup
Treatment:
Glucocorticoid replacement, 9-fluorohydrocortisone
Clinical
symptoms
(not
treated):
Salt-losing crisis in males that often

results in death. Virilization (ambiguous
genitalia) in females
Con gen ital Hypoth yroidism
Prevalence:
1:3,000
Substance
measured:
Thyroid-stimulating hormone (TSH)

and/or thyroxine (T4 )
Determined
by:
Immunochemistry
Elevated TSH: typical cutoff range: 20
50 g/dL (258645 nmol/L) (program
Abnormal
(cutoff):
dependent)
Decreased T4 : typical cutoff range: 68
g/dL (77103 nmol/L) (program
dependent)
Interfering
factors:
False positives can be expected in

early (<24 hour) discharges. False
negatives can occur in very-low-birthweight babies.
Additional
diagnostic
testing:
Serum T4 and TSH measurements

Thyroid scan (warranted in some
cases)
Treatment:
Synthroiddaily supplements
Clinical
symptoms
(not
treated):
Mental retardation, cretinism, liver

failure
Cystic Fibrosis (CF)
P. 81
Prevalence:
1:4000 (Caucasians)
Substance
measured:
Immunoreactive trypsinogen (IRT)

Mutant alleles
Determined
by:
Immunochemistry
Mutation analysis
Interfering
factors:
False negatives can occur because

some CF mutations may not cause an
IRT elevation.
Abnormal
(cutoff):
Elevated IRT: typical cutoff range:

140180 ng/mL (program dependent)
Mutation analysis: detection of mutant
allele(s)
Additional
diagnostic
testing:
Pilocarpine iontophoresis sweat

chloride test
Treatment:
Care at a CF foundationapproved
center
Clinical
symptoms
(not
treated):
Persistent diarrhea, malnutrition,

chronic cough, respiratory diseases
(infections)
Hemoglobin opath ies (Sickle Cell Disease)
Prevalance:
1:400 (African Americans)
Substance
measured:
Hemoglobin fractions (eg, fetal,

sickle, adult, hemoglobin C)
Determined by:
Electrophoresis and/or high

performance liquid chromatography
(HPLC)
Detection of hemoglobin(s) other
Abnormal:
than fetal and adult
Interfering
factors:
Transfusions will invalidate testing

for up to 60 days
Additional
diagnostic
testing:
Hemoglobin detection and

quantification on whole blood
Treatment:
Penicillindaily supplements
Clinical
symptoms (not
treated):
Sepsis, pain crisis, death (25% of

babies)
Fatty Acid Oxidation (FAO) Disorders
Prevalence:
Medium-chain acyl-CoA dehydrogenase
(MCAD)
1:20,000
Short-chain acyl-CoA dehydrogenase

(SCAD)
1:10,000
Long-chain 3-hydroxyacyl-CoA
dehydrogenase (LCHAD)
1:50,000
Very-long-chain acyl-CoA
dehydrogenase (VLCAD)
1:50,000
Glutaricacidemia type II (GAII)
1:100,000
Carnitine palmitoyltransferase
deficiency type II (CPT-II)
Unknown
2,4-Dienoyl-CoA reductase deficiency
Unknown
Substance
measured:
Acylcarnitines
Determined
by:
Tandem mass spectrometry
Abnormal:
Each FAO disorder has a distinctive

acylcarnitine profile. The exact profile is
program dependent.
Interfering
factors:
False negatives may occur if specimen

collection is delayed (>14 days).
Diagnostic
testing:
Consult with a certified biochemical

geneticist.
Urine organic acids; mutation analysis
Treatment:
Diet restrictions that are disorder

dependent
Clinical
symptoms
(not
treated):
Vomiting, lethargy, hypoglycemia,

hypotonia; sudden death or permanent
neurologic damage can occur
P.
Galactosemia
Prevalence:
1:50,000
Substance
measured:
Total metabolites (galactose and

galactose-1-phosphate) and/or
galactose-1-phosphate uridyl
transferase (GALT)
Determined
by:
Basic chemistry
Abnormal
(cutoff)
Elevated metabolites
Typical cutoff range: 1015 mg/dL or
555832 mol/L (program dependent)
No GALT activity
Interfering
factors:
False negatives may occur if there

hasn't been a lactose load before
specimen collection. Transfusions may
cause false negatives also.
Additional
diagnostic
testing:
Serum/plasma metabolite levels, GALT

activity quantification
Mutation analysis
Treatment:
Lactose restriction diet
Clinical
symptoms
(not
treated):
Sepsis, milk intolerance; mental

retardation, sudden death can occur
Organ ic Acidemias
Prevalence:
Glutaryl-CoA dehydrogenase (GA-I)
1:50,000
3-Methylcrotonyl-CoA carboxylase
deficiency (3-MCC)
1:20,000
Isovaleryl-CoA dehydrogenase
deficiency (IVA)
1:50,000
Propionyl-CoA carboxylase deficiency

(PA)
1:50,000
Methylmalonicacidemia (MMA)
1:50,000
Mitochondrial acetoacetyl-CoA thiolase

deficiency (bKT)
Unknown
3-Hydroxy-3-methylglutaryl-CoA lyase
deficiency (HMG)
Unknown
Substance
measured:
Acylcarnitines
Determined
by:

Each OA disorder has a distinctive
Abnormal:
acylcarnitine profile. The exact profile is

program dependent.
Interfering
factors:
False negatives may occur if specimen

collection is delayed (>14 days).
Additional
diagnostic
testing:
Consult with a certified biochemical

geneticist.
Urine organic acids; mutation analysis
Treatment:
Diet restrictions that are disorder

dependent
Clinical
symptoms
(not
treated):
Vomiting, metabolic acidosis, ketosis,

dehydration or coma, hyperammonuria,
hypoglycemia, hypotonia, sepsis,
developmental delay. Sudden death or
permanent neurologic damage can
occur.
Ph en ylketon u ria (PKU)
P. 81
Prevalence:
1:15,000
Substance
measured:
Phenylalanine
Determined
by:
Basic chemistry or tandem mass

spectrometry
Abnormal
Elevated phenylalanine: typical cutoff
(cutoff):
range: 2.04.0 mg/dL or 121.1242.2

mol/L (program dependent)
Interfering
factors:
False negatives may occur due to lack

of protein.
Diagnostic
testing:
Serum/plasma amino acid

quantification.
Treatment:
Dietary restriction of phenylalanine
Clinical
symptoms
(not
treated):
Mental retardation
Maple Syru p Urin e Disease (MSUD)
Prevalence:
1:100,000
Substance
measured:
Leucine, isoleucine, valine
Determined
by:

spectrometry
Abnormal
(cutoff):
Elevated leucine/isoleucine/valine.
Typical cutoff range: 4.06.0 mg/dL or
304.9457.4 mol/L (program
dependent)
Interfering
factors:
of protein.
Diagnostic
testing:
Serum/plasma amino acid quantification
Treatment:
Dietary restrictions of branched-chain

amino acids
Clinical
symptoms
(not
treated):
Lethargy, vomiting, coma, mental

retardation
Homocystin u ria
Prevalence:
1:150,000
Substance
measured:
Methionine
Determined
by:

spectrometry
Abnormal
(cutoff):
Elevated methionine. Typical cutoff

range: 1.02.0 mg/dL or 67134 mol/L
(program dependent)
Interfering
factors

of protein.
Diagnostic
testing:
Serum/plasma amino acid quantification
Treatment:
Dietary restrictions of methionine.

Cystine supplementation, folic acid,
betaine
Clinical
symptoms
(not
treated):
Dislocated lenses, cataracts, muscle

weakness, arterial and venous
thrombosis, developmental delay
Tyrosin emia
Prevalence:
1:150,000
Substance
measured:
Tyrosine
Determined
by:

spectrometry
Abnormal
(cutoff):
Elevated tyrosine: typical cutoff range:

4.06.0 mg/dL or 220.8331.0 mol/L
(program dependent)
Interfering
factors

of protein
Additional
diagnostic
testing:

quantification
Treatment:
Dietary restrictions of phenylalanine

and tyrosine Liver transplants
Clinical
symptoms
(not
treated):
Vomiting, diarrhea, renal dysfunction,

chronic liver disease, speech delays
P.
Citru llin emia
Prevalence:
1:150,000
Substance
measured:
Citrulline
Determined
by:
Abnormal
(cutoff):
Elevated citrulline: typical cutoff range:

1.02.0 mg/dL or 57.1114.2 mol/L
(program dependent)
Interfering
factors:

of protein.
Additional
diagnostic
testing:

quantification
Urinenormal levels of
argininosuccinic acid
Treatment:
Dietary protein restriction of arginine
Clinical
symptoms
Vomiting, lethargy, coma, seizures,
(not
treated):
anorexia, death
Argin in osu ccin ic Acidemia
Prevalence:
1:150,000
Substance
measured:
Citrulline
Determined
by:
Abnormal
(cutoff):
Elevated citrulline: typical cutoff range:

1.02.0 mg/dL or 57.1114.2 mol/L
(program dependent)
Interfering
factors:

of protein.
Additional
diagnostic
testing:

quantification
Urine elevations of argininosuccinic
acid
Treatment:
Dietary restriction of protein; arginine

supplement
Clinical
symptoms
(not
treated):
Lethargy, coma, progressive neurologic

deterioration, atoxia
1. Most of t he congenit al disorders are aut osomal recessive genet ic disorders
(t he except ion being hypot hyroidism). This means t hat f or t he baby t o have
one of t hese disorders, bot h t he mot her and f at her have t o carry t he
abnormal gene t hat causes t he disorder. I n t his case, t here is a 1-in-4
chance t hat w it h each pregnancy, t he couple w ill have an aff ect ed baby.
2. Alt hough t he sympt oms of t he various disorders can be quit e varied, t here
are common issues. All t he disorders are relat ively rare. The most f requent ly
det ect ed disorder is hypot hyroidism, w hich occurs in 1 of 3000 birt hs in most
st at es or regions. Some disorders have f requency rat es of 1 in 100, 000 or
less. All of t he disorders, if not det ect ed early and t reat ed prompt ly, w ill
cause very severe complicat ions. These complicat ions include ment al
ret ardat ion, neurologic problems, or deat h.
3. All of t he disorders can be det ect ed by laborat ory t est s in t he f irst f ew days
of lif e bef ore t here are any clinical sympt oms.
4. I f det ect ed early and prompt ly t reat ed, t he baby can develop essent ially
normally, bot h ment ally and physically.
5. The t reat ment s are relat ively simple and inexpensive w hen compared w it h
lif et ime inst it ut ional care. For example, several of t he met abolic disorders
are t reat ed by changes in diet and vit amin supplement s.
Interventions
1. Remember t hat it is import ant t hat t he parent s be inf ormed about t he t iming
and import ance of new born screening. The st at e new born screening
programs provide, f ree of charge, educat ional brochures regarding new born
screening. Be sure t he parent s receive t his mat erial.
2. Be aw are t hat most st at es do not require inf ormed consent t o perf orm
new born screening and have limit ed reasons f or parent al ref usals. I f t he
parent ref uses t o have t he baby screened and t he reason is valid under
specif ic st at e crit eria, have t he parent s sign a w aiver f or t he baby's healt h
care record.
3. Complet e t he f orm associat ed w it h t he new born screening blood collect ion
kit . Be sure t he name on t he blood collect ion card mat ches t he baby w hose
blood is being draw n.

4. Collect t he new born screening specimen bef ore discharge f rom t he hospit al.
I f t he init ial specimen w as collect ed bef ore 24 hours of age, obt ain a repeat
in about 14 days as recommended by t he American Academy of Pediat rics.
5. For premat ure and sick inf ant s, collect an init ial specimen as soon as
medically possible but no lat er t han t he f irst w eek of lif e. Be f amiliar w it h
your local new born screening laborat ory procedures and policies regarding
init ial and repeat t est ing.
6. Collect init ial specimen bef ore t ransf usion, if possible. Be f amiliar w it h your
local new born screening laborat ory procedures and policies regarding repeat
t est ing w hen a baby has been t ransf used.
7. Record t he dat e t he specimen w as sent t o t he screening laborat ory.

1. Af t er t he t est ing is complet e, t he screening laborat ory w ill send a report
back t o t he hospit al. Record t he receipt and review of t he report . The
new born screening laborat ory should be cont act ed if a report is
unreasonably delayed (w it hin 10 days of specimen being sent ). All report s
should be added t o t he baby's healt h care records as soon as possible af t er
receipt .
2. Be aw are t hat most new born screening programs report t w o t ypes of
abnormal result s. O ne t ype is considered borderline or possible, w hen
t he t est result s are unequivocal or only marginally indicat ive of a disorder. I n
most cases, t he recommendat ion is t o repeat t he new born screening t est ing.
I f t he repeat t est result s are normal, no f urt her act ion is necessary. Care
must be t aken t o neit her alarm t he parent s nor t rivialize t he import ance of
repeat t est ing. The second t ype of report issued is w hen t he screening t est
result is highly indicat ive of a part icular disorder. I n t his case, t he screening
laborat ory w ill cont act t he clinician direct ly, provide recommendat ions, and
of t en ref er t he baby and parent s t o a specialt y clinic f or evaluat ion.
3. Do not inst it ut e disorder-specif ic int ervent ion (eg, diet changes, ant ibiot ics)
unt il direct ed by clinician af t er consult at ion w it h a specialist . The st at e
new born screening program can provide cont act f or appropriat e specialt y
clinics or expert s in t he disorders.
4. Ensure t hat genet ic counseling is provided.
Clin ical Alert

1. I f t here is a f amily hist ory of one of t he disorders screened f or, not if y t he
new born screening laborat ory so t hat t he specialist can be alert ed.
2. The most f requent reason f or a ret est is t hat t he f irst specimen w as
unsat isf act ory (inadequat e amount of blood or improper use of capillary
collect ion t ubes).
3. Be sure t he baby get s t he new born screen bef ore hospit al discharge or by
t he sevent h day of lif e f or ext ended hospit al st ays.
P.
4. Ensure t here is a posit ive correlat ion bet w een t he name w rit t en on t he
blood collect ion card and t he name of t he baby being screened.
5. Ensure t here is a new born screening t est report in t he medical report .
6. Check new born screening result s (including calling t he new born screening
laborat ory) on babies being readmit t ed t o hospit al w it h severe jaundice,
anemic, f ailure t o t hrive, seizures, and so f ort h.
7. Follow up:
a. Det ermine w het her f amily of aff ect ed children are compliant w it h
appropriat e care.
b. Addit ional new born t est ing may be done (eg, elect roencephalogram
procedure f or evoked audit ory response).
Specific Genetic Tests

Genetics of Type 1 and Type 2 Diabetes M ellitus The
cause of diabetes mellitus is deficient insulin action
(insulin action is equal to the product of insulin
concentration [B-cell control] and insulin sensitivity
[target cell function]). Deficient insulin action leads to
disordered carbohydrate, lipid, and protein
metabolism. Type 1 results from insulin deficiency;
type 2 results from a combination of insulin resistance
and relative insulin deficiency.
Type 1: Aut oimmune diabet es may result f rom an int eract ion of genet ics and t he
environment and result s in an absolut e insulin def iciency. Type 1 diabet es
result ing f rom aut oimmune dest ruct ion of pancreat ic B cells is not inherit ed, but
suscept ibilit y t o t ype 1 disease is. The major genet ic loci indicat ive of
suscept ibilit y t o t ype 1 is locat ed in t he HLA complex: DRBI , DQ AI , and DQ BI .
Type 2: Pat ient s w it h t ype 2 diabet es (due t o insulin resist ance and B-cell
f ailure) of t en have a f irst -degree relat ive w it h t he disease and a genet ic
predisposit ion t o t ype 2 result ing in a rest rict ed abilit y of t he B cells t o secret e
insulin. Type 2 diabet es mellit us is inherit ed as a dominant gene, alt hough not all
cases are heredit ary. Persons at risk include t hose w it h a f amily hist ory and
t hose w ho develop gest at ional diabet es.
Genetics of Hereditary Hemochromatosis (Primary Iron

Overload) Hemochromatosis is a relatively common
disorder that leads to liver dysfunction at 40 to 50
years of age; it is not a rare genetic disease as once
thought. Prevalence in the United States is 1 in 200
Caucasians (possibly also other ethnic groups). This
disorder, treated by phlebotomy at regular intervals, is
fatal if not diagnosed early. At the present time,
genotyping is done of the HFE gene to include the
C2824 and H63D mutations.
Biochemical Genetics
Test ing f or heredit ary met abolic disorders ident if ies inborn errors of met abolism
(I EM) and enzyme disorders. I ncluded are amino acids, carbohydrat es,
cholest erol, cof act ors and vit amins, lysosomal short age, lact ic acids, f at t y acids,
carnit ines, organic acids, porphyrins, purines and pyrimidine, and urea.
Molecular genet ics includes t he diagnosis of neoplast ic disorders (eg,
Philadelphia chromosome and neuroblast oma) and t he carrier ident if icat ion and
prenat al diagnosis of various inherit ed disorders (eg, t halassemia, cyst ic
f ibrosis, hemophilia A). I n general, it is t he mat ure prot ein product of a gene t hat
carries out it s f unct ion.
Population Genetics
Populat ion genet ics is t he st udy of genes in populat ions and of f act ors t hat
maint ain or change t he f requency of genes and genot ypes f rom generat ion t o
generat ion. Mult if act orial inherit ed disease deals w it h t rait s or diseases not
inherit ed in f act ors believed t o play an import ant role in causat ion; examples of
t hese disorders are hypert ension, schizophrenia, diabet es mellit us, and common
birt h def ect s such as clef t lip, clef t palat e, and neural t ube def ect s.
Treatment of Genetic Diseases Environmental therapy

to restrict potentially toxic agents, use of diet or
medications, and gene therapy are the main treatments

for genetic diseases. The follow ing is a brief summary
of the therapies.
1. Di etary and drug restri cti ons. Examples include cholest erol and sat urat ed
f at s in f amilial hypercholest erolemia, ant imalarial drugs and cert ain
ant ibiot ics in glucose-6-phosphat e dehydrogenase def iciency; in alphal ant it rypsin def iciency, no cigaret t e smoking; evidence of alcohol in
hemat ochromat osis.
2. Repl acement therapy. Examples include f act or VI I I in hemophilia A, liver
t ransplant at ion in homozygous hypercholest erolemia, bone marrow
t ransplant at ion in sickle cell anemia, and kidney t ransplant at ion in cyst inosis.
3. Removal of toxi c agents. Examples include abnormal copper accumulat ion
t reat ed by penicillin phlebot omy t o remove iron in hemochromat osis, and
st at ins (eg, Lovast at in) t o t reat and low er cholest erol in f amilial
hypercholest erolemia.
4. G ene therapy. G ene t herapy is t he t reat ment of disease by t ransf er of
genet ic mat erial (DNA or RNA) int o t he pat ient . G ene t herapy int ervent ions
are based on t he t ype of t issue involved. I n germline t issue t herapy, t he gene
modif icat ion w ould be int roduced int o all cells (including ovaries and t est es),
result ing in t he modif ied gene passed on t o subsequent generat ions, but t his
t ype of t herapy is not current ly done.
5. Somati c gene therapy. The genet ic modif icat ion is rest rict ed t o somat ic cells
(not int o ovaries and t est es) and does not t ransmit genet ic alt erat ions t o
subsequent generat ions. I t is in t his area t hat most research is current ly
involved. Diff icult ies w it h delivery of t he gene t o t arget cells and obt ained
adequat e expression are abst ract s t o use of gene t herapy in humans.
Pharmacogenomics
Pharmacogenomics st udies genet ic variat ions and drug met abolism t o mat ch t he
best drug f or phenot ype (in specif ic diseases) bef ore beginning t herapy.
Mat ching eff ect ive drugs t o DNA-based diagnost ic and predict ive markers is
expect ed t o be at t he f oref ront of t reat ment . Examples of t est s and collaborat ing
drug and diagnost ic t est companies include: diagnost ic t est s, genet ic markers
and drug t arget s f or schizophrenia, hemat ochromat osis, peripheral art erial
occlusive disease, rheumat oid art hrit is, obesit y, severe anxiet y, st roke, t ype 2
diabet es (Roche and deCode G enet ics Co. ), progression of advanced heart
disease (Pharmacia and deCode G enet ic Companies), obesit y and diabet es
(Bayer Corp, and CuraG en Corp. ), and markers f or colon, breast , and ovarian
cancer.
BIBLIOGRAPHY
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November 2000. (O nline. ) Accessible at
ht t p: / / w w w. cyt opat hology. org/ guidelines/ guide_cervical_cyt ology. php
Brow n E, Markman M: Tumor chromosensit ivit y and chemoresist ance assays.
Cancer 77: 10201025, 1996
Burke W, At kins D, G w inn M: G enet ic t est evaluat ion: I nf ormat ion needs of
clinicians, policy makers, and t he public. Am J Epidemiology, 156, 4: 311318,
2002
Cyt yc Corp. : The ThinPrep Pap Test . December 2002. (O nline. ) Accessible at
ht t p: / / w w w. cyt yc. com/ 85506Prd/ prepuse. ht m
DeMay RM: The Art & Science of Cyt opat hology. Chicago, ASCP Press, 1996
DeMay RM: Pract ical Principles of Cyt opat hology. Chicago, ASCP Press,
1999
DeVit a VT: Cancer: Principles and Pract ice of O ncology, Chapt er 17,
Principles of Cancer Management : Chemot herapy, 6t h ed. Philadelphia,
Digene Corp. : Clinician Q & As. January 2003. (O nline. ) Accessible at
ht t p: / / w w w. digene. com/ clinician_3_1. ht ml
Fabian CJ, Kimler BF, Zalles CM, et al. : Short -t erm breast cancer predict ion
by random periareolar f ine-needle aspirat ion cyt ology and t he G ail risk model.
J Nat l Cancer I nst 92: 12171227, 2000
Fruehauf JP, Bosanquet AG , updat e by Rosenberg SA: I n vit ro det erminat ion
of drug response: A discussion of clinical applicat ions. I n: Principles and
Pract ice of O ncology. PPO Updat es 7(12): 116, 1993
G ail MH, Brint on LA, Byar DP, et al: Project ing individualized probabilit ies of
developing breast cancer f or w hit e f emales w ho are being examined annually.
J Nat l Cancer I nst 81: 18791886, 1989
Hoskins I A: G enet ic counseling f or cancer pat ient s and t heir f amilies.

O ncology, 3: 8498, 1989
Kiesner F: O ncot ech announces collaborat ive research w it h Sout hw est
O ncology G roup (SWO G ) t o evaluat e t he recent ly pat ent ed O ncot ech
radiat ion resist ance assay as a predict or of clinical out come in cervical
carcinoma pat ient s. Press Release, November 9, 2001
Kiesner F: O ncot ech and t he Johns Hopkins Cancer Cent er I nst it ut e research
collaborat ion t o eliminat e unnecessary explorat ory surgery. Press Release,
November 2, 2001
Kiesner F, Brozel M: Transamerica Medicare ext ends f ull coverage t o t he
O ncot ech ext reme drug resist ance (EDR) assay. Press Release, Sept ember
2000
Mechnet ner E, et al. : Levels of mult idrug resist ance (MDR-1) P-glycoprot ein
expression by human breast cancer correlat es w it h in vit ro resist ance t o Taxol
and doxorubicin. Clin Cancer Res 4: 389398, 1998
Pasacret a JV, Jacobs L, Cat aldo JK: G enet ic t est ing f or breast and ovarian
cancer risk: The psychological issues. Am J Nursing 102 (12): 4047, 2002
Pelef sky JM, et al. : Anal cyt ology as a screening t ool f or anal squamous
int raepit helial lesions. Journal of Acquired I mmune Def iciency Syndromes and
Human Ret rovirology 14: 415422, 1997
Saslow D, et al. : American Cancer Societ y guidelines f or t he early det ect ion
of cervical neoplasia and cancer. CA: A Cancer Journal f or Clinicians.
December 2002. (O nline. ) Accessible at ht t p: / / Caonline. AmCancerSoc. org
Scholef ield JH, et al. : G uidelines f or anal cyt ology t o make cyt ological
diagnosis and f ollow -up much more reliable. Cyt opat hology 9(1): 1522, 1998
Solomon D, et al. : Forum G roup Members, The Bet hesda 2001 Workshop.
The 2001 Bet hesda Syst em: Terminology f or report ing result s of cervical
cyt ology. JAMA 287: 21142119, 2002
Tit us K: Breast specimens: FNA, core, more. CAP Today, 16(2): 2002
Tripat h Care Technologies: U. S. Product s. January 2003. (O nline. ) Accessible
at ht t p: / / w w w. t ripat himagining. com/ usproduct s/ index. ht m.

Wright TC, et al. : 2001 Consensus guidelines f or t he management of w omen
w it h cervical cyt ological abnormalit ies (consensus st at ement ). JAMA
287: 21202129, 2002

Wilkins
> Table of C ontents > 12 - E ndos c opic S tudies
12
Endoscopic Studies
OVERVIEW OF ENDOSCOPIC STUDIES

Endoscopy is t he general t erm given t o all examinat ion and inspect ion of body
organs or cavit ies using endoscopes. These inst rument s can also provide access
f or cert ain kinds of surgical procedures or t reat ment s. Endoscopes, know n
generally as f i beropti c i nstruments, are used f or direct visual examinat ion of
cert ain int ernal body st ruct ures by means of a light ed lens syst em at t ached t o
eit her a rigid or f lexible t ube. The new est inst rument s t ransmit signals f rom t he
t ip of t he scope t o a TV monit or. Light t ravels t hrough an opt ic f iber by means of
mult iple ref lect ions. Fiberopt ic inst rument s, composed of f iber bundle syst ems,
redirect and t ransmit light around t w ist s and bends in cavit ies and hollow organs
of t he body. An image f iber and a light f iber allow visualizat ion at t he dist al t ip of
t he scope. Separat e port s allow inst illat ion of drugs, lavage, suct ion, and
insert ion of a laser, brushes, f orceps, or ot her inst rument s used f or excision,
sampling, or ot her diagnost ic and t herapeut ic procedures. The f lexible scope can
be insert ed int o orif ices or ot her areas of t he body not easily accessible or
direct ly visualized by rigid scopes or ot her means. Procedures are done f or
healt h screening, diagnosis of pat hologic condit ions, or t herapy, such as removal
of t issue (polyps) or f oreign object s. Sedat ives or analgesia (t o achieve a st at e
of conscious sedat ion) or local or general anest het ics may be used. The use of
video document at ion and endoscopic sonography also aid in cancer diagnosis,
st aging of cancer, and operabilit y. Biopsy t issue is submit t ed t o t he laborat ory
f or hist ologic examinat ion (see Chap. 11).
Clin ical Alert

Endoscopically relat ed bact eremia inf ect ions may result f rom t issue
manipulat ions, blood st ream invasion by pat hogens, or a cont aminat ed
endoscope, usually due t o improper cleansing and disinf ect ion. Af t er
endoscopic procedures, assess f or f ever, elevat ed w hit e blood cells, signs of
bloodst ream inf ect ion, and signs of sepsis (rigors and hypot ension,
hypot hermia or hypert hermia). I t is import ant t hat st rict inf ect ion cont rol
guidelines be f ollow ed by persons w ho clean and disinf ect t he endoscopes.
Hospit als and clinics should f ollow t he inf ect ion cont rol policies f or t heir
inst it ut ion, w hich should include document at ion of all endoscopic procedures,
including name of pat ient , t ype of procedure, dat e and t ime of procedure, and
serial number of t he endoscope used in each procedure. A log document ing
t he t ime, dat e, and serial number of each endoscope cleaned and disinf ect ed
should also be maint ained. These records allow f or t racing an inf ect ion back
t o a specif ic inst rument . Any inf ect ions suspect ed t o have been caused by a
cont aminat ed inst rument should be report ed immediat ely t o t he appropriat e
inf ect ion cont rol and risk management depart ment s f or invest igat ion.
Clin ical Alert
1. O bserve st andard precaut ions and lat ex precaut ions f or all endoscopic
procedures. See Appendix A and Appendix B.
2. Endoscopic procedures have not proved usef ul in U. S. , but screenings are
helpf ul in Japan and China w here deat h and cure rat es of esophageal and
st omach cancer are improved by endoscopic det ect ion.
3. Some invest igat ors and clinicians have concerns about t issue damage,
immunosuppression, and post sit e met ast ases af t er endoscopic procedure
(DeVit a, Hellman, Rosenberg, 2001, pp. 740741).
Mediastinoscopy
Mediast inoscopy, perf ormed under general anest hesia, requires insert ion of a
light ed mirror-lens inst rument , similar t o a bronchoscope, t hrough an incision at
t he base of t he ant erior neck, t o examine and biopsy mediast inal lymph nodes.
Because t hese nodes receive lymphat ic drainage f rom t he lungs, mediast inal
biopsy specimens can allow ident if icat ion of diseases such as carcinoma,
granulomat ous inf ect ion, sarcoidosis, coccidioidomycosis, or hist oplasmosis.
Mediast inoscopy is used t o st age lung t umors, diagnose sarcoidosis, biopsy
mediast inal lymph nodes direct ly, and assess hilar adenopat hy of unknow n origin.
I t has virt ually replaced scalene f at pad biopsy f or examining suspicious nodes
on t he right side of t he mediast inum. I t is t he rout ine met hod of est ablishing
t issue diagnosis and st aging of lung cancer and f or evaluat ing t he ext ent of lung
t umor met ast asis done just bef ore t horacot omy. Nodes on t he lef t side of t he
chest are usually resect ed t hrough lef t ant erior t horacot omy (mediast inoscopy)
or occasionally by scalene f at pad biopsy. This procedure is perf ormed by a
t horacic surgeon.
Reference Values
Normal
No evidence of disease Normal lymph glands
Procedure
1. Mediast inoscopy is considered a surgical procedure and is usually perf ormed
under general anest hesia in a hospit al.
2. Biopsy is perf ormed t hrough a suprast ernal incision in t he neck (23 cm or
34 cm), just above t he st ernal not ch. When t he Chamberlain procedure is
perf ormed, a small t ransverse incision is done in t he second int ercost al
space or over t he 2nd or 3rd cost al cart ilage.
3. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed i ntratest care .
1. Abnormal f indings may include t he f ollow ing condit ions:
a. Sarcoidosis
b. Tuberculosis
c. Hist oplasmosis
d. Hodgkin's disease
e. G ranulomat ous inf ect ions and inf lammat ory processes
f. Carcinomat ous lesions
g. Coccidioidomycosis
h. Pneumocysti s cari ni i inf ect ion
2. Result s assist in def ining t he ext ent of met ast at ic process, st aging of cancer
(N2 and N3I I I a and I I I b), and possibilit y of successf ul surgical resect abilit y.
Interventions
1. Explain purpose, procedure, benef it s, and risks of t he t est . I t is usually used
af t er CT scan and indicat es enlarged mediast inal nodes (>1 cm).
2. Be aw are t hat a legal surgical consent f orm must be appropriat ely signed
and w it nessed preoperat ively (see Chap. 1).
3. Remember t hat preoperat ive care is t he same as t hat f or any pat ient
undergoing general anest hesia and surgery.
4. Have t he pat ient f ast f or 8 or more hours bef ore t he t est .
Posttest Patient Aftercare Care is the same as for any

patient who has had surgery under general anesthesia.
1. Evaluat e breat hing and lung sounds; check w ound f or bleeding and
hemat oma.
2. At t ime of discharge, monit or f or complicat ions (eg, breat hing diff icult ies,
coughing up blood). I nst ruct t he pat ient t o call physician if problems occur.
3. I nt erpret t est out comes, monit or appropriat ely, and explain any need f or
f ollow -up t est s and/ or t reat ment (medicat ion f or TB, ant ibiot ics).
care.
Clin ical Alert

1. Previous mediast inoscopy cont raindicat es repeat examinat ion because
adhesions make sat isf act ory dissect ion of nodes ext remely diff icult or
impossible.
2. Complicat ions can result f rom t he risks associat ed w it h general anest hesia
and f rom preexist ing condit ions, pneumot horax, and subcut aneous
emphysema.
3. Damage t o major vessels can occur during t his procedure.
Bronchoscopy
Bronchoscopy permit s visualizat ion of t he t rachea, bronchi, and select
bronchioles. There are t w o t ypes of bronchoscopy: f lexible f iberopt ic (Fig. 12. 1),
w hich is almost alw ays used f or diagnost ic purposes, and rigid, w hich is less
f requent ly used. This procedure is done t o diagnose t umors, coin lesions, or
granulomat ous lesions; t o f ind hemorrhage sit es; t o evaluat e t rauma or nerve
paralysis; t o obt ain biopsy specimens; t o t ake brushings f or cyt ologic
examinat ions; t o improve drainage of secret ions; t o ident if y inf lammat ory
inf ilt rat es; t o lavage; and t o remove f oreign bodies. Bronchoscopy can det ermine
resect abilit y of a lesion as w ell as provide t he means t o diagnose bronchogenic
carcinoma. A t ransbronchial needle biopsy may be perf ormed during
t his procedure, t hus obviat ing t he need f or diagnost ic open-lung biopsy. A f lexible
needle is passed t hrough t he t rachea or bronchus and is used t o aspirat e cells
f rom t he lung. This procedure is perf ormed on pat ient s w it h suspect ed
sarcoidosis or pulmonary inf ect ion.
FI G URE 12. 1 Fiberopt ic bronchoscope (O lympus BF Type P40). (Source:

O lympus America I nc. , Melville, New York, USA. )
Indications
1. Diagnost ic:
a. St aging of bronchogenic carcinoma
b. Diff erent ial diagnosis in recurrent unresolved pneumonia
c. Evaluat ion of cavit ary lesions, mediast inal masses, and int erst it ial lung
disease
d. Localizat ion of bleeding and occult sit es of cancer
e. Evaluat e immunocompromised pat ient s (eg, human immunodef iciency
virus [ HI V] -inf ect ed pat ient s, bone marrow or lung t ransplant recipient s)
f. Diff erent iat e reject ion f rom inf ect ion in lung t ransplant at ion
g. Assess airw ay damage in t horacic t rauma
h. Evaluat e underlying et iology of nonspecif ic sympt oms of pulmonary
disease such as chronic cough (>6 mont hs), hemopt ysis, or unilat eral
w heezing
2. Therapeut ic:
a. Removal of mucus plugs and polyps
b. Removal of an aspirat ed f oreign body and t o relieve endobronchial
obst ruct ion
c. Brachyt herapy (radioact ive t reat ment of malignant endobrachial t umors)
d. Placement of a st ent t o maint ain airw ay pat ency
e. Drainage of lung abscess

f. Decompression of bronchogenic cyst s
g. Laser phot oresect ion of endot racheal lesions
h. Bronchoalveolar lavage t o remove int raalveolar prot einaceous mat erial
i. Alt ernat ive f or diff icult endot racheal int ubat ions
j. Cont rol bleeding and airw ay hemorrhage in t he presence of massive
hemopt ysis
k. Debridement of t umors using new er drugs, eg, Phot of ren I I (t o achieve a
st at e of conscious sedat ion)
The examinat ion is usually done under local anest hesia combined w it h some f orm
of sedat ion in an out pat ient set t ing, diagnost ic cent er, or operat ing room. I t also
can be done in a crit ical care unit , in w hich case t he pat ient may be
unresponsive or vent ilat or dependent .
Reference Values
Normal
Normal t rachea, bronchi, nasopharynx, pharynx, and select bronchioles
(convent ional bronchoscopy cannot visualize alveolar st ruct ures)
Procedure
1. Spray and sw ab t opical anest het ic (eg, 4% lidocaine) ont o t he back of t he
nose, t he t ongue, t he pharynx, and t he epiglot t is. G ive an ant isialagogue (eg,
at ropine) t o reduce secret ions. I f t he pat ient has a hist ory of
bronchospasms, administ er a bronchodilat or (eg, albut erol) via a hand-held
nebulizer.
2. I nsert t he f lexible or rigid bronchoscope caref ully t hrough t he mout h or nose
int o t he pharynx and t he t rachea (Fig. 12. 2). The scope also can be insert ed
t hrough an endot racheal t ube or t racheost omy. Suct ioning, oxygen delivery,
and biopsies are accomplished t hrough bronchoscope port s designed f or
t hese purposes.
FI G URE 12. 2 View of t he airw ay t hrough a bronchoscope. (Source:

O lympus America I nc. , Melville, New York, USA. )
3. Be advised t hat because of sedat ion, usually w it h diazepam (Valium),

midazolam (Versed), or meperidine (Demerol), t he pat ient is usually
comf ort able w hen a st at e of conscious sedat ion is achieved. How ever, w hen
t he bronchoscope is advanced, some pat ient s may f eel as if t hey cannot
breat he or are suff ocat ing.
4. The right lung, by convent ion, is normally examined bef ore t he lef t lung.
5. Bronchoscopic procedures include any one or a combinat ion of t he f ollow ing:
a. Bronchial w ashings f or cyt ology and st aining f or f ungi and mycobact eria
b. Bronchoalveolar lavage (BAL) f or inf ect ious (eg, alveolar prot einosis,
eosinophilic granuloma) diseases
c. Bronchial brushings of bot h visible and peripheral (under f luoroscopy)
endobronchial lesions and/ or t ransbronchial biopsies, bot h visible and
peripheral
Clin ical Alert

1. Morphine sulf at e is cont raindicat ed in pat ient s w ho have problems w it h
bronchospasm or ast hma because it can cause bronchospasm. Analgesics,
barbit urat es, t ranquilizers-sedat ives, and at ropine may be ordered and
administ ered 30 minut es t o 1 hour bef ore bronchoscopy. The pat ient
should be as relaxed as possible bef ore and during t he procedure but also
needs t o know t hat anxiet y is normal. The pat ient may need addit ional
int ravenous sedat ives during t he procedure. Ref er t o conscious sedat ion
precaut ions in Appendix C.
a. Art erial blood gas measurement during and af t er bronchoscopy may be
ordered, and art erial blood oxygen may remain alt ered f or several
hours af t er t he procedure. Sput um specimens t aken during and af t er
bronchoscopy may be sent f or cyt ologic examinat ion or cult ure and
sensit ivit y t est ing. These specimens must be handled and preserved
according t o inst it ut ional prot ocols (see Chap. 14).
2. Cont inuous monit oring of elect rocardiogram, blood pressure, pulse
oximet ry, and respirat ions is rout inely perf ormed. Monit oring of pulse
oximet ry is especially import ant t o indicat e levels of oxygen sat urat ion
bef ore, during, and af t er t he procedure.
Clinical Implications Abnormalities revealed through

bronchoscopy include the follow ing conditions:
1. Abscesses
2. Bronchit is
3. Carcinoma of t he bronchial t ree (occurs in t he right lung more of t en t han t he
lef t )
4. Tumors (usually appear more of t en in larger bronchi)
5. Tuberculosis
6. Alveolit is
7. Evidence of surgical nonresect abilit y (eg, involvement of t racheal w all by
t umor grow t h, immobilit y of a main-st em bronchus, w idening and f ixat ion of
t he carina)
8. Pneumocysti s cari ni i inf ect ion
9. I nf lammat ory processes
10. Cyt omegalovirus inf ect ion
11. Aspergillosis
12. I diopat hic nonspecif ic pulmonary f ibrosis
13. Cryptococcus neof ormans inf ect ion
14. Coccidioidomycosis
15. Hist oplasmosis
16. Blast omycosis
17. Phycomycosis
Clinical Considerations The follow ing data must be

available before the procedure: history and physical
examination, recent chest x-ray film, recent arterial
blood gas values, and, if the patient is > 40 years of
age or has heart disease, electrocardiogram (ECG).
Appropriate blood w ork (coagulation), urinalysis,
pulmonary function tests, and sputum studies
(especially for acid-fast bacilli) must be done as w ell.
Bronchoscopy is often done as an ambulatory surgical
procedure.
Interventions
Pretest Patient Preparation for Traditional
Bronchoscopy
1. Reinf orce inf ormat ion relat ed t o t he purpose, procedure, benef it s, and risks
of t he t est . Record signs and sympt oms (eg, dyspnea, bloody sput um,
coughing, hoarseness).
2. Emphasize t hat pain is not usually experienced because lungs do not have
pain f ibers.
3. Explain t hat t he local anest het ic may t ast e bit t er, but numbness w ill occur in
a f ew minut es. Feelings of a t hickened t ongue and t he sensat ion of
somet hing in t he back of t he t hroat t hat cannot be coughed out or sw allow ed
are not unusual. These sensat ions w ill pass w it hin a f ew hours f ollow ing t he
procedure as t he anest het ic w ears off .
4. Be aw are t hat an inf ormed consent f orm must be properly signed and
w it nessed (see Chap. 1).
5. Have t he pat ient f ast f or at least 6 hours bef ore t he procedure t o reduce t he
risk f or aspirat ion. G ag, cough, and sw allow ing ref lexes w ill be blocked
during and f or a f ew hours af t er surgery.
6. Ensure t hat t he pat ient removes w igs, nail polish, makeup, dent ures, jew elry,
and cont act lenses bef ore t he examinat ion.
7. Use relaxat ion t echniques t o help t he pat ient relax and breat he more
normally during t he procedure. The more relaxed t he pat ient is, t he easier it
is t o complet e t he procedure.
Posttest Patient Aftercare for Traditional Bronchoscopy

1. Be cert ain t hat sw allow, gag, and cough ref lexes are present bef ore allow ing
f ood or liquids t o be ingest ed orally. Usually t he pat ient has f ast ed f or at
least 2 hours bef ore t he procedure.
2. Provide gargles t o relieve mild pharyngit is. Monit or ECG , blood pressure,
t emperat ure, pulse, pulse oximet er readings, skin and nail bed color, lung
sounds, and respirat ory rat e and pat t erns according t o inst it ut ion prot ocols.
Document observat ions.
3. Be aw are t hat t he f ollow ing may be ordered:
a. O xygen by mask or nasal cannula. Humidif ied oxygen at specif ic
concent rat ions up t o 100% by mask may be necessary.
b. A chest x-ray f ilm. This w ill check f or pneumot horax or t o evaluat e t he
lungs.
c. Sput um specimens. These must be preserved in t he proper medium or
solut ion.
4. Elevat e t he head of t he bed f or comf ort .
5. I nt erpret t est out comes, monit or appropriat ely, and explain need f or ot her
t est s or t reat ment . Follow -up procedures may be necessary. Comput ed
t omography (CT)-guided f ine-needle cyt ology aspirat ion may be done w hen
bronchoscopy is not diagnost ic.
6. Ref er t o int ravenous sedat ion precaut ions in Appendix C.
Contraindications to Bronchoscopy Contraindications

to bronchoscopy include the follow ing conditions:
1. Severe hypoxemia
2. Severe hypocapnia (carbon dioxide ret ent ion)
3. Cert ain cardiac arrhyt hmias, cardiac st at es
4. Hist ory of being hepat it is B carrier
5. Bleeding or coagulat ion disorders
6. Severe t racheal st enosis
Clin ical Alert

A. O bserve f or possible complicat ions of t radit ional bronchoscopy, w hich may
include t he f ollow ing condit ions:
1. Shock
2. Bleeding f ollow ing biopsy (rare, but can occur if t here is excessive
f riabilit y of airw ays or massive lesions, or if pat ient is uremic or has a
hemat ologic disorder)
3. Hypoxemia
4. Part ial or complet e laryngospasm (inspirat ory st ridor) t hat produces a
crow ing sound; may be necessary t o int ubat e
5. Bronchospasm (pallor and increasing dyspnea are signs)
6. I nf ect ion or gram-negat ive bact erial sepsis
7. Pneumot horax
8. Respirat ory f ailure
9. Cardiac arrhyt hmias
10. Anaphylact ic react ions t o drugs
11. Seizures
12. Febrile st at e
13. Hypoxia, respirat ory dist ress
14. Empyema
15. Aspirat ion
B. Virt ual noninvasive bronchoscopy using spinal CT t echnology requires no
sedat ion or analgesics. I ndicat ions include pulmonary embolism and
st aging of lung cancer.
Special Pediatric Considerations Bronchoscopy

instruments can decrease an already small airw ay
lumen even more by causing inflammation and edema.
Consequently, a child can rapidly become hypoxic and
desaturate oxygen very quickly. Resuscitation, oxygen
administration equipment, and drugs must be readily
accessible w hen this procedure is performed on a
child. Close monitoring of respiratory and cardiac
status is imperative during and after the procedure.
The same precautions and treatment
apply to children and adults. M ost children suffer

cardiac arrest because of respiratory problems, not
cardiac problems.
Thoracoscopy
Thoracoscopy is an examinat ion of t he t horacic cavit y using an endoscope.
Video-assist ed t horacoscopy (VAT) is a recent addit ion t o t he procedures
available f or diagnosing int rat horacic diseases. This procedure is making a
comeback because it can be used as a diagnost ic device w hen ot her met hods of
diagnosis f ail t o present adequat e and accurat e f indings. Moreover, t he
discomf ort and many of t he risks associat ed w it h t radit ional diagnost ic
t horacot omy procedures are reduced w it h t horacoscopy versus ot her
procedures. Thoracoscopy allow s visualizat ion of t he pariet al and visceral
pleura, pleural spaces, t horacic w alls, mediast inum, and pericardium w it hout t he
need f or more ext ensive procedures. I t is used most f requent ly t o invest igat e
pleural eff usion and can be used t o perf orm laser procedures; diagnose and
st age lung disease; assess t umor grow t h, pleural eff usion, emphysema,
inf lammat ory processes, and condit ions predisposing t o pneumot horax; and
perf orm biopsies of pleura, mediast inal lymph nodes, and lungs.
Reference Values
Normal
Thoracic cavit y and t issues normal and f ree of disease
Procedure
1. Be advised t hat t horacoscopy is considered an operat ive procedure. The
pat ient 's st at e of healt h, t he part icular posit ioning needed, and t he
procedure it self det ermine t he need f or eit her local or general anest hesia.
The incision is usually made at t he midaxillary line and t he sixt h int ercost al
space.
2. Schedule admission t he morning of t he procedure. Many pat ient s are
discharged t he f ollow ing day, provided t he lung has reexpanded properly and
chest t ubes have been removed.
Clinical Implications Abnormal findings can include the
follow ing conditions:

1. Carcinoma or met ast asis of carcinoma
2. Empyema
3. Pleural eff usion
4. Condit ions predisposing t o pneumot horax or ulcers
5. I nf lammat ory processes
6. Bleeding sit es
7. Tuberculosis, coccidioidomycosis, or hist oplasmosis
Interventions
1. Reinf orce and explain t he purpose, procedure, benef it s, and risks of t he
examinat ion and describe w hat t he pat ient w ill experience. Record
preprocedure signs and sympt oms.
2. Be aw are t hat a surgical consent f orm must be appropriat ely signed and
w it nessed bef ore t he procedure begins (see Chap. 1).
3. Complet e and review required blood t est s, urinalysis, recent chest x-ray f ilm,
and ECG (f or cert ain individuals) bef ore t he procedure.
4. Have t he pat ient f ast f or 8 hours bef ore t he procedure.
5. I nsert an int ravenous line f or t he administ rat ion of int raoperat ive int ravenous
f luids and int ravenous medicat ion.
6. Perf orm skin preparat ion and correct posit ioning in t he operat ing room.
7. Place a chest t ube and connect t o negat ive suct ion or somet imes t o gravit y
change af t er t he t horacoscopy is complet ed.
care.

1. Take a post operat ive chest x-ray f ilm t o check f or abnormal air or f luid in t he
chest cavit y.
2. Monit or vit al signs, amount and color of chest t ube drainage, f luct uat ion of
f luid in t he chest t ube, bubbling in t he chest bot t le, and respirat ory st at us,
including art erial blood gases. Prompt ly report abnormalit ies t o t he
physician.
3. Administ er pain medicat ion as necessary. Encourage relaxat ion exercises as
a means t o lessen t he percept ion of pain. Monit or qualit y and rat e of
respirat ions. Be alert t o t he possibilit y of respirat ory depression relat ed t o
narcot ic administ rat ion or int rat hecal narcot ics.
4. Encourage f requent coughing and deep breat hing. Assist t he pat ient in
splint ing t he incision during coughing and deep breat hing t o lessen
discomf ort . Promot e leg exercises w hile in bed and assist w it h f requent
ambulat ion if permit t ed.
5. Use open-ended quest ions t o provide t he pat ient w it h an opport unit y t o
express concerns.
6. Document care accurat ely.
care. Provide w rit t en discharge inst ruct ions.
Clin ical Alert

1. Do not cl amp chest tubes unl ess speci f i cal l y ordered to do so. Clamping
chest t ubes may cause a t ension pneumot horax. Sudden onset of sharp
pain, dyspnea, uneven chest w all movement , t achycardia, anxiet y, and
cyanosis may indicat e pneumot horax. Not if y t he physician immediat ely.
2. Possible w ound and pulmonary complicat ions include t he f ollow ing:
a. Acut e respirat ory dist ress, hypoxia
b. I nf ect ion
c. Hemorrhage (w at ch f or unusually large out put s of blood in a relat ively
short period of t ime int o t he chest bot t le and not if y physician
immediat ely)
d. Empyema
e. At elect asis
f. Aspirat ion
3. Nerve damage may occur during t he procedure.
Esophagogastroduodenoscopy (EGD); Upper

Gastrointestinal (UGI) Study; Endoscopy; Gastroscopy
Endoscopy is a general term for visual inspection of

any body cavity with an endoscope. Endoscopic
examination of the upper gastrointestinal (UGI) tract
(mouth to upper jejunum) is referred to when the
following examinations are ordered: panendoscopy,
esophagoscopy, gastroscopy, duodenoscopy,
esophagogastroscopy, or
esophagogastroduodenoscopy (EGD).
Esophagogast roduodenoscopy allow s direct visualizat ion of t he int erior lumen of
t he upper gast roint est inal t ract w it h a f iberopt ic inst rument designed f or t hat
purpose. EG D is indicat ed f or pat ient s w it h dysphagia; ref lux sympt oms; w eight
loss; hemat emesis; melena; persist ent nausea and vomit ing; persist ent
epigast ric, abdominal, or chest pain; and persist ent anemia.
EG D can conf irm suspicious x-ray f indings and est ablish a diagnosis of
sympt omat ic pat ient s w it h negat ive x-ray report s. EG D can be used t o diagnose
and t reat many abnormalit ies of t he UG I t ract , including hernias,
gast roesophageal ref lux disease (G ERD), esophagit is, gast rit is, st rict ures,
varices, ulcers, polyps, and t umors. I t can be used t o remove f oreign bodies
(such as a sw allow ed coin in a small child) and f or placement of a percut aneous
gast ric or duodenal f eeding t ube. For pat ient s w ho require some f orm of UG I
surgery, it provides a saf e w ay t o perf orm presurgical screening and
post surgical surveillance.
Reference Values
Normal
UG I t ract w it hin normal limit s
Procedure
1. Remember t hat t his examinat ion is usually perf ormed in an out pat ient set t ing
of a hospit al or ambulat ory clinic. I t also may be perf ormed in t he operat ing
room or in a crit ical care set t ing.
2. Use a t opical spray t o anest het ize t he pat ient 's t hroat .
3. St art an int ravenous line and use f or administ rat ion of sedat ion alone or in
combinat ion w it h analgesics. These medicat ions are given t o achieve a st at e
of conscious sedat ion (see Appendix C). Resuscit at ion equipment must be
available.
4. Perf orm cont inuous monit oring of t he pat ient 's vit al signs, ECG , and oxygen
sat urat ion (pulse oximet ry).
5. Remove part ial dent al plat es or dent ures. I nsert a mout hpiece t o prevent t he
pat ient f rom bit ing t he endoscope and t o prevent injury t o t he pat ient 's t eet h,
t ongue, or ot her oral st ruct ures.
6. Lubricat e t he endoscope w ell. G ent ly insert t hrough t he mout hpiece int o t he
esophagus and advance slow ly int o t he st omach and duodenum. I nsuff lat e air
t hrough t he scope t o dist end t he area being examined so t hat opt imal
visualizat ion of t he mucosa is possible. O bt ain t issue biopsy specimens and
brushings f or cyt ology. Take phot os t o provide a permanent record of
observat ions.
7. I nf orm t he pat ient t hat he or she may have an init ial gagging sensat ion t hat
quickly subsides. During t he procedure, t he pat ient may belch f requent ly.
Sensat ions of abdominal pressure or bloat ing are normal, but t he pat ient
should not experience act ual pain.
8. I mmediat ely af t er t he examinat ion is complet ed, ask t he pat ient t o remain on
his or her lef t side unt il f ully aw ake.
Clinical Implications Abnormal results may indicate the

1. Hemorrhagic areas or erosion of an art ery or vein
2. Hiat al hernia
3. Esophagit is, gast rit is
4. Neoplast ic t issue
5. G ast ric ulcers (benign or malignant )
6. Esophagit is, gast rit is, duodenit is
7. Esophageal or gast ric varices
8. Esophageal, pyloric, or duodenal st rict ures
Interventions
1. Explain t he purpose and procedure of t he examinat ion, t he sensat ions t hat
may be experienced, and t he benef it s and risks of t he t est . Ref er t o
int ravenous conscious sedat ion precaut ions in Appendix C. Reassure t he
pat ient t hat t he endoscope is t hinner t han most f ood

sw allow ed. I nf orm t he pat ient t hat he or she may be quit e sleepy during t he
EG D and may not recall much or any of t he experience. Record
preprocedure signs and sympt oms (eg, vomit ing, melena, dysphagia, and
persist ent upper G I pain).
2. Pat ient s should be inst ruct ed t o f ast bef ore t he procedure, according t o t he
hospit al or clinic policy. G enerally, adult pat ient s should f ast 68 hours
bef ore t he examinat ion, and children may have clear liquids up unt il 2 hours
bef ore t he procedure; how ever, each pat ient should be assessed on an
individual basis, according t o age, size, and general healt h st at us. I npat ient s
may have int ravenous f luids t o prevent dehydrat ion. O ut pat ient s need
educat ion about pot ent ial risks f or aspirat ion and possible cancellat ion of t he
procedure if f ast ing is not maint ained.
3. Conf irm inf ormed consent . A legal consent must be signed and w it nessed
4. Encourage t he pat ient t o urinat e and def ecat e if possible bef ore t he
examinat ion.
care.

1. Do not permit f ood or liquids unt il t he pat ient 's gag ref lex ret urns.
2. Monit or blood pressure, pulse, respirat ions, and oxygen sat urat ion according
t o t he hospit al or clinic policy, usually every 1530 minut es, unt il t he pat ient
is f ully aw ake.
3. Ask t he pat ient t o remain on his or her lef t side w it h side-rails raised unt il
f ully aw ake. This posit ion usually prevent s aspirat ion.
4. Encourage t he pat ient t o belch or expel air insert ed int o t he st omach during
t he examinat ion.
5. Remember t hat t he pat ient should not experience discomf ort or side eff ect s
once t he sedat ive has w orn off . O ccasionally, t he pat ient may complain of a
slight sore t hroat . Sucking on lozenges af t er sw allow ing ref lexes ret urn may
be helpf ul if t hese are permit t ed.
Clin ical Alert

Complicat ions are rare; how ever, t he f ollow ing complicat ions can occur:
1.
2.
3.
4.
5.
Perf orat ion

Bleeding or hemorrhage
Aspirat ion
I nf ect ion
Complicat ions f rom drug react ion (leading t o hypot ension, respirat ory
depression or arrest , allergic or anaphylact ic response)
6. Complicat ions f rom unrelat ed diseases (such as myocardial inf arct ion,
cerebrovascular accident )
7. Deat h (very rare)
Esophageal Manometry Esophageal manometry

measures the movement, coordination, and strength of
esophageal peristalsis as well as the function of the
upper and lower esophageal sphincters. The test
consists of recording intraluminal pressures at various
levels in the esophagus and at the upper and lower
esophageal sphincters. Intraluminal pressures can be
measured with the use of a manometric catheter, which
is passed intranasally to the patient and then attached
to an infusion pump, transducer, and recorder. The
intraluminal pressures produce waveform readings
(somewhat similar to ECG readings), which can be
used to assess esophageal function.
1. Abnormal esophageal muscle f unct ion
2. Diff icult y sw allow ing (dysphagia)
3. Heart burn
4. Noncardiac chest pain
5. Regurgit at ion
6. Vomit ing
7. Esophagit is
Anot her t est , of t en done in conjunct ion w it h manomet ry, is t he Bernst ein t est
(discussed lat er). This procedure is usef ul f or evaluat ing heart burn, esophagit is,
and noncardiac chest pain.
Reference Values
Normal
Normal esophageal and st omach pressure readings Normal cont ract ions
No acid ref lux
Procedure
1. Remember t hat t he examinat ion is usually perf ormed in an out pat ient set t ing,
such as an ambulat ory clinic or physician's off ice.
2. At t ach t he manomet ric cat het er t o t he inf usion pump. Set up t he t ransducer
and recording equipment and calibrat e according t o manuf act urer's
recommendat ions.
3. Assess t he pat ient 's nasal passage f or adequat e size and pat ency.
G enerously apply a t opical anest het ic t o t he select ed nost ril.
4. Lubricat e t he manomet ric cat het er and pass it t hrough t he nost ril, dow n t he
esophagus, and just below t he low er esophageal sphinct er w it h t he pat ient in
a sit t ing posit ion. Facilit at e t his w it h t he pat ient drinking sips of w at er
t hrough a st raw.
5. Begin recording. Pull t he cat het er t hrough t he low er esophageal sphinct er,
t hen t he esophageal body, and f inally t he upper esophageal sphinct er.
Diff erent t echniques may be used t o obt ain recordings. The pat ient may be
asked t o sw allow, not sw allow, t ake sips of w at er, or hold his or her breat h
w hile t he cat het er is pulled t hrough.
6. Be aw are t hat t he Bernstei n test evaluat es f or acid ref lux by means of a
nasogast ric t ube passed t o a point 5 cm above t he gast roesophageal
junct ion. Concent rat ion of hydrochloric acid (0. 1 normal HCl) is inf used f or 10
minut es int o t he esophagus t o reproduce sympt oms of heart burn or chest
discomf ort . I n t he f irst 5 minut es of t est ing, 0. 9% sodium chloride (NaCl) is
inf used as a cont rol. Test ing t akes about 15 minut es. The pat ient may lie
dow n or sit up.
care.
Clinical Implications Abnormal recordings reveal the

1. Primary esophageal mot ilit y disorders, such as achalasia, nut cracker
esophagus, or diff use esophageal spasm.
2. Hypert ensive low er esophageal sphinct er
3. Acid ref lux
Interventions
1. Explain t he purpose, procedure, benef it s and risks of t he t est .
2. O bt ain an inf ormed consent t hat is properly signed and w it nessed.
3. Conf irm t hat t he pat ient has f ast ed f or 6 hours bef ore t est ing.
4. I nst ruct t he pat ient on t he t echniques of sw allow ing, sipping w at er, and so
f ort h t o f acilit at e accurat e recordings.
care.

1. Advise t he pat ient t hat a sore t hroat and nasal passage irrit at ion are
common f or 24 hours af t er t he examinat ion. Sensat ions of heart burn may
also persist . Administ er ant acids if ordered.
2. O bserve f or or inst ruct pat ient t o w at ch f or nasal bleeding, gast roint est inal
bleeding, or unusual pain.
3. I nt erpret t est out comes, counsel, and monit or appropriat ely as above.
Provide w rit t en discharge inst ruct ions.
Clin ical Alert

Complicat ions are rare; how ever, t he f ollow ing can occur: aspirat ion;
perf orat ion of nasopharynx, esophagus, or st omach; epist axis.
Endoscopic Retrograde Cholangiopancreatography

(ERCP) and Manometry This examination of the
hepatobiliary system is done through a side-viewing
flexible fiberoptic endoscope by instillation of contrast
medium into the duodenal papilla, or ampulla of Vater.
This allows for radiologic visualization of the biliary
and pancreatic ducts. It is used to evaluate jaundice,
pancreatitis, persistent abdominal pain, pancreatic
tumors, common duct stones, extrahepatic and
intrahepatic biliary tract disease, malformation, and
strictures and as a follow-up study in confirmed or
suspected cases of pancreatic disease.
ERCP manomet ry can be done t o obt ain pressure readings in t he bile duct ,
pancreat ic duct , and sphinct er of O ddi at t he papilla. Measurement s are
obt ained using a cat het er t hat is insert ed int o t he endoscope and placed w it hin
t he sphinct er zone.
Reference Values
Normal
Normal appearance and pat ent pancreat ic duct s, hepat ic duct s, common bile
duct s, duodenal papilla (ampulla of Vat er), and gallbladder
Manomet ry: Normal pressure readings of bile and pancreat ic duct s and sphinct er
of O ddi
Procedure
1. Remember t hat t his examinat ion is usually perf ormed in a hospit al or
out pat ient set t ing w here f luoroscopy and x-ray equipment are available.
2. Have t he pat ient gargle w it h or spray his or her t hroat w it h a t opical
anest het ic.
3. St art an int ravenous line and use f or administ rat ion of sedat ives and
analgesics. These medicat ions are given t o achieve a st at e of conscious
sedat ion (see Appendix C). I n some sit uat ions, general anest hesia may be
used. Resuscit at ion equipment must be available.
6. Have t he pat ient assume a lef t lat eral posit ion w it h t he knees f lexed. The
endoscope is w ell lubricat ed and insert ed via t he mout hpiece, dow n t he
esophagus and st omach, and int o t he duodenum. At t his point , have t he
pat ient assume a prone posit ion w it h t he lef t arm posit ioned behind him or
her.
7. I nst ill simet hicone t o reduce bubbles f rom bile secret ions. G ive glucagon or
ant icholinergic agent s int ravenously t o relax t he duodenum so t hat t he papilla
can be cannulat ed. (At ropine increases t he heart rat e. )
8. Pass a cat het er int o t he ampulla of Vat er and inst ill a cont rast agent t hrough
t he cannula t o out line t he pancreat ic and common bile duct s. Perf orm
f luoroscopy and x-rays at t his t ime.
9. Take biopsy specimens or cyt ology brushings bef ore t he endoscope is
removed.
10. Monit or f or side eff ect s and drug allergy react ions (eg, diaphoresis, pallor,
rest lessness, hypot ension).
Clinical Implications Abnormal results reveal stones,

stenosis, and other abnormalities that are indicative of
the follow ing conditions:
1. Biliary cirrhosis
2. Primary sclerosing cholangit is
3. Cancer of bile duct s, gallst ones
4. Pancreat ic cyst s
5. Pseudocyst s
6. Pancreat ic t umors
7. Cancer of head and pancreas
8. Chronic pancreat it is
9. Pancreat ic f ibrosis
10. Cancer of duodenal papilla

11. Papillary st enosis
12. Pept ic ulcer disease
Clin ical Alert

1.
2.
3.
4.
5.
6.
Acut e pancreat it is, pancreat ic pseudocyst s, and cholangit is

O bst ruct ions or st rict ures w it hin t he esophagus or duodenum
Acut e inf ect ions
Recent myocardial or severe pulmonary disease
Coagulopat hy
Recent barium x-rays of t he G I t ract (barium obscures view s during
ERCP)
Interventions
1. Explain t he purpose, procedure, benef it s, and risks of t he t est . I f done as an
out pat ient procedure, t he pat ient should arrange f or a ride home and should
leave all valuables at home. Blood w ork, urinalysis, x-ray f ilms, and scans
should be review ed and chart ed bef ore t he procedure. Record baseline vit al
signs and preprocedure signs and sympt oms (eg, jaundice, persist ent
abdominal pain, and signs of pancreat ic cancer).
2. Be aw are t hat an inf ormed consent f orm must be properly signed and
w it nessed.
3. Have t he pat ient f ast f or 812 hours bef ore ERCP.
4. I nf orm t he pat ient t o expect t he f ollow ing:
a. The pat ient may be quit e sleepy during t he ERCP and may not recall
much of t he experience.
b. The pat ient should sw allow w hen request ed t o do so and should not
at t empt t o t alk (t o prevent damage t o t he oral pharynx).
c. I nit ially, t he pat ient may experience a gagging or choking sensat ion t hat
quickly subsides. Slow, deep breat hing may help w it h t his f eeling.
Sensat ions of abdominal pressure or bloat ing are normal.
d. The pat ient w ill have t o lie quiet ly w hile x-rays are being t aken.
e. Encourage t he pat ient t o urinat e and def ecat e bef ore t he procedure.
5. Ref er t o conscious sedat ion precaut ions in Appendix C.
care.

1. Do not permit f ood or liquids unt il t he pat ient 's gag ref lex ret urns.
2. Monit or t he blood pressure, pulse, respirat ions, oxygen sat urat ion, and
t emperat ure according t o inst it ut ional policy.
3. O bserve t he pat ient f or signs of complicat ions such as inf ect ion, urinary
ret ent ion, cholangit is, or pancreat it is. Check f or t emperat ure elevat ion, w hich
may be t he f irst sign of inf lammat ion. Monit or t he w hit e blood cell count and
assess f or signs of sepsis.
4. I nf ect ion may result f rom obst ruct ed and inf ect ed biliary syst ems and/ or
cont aminat ed endoscopes used during t he procedure.
5. Monit or f or respirat ory and cent ral nervous syst em depression f rom
narcot ics (naloxone may be used t o reverse narcot ic eff ect s, and f lumazenil
is used f or reversing diazepam-like drugs).
6. Explain t hat some abdominal discomf ort may be experienced f or several
hours af t er t he procedure.
7. Advise pat ient t hat drow siness may last up t o 24 hours. During t his t ime, t he
pat ient should not perf orm any t asks t hat require ment al alert ness, and legal
document s should not be signed.
8. Tell pat ient t hat a sore t hroat can be relieved by gargles, ice chips, f luids, or
lozenges if permit t ed.
9. Not if y physician of any of t he f ollow ing signs or sympt oms:
a. Prolonged, sharp abdominal pain; abnormal w eakness; f aint ness
b. Fever
c. Nausea or vomit ing
care. Provide w rit t en inst ruct ions t o out pat ient s. O ut pat ient s should be
discharged t o t he care of a responsible adult .
Clin ical Alert

O bserve f or possible complicat ions:
1.
2.
3.
4.
5.
6.
Pancreat it is and sepsis (t he most common complicat ions of ERCP)

Hemorrhage
Perf orat ion
Aspirat ion
Respirat ory depression or arrest
Medicat ion react ion
Enteroscopy
Ent eroscopy is t he endoscopic examinat ion of t he small bow el w it h f iberopt ic
endoscope. The endoscope is about 250300 cm long, depending on t he
manuf act urer. This long inst rument is passed dow n t he esophagus, t hrough t he
st omach, t hrough t he dist al duodenum, and t hen int o t he jejunum. O nce in t he
jejunum, t he endoscopist uses a series of movement s t o advance t he endoscope
as f ar as possible. A device know n as an overt ube may be applied t o t he
endoscope t o prevent it f rom looping in t he st omach and inhibit ing deep
int ubat ion of t he small int est ine. Fluoroscopy may also be usef ul in det ermining
t he posit ion of t he endoscope in t he small bow el.
The main indicat ion f or ent eroscopy is unexplained gast roint est inal bleeding. I t
may also be used t o help diagnose pat ient s w it h unexplained chronic diarrhea or
suspicious x-ray f indings. I t is very usef ul in diagnosing a small bow el
abnormalit y out of reach of a st andard endoscope t hat might ot herw ise be done
surgically.
Reference Values
Normal
Small int est inal t ract w it hin normal limit s
Procedure
1. This examinat ion is usually perf ormed in an out pat ient set t ing of a hospit al or
ambulat ory clinic. I t also may be perf ormed in t he operat ing room or in a
crit ical care set t ing.
2. Use a t opical spray t o anest het ize t he pat ient 's t hroat .
3. St art an int ravenous line and use f or administ rat ion of sedat ion alone or in
combinat ion w it h analgesics. These medicat ions are given t o achieve a st at e
of conscious sedat ion (see Appendix C). Resuscit at ion equipment must be
available.
6. Be aw are t hat depending on t he endoscopist 's pref erence, an overt ube may
be back-loaded ont o t he endoscope. The endoscope is w ell lubricat ed and
gent ly insert ed t hrough t he mout hpiece int o t he esophagus and advanced int o
t he st omach and duodenum. To advance int o t he dist al duodenum and
jejunum, t he endoscopist may use a series of pushing and pulling movement s
t hat serve t o pleat t he small bow el ont o t he endoscope, allow ing deeper
int ubat ion. Fluoroscopy is usef ul t o det ermine locat ion in t he small bow el.
7. O bt ain biopsy specimens and brushing f or cyt ology. Take phot os t o provide a
permanent record of observat ions.
8. I nf orm t he pat ient t hat he or she may init ially have a st rong gagging or
choking sensat ion. During t he procedure, t he pat ient may belch f requent ly
and have a sensat ion of abdominal pressure and bloat ing.
9. I mmediat ely af t er t he procedure, have t he pat ient remain on his or her lef t
side unt il f ully aw ake.
Clinical Implications Abnormal results w ould indicate

the follow ing:
1. Vascular abnormalit ies, such as angiodysplasia or varices
2. Ulcerat ive lesions, such as in Crohn's disease
3. Divert icula, such as Meckel's divert iculum
4. Tumors
Interventions
1. Explain t he purpose and procedure of t he examinat ion, t he sensat ions t hat
may be experienced, and t he benef it s and risks of t he t est . Ref er t o t he

conscious sedat ion and analgesia precaut ions in Appendix C.
2. I nf orm t he pat ient t hat t he procedure may be several hours long, depending
on t he ease of passing t he endoscope, diagnosis, and t reat ment .
3. I nf orm t he pat ient t hat he or she might be quit e sleepy during t he t est and
may not recall much of t he experience.
4. I nst ruct t he pat ient on f ast ing 1012 hours bef ore t he procedure t o avoid t he
risks f or aspirat ion and possible cancellat ion of t he procedure.
5. Conf irm inf ormed consent . A legal consent f orm must be signed and
w it nessed bef ore t he procedure.
6. Encourage t he pat ient t o urinat e and def ecat e if possible bef ore t he
examinat ion.
care.

1. No f ood or liquids are permit t ed unt il t he pat ient 's gag ref lex ret urns.
Sucking on ice chips or t hroat lozenges may be helpf ul t o relieve a sore
t hroat .
2. Monit or blood pressure, pulse, respirat ions, and oxygen sat urat ion according
t o t he hospit al or clinic policy, unt il t he pat ient is f ully aw ake.
3. The pat ient should remain on his or her lef t side w it h side-rails raised unt il
f ully aw ake.
4. Encourage t he pat ient t o belch t o expel air insert ed during t he procedure.
6. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, and inf ormed
posttest care. Provide w rit t en discharge inst ruct ions t o out pat ient s.
O ut pat ient s should be discharged t o t he care of a responsible adult .
Edu cation Alert

New t echnology in t he f orm of a video capsule may aid diagnosis of small
bow el abnormalit ies. The video capsule is basically a w ireless virt ual
endoscope t hat t ransmit s video images t o a recorder. The pat ient f ast s f or 12
hours, t hen sw allow s t he video capsule (w hich is t he size of a large pill) and
w ears a recorder around t he w aist . The pat ient can begin drinking and eat ing
several hours lat er. The video capsule t ravels t hrough t he ent ire G I t ract via
normal perist alsis, recording images. The images f rom t he recorder can t hen
be dow nloaded and review ed f or diagnost ic purposes.
Clin ical Alert

Pot ent ial complicat ions include:
1. Shearing or st ripping of gast ric mucosa (w hich may arise f rom use of t he
overt ube)
2. Pancreat it is
3. Hemorrhage
4. Perf orat ion
Colposcopy
Colposcopy permit s examinat ion of t he vagina and cervix w it h t he colposcope, an
inst rument w it h a magnif ying lens. The colposcope is also used t o examine male
genit al lesions suspect ed in sexually t ransmit t ed diseases, condylomas, or
human papillomavirus. I ndicat ions f or t his procedure in w omen include abnormal
Papanicolaou (Pap) smear result s and/ or ot her cervical lesions, leukoplakia, and
ot her cancerous lesions. Biopsy specimens and cell scrapings are obt ained
under direct visualizat ion. Colposcopy is also valuable f or assessing w omen w it h
a hist ory of exposure t o diet hylst ilbest rol. Advant ages of colposcopy include t he
f ollow ing:
1. Lesions can be localized and t heir ext ent det ermined.
2. I nf lammat ory processes can be diff erent iat ed f rom neoplasia.
3. I nvasive or noninvasive disease processes can be diff erent iat ed.
Colposcopy cannot readily det ect endocervical lesions. Cervicit is and ot her
changes can produce abnormal f indings. When combined w it h f indings f rom Pap
smears, colposcopy can be a means of enhancing diagnost ic accuracy. Tables
12. 1 and Tables 12. 2 present correlat ion of f indings and advant ages and
disadvant ages of Pap smears and colposcopy. See Chapt er 11 f or Pap smear
procedure.
Table 12.1 Correlation of Colposcopic and Histologic

(Tissue) Findings
Colposcopic
Term
Colposcopic
Appearance
Histologic
Correlate
Original
squamous
epithelium
Smooth, pink;
indefinitely outlined
vessels; no change
after application of
acetic acid
Squamous
epithelium
Columnar
epithelium
Grapelike structures
acetic acid
Columnar
epithelium
Transformation
zone
Tongues of
squamous
metaplasia; gland
openings; nabothian
cysts
Metaplastic
squamous
epithelium
W hite
epithelium
W hite, sharpbordered lesion

visible only after
application of acetic
acid; no vessels
visible
From minimal
dysplasia to
carcinoma in
situ
Punctuation
Sharp-bordered
lesion; red stippling;
epithelium whiter
From minimal
dysplasia to
carcinoma in
acetic acid
situ
Sharp-bordered
lesion, mosaic
pattern; epithelium
whiter after
acid
Usually
hyperkeratosis
or
parakeratosis;
seldom
carcinoma in
situ or
invasive
disease
Hyperkeratosis
W hite patch; rough

surface; already
visible before
acid
Usually
hyperkeratosis
or
parakeratosis;
seldom
carcinoma in
situ or
invasive
disease
Atypical vessel
Horizontal vessels
running parallel to
surface;
constrictions and
dilatations of
vessels; atypical
branching, winding
course
From
carcinoma in
situ to
invasive
carcinoma
Mosaic
Table 12.2 Pros and Cons of Colposcopy and

Cytology (Examination of Cells)
Advantages
Disadvantages
COLPOSCOPY
Localizes lesion
Inadequate for detection of

endocervical
Diagnostic biopsy
reveals cause of
lesions
cancer
More intensive training is

necessary
Evaluates extent of
lesion
Cervicitis and regenerative

changes may
Differentiates between
inflammatory
produce abnormal findings
atypia and neoplasia

Differentiates between
invasive and
noninvasive cervical
lesions
Enables follow-up
CYTOLOGY
Ideal for mass screening
Cannot localize lesion
Economical
Inflammation, atrophic
changes, or folic
Detection of HPV by DNA

for cervical
acid deficiency may

produce suspicious
cancer
changes
Specimen can be
obtained by most
Many steps between

patient and
health care personnel
cytopathologist allow
misdiagnosis
Detects lesion in
endocervical canal
Value of single smear is

limited
Detects endocervical and

endometrial
False-negative rate is 5%
10%
carcinoma
High correlation with
biopsy material
(>90%)
See Chapter 11 for more information on cytology and
histology.
Whit ish areas of epit helium (leukoplakia), mosaic st aining pat t erns, irregular
blood vasculat ure, hyperkerat osis, and ot her abnormal-appearing t issues can be
seen using colposcopy. Leukoplakia vulva is a precancerous condit ion
charact erized by w hit e t o grayish inf ilt rat ed pat ches on t he vulvar mucosa. The
colposcope has a def init e advant age f or det ect ing at ypical epit helium,
designat ed in t he lit erat ure as basal cel l acti vi ty. At ypical epit helium cannot be
called benign and yet does not f ulf ill all crit eria f or carcinoma in sit u. I t s early
det ect ion promot es cancer prophylaxis.
Pat ient s receiving colposcopy may of t en be spared having t o undergo surgical
conizat ion (t he removal of a cone of t issue f rom t he cervix).
Anot her gynecology procedure, a hyst eroscopy, can be done t o det ermine t he
cause of abnormal ut erine bleeding, size and shape of t he ut erine cavit y, locat ion
of a misplaced int raut erine device (I UD), and ut erine abnormalit ies. A
hyst eroscopy is perf ormed early in t he menst rual cycle in a physician's off ice. A
local anest het ic is usually administ ered int o t he cervix and paracervical area
bef ore insert ion of t he hyst eroscope.
Reference Values
Normal
Normal vagina, cervix, vulva, and genit al areas Normal pink squamous epit helium
and capillaries Normal color, t one, and surf ace cont ours
Procedure
1. Place t he pat ient in t he modif ied lit hot omy posit ion. Expose t he vagina and
cervix w it h a speculum af t er t he int ernal and ext ernal genit alia have been
caref ully examined. Do not insert any part of t he colposcope int o t he vagina.
2. Sw ab t he cervix, vagina, or male genit al areas w it h 3% acet ic acid as
needed during t he procedure t o improve visibilit y of epit helial t issues (it
precipit at es nuclear prot eins w it hin t he cells). Remove t he cervical mucus
complet ely. Do not use cot t on-w ool sw abs because f ibers lef t on t he cervix
int erf ere w it h proper visualizat ion.

3. Begin act ual visualizat ion w it h t he colposcope w it h a f ield of w hit e light and
decreased magnif icat ion t o f ocus on sit es of w hit e epit helium or irregular
cervical cont ours. The light is t hen sw it ched t o a green f ilt er f or
magnif icat ion of vascular changes.
a. Diagram suspicious lesions and t ake phot ographs f or t he permanent
healt h care record.
b. The t ransf ormat ion zone and squamocolumnar junct ion (w here t he
squamous epit helium meet s t he columnar epit helium of t he cervix) are
areas w here many w omen exhibit at ypical cells. I t is imperat ive t hat
t hese zones be visualized complet ely, especially in older w omen,
because of changes associat ed w it h aging.
4. O bt ain biopsy specimens of t he lesions using a f ine biopsy f orceps. Some
pat ient s not e discomf ort at t his t ime.
5. Place specimen in proper preservat ive, label accurat ely, and rout e t o t he
appropriat e depart ment .
a. Endocervical curet t age must be perf ormed bef ore colposcope-direct ed
biopsy so t hat epit helial f ragment s dislodged during colposcopy do not
cause f alse-posit ive result s in t he endocervical curet t age. The
endocervical smear (curet t age biopsy samples) should be placed on a
slide in f ormalin.
b. St erile saline or st erile w at er should be used t o cleanse and rinse acet ic
acid f rom t he vaginal area t o prevent burning or irrit at ion. Bleeding can
be st opped by applying t oughened silver nit rat e caut ery st icks or f erric
subsulf at e (Monsel's solut ion).
6. Alert pat ient t hat a small amount of vaginal bleeding or cramping f or a f ew
hours is not abnormal.
7. Be aw are t hat a paracervical block may be necessary in pat ient s w ho are
ext remely anxious and af raid.
care.
Edu cation Alert

Bef ore undergoing t his procedure, t he pat ient know s t hat t he cervical (Pap)
smear is abnormal. Women of t en believe t hat t hey do have cancer unless it is
explained t hat t hey do not.
1. Abnormal lesions or unusual epit helial pat t erns include t he f ollow ing:
a. Leukoplakia
b. Abnormal vasculat ure
c. Slight , moderat e, or marked dysplasia
d. Abnormal-appearing t issue is classif ied by punct uat ion (ie, sharp
borders, red st ippling, epit helium w hit er w it h acet ic acid); mosaic pat t ern
(ie, sharp borders, mosaic pat t ern, epit helium w hit er w it h acet ic acid); or
hyperkerat osis (ie, w hit e epit helium, rough, visible w it hout acet ic acid)
2. Ext ent of abnormal epit helium (w it h acet ic acid) and ext ent of nonst aining
w it h iodine
3. Clinical cervical cancer, cervical exf et at ion pain
4. Acut e inf lammat ion w it h human papillomavirus or bact erial inf ect ions (eg,
chlamydia), bact erial vaginosis and gonorrhea
Interventions
1. Explain t est purpose and procedure. Record preprocedure signs and
sympt oms (eg, abnormal Pap, cervical or vaginal drainage or bleeding).
2. O bt ain a urine specimen and a pert inent gynecologic hist ory.
care.
Clin ical Alert

1. Pat ient s may experience a vasovagal response. Wat ch f or bradycardia
and hypot ension and t reat accordingly. Have t he pat ient sit f or a short
w hile bef ore st anding.
2. Ant i-inf lammat ory agent s such as ibuprof en may relieve cramping.
3. Cervical scars f rom previous event s may prevent sat isf act ory visualizat ion.
4. Monit or f or complicat ions, including heavy bleeding, inf ect ion, or pelvic
inf lammat ory disease.
5. Development of cervical changes and pot ent ial cervical carcinoma is a
great er risk in t hese pat ient s. An annual Pap smear is mandat ory f or t hose
w ho have undergone colposcopy.
6. A paracervical block may be used w it h t he procedure.

1. I nst ruct t he pat ient t o abst ain f rom sexual int ercourse and t o not insert
anyt hing int o t he vagina f or 2 t o 7 days (per physician's orders) af t er t he
procedure.
2. I f specimens are t aken, slight vaginal bleeding may occur. Excessive
bleeding, pain, f ever, or abnormal vaginal discharge should be report ed
immediat ely. I buprof en may relieve cramps.
3. I nt erpret t est out comes and counsel appropriat ely regarding f ollow -up
t reat ment such as cone biopsy and loop elect rosurgical excision procedure
(LEEP). I f radiat ion t reat ment is prescribed, cervical t umor t issue may be
t est ed f or t he presence of glut at hione as a possible indicat or of radiat ion
resist ance.
Loop Electrosurgical Excision Procedure (LEEP), Cone

Biopsy, Cervical Conization These procedures are done
as a follow-up for an abnormal Pap smear and
colposcopy findings, to enhance accuracy of
colposcopy, and to investigate squamous
intraepithelial lesions (SILs). They are done to exclude
invasive cancer, determine extent of noninvasive
lesions, and treat (LEEP and cone biopsy) and remove
abnormal cervical dysplasia, based on lesion size,
distribution, and grade, when there is lack of
correlation between Pap smear, previous biopsy, and
colposcopy.
Reference Values
Normal
Normal cervix cells, w hich f lat t en as t hey grow
Procedure
1. Place t he pat ient 's f eet in st irrups and insert a speculum, as w it h a Pap t est
and colposcopy.
2. Apply a local anest het ic t o t he cervix and a mild vinegar (acet ic acid) or
iodine, depending on t he procedure t ype. For LEEP procedures, insert a f ine
w ire loop w it h a special high-f requency current t o remove a small piece of
cervical t issue.
3. Apply a past e t o t he cervix t o reduce bleeding. This may cause a dark
vaginal discharge. A laser or a cone biopsy may also be one of t he
procedures.
Clin ical Alert

Complicat ions may include heavy bleeding, severe cramping, inf ect ion, and
accident al cut t ing or burning of normal t issue. Cervical st enosis may be an
unt ow ard eff ect of t his procedure.
Clinical Implications Abnormal findings include

dysplasia and invasive cancer into deeper parts of the
cervix.
Interventions
1. Explain purpose and procedure and equipment used f or procedures. Tell
pat ient t hat t he most common sympt om of cervical cancer is abnormal
vaginal discharge or bleeding.
2. Provide support and t ake measures t o relieve f ear and anxiet y about
possible diagnosis of cervical cancer.
3. Ref er t o Chapt er 1 guidelines regarding saf e, eff ect ive, inf ormed pretest
care.

1. I nst ruct pat ient t o call physician if heavy or bright -red bleeding or clot s,
chills, aching, severe abdominal pain (not relieved by pain medicat ion), f oul-
smelling discharge, or unusual sw elling occurs.

2. Wat ery discharge and w hit e, dark, and light spot t ing may last approximat ely
4 w eeks. The heaviest discharge occurs about 1 w eek af t er t reat ment . Do
not use t ampons.
3. No douching or bubble bat hs. Delay sexual int ercourse f or approximat ely 4
w eeks. Check w it h physician.
4. Be sure t o st ress t he import ance of ret urning f or f ollow -up appoint ment t o
evaluat e sat isf act ory healing.
care.
Flexible Proctoscopy; Sigmoidoscopy;

Proctosigmoidoscopy These tests involve the
examination of the rectum, anal canal, and sigmoid
colon, up to 65 cm, with a proctosigmoidoscope. Rigid
scopes are not as commonly used since the advent of
flexible fiberoptic instruments, which are more
comfortable for patients. Their main use is for the
investigation of rectal bleeding, evaluation of colonic
symptoms, detection and diagnosis of cancers and
other abnormalities such as diverticula in this area of
the gastrointestinal tract. These examinations should
be routine (every 35 years) for cancer screening of
individuals >50 years of age. These tests can also
evaluate hemorrhoids, polyps, blood or mucus in the
stool, unexplained anemia, and other bowel conditions.
Sigmoidoscopy is used along with air-contrast barium
studies.
Reference Values
Normal
Normal anal, rect al, and sigmoid colon mucosa
Procedure
1. Have t he pat ient assume t he knee-t o-chest posit ion f or rigid proct oscopy
(insert ed 25 cm). When t he f lexible proct oscope is used, t he pat ient must be
in t he lef t lat eral posit ion. Caref ully insert t he proct oscope (insert ed 3560
cm) or sigmoidoscope int o t he rect um.
2. Remember t hat t he examinat ion can be done w it h t he pat ient in bed or
posit ioned on a special t ilt -t able.
3. I nf orm t he pat ient t hat he or she may f eel a very st rong urge t o def ecat e or
pass gas. The pat ient may also experience a f eeling of bloat ing or cramping,
w hich is normal.
Clinical Implications Examination may reveal the

follow ing: edematous, red, or denuded mucosa;
granularity; friability; ulcers; polyps; cysts; thickened
areas; changes in vascular pattern; pseudomembranes;
spontaneous bleeding; or normal mucosa. These
findings may help to confirm or to rule out the
1. I nf lammat ory bow el disease
a. Chronic ulcerat ive colit is
b. Crohn's disease
c. Proct it is (acut e and chronic)
d. Pseudomembranous colit is
e. Ant ibiot ic-associat ed colit is
2. Polyps
a. Adenomat ous
b. Familial
c. Diminut ive
3. Cancer and t umors
a. Adenocarcinoma
b. Carcinoids
c. O t her t umors such as lipomas

4. Anal and perianal condit ions
a. Hemorrhoids
b. Abscesses and f ist ulas
c. St rict ures and st enoses
d. Rect al prolapse
e. Fissures
f. Cont ract ures
Interventions
1. Explain t est purpose, procedure, and benef it s (w hen used w it h annual f ecal
occult blood t est ) and risks (a saf e procedure). Record pert inent
preprocedure signs and sympt oms (eg, rect al bleeding). O bt ain a signed,
w it nessed inf ormed consent , if required.
2. Be aw are t hat t here is no need f or t he pat ient t o f ast . How ever, a rest rict ed
diet such as clear liquids t he evening bef ore t he t est may be prescribed.
3. Remind pat ient t hat laxat ives and enemas may be t aken t he night bef ore t he
examinat ion. Enemas or a rect al laxat ive supposit ory may be administ ered
t he morning of t he procedure. For pat ient s of all ages, one or t w o phosphat e
(Fleet ) enemas are f requent ly ordered t o be perf ormed about 1 t o 2 hours
bef ore t he examinat ion. This is considered ample preparat ion by many
endoscopy depart ment s.
Clin ical Alert

1. Pat ient s w it h acut e sympt oms, part icularly t hose w it h suspect ed ulcerat ive
or granulomat ous colit is, should be examined wi thout any preparat ion (ie,
w it hout enemas, laxat ives, or supposit ories).
2. Perf orat ion of t he int est inal w all can be an inf requent complicat ion of
t hese t est s.
3. Not if y t he pat ient 's physician bef ore administ ering laxat ives or enemas t o
a pregnant w oman.
4. Not if y physician immediat ely of any inst ance of decreased blood pressure,
diaphoresis, or bradycardia.

1. I nt erpret t est out comes. Monit or and counsel appropriat ely about possible
f urt her t est ing (colonoscopy).
Colonoscopy
Colonoscopy visualizes, examines, and phot ographs t he large int est ine w it h a
f lexible f iberopt ic or video-colonoscope insert ed t hrough t he anus and advanced
t o t he ileocecal valve. Air int roduced t hrough an accessory channel of t he
colonoscope dist ends t he int est inal w alls t o enhance visualizat ion. Colonoscopy
can diff erent iat e inf lammat ory disease f rom neoplast ic disease and can evaluat e
polypoid lesions t hat are beyond t he reach of t he sigmoidoscope. Polyps, f oreign
bodies, and biopsy specimens can be removed via t he colonoscope. Phot ographs
of t he large int est ine lumen can also be t aken. Bef ore colonoscopy w as
available, major abdominal surgery w as t he only w ay t o remove polyps or
suspicious t issue t o det ermine malignancy or nonmalignancy. Periodic
colonoscopy is a valuable adjunct t o t he f ollow -up of persons w it h previous
polyps, colon cancer, f amily hist ory of colon cancer, or high risk f act ors. I t is
also helpf ul in locat ing t he source of low er gast roint est inal bleeding. I t provides
a saf e w ay t o perf orm presurgical screening and post surgical surveillance of
sut ure lines and anast omoses. Colonoscopy, along w it h st ool occult blood
t est ing, is recommended as t he primary diagnost ic t ool f or f irst -degree relat ives
in colon cancer f amilies.
Reference Values
Normal
Normal large int est ine mucosa
Procedure
1. Be aw are t hat a clear liquid diet is usually ordered f or 48 t o 72 hours bef ore
examinat ion. Have t he pat ient f ast f or 8 hours bef ore t he procedure.
Laxat ives may be ordered t o
be t aken f or 1 t o 3 days bef ore t he t est ; enemas may be ordered t o be given
t he night bef ore t he t est .

2. For an oral saline iso-osmot ic and isot onic laxat ive, have t he pat ient drink 3
t o 6 lit ers of t he prescribed solut ion over a 2- t o 3. 5-hour period. The t ypical
volume t aken is 1 gallon (~4 lit ers), and t his volume of f luid can be
administ ered by nasogast ric t ube if necessary. Expect init ial result s in 30
minut es t o 1 hour. I ngest ion of t he w ashout solut ion cont inues unt il f eces
expelled are not hing but clear liquid. Not if y t he physician bef ore
administ ering >6 lit ers of t his solut ion. Be aw are t hat pat ient s w it h
congest ive heart f ailure or renal f ailure may be at risk f or f luid volume
overload if t his preparat ion is used. See Pat ient Preparat ion f or ot her
preparat ion measures.
3. St art an int ravenous line and use f or administ rat ion of sedat ives and
narcot ics. These medicat ions are given t o achieve a st at e of conscious
sedat ion (see Appendix C). Ensure t hat t he pat ient is responsive enough t o
inf orm t he doct or of any subject ive react ions during t he examinat ion. Ensure
t hat resuscit at ion equipment is available.
5. Be aw are t hat , on occasion, int ravenous ant icholinergic agent s and glucagon
may be used t o relax bow el spasms.
6. Have t he pat ient assume t he lef t -sided or Sims' posit ion, and drape properly.
I nsert a w ell-lubricat ed colonoscope about 12 cm int o t he bow el. Ask t he
pat ient t o t ake deep breat hs t hrough t he mout h during t his t ime. I nt roduce air
int o t he bow el t hrough a special port on t he colonoscope t o aid view ing. As
t he colonoscope advances, t he pat ient may need t o be reposit ioned several
t imes t o aid in proper visualizat ion of t he colon. Sensat ions of pressure, mild
pain, or cramping are not unusual.
7. Remember t hat t he best view s are obt ained during w it hdraw al of t he
colonoscope. Theref ore, a more det ailed examinat ion is usually perf ormed
during w it hdraw al t han during advancement .
Clin ical Alert

A virt ual colonoscopy preceded by t radit ional bow el cleansing is a noninvasive
procedure (no sedat ion or analgesia is required f or virt ual colonoscopy) using
t he lat est CAT scan equipment t o rule out abnormalit ies. The same abnormal
condit ions can be ident if ied. How ever, t he t radit ional invasive procedure must
be repeat ed if t here are abnormal f indings and it is necessary t o remove
polyps and t ake biopsy specimens.
Clinical Implications Abnormal findings may reveal the

1. Polyps
2. Tumors (benign or malignant )
3. Areas of ulcerat ion
4. I nf lammat ion
5. Colit is, divert icula
6. Bleeding sit es
7. St rict ures
8. Discovery and removal of f oreign bodies
Clin ical Alert

To be eff ect ive, a purgat ive must produce f luid diarrhea. This show s t hat
unalt ered small int est inal cont ent s are emerging and colonic residue has been
cleared. Enemas must be repeat ed unt il solid mat t er is no longer expelled
(clear liquid ret urns). Soapsuds enemas are cont raindicat ed because t hey
cause increased mucus secret ion as a result of irrit ant st imulat ion.
1. Keep colon elect rolyt e lavage preparat ions ref rigerat ed; how ever, t he pat ient
may drink t he solut ion at room t emperat ure. Use w it hin 48 hours of
preparat ion, and discard unused port ions.
2. Bef ore t est ing, t he complet e blood count , prot hrombin t ime, plat elet count ,
and t hromboplast in t ime result s should be review ed and chart ed.
3. Preparat ion f or pat ient s w it h a colost omy or w ho are paralyzed is t he same
w het her or not t he pat ient is t aking aspirin or any blood t hinners.
4. Persons w it h know n heart disease may receive prophylact ic ant ibiot ics
bef ore t est ing.
5. Pat ient s should not mix or drink anyt hing w it h t he w ashout preparat ion. Do
not add ice or glucose t o t he solut ion.
6. Diabet ic persons are usually advised not t o t ake insulin bef ore t he procedure
but t o bring insulin w it h t hem t o t he clinic.
Interventions
1. Explain t he purpose, procedure, benef it s and risks of t he t est . Record
preprocedure signs and sympt oms (eg, G I bleeding). I f done as an
out pat ient procedure, t he pat ient should arrange f or a ride home and should
leave valuables at home. Blood w ork, urinalysis, x-ray f ilms, and scans
should be review ed and chart ed bef ore t he procedure. Record baseline vit al
signs.
2. When ordered, have t he pat ient t ake one 12-ounce glass of liquid
preparat ion every 10 minut es bef ore t he examinat ion. (Each gallon holds
10. 7 12-ounce [ 360 mL] glasses). The ent ire gallon should be t aken in 2
hours, if possible. Timing is import ant . Slow er drinking does not clean t he
colon properly. Some pat ient s w ill receive anot her t ype of preparat ion w hen
ordered (eg, Propulcid capsules and liquid Fleet laxat ives and enemas).
3. Remember t hat some pat ient s w ill be on a clear-liquid diet f or 72 hours
bef ore t he t est , t hen f ast ing, except f or medicat ions, af t er a clear-liquid
supper t he evening bef ore t he t est . No solid f ood, milk, or milk product s are
permit t ed. St rained f ruit juices w it hout pulp (eg, apple, w hit e grape),
lemonade, Hi-C drink, w at er, clear liquid, G at orade, Kool-Aid, Jell-O ,
Popsicles, and hard candy are permit t ed, but no red or purple f luids are
allow ed.
4. Administ er purgat ives and cleansing enemas as ordered. Preparat ion is
complet e w hen f ecal discharge is clear. I f ret urns are not clear af t er 4 lit ers
of solut ion have been ingest ed, cont inue unt il ret urns are clear, up t o 6 lit ers
t ot al (see previous not e under Procedure).
5. Be aw are t hat a legal consent f orm must be signed and properly w it nessed
(see Chap. 1) af t er pat ient has received proper inst ruct ion about t he t est .
6. Discont inue iron preparat ions 3 or 4 days bef ore examinat ion because iron
residues produce an inky, black, st icky st ool t hat int erf eres w it h
visualizat ion, and t he st ool can be viscous and diff icult t o clear. Aspirin and
aspirin-cont aining product s should also be discont inued 1 w eek bef ore t he
examinat ion because t hey may cause bleeding problems or localized
hemorrhages.
7. I nf orm t he pat ient t o expect t he f ollow ing:
a. The pat ient may f eel quit e sleepy during t he t est and may not recall
much of t he procedure.
b. The pat ient may experience abdominal pressure, mild pain, or cramping.
c. The pat ient may pass gas (expel f lat us) or have t he urge t o def ecat e,
w hich is normal.
d. The pat ient may be asked t o assume various posit ions t o aid w it h
passing t he colonoscope.
care.

1. The pat ient may have liquids or a light meal w hen f ully aw ake.
2. St ools should be observed f or visible blood. The pat ient should be inst ruct ed
t o report abdominal pain or ot her unusual sympt oms because perf orat ion and
hemorrhage are possible complicat ions.
3. Monit or t he blood pressure, pulse, respirat ions, and oxygen sat urat ion,
according t o inst it ut ional policy, unt il t he pat ient is f ully aw ake.
4. The most f requent adverse react ions t o oral purgat ives include nausea,
vomit ing, bloat ing, rect al irrit at ion, chills, and f eelings of w eakness.
5. The pat ient may expel large amount s of f lat us af t er t he procedure.
6. I nt erpret t est out comes and counsel appropriat ely. Monit or f or complicat ions.
Provide w rit t en discharge inst ruct ions t o out pat ient s. O ut pat ient s should be
discharged t o t he care of a responsible adult .
Clin ical Alert

1. Solid f ood should never be t aken w it hin 2 hours bef ore t he oral cleansing
regimen is begun.
2. O rally administ ered colon lavage is cont raindicat ed in t he f ollow ing
condit ions:
a. Act ual or suspect ed ulcers
b. G ast ric out let obst ruct ion
c. Weight < 20 kg
d. Toxic colit is
e. Megacolon
3. Relat ive cont raindicat ions f or colonoscopy include t he f ollow ing condit ions:
a. Perf orat ing disease of t he colon
b. Perit onit is
c.
d.
e.
f.
4.
5.
6.
7.
8.
Radiat ion ent erit is

Recent abdominal or bow el surgery
Acut e condit ions of t he anus and rect um
Serious cardiac or respirat ory problems (eg, recent myocardial
inf arct ion)
g. Sit uat ions in w hich t he bow el cannot be adequat ely prepared f or t he
procedure (ie, f ulminant granulomat ous or irradiat ion colit is)
O bserve f or t he f ollow ing possible complicat ions:
a. Perf orat ions of t he bow el
b. Hypot ensive episodes
c. Cardiac or respirat ory arrest , w hich can be provoked by t he
combinat ion of oversedat ion and int ense vagal st imulus f rom
inst rument at ion
d. Hemorrhage, especially if polypect omy has been perf ormed
e. Deat h (ext remely rare)
I f colon preparat ions are administ ered by lavage t o an unconscious pat ient
or t o a pat ient w it h impaired gag ref lexes, observe f or aspirat ion or
regurgit at ion, especially if a nasogast ric t ube is in place. Keep t he head of
t he bed elevat ed. I f t his is not possible, posit ion t he pat ient on his or her
side. Have cont inuous suct ion equipment and supplies readily available.
No barium st udies should be done during t he preparat ion phase f or
colonoscopy.
Signs of bow el perf orat ion include malaise, rect al bleeding, abdominal
pain, dist ent ion, and f ever.
Bloat ing, nausea, and occasional vomit ing af t er oral laxat ives is common.
Advise pat ient t o adhere t o inst ruct ions if at all possible.
Peritoneoscopy; Laparoscopy; Pelviscopy;

Fertiloscopy These examinations of the intraabdominal
and pelvic cavities are performed using a laparoscope
or pelviscope inserted through a slit in the anterior
abdominal wall. The pelvic organs, as well as
abdominal organs such as the greater curvature of the
stomach or the liver, can be viewed. The use of
laparoscopic intracorporeal ultrasound probe (LICU) in
the evaluation of GI malignancies is an important new
technology. The different types of examinations include

peritoneoscopy, laparoscopy (intraabdominal),
pelviscopy (gynecologic), and fertiloscopy
(gynecologic). These procedures are frequently
performed under general anesthesia in a surgical
setting; however, many are also done with local
anesthesia.
Perit oneoscopy is most commonly done t o evaluat e liver disease and t o obt ain
biopsy specimens w hen t he liver is t oo small, w hen previous liver biopsy proves
inadequat e, w hen cont raindicat ions t o percut aneous liver biopsy exist (eg,
ascit es), w hen t here is unexplained port al hypert ension or liver f unct ion
abnormalit ies, and w hen t he liver cannot be properly palpat ed f or a convent ional
liver biopsy. I t does aw ay w it h t he need f or a blind liver biopsy. O t her indicat ions
f or perit oneoscopy include unexplained ascit es, st aging of lymphomas, or st aging
and f ollow -up of ovarian cancer or abdominal masses. Somet imes pat ient s w it h
advanced chest , gast ric, pancreat ic, endomet rial, or rect al t umors are evaluat ed
by perit oneoscopy bef ore surgical int ervent ion is at t empt ed.
I ndicat ions f or laparoscopy include diagnosis and st aging of cancer, evaluat ing
cause of ascit es, and examinat ion of abdomen w it h ult rasound probes. Biopsies
of abdominal and lymph node masses and hepat ic lesions can also be done using
a core needle biopsy, w edge biopsy using elect rocaut ery, and cup f orceps
biopsy.
G ynecologic laparoscopy and pelviscopy are used t o diagnose cyst s, adhesions,
f ibroids, malignancies, inf lammat ory processes, or inf ect ions in persons w it h
pelvic and abdominal pain. Evaluat ion of t he f allopian t ubes can be done f or
inf ert ile pat ient s. These procedures also provide a means t o release adhesions,
t o obt ain biopsy specimens, t o do select operat ive procedures such as t ubal
ligat ions, or t o perf orm laser t reat ment s f or endomet riosis. G ynecologic
laparoscopy or pelviscopy is commonly perf ormed under general anest hesia as a
same-day surgical procedure.
These t echniques can f requent ly replace laparot omy. They are less st ressf ul t o
t he pat ient ; require only small incisions; can be done in short er periods of t ime;
can be done using local, spinal, or general anest het ics; reduce pot ent ial f or
f ormat ion of adhesions; and hast en healing and recovery t ime.
Pelviscopy diff ers f rom laparoscopy in t w o major respect sendocoagul ati on as
a met hod f or cont rolling bleeding and endol i gati on as a t echnique t hat permit s
sut uring using ext racorporeal (out side t he body) or int racorporeal (inside t he
body) ligat ing and sut uring met hods by means of special inst rument s.
The pelviscope is angled at 30 degrees f or bet t er visualizat ion. A videocamera
at t achment off ers t he physician a choice of view ing t he process on a
videoscreen inst ead of t hrough t he

scope. Print out s and videot apes of t he pelviscopy can be produced. Thus,
pelviscopy is bot h a diagnost ic and an operat ive modalit y.
Fert iloscopy, using a new inst rument called a f erti l oscope, is used t o examine
t he ent ire f emale reproduct ive syst em. I t is used t o diagnose inf ert ilit y and
replaces laparoscopic t est s done t o diagnose inf ert ilit y. Local anest het ics are
used. Fut ure applicat ions include t est ing t o rule out ovarian cancer, biopsy of t he
ovary, and drainage of cyst s.
Reference Values
Normal
G ynecologic examinat ion: normal size, shape, and appearance of ut erus,
f allopian t ubes, and ovaries.
I nt raabdominal examinat ion: normal liver, gallbladder, spleen, and great er
curvat ure of t he st omach
Procedure
1. Have t he pat ient lie supine during all procedures except gynecologic
laparoscopy, in w hich case t he pat ient is placed in a lit hot omy posit ion.
2. Cleanse t he skin and, if t he procedure is t o be perf ormed under local
anest hesia, inject a local anest het ic int o areas w here t he scope w ill be
int roduced. O t herw ise, prep t he pat ient as f or an abdominal procedure under
general anest hesia. Maint ain a st erile f ield.
3. Place an int ravenous line so t hat medicat ions may be given int ravenously as
needed.
4. Place an indw elling cat het er int o t he bladder t o reduce t he risk f or bladder
perf orat ion.
5. Make a small incision near t he umbilicus t hrough w hich a t rocar is
int roduced, f ollow ed by passage of t he pelviscope or laparoscope.
Somet imes, more t han one punct ure sit e w ill be made so t hat accessory
inst rument s can be used during t he procedure. Carbon dioxide int roduced
int o t he perit oneal cavit y causes t he oment um t o rise aw ay f rom t he organs
and allow s f or bet t er visualizat ion. A f ew st it ches or St eri-St rips are usually
needed t o close t he incisions. Apply adhesive bandages as dressings.
Clinical Implications Abnormal findings can reveal the

1. Endomet riosis
2. O varian cyst s
3. Pelvic inf lammat ory disease
4. Met ast asis st age of cancer
5. Ut erine f ibroids
6. Abscesses
7. Tumors (benign and malignant )
8. Enlarged f allopian t ubes (hydrosalpinx)
9. Ect opic pregnancy
10. I nf ect ion
11. Adhesions or scar t issue
12. Ascit es
13. Cirrhosis
14. Liver nodules (of t en an indicat ion of cancer)
15. Engorged perit oneal vasculat ure (correlat es w it h port al hypert ension)
Clin ical Alert

1. These procedures may be cont raindicat ed in persons know n t o have t he
a. Advanced abdominal w all cancer
b. Severe respirat ory or cardiovascular disease
c. I nt est inal obst ruct ion, dilat ed bow el loops
d. Palpable abdominal mass
e. Large abdominal hernia
f. Chronic t uberculosis
g. Hist ory of perit onit is
h. Noncorrect able coagulat ion disorders
2. Possible complicat ions include t he f ollow ing:
a. Bleeding f rom t he punct ure injury or f rom liver biopsy
b. Misplacement of gas
c. Thermal burns
3. The endoscopy should be abort ed in f avor of a laparot omy in t he event of
uncont rolled bleeding or suspect ed malignancy.
Interventions
1. Complet e laborat ory t est s and ot her appropriat e diagnost ic modalit ies
bef ore t hese endoscopies.
2. Remember t hat bow el preparat ion may include an enema or supposit ory.
3. Explain t he t est purpose and procedure and t he t ype of anest hesia chosen
(general, spinal, or local) as w ell as post operat ive expect at ions such as
act ivit y, deep breat hing, and shoulder pain.
4. Ensure t hat a legal permit is properly signed and w it nessed (see Chap. 1).
5. Maint ain sensit ivit y t o cult ural, sexual, and modest y issues as an import ant
part of psychological support .
care.

1. Check blood pressure f requent ly according t o inst it ut ional policies.
2. O bserve f or inf ect ion, hemorrhage, and bow el or bladder perf orat ion.
3. Advise t he pat ient t hat shoulder and abdominal discomf ort may be present
f or 1 t o 2 days because of residual carbon dioxide gas in t he abdominal
cavit y. This can be cont rolled w it h mild oral analgesics. Sit t ing or rest ing in a
semi-Fow ler's posit ion can also alleviat e discomf ort .
4. I f t he pat ient has had a general or spinal anest het ic, f ollow t he usual
caut ions and prot ocols f or t he care of any person having undergone t hose
t ypes of anest hesia.
Cystoscopy (Cystourethroscopy) Cystoscopy and

cystourethroscopy are used to diagnose and treat
disorders of the lower urinary tract. They provide views
of the interior bladder, urethra, male prostatic urethra,
and ureteral orifices by means of tubular, lighted,
telescopic lens instruments called cystoscopes or
cystourethroscopes. These scopes come in many sizes
and variations as well as in flexible fiberoptic
instruments. Urethroscopy is an important part of this
examination because it allows visualization of the male
prostate gland.
Cyst oscopy is t he most common of all urologic diagnost ic procedures. I t may be
indicat ed in t he f ollow ing condit ions:
1. Unexplained hemat uria (gross or microscopic)
2. Recurrent or chronic urinary t ract inf ect ion
3. I nf ect ion resist ant t o medical t reat ment
4. Unexplained urinary sympt oms such as dysuria, f requency, urgency,
hesit ancy, int ermit t ency, st raining, incont inence, enuresis, or ret ent ion
5. Bladder t umors (benign and malignant )
6. Pediat ric considerat ions include t he above and t he f ollow ing:
a. Post erior uret hral valves, uret eroceles in f emales, and ot her congenit al
anomalies
b. Complet e w orkup of children w it h dayt ime incont inence usually done in
conjunct ion w it h urodynamic st udies
c. Removal of f oreign object s and st ent s placed in previous surgeries
Because int ravenous pyelogram (I VP) does not allow proper visualizat ion of t he
area f rom t he neck of t he bladder t o t he end of t he uret hra, cyst oscopy makes it
possible t o diagnose and t o t reat abnormalit ies in t his area.
Cyst oscopy may be used t o perf orm meat ot omy and t o crush and ret rieve small
st ones and ot her f oreign bodies f rom t he uret hra, uret er, and bladder. Biopsy
specimens can be obt ained. Bladder t umors can be f ulgurat ed, and st rict ures
can be dilat ed t hrough t he cyst oscope. I n conjunct ion w it h cyst oscopy,
uret eroscopy can be done t o det ermine t he cause of hemat uria, t o det ect t umors
and st ones, and t o manipulat e st ones.
Reference Values
Normal
Normal st ruct ure and f unct ion of t he int erior bladder, uret hra, uret eral orif ices,
and male prost at ic uret hra
Procedure
1. The examinat ion can be perf ormed in a special operat ing room designed f or
t hat purpose in a clinic or in t he urologist 's off ice. The pat ient 's age, st at e of
healt h, and ext ent of surgical procedure necessary det ermine t he set t ing.
Pediat ric cyst oscopy is done in t he operat ing room under general
anest hesia.
2. The ext ernal genit alia are prepped w it h an ant isept ic solut ion such as
povidone-iodine af t er t he pat ient is properly grounded, padded, and draped.
3. Local anest het ic jelly is inst illed int o t he uret hra. For males, t he anest het ic is
ret ained in t he uret hra by a clamp applied near t he end of t he penis. For
best result s, t he local anest het ic should be administ ered 5 t o 10 minut es
bef ore passage of t he cyst oscope.
4. The scope is connect ed t o an irrigat ion syst em, and f luid is inf used int o t he
bladder t hroughout t he procedure. Solut ions used are nonconduct ive and
ret ain clarit y during t he procedure (eg, glycine, st erile w at er). The solut ion
also dist ends t he bladder t o allow bet t er visualizat ion. The inf usion is
st opped and t he bladder drained w hen it becomes f illed w it h 300 t o 500 mL
of f luid.
5. Should blood or ot her mat t er be present in t he bladder, t he f iberopt ic
cyst oscope w ill not provide as clear a view as a rigid cyst oscope because it
is more diff icult t o f lush.
6. I nst it ut ional policies dict at e general perioperat ive care and procedures.
Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, inf ormed i ntratest
care.
Clin ical Alert

During t ransuret hral resect ion procedures, venous sinuses may be opened,
and irrigat ion f luid may ent er t he circulat ory syst em, causing w at er
int oxicat ion. Theref ore, isot onic solut ions such as sorbit ol, mannit ol, or glycine
must be used.
Clinical Implications Abnormal conditions revealed by

cystoscopy include the follow ing:
1. Prost at ic hyperplasia or hypert rophy
2. Cancer of t he bladder
3. Bladder st ones
4. Uret hral st rict ures or abnormalit ies
5. Prost at it is
6. Uret eral ref lux (show n on cyst ogram)
7. Vesicle neck st enosis
8. Urinary f ist ulas
9. Uret erocele
10. Divert icula
11. Abnormally small or large bladder capacit y
12. Polyps
Interventions
1. Explain t he purpose and procedure of t he t est . Special sensit ivit y t o concern
f or cult ural, social, sexual, and modest y issues are an import ant part of
psychological support . Emphasize t hat t here is lit t le pain or discomf ort f rom
cyst oscopy; how ever, a st rong desire t o void may be experienced.
2. Facilit at e bow el preparat ion and ot her laborat ory and diagnost ic t est s if
ext ensive procedures are planned.
3. Remember t hat if cyst oscopy is perf ormed in t he hospit al, a properly signed
and w it nessed surgical permit must be obt ained (see Chap. 1).
4. Allow t he pat ient t o t ake a f ull liquid breakf ast at t imes. Liquids may be
encouraged unt il t he t ime of t he examinat ion t o promot e urine f ormat ion if t he
procedure is a simple cyst oscopy done under local anest hesia. Fast ing
guidelines are f ollow ed w hen spinal or general anest hesia is planned.
5. St art an int ravenous line f or t he administ rat ion of drugs t o achieve a st at e of
conscious sedat ion. Medicat ions such as diazepam (Valium) or midazolam
(Versed) are used t o relax t he pat ient . Amnesia may be a side eff ect .
Younger men may experience more pain and discomf ort t han older men.
Women usually require less sedat ion because t he f emale uret hra is short er.
The pat ient should be inst ruct ed t o relax t he abdominal muscles t o lessen
discomf ort . See Appendix C regarding sedat ion and analgesia precaut ions.
care.

1. Af t er cyst oscopy, voiding pat t erns and bladder empt ying should be
monit ored. Check vit al signs as necessary.
2. The int ake of f luids should be encouraged.
3. Clot s may f orm and may cause diff icult y in voiding.
4. Report unusual bleeding or diff icult urinat ion t o t he physician prompt ly.
5. Urinary f requency, dysuria, pink t o light -red urine, uret hral burning, and
post t est bladder spasms are common af t er cyst oscopy.
6. Ant ibiot ics may be prescribed bef ore and af t er cyst oscopy t o prevent
inf ect ion. Rect al opium supposit ories may also be administ ered.
7. The pot ent ial f or gram-negat ive shock is alw ays present w it h urologic
procedures because t he uret hra is such a vascular organ t hat any break in
t he t issues can allow bact eria t o ent er t he bloodst ream direct ly. O nset of
sympt oms can be rapid and may act ually begin during t he procedure if it is
f airly lengt hy. O bserve f or and promptl y report chills, f ever, increasing
t achycardia, hypot ension, and back pain t o t he physician. Blood cult ures are
usually ordered, f ollow ed by an aggressive regimen of ant ibiot ic t herapy.
8. Uret eral cat het ers may be lef t in place t o f acilit at e urinary drainage,
especially if t here is concern about edema.
9. Rout ine cat het er care is necessary f or ret ent ion of uret hral cat het ers. Follow
inst it ut ional prot ocols. The pat ient may need inst ruct ions if discharged w it h
cat het er in place.
Clin ical Alert

1. I f uret hral dilat at ion has been part of t he procedure, t he pat ient is advised
t o rest and t o increase f luid int ake.
2. Monit or pat ient 's voiding pat t erns and bladder empt ying (or inst ruct t o
self -monit or).
3. Evaluat e and inst ruct t he pat ient t o w at ch f or edema. Edema may cause
urinary ret ent ion, hesit ancy, w eak urinary st ream, or urinary dribbling any
t ime w it hin several days af t er t he procedure. Warm sit z bat hs and mild
analgesics may be helpf ul; how ever, an indw elling cat het er may somet imes
be necessary f or relief .
URODYNAM IC STUDIES
Cystometrogram (CMG); Urethral Pressure Profile
(UPP); Rectal Electromyogram (EMG);
Cystourethrogram These tests evaluate bladder,
urethral, and sphincter function, identify abnormal
voiding patterns, check status of neuroanatomic
connectives between brain, spinal cord, and bladder,
and consist of two main components: the
cystometrogram (CMG) and the sphincter
electromyogram (EMG). The combined measurement of
the CMG and the EMG provides information about how
the bladder adapts to being filled as well as how it
reacts to the filling itself. These studies are indicated
in an incontinent person and when there is evidence of
neurologic disease (neurogenic bladder), spinal cord
injury, dysuria, enuresis, infection, or specific
neuropathies such as those found in multiple sclerosis,
diabetes, and tabes dorsalis.
Reference Values
Normal
Normal bladder sensat ions of f ullness, heat , and cold Adul t: Normal bladder
capacit y of 400 t o 500 mL, residual urine less t han 30 mL, desire t o void is at
175 t o 250 mL; sensat ion of f ullness f elt at 350 t o 450 mL; st ream is st rong and
unint errupt ed.
Normal voiding pressures and muscle coordinat ion
Normal rect al EMG readings; uret hral pressure prof ile readings normal Pedi atri c:
Bladder capacit y varies w it h age. Compliant bladder: st ret ches t o capacit y
w it hout pressure increase. Bladder st abilit y: no involunt ary cont ract ions
Procedures
1. Cyst omet rogram (CMG )
a. Have t he pat ient void and record urine f low rat e, voiding pressure, and
residual amount of urine voided.
b. I nsert a nonlat ex double-lumen cat het er int o t he bladder. Place adhesive
pat ch elect rodes parallel on each side of t he anus. Measure residual
urine. Connect t he cat het er t o t he cyst omet er. (A cyst omet er evaluat es
t he neuromuscular mechanism of t he bladder by measuring bladder
capacit y and pressure. ) The bladder is gradually f illed w it h st erile saline
or st erile w at er or carbon dioxide gas in predet ermined increment s, and
pressure readings are t aken at t hese increment s. Wat er or saline off ers
a more physiologic result and is less irrit at ing.
c. Make observat ions during t he CMG about t he pat ient 's percept ion of
heat and cold, bladder f ullness, urge t o void, and abilit y t o inhibit voiding
w hen bladder cont ract ions occur.
d. Remove t he cat het er and pat ch elect rodes w hen t he bladder is
complet ely empt ied of f luid.
e. I nject cholinergic and/ or ant icholinergic drugs (eg, met hant heline bromide
[ Bant hine, at ropine] or bet hanechol chloride [ Urecholine] ) t o det ermine
t heir eff ect s on bladder f unct ion (af t er CMG procedure).
f. Perf orm t he cyst omet ric st udy as a cont rol, f ollow ed by repeat st udy 20
t o 30 minut es af t er inject ion of t he drugs.
g. Be aw are t hat a change in post ure f rom supine t o st anding or w alking
may be required during t he examinat ion.
h. Remember t hat sleep st udies may be perf ormed in conjunct ion w it h an
elect roencephalogram (EEG ) t o evaluat e persons having noct urnal
incont inence (see Chap. 16 f or EEG st udy).
i. Pediat ric CMG s: The bladder is f illed unt il t he pressures reach 40 t o 60
cm of w at er, t he child voids around t he cat het er, or t he child seems very
uncomf ort able. I n older children, ask quest ions about bladder f ullness,
w hen t hey w ould normally void, and ask t hem t o hold urine unt il ext reme
urgency ensues. Pat ient s may void on t he t able w it h t he cat het er in
place, or t hey may void in a special cont ainer t hat measures urine f low,
voiding pressure, and lengt h of t ime t o void. These pressures are
depict ed on a graph.
2. Rect al elect romyogram (EMG )monit ors t he pelvic f loor muscles
responsible f or holding urine in t he bladder.
a. Apply elect rodes next t o t he anus, and at t ach a ground t o t he t high, or
int roduce a needle elect rode int o t he periuret hral st riat ed muscle. These
elect rodes record elect romyographic act ivit y during voiding and produce
a simult aneous recording of urine f low rat e. (See Chap. 16 f or EMG
st udy. )
b. Pediat ric rect al EMG : Pat ch elect rodes record t he coordinat ion of t he
ext ernal sphinct er and t he pelvic f loor muscle response t o f illing and t he
abilit y t o inhibit bladder cont ract ions. I f t he child voids on t he t able, t he
sphinct er relaxes during voiding (w hich is normal).
3. Uret hral pressure prof ile (UPP)
a. Use a specially designed cat het er, coupled t o a t ransducer, t o record
pressures along t he uret hra as it is slow ly w it hdraw n.
b. Pediat ric UPP: This prof ile assesses t he f unct ional uret hral lengt h as
w ell as general compet ency of t he uret hra and sphinct er. The same
double-lumen cat het er is used, w hich has premarked lines on it f or bot h
t he CMG and t he UPP. Slow ly w it hdraw t he cat het er, and not e t he
pressures at t he premarked spot s.
4. Cyst ouret hrogramevaluat es bladder w all and uret hral abnormalit ies and
t umors. I t can be used t o assess ref lux and st ress incont inence in w omen
and t o ident if y post t raumat ic urine ext ravasat ion.
a. I nst ill an x-ray cont rast medium int o t he bladder t hrough a cat het er unt il
t he bladder f ills. Clamp t he cat het er and t ake x-rays w it h t he pat ient
assuming several diff erent posit ions.
b. Remove t he cat het er and t ake more x-rays as t he pat ient voids and t he
cont rast mat erial passes t hrough t he uret hra (voiding cyst ouret hrogram).
c. Pediat ric cyst ouret hrogram: Rarely are voiding cyst ouret hrograms
(VCUG s) done at t he same t ime as EMG s. VCUG s are done in children
t o assess vesicle uret hral ref lux, t o ident if y st ruct ural abnormalit ies, and
t o evaluat e f or voiding dysf unct ion; and t hey are usually done as part of
t he w orkup bef ore considering EMG .
5. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed i ntratest care f or all
procedures.
Clin ical Alert

I n children, t he bladder is f illed at 10% of w hat t he bladder is expect ed t o
hold at a specif ic age (ex: age capacit y [ in ounces] plus 2 ounces).
Clinical Implications Abnormal results reveal motor and

sensory defects, altered pressures and/or bladder
capacity, and inappropriate or absent contractions of
the pelvic floor muscles and internal sphincter during
voiding.
1. Bladder noncompliance: During f illing, t he bladder is st iff , does not st ret ch

as expect ed, and can possibly compromise kidney f unct ion over t ime. A
large-capacit y low -pressure bladder (high compliance) may indicat e chronic
overdist ent ion f rom inf requent voiding habit s or dist urbed muscle
coordinat ion.
2. Bladder inst abilit y (hyperref lexia): During f illing, t he bladder cont ract s
involunt arily; t his occurs w hen t he pressures go up and dow n in a w avelike
pat t ern during f illing due t o overact ivit y of involunt ary cont ract ions. The
unst able bladder may be asympt omat ic; many t imes no cont ract ions are f elt ,
but commonly pat ient s have f requency, urgency, and incont inence.
3. The most common cause of incont inence is a vesicle-sphinct er dyssynergia
(dist urbance of muscular coordinat ion). This dyssynergia is t hought t o be
responsible f or incomplet e empt ying of t he bladder, inappropriat e voiding,
perineal dampness, and predisposit ion t o urinary t ract inf ect ions.
4. Det rusor hyperref lexia: The pat ient cannot suppress voiding on command
ow ing t o upper or low er mot or neuron lesions, as in cerebrovascular
aneurysm, Parkinson's disease, mult iple sclerosis, cervical spondylosis, and
spinal cord injury above t he conus medullaris.
5. Det rusor aref lexia occurs w hen t he det rusor ref lex cannot be evoked
because t he peripheral innervat ion of t he det rusor muscle has been
int errupt ed, result ing in diff icult y in init iat ing voiding w it hout a residual
volume being present in t he bladder. The cause may be associat ed w it h
t rauma, spinal arachnoidit is, spinal cord birt h def ect s, diabet ic neuropat hy,
or ant icholinergic eff ect s of phenot hiazides. I n post menopausal w omen, t he
uret hral pressure prof ile may be alt ered because t he mucosal sphinct er is
deprived of est rogen.
6. Uret hrovesical hyperref lexia is caused by benign prost at ic hypert rophy and
st ress urge incont inence.
Interfering Factors Disorientation or inability of the

patient to cooperate affects the test results.
Interventions
1. Explain t he purpose and procedure of t he bladder f unct ion t est , of t en done
bef ore and af t er cert ain t ypes of spinal surgery. Be sensit ive t o t he pat ient 's
pot ent ial anxiet y and embarrassment . Record signs and sympt oms of
incont inence and voiding problems.
2. Ensure t hat t he pat ient is relaxed and cooperat ive f or accurat e result s. For
children, a f avorit e t oy or book may provide securit y. Sedat ion is not given
because pat ient part icipat ion is necessary t o verif y sensat ions and
percept ions. How ever, t he pat ient must avoid movement during t he
examinat ion unless inst ruct ed ot herw ise.
3. Allow t he t est and f illing of t he bladder t o cont inue unt il t he pat ient eit her
leaks or voids around t he cat het er.

1. Encourage t he pat ient t o increase oral f luid int ake t o dilut e t he urine and t o
minimize bladder sensit ivit y.
2. Explain t hat some minor discomf ort or burning may be not ed, especially if
carbon dioxide is used, but it w ill lessen and disappear w it h t ime.
3. I nt erpret t est out comes and counsel appropriat ely (bladder capacit y varies
w it h age). Explain possible t reat ment s (medicat ion).
Clin ical Alert

1. Cert ain pat ient s w it h cervical cord lesions may exhibit an aut onomic ref lex
t hat produces an elevat ed blood pressure, severe headache, low er pulse
rat e, f lushing, and diaphoresis. Propant heline bromide (Pro-Bant hine)
alleviat es t hese sympt oms.
2. Caref ul use of st erile t echnique reduces t he incidence of urinary t ract
inf ect ions. Preprocedural urinary t ract inf ect ions can lead t o sepsis as a
result of bact erial spread int o t he bloodst ream.
Arthroscopy
Art hroscopy is t he direct visual examinat ion of t he int erior of a joint by means of
a specially designed f iberopt ic endoscope and is f requent ly associat ed w it h a
surgical procedure. I t is most commonly done f or t he diagnosis of at hlet ic
injuries (meniscus, pat ella, condyle, ext rasynovial area, and synovium) and f or
t he diff erent ial diagnosis of acut e or chronic joint disorders. For example,
degenerat ive processes can be accurat ely diff erent iat ed f rom injuries.
Post operat ive rehabilit at ion programs can be init iat ed t o short en recovery
periods. Art hroscopy can also assess response t o t reat ment or ident if y w het her
ot her correct ive procedures are indicat ed.
Alt hough t he knee is t he joint most f requent ly examined, t he shoulder, ankle, hip,
elbow, w rist , and met acarpophalangeal joint s can also be explored. Calcium
deposit s, biopsy specimens, loose bodies, bone spurs, t orn meniscus or
cart ilage, and scar t issue can be removed during t he procedure. Current ly, many
of t hese procedures are perf ormed in an ambulat ory surgical set t ing.
Clin ical Alert

Art hroscopy is an inst rument and equipment -dependent procedure (Phippen &
Mells, 2000) (eg, video and irrigat ion f ailure, scrat ches on lens).
Reference Values
Normal
Normal joint : normal vasculat ure and color of t he synovium, capsule, menisci,
ligament s, and art icular cart ilage
Procedure
1. Be aw are t hat t he examinat ion is usually perf ormed under general or spinal
anest hesia f or t he f ollow ing reasons:
a. The joint is very painf ul.
b. Def init ive t reat ment or surgical int ervent ion can be done at t he same t ime
if w it hin t he realm of art hroscopic surgery.
c. An inf lat ed t ourniquet may be used during part of t he procedure t o
minimize bleeding at t he sit e.
d. Complet e muscle relaxat ion permit s a t horough examinat ion and
eliminat es t he risk of inadvert ent pat ient movement w hile t he art hroscope
is in t he joint .
2. St art an int ravenous line. Drape and prep t he surgical sit e according t o
inst it ut ional prot ocols. At t ach proper monit oring equipment t o t he pat ient .
3. Apply a t ourniquet t o t he appropriat e area (by use of an elast ic bandage or
elevat ion), t hen insert an art hroscope int o t he joint t hrough a small insert ion.
Some surgeons choose not t o inf lat e t he t ourniquet unless bleeding cannot
be cont rolled by irrigat ion.
4. Aspirat e t he joint , t hen perf orm cont inuous irrigat ion and f lushing t hroughout
t he procedure.
5. Collect joint w ashings and examine f or loose bodies or cart ilage f ragment s.
6. Examine all part s of t he joint caref ully. Take phot ographs or videot apes of
t he procedure. The physician may choose t o perf orm surgical int ervent ions
f or problems t hat can be correct ed via art hroscopy.
7. As you w it hdraw t he art hroscope, accessory pieces, and irrigat ing needles
slow ly, compress t he joint t o squeeze out excess irrigat ion f luid.
8. I nject st eroids or local anest het ics int o t he joint f or post operat ive pain
cont rol and reduct ion of inf lammat ion. Close t he w ounds w it h sut ures or
adhesive st rips, and apply small dressings t o t he w ound or w ounds (eg, t w o
t o t hree small incisions f or t he knee joint ). Apply compressive dressings and
splint s or immobilizers.
Clinical Implications Abnormal results reveal the

1. Torn or displaced meniscus or cart ilage (sympt oms relat e t o clicking,
locking, and/ or sw elling of t he joint )
2. Trapped synovium
3. Loose f ragment s of joint cont ent s
4. Torn or rupt ured ligament s
5. Necrosis
6. Nerve ent rapment
7. Fract ures or nonunion of f ract ures
8. G anglions
9. I nf ect ions
10. Degenerat ive disease. O st eochondrit is dissecans: inf lammat ion of bone or
cart ilage occurs w hen a cart ilage f ragment and underlying bone det ach f rom
t he art icular surf ace (common in t he knee)
11. Chronic inf lammat ory art hrit is
12. Secondary ost eoart hrit is caused by injury, met abolic disorders, and w earing
aw ay of w eight -bearing joint s
13. Chondromalacia of f emoral condyle (w earing dow n of back of kneecap, of t en
producing a grinding sensat ion)
Interfering Factors Ankylosis, fibrosis, sepsis, or

presence of contrast agent from previous arthrogram
may affect results.
Interventions
1. Make sure t he hist ory and physical examinat ion, requisit e laborat ory w ork, xray f ilms, and ot her preoperat ive requirement s are complet ed, review ed, and
document ed on t he pat ient 's record.
2. Explain t he purpose and procedure of t he t est . The pat ient should f ast f rom
midnight bef ore t he examinat ion unless ot herw ise ordered (eg, if scheduled
lat e in t he day, a liquid breakf ast may be permit t ed).
3. Be aw are t hat a properly signed and w it nessed permit must be complet ed
(see Chap. 1).
4. Check peripheral pulses in t he operat ive area. The surgical sit e is prepped,
posit ioned, and draped according t o inst it ut ional prot ocols. An int ravenous
line is st art ed.
5. Teach crut ch-w alking bef ore t he procedure if it s necessit y is ant icipat ed
post operat ively.
6. Follow Chapt er 1 guidelines regarding saf e, eff ect ive, inf ormed pretest care .

1. Assess vit al signs, bleeding, neurologic st at us, and circulat ory st at us of t he
aff ect ed ext remit y (eg, color, pulse, t emperat ure, capillary ref ill t imes,
sensat ion, and mot ion).
2. Apply ice immediat ely and, if ordered, elevat e t he ext remit y t o minimize
sw elling and pain. Dressing changes and sut ure removal are perf ormed at
t he physician's discret ion. The dressing must be kept clean and dry. Not if y
t he physician of unusual bleeding or sw elling.
3. Administ er appropriat e pain medicat ion.
4. Remember t hat t he pat ient can usually be ambulat ory af t er recovery f rom t he
anest het ic. Crut ches may be used. Degree of w eight -bearing and joint mot ion
is at t he discret ion of t he physician; how ever, pat ient should be caut ioned t o
avoid excessive joint use f or at least 24 t o 48 hours.
5. Exercise and physical t herapy may be ordered post operat ively. These are
designed t o st rengt hen and maximize use of t he joint .

6. Make arrangement s f or t ransport at ion by anot her person preoperat ively if
t he pat ient is discharged t he same day as t he procedure. The pat ient should
not drive f or at least 24 hours.
7. Advise t he pat ient t o consume no alcohol f or 24 hours af t er t he procedure.
Progress diet f rom f luid t o solid f oods as t olerat ed.
8. I nst ruct t he pat ient t o report f ever, alt ered sensat ion, numbness, t ingling,
coldness, duskiness (ie, bluish color), sw elling, bleeding, or abnormal pain t o
t he physician immediat ely. Mild soreness and a mild grinding sensat ion f or a
f ew days are normal.
Clin ical Alert

1. Art hroscopy is usually cont raindicat ed if ankylosis or f ibrosis is present
because it is very diff icult t o maneuver t he examining inst rument in t his
t ype of joint .
2. For knee art hroscopy, t he post erior approach is not used because of t he
neurovascular st ruct ures present in t hat area.
3. Do not place pillow s under t he knee; f lexion cont ract ures can occur as a
result . I f t he pat ient 's leg is ordered t o be elevat ed, make sure t he ent ire
leg is elevat ed in a st raight posit ion. The knee is not f lexed because a
f lexion cont ract ure may result . Pad pressure point s such as t he heel.
4. I f t here is risk f or sepsis or if sepsis is present in any part of t he body,
t he procedure should not be done.
5. Art hroscopy is usually not done < 7 t o 10 days af t er art hrography because
chemical synovit is caused by a cont rast medium can adversely aff ect t he
visual examinat ion. How ever, it may be necessary t o perf orm art hroscopy
if t he pat ient is experiencing severe pain. I n t his case, t he joint must be
t horoughly irrigat ed t o remove cont rast medium.
6. Be alert f or signs of t hrombophlebit is post operat ively. I nst ruct pat ient t o
w at ch f or calf t enderness, pain, and heat and t o report t hese sympt oms t o
t he physician immediat ely. Warn the pati ent not to massage the af f ected
area.
7. O t her complicat ions may include hemart hrosis, adhesions, neurovascular
injury, pulmonary embolus, eff usion, scarring, and compart ment al
syndrome as a result of sw elling. Compart ment al syndrome is a
musculoskelet al complicat ion t hat occurs most commonly in t he f orearm or
leg. The compart ment of f ascia surrounding muscles does not expand
w hen bleeding or edema occurs. Consequent ly, t he neurovascular st at us
of t he ext remit y may be severely compromised. This present s an
emergency sit uat ion t hat usually requires surgical int ervent ion t o release
pressure. Assess t he neurovascular st at us of an aff ect ed ext remit y
f requent ly f or 24 hours af t er t he procedure.
Sinus Endoscopy
Sinus endoscopy visualizes t he ant erior et hmoid, middle t urbinat e region, and
middle meat us sinus areas. Alt hough t he purposes of sinus endoscopy are
primarily t o relieve inf ect ion and ot her sympt oms of inf lammat ion and t o alt er
st ruct ural abnormalit ies in t hese areas, it can also be a valuable diagnost ic t ool.
Ret ained secret ions may cont ribut e t o chronic recurrent sinus inf ect ions, w hich
may lead t o syst emic inf ect ions, cyst f ormat ion, or mucoceles t hat can erode
sinus w alls int o areas of t he eyeball, eye orbit , or brain.
Pat ient s having recurrent episodes of acut e or chronic sinusit is t hat are not
responsive t o ant ibiot ic and/ or allergy t herapy are candidat es f or sinus
endoscopy as bot h a diagnost ic and t herapeut ic modalit y.
Reference Values
Normal
Normal sinuses or resolut ion of sinus disease
Procedure
Sinus endoscopy may be perf ormed as an out pat ient or off ice procedure.
Normally, t he diagnost ic procedure is perf ormed in t he off ice. More ext ensive
examinat ion and operat ive procedures normally require out pat ient admission t o a
healt h care f acilit y or special diagnost ic cent er.
1. Spray a cocaine solut ion of select concent rat ion int o t he nares t o produce
local anest hesia. I nt roduce t he endoscope t o permit visualizat ion of t he nasal
int erior; t he sinus cavit ies are not opened. Some pat ient s become very
t alkat ive and euphoric as a response t o cocaine.
2. Be aw are t hat sinus comput ed axial t omography (CT, CAT) scans and
magnet ic resonance imaging (MRI ) may be necessary adjunct s t o t his
procedure t o permit visualizat ion of areas not accessible t hrough endoscopy.
3. Perf orm t reat ment f or underlying disease or malf ormat ions using local or
general anest hesia and medicat ions t o achieve st at e of conscious sedat ion.
Diagnost ic and surgical t echniques vary according t o preoperat ive f indings.

4. Remember t hat endoscopes using a f iberopt ic light delivery syst em are t he
mainst ay of visualizat ion f or diagnosis and last t reat ment .
Clinical Implications Abnormalities that may be

revealed include the follow ing conditions:
1. Chronic sinusit is (edemat ous or polypoid mucosa)
2. Cyst s
3. Mucocele
4. Sinus erosion
5. Anat omic def ormit ies or obst ruct ions
6. Pat hologic sinus discharge (inf ect ious process)
7. Enlarged middle t urbinat es
Interventions
1. Explain t est purpose, benef it s, risks, and procedure. (St eps 2 t hrough 6
ref er t o t reat ment modalit ies. ) The procedure may t ake place in t he off ice or
out pat ient hospit al set t ing.
2. Review and document in t he healt h care record a properly signed and
w it nessed surgical consent f orm (see Chap. 1), appropriat e laborat ory and
diagnost ic t est result s, hist ory and physical examinat ion, current drug
t herapies, and allergies bef ore t he procedure.
3. Preprocedure preparat ion may require t he pat ient t o:
a. Be processed t hrough preadmission t est ing if procedure w ill be done in a
hospit al surgical set t ing
b. Fast f rom midnight t he day of t he procedure
c. Remove f acial prost heses, dent ures, hairpieces, and jew elry bef ore t he
procedure
d. Have an int ravenous line placed
e. Arrange t ransport at ion home w hen discharged
4. Have t he pat ient assume a supine posit ion in t he surgical suit e. Prep t he
f ace and t hroat according t o est ablished prot ocols, and properly drape t he
area. Tape eye pads in place t o prot ect t he eyes f rom injury. Perf orm ot her
posit ioning and pressure-point padding as necessary.
5. Administ er int ravenous sedat ion as needed. Spray t he nose w it h a t opical
anest het ic, and inject a small amount of 1% lidocaine w it h 1: 200, 000
aqueous epinephrine int o t he appropriat e areas (unless cont raindicat ed
because of allergy or f or ot her reasons) t o provide anest hesia and cont rol of
bleeding. Ref er t o Appendix C f or int ravenous conscious sedat ion
precaut ions.
6. Fill a 10-mL syringe w it h ant ibiot ic oint ment at t he end of t he procedure. Use
a small cat het er at t ached t o t he syringe t ip t o direct oint ment t o t he
appropriat e areas. Tape a small (2- 2-inch) must ache dressing t o t he end
of t he nose t o collect secret ions and blood. Usually, t his dressing can be
changed as needed. I nsert nasal packing int o t he nares.

1. Encourage oral f luids af t er nausea or vomit ing has resolved; t he pat ient may
experience nausea or vomit ing if blood is sw allow ed because blood is
irrit at ing t o t he gast roint est inal syst em.
2. Remember t hat post procedural inst ruct ions may include t he f ollow ing:
a. Take prescribed medicat ions as ordered (usually a broad-spect rum
ant ibiot ic and pain medicat ion). Soot hing gargles may be ordered.
b. Report excessive bleeding or sinus discharge, unusual pain, f ever,
nausea or vomit ing, or visual problems immediat ely. Provide pat ient w it h
phone numbers of hospit al and physician and inst ruct him or her t o
cont act t he physician (or t he out pat ient surgical depart ment or
emergency depart ment if unable t o reach physician) in t he event of an
emergency. This process may diff er according t o various healt h
insurance regulat ions and prot ocols.
c. Do not allow t he pat ient t o drive or sign legal document s f or 24 hours
because t he eff ect s of anest het ics and sedat ion.
3. Follow t he usual caut ions involved in t he care of any person having received
sedat ion and analgesia. The pat ient w ho has received drugs t o achieve
conscious sedat ion may require closer monit oring, posit ioning on t he side t o
prevent aspirat ion, and a longer recovery t ime t han t hose w ho receive local
anest hesia.
4. I nt erpret t est out comes and counsel appropriat ely about possible t reat ment
(medicat ions [ eg, st eroids, ant ibiot ics] ). Numbness of t he f ace may cont inue
f or several w eeks.
Clin ical Alert

1. Sinuses are poorly visualized t hrough rout ine sinus x-ray f ilms.
2. I f sinus problems appear t o be relat ed t o dent al problems, t he pat ient
should see a dent ist or oral surgeon bef ore sinus endoscopy is perf ormed.
3. Severe nasal-sept al deviat ion must be correct ed bef ore endoscopy.
4. Pot ent ial complicat ions include periorbit al bleeding, cerebrospinal f luid
leak, cellulit is, visual dist urbances, and subcut aneous orbit al emphysema.
5. Direct t rauma t o t he nasof ront al duct is associat ed w it h increased risk f or
post operat ive st enosis.
BIBLIOGRAPHY
American Societ y of Anest hesiologist s, I nc. , Task Force on Sedat ion and
Analgesia by Non-Anest hesiologist s: Pract ice guidelines f or sedat ion and
analgesia by non-anest hesiologist s. Anest hesiology, 84: 459471, 1996
Brunner LS, Suddart h DS: The Lippincot t Manual of Nursing Pract ice, 9t h ed.
Clinical New s I nf ect ion Cont rol: TB and t he link t o bronchoscopies. AJN 98(4):
9, April 1998; Source: JAMA 2781077, 1093, 1111, 1997 (edit orial) DeVit a
VT, Hellman S, Rosenberg SA: Cancer Principles and Pract ice of O ncology,
6t h ed. Philadelphia, Lippincot t Williams & Wilkins, 2001
Favaro MS, Pugliese G : I nf ect ions t ransmit t ed by endoscopy: An int ernat ional
problem. Am J I nf ect Cont rol 24: 343345, 1996
Finkelmeier BA: Cardiot horacic Surgical Nursing, 2nd ed. Philadelphia,

Finkelst ein LE: I nf ect ion risks f rom cont aminat ed endoscopes. AJN 97(2): 56,
1997
Forsh R: Best bow el prep f or f lexible sigmoidoscopy. J Fam Pract 45(2): 98
106, 1997
G oroll AH, May LA, Mulley AG Jr (eds): Primary Care Medicine: O ff ice
Evaluat ion and Management of t he Adult Pat ient , 4t h ed. Philadelphia,
Lanser K: Bronchoscopy in respirat ory t ract disease (review ). I nt ernist 22(6):
564568, 1995
Lef t on HB, Pelchman J, Harnat z A: Colon cancer screening and t he evaluat ion
and f ollow -up of colonic polyps. Primary Care 23(3): 515523, 1996
Muller AD, Sonnenberg A: Prot ect ion by endoscopy against deat h f rom
colorect al cancer. Arch I nt ern Med 155: 17411748, 1995
Norris TE: Esophagogast roduodenoscopy. Primary Care 24(2): 327340, 1997
Phippen ML, Mells MP: Pat ient Care During O perat ive and I nvasive
Procedures. Philadelphia, WB Saunders, 2000
Pierzchajilo K, Ackerman RJ, Vogel RL: Esophagogast roduodenoscopy
perf ormed by a f amily physician, a case series of 793 procedures. J. Fam
Pract 46(1): 4146, 1998
Pierzchajilo K, Ackerman RJ, Vogel RL: Colonoscopy perf ormed by a f amily
physician. J Fam Pract 44(5): 473478, 1997
Raju T, St eel R, Ahnja S: Complicat ions of urological laparoscopy. J Urol 156:
64696471, August 1996
Sharma VK, et al: Best bow el prep f or f lexible sigmoidoscopy. Am J
G ast roent erology 92: 809811, 1997
Societ y of G ast roent erology Nurses and Associat es, Core Curriculum
Commit t ee: G ast roent erology Nursing: A Core Curriculum. St . Louis, Mosby,
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Thompson JM, McFarland G K, Hirsch JE, Tucker SM: Clinical Nursing, 5t h ed.
St . Louis, Mosby, 2002

Wilkins
> Table of C ontents > 13 - Ultr as ound S tudies
13
Ultrasound Studies
OVERVIEW OF ULTRASOUND STUDIES

Ult rasonography is a noninvasive procedure f or visualizing sof t t issue st ruct ures
of t he body by recording t he ref lect ion of inaudible sound w aves direct ed int o t he
t issues. The diagnost ic procedure, w hich requires very lit t le pat ient preparat ion,
is now used in many branches of medicine f or accurat e diagnosis of cert ain
pat hologic condit ions (Chart 13. 1). I t may be used diagnost ically w it h t he
obst et ric, gynecologic, or cardiac pat ient and in pat ient s w it h abnormal
condit ions of t he kidney, pancreas, gallbladder, lymph nodes, liver, spleen,
t hyroid, or peripheral blood vessels. Frequent ly, it is used in conjunct ion w it h
radiology or nuclear medicine scans. The procedure is relat ively quick (of t en
requiring only a f ew minut es t o an hour) and causes lit t le discomf ort . No harmf ul
eff ect s have yet been est ablished at t he low int ensit ies t hat are used (<100
mW/ cm 2 ). How ever, as w it h any diagnost ic procedure, ult rasound should not be
used f rivolously. The t erms ul trasound and sonogram are used int erchangeably.
Ch art 13.1 Uses of Ultrasound Obstetric ultrasound: Common ly

performed to evalu ate fetal h ealth , size, an d n u mber of fetu ses,
level of amn iotic flu id, an d matern al an d placen tal an atomy.
Abdomi nal ul trasound: Used t o charact erize sof t t issue organs, including
Hepat obiliary: t o evaluat e organ size and presence of masses, calculi, or
diff use parenchymal condit ions. Doppler ult rasound is helpf ul in demonst rat ing
signs of port al hypert ension.
Pancreas: t o det ect pat hologic st at es such as t umor involvement ,
pseudocyst s, and inf lammat ory processes Kidneys: t o diagnose cyst s,
masses, hydronephrosis, and cert ain diff use condit ions. Doppler evaluat ion of
t he renal vessels and parenchyma is commonly used t o evaluat e t ransplant ed
kidneys and in t he st aging of know n renal cell carcinoma.
Aort a and ot her large abdominal vessels: t o det ect aneurysms, t he presence
of clot s or t umors, and ot her def ect s Spleen and lymph nodes: t o evaluat e
organ size and pat hologic st at es such as lymphoma and met ast at ic spread of
know n cancers Addit ional st ruct ures: t o demonst rat e suspect ed ascit es,
abscesses, ret roperit oneal t umors, and signs of appendicit is Pel vi c
ul trasound: G ynecologic scan is done t o evaluat e t he urinary bladder, ut erus,
and ovaries; is used t o monit or f ollicle development during inf ert ilit y
t reat ment s and also as a guide f or oocyt e ret rieval Mal e reproducti ve organs
sonogram: Used t o evaluat e scrot al masses and sw elling and combined w it h
Doppler examinat ion of t he penis t o det ect physiologic causes f or male
impot ence. Transrect al ult rasound is an accept ed met hod of screening f or
prost at ic disease.
Head and neck sonogram: Used t o evaluat e pat hologies in t he f ollow ing
st ruct ures: Thyroid and parat hyroid: f or diff erent iat ing cyst s f rom solid t umors
Carot id and vert ebral art eries: t o demonst rat e vessel pat ency and f low
pat t erns.
Eye: t o assist opht halmologist in t he removal of f oreign bodies and in t he
evaluat ion of t he eye's st ruct ure Neonat al brain: t o diagnose cerebral
hemorrhage and ot her int racranial pat hologies.
Adult cerebral blood f low : By using a met hod know n as t ranscranial Doppler,
t he larger blood vessels w it hin t he brain may be int errogat ed t o rule out
vascular dist urbance.
Breast sonograms: Perf ormed t o diff erent iat e cyst s f rom solid lesions and t o
guide cyst aspirat ions and needle biopsies Extremi ti es sonograms: Used t o
evaluat e art erial and venous blood f low and t o charact erize sof t t issue masses
such as Baker's cyst s. Sonography is of t en used t o evaluat e t he pediat ric hip
f or dislocat ions or ot her st ruct ural def ormit ies. Cert ain adult joint anat omy can
be visualized, such as t he w rist in t he evaluat ion of carpal t unnel syndrome.
Invasi ve procedures: Serve as a guide f or diagnost ic procedures, such as
paracent esis, amniocent esis, t horacent esis, and biopsy Heart sonograms:
Perf ormed t o evaluat e t he cardiac st ruct ure and blood f low t hrough chambers
and valves
Principles and Techniques Ultrasound uses highfrequency sound waves to produce an echo map that
characterizes the position, size, form, and nature of
soft tissue organs. Echoes of varying strength are
produced by different types of tissues and are
displayed as a visual pattern after computer
processing of the echo information. The capability of
acquiring real-time images means that ultrasound can
readily demonstrate motion, as in the fetus or the
heart. Ultrasound, however, cannot appropriately image
air-filled structures such as the lungs.
Doppler M ethod
A phenomenon t hat accompanies movement , t he Doppl er ef f ect, can be combined
w it h diagnost ic ult rasound imaging t o produce duplex scans. Duplex scans
provide anat omic visualizat ion of blood vessels and a graphic represent at ion of
blood f low charact erist ics. Flow direct ion, velocit y, and t he presence of f low
dist urbances can readily be assessed. Cert ain equipment is capable of advanced
Doppler imaging t echniques, such as:
1. Col or Doppl er imaging provides a color-coded depict ion of select ed blood

f low paramet ers.
2. A t echnology know n as color Doppl er energy, power Doppl er, or col or angi o
is sensit ive t o very low blood velocit y st at es and is of t en used t o evaluat e
blood f low t hrough solid organs.
3. B-f l ow Doppl er images t he blood it self , producing images t hat resemble an
angiogram.
These t echniques est ablish t he pat ency of a given blood vessel and are usef ul in
invest igat ing perf usion t o an organ or mass. They are also helpf ul in evaluat ing
complicat ions in t ransplant ed organs.
General Procedure
1. A gel or lubricant is applied t o t he skin over t he area t o be examined t o
conduct t he sound w aves.
2. An operat or, know n as a sonographer, holds a microphone-like device called
a transducer. The t ransducer is moved over a specif ic body part , producing a
display t hat is view ed on t he monit or.
3. Sonography of st ruct ures in t he abdominal region of t en require t hat t he
pat ient cont rol breat hing pat t erns. Deep inspirat ion and exhalat ion may be
used.
4. Select ed images are recorded f or document at ion purposes.
5. The examinat ion causes no physical pain. How ever, in cert ain applicat ions,
pressure may be applied t o t he t ransducer, causing some degree of
discomf ort . Long examinat ions may leave t he pat ient f eeling t ired.
6. Test s usually t ake 20 t o 45 minut es. This is t he act ual procedure t ime and
does not include w ait ing and preparat ion t imes.
7. Some examinat ions require t he pat ient t o f ast or t o have a f illed urinary
bladder. Each examining depart ment det ermines it s ow n guidelines f or
pat ient preparat ion.
Advances in t echnology have allow ed t he development of very small, highresolut ion t ransducers. Cat het er-sized t ransducers are used t o visualize blood
vessels f rom t he inside out during angiographic procedures. Endoscopic
ult rasound is used t o evaluat e gast roint est inal lesions and may be used t o
visualize pancreat ic biliary st ruct ures. Small t ransducers passed t hrough t he
esophagus permit exquisit e visualizat ion of t he heart during t ransesophageal
echocardiography (TEE). Slim t ransducers are int roduced int o t he vagina t o

visualize gynecologic anat omy. Transrect al visualizat ion of t he prost at e gland is
an accept ed met hod of screening f or disease in t he organ. O f course, bef ore
int roduct ion int o t he body, t hese small t ransducers are properly cleansed and/ or
draped.
Implications of Ultrasound Studies
Benefits and Risks

1. Ult rasonography is a noninvasive procedure w it h no radiat ion risk t o pat ient
or examiner.
2. I t requires lit t le, if any, pat ient preparat ion and af t ercare.
3. As f ar as is know n, t he examinat ion can be repeat ed as of t en as necessary
w it hout being injurious t o t he pat ient . No harmf ul cumulat ive eff ect has been
seen.
4. Because ult rasound st udies demonst rat e st ruct ure rat her t han f unct ion, t hey
may be usef ul f or pat ient s w hose organ f unct ion is impaired.
5. Ult rasound is usef ul in t he det ect ion and examinat ion of moving part s, such
as t he heart .
6. I t does not require t he inject ion of cont rast mat erials or isot opes or ingest ion
of opaque mat erials.
Disadvantages
1. An ext remely skilled examiner is required t o operat e t he t ransducer. The
scans should be read immediat ely and int erpret ed f or adequacy. I f t he scans
are not sat isf act ory, t he examinat ion must be repeat ed.
2. Air-f illed st ruct ures (eg, t he lungs) cannot be st udied by ult rasonography.
3. Cert ain pat ient s (eg, rest less children, ext remely obese pat ient s) cannot be
st udied adequat ely unless t hey are specially prepared.
Difficult-to-Study Patients The follow ing general

categories of patients may provide some difficulties in
ultrasound studies:
1. Postoperati ve pati ents and those wi th abdomi nal scars: The area
surrounding an incision is t o be avoided w henever possible. I f a scan must

be perf ormed over an incision, t he dressing must be removed and a st erile
coupling agent and probe must be employed.
2. Chi l dren and agi tated adul ts: Because t he procedure requires t he pat ient t o
remain st ill, some pat ient s may need t o be sedat ed so t hat t heir movement s
do not cause art if act s.
3. O bese pati ents: Cert ain pat ient s cannot be st udied adequat ely in any case.
For example, it may be diff icult t o obt ain an accurat e scan on a very obese
pat ient , ow ing t o alt erat ion of t he sound beam by f at t y t issue. There is no
preparat ion t hat w ould help here.
Interfering Factors
1. Barium has an adverse eff ect on t he qualit y of abdominal st udies, so
sonograms should be scheduled bef ore barium st udies are done.
2. I f t he pat ient has a large amount of gas in t he bow el, t he examinat ion may
be rescheduled because air (bow el gas) is a very st rong ref lect or of sound
and does not permit accurat e visualizat ion.
OBSTETRIC AND GYNECOLOGIC SONOGRAM S

Obstetric Sonogram Ultrasound studies of the obstetric
patient are valuable in (1) confirming pregnancy; (2)
facilitating amniocentesis by locating a suitable pool of
amniotic fluid; (3) determining fetal age; (4) confirming
multiple pregnancy; (5) ascertaining whether fetal
growth is normal, through sequential studies; (6)
determining fetal viability; (7) localizing placenta; (8)
confirming masses associated with pregnancy; (9)
identifying postmature pregnancy (increased amount of
amniotic fluid and degree of placental calcification);
and (10) as a guidance method for chorionic villus
sampling (CVS), embryo transfer, intrauterine device
(IUD) extraction, and percutaneous umbilical vein
sampling (PUVS). A pregnancy can be dated with
considerable accuracy if a sonogram is done at 20
weeks' gestation and a follow-up scan is done at 32
weeks' gestation. This validation is most important
when early delivery is anticipated and prematurity is to
be avoided. Conditions in which determination of
pregnancy duration is useful include maternal
diabetes, Rh immunization, and preterm labor (Chart
13.2).
Ch art 13.2 Major Uses of Obstetric UltrasoundLevels I and II*
In dication s du rin g First Trimester Con firm pregn an cy
Conf irm viabilit y
Rule out ect opic pregnancy in t he f irst t rimest er Conf irm gest at ional age
Birt h cont rol pill use
I rregular menses
No dat es
Post part um pregnancy
Previous complicat ed pregnancy

Cesarean delivery
Rh incompat ibilit y
Diabet es mellit us
Fet al grow t h ret ardat ion
Clarif y discrepancy bet w een dat es and size
I f large f or dat es rule out :
Leiomyomas
Bicornuat e ut erus
Adnexal mass
Mult iple gest at ion
Poor est imat e of dat es
Missed abort ion
Blight ed ovium
As guidance met hod f or:
Chorionic villus sampling
Amniocent esis
Embryo t ransf er
In dication s du rin g Secon d Trimester Establish or con firm

dates
I f no f et al heart t ones:
Clarif y discrepancy bet w een dat es and size
I f large f or dat es, rule out :
Molar pregnancy
Leiomyomas
Polyhydramnios
Congenit al anomalies
I f small f or dat es, rule out :
O ligohydramnios
I f hist ory of bleeding, rule out t ot al placent a previa I f Rh incompat ibilit y, rule
out f et al hydrops Evaluat ion and f ollow -up of suspect ed f et al anomalies
In dication s du rin g T h ird Trimester If n o fetal h eart ton es:

Clarif y discrepancy bet w een
Dat es and size
I f large f or dat es, rule out :
Macrosomia (diabet es mellit us)
Polyhydramnios
I f small f or dat es, rule out :
O ligohydramnios
Det ermine f et al posit ion, rule out :
Breech
Transverse lie
I f hist ory of bleeding, rule out :
Placent a previa
Abrupt io placent ae
Det ermine f et al mat urit y
Amniocent esis f or lecit hin/ sphingomyelin rat io
Placent al mat urit y (grade 03)
Evaluat ion and f ollow -up of suspect ed f et al anomalies
Est imat ion of f et al w eight
Footn otes
*Ult rasound is a diagnost ic t ool f or assessment of f et al age, healt h, and
grow t h. Level I ult rasound is perf ormed t o assess gest at ional age, number of
f et uses, f et al viabilit y, and t he placent a. Level I I ult rasound is used f or
assessment of specif ic congenit al anomalies or abnormalit ies. (See also Fet al
Echocardiography, page 870. )
Accuracy 3 days.
Accuracy 1 t o 1. 5 days.
The pregnant ut erus is ideal f or echographic evaluat ion because t he amniot ic

f luidf illed ut erus provides st rong t ransmit t ing int erf aces bet w een t he f luid,
placent a, and f et us. Ult rasonography has become t he met hod of choice f or
evaluat ing t he f et us and placent a, eliminat ing t he need f or t he pot ent ially
injurious radiographic st udies t hat w ere used previously.
Reference Values
Normal Obstetric Sonogram Normal image of placental
position, size, and structure Normal fetal position and
size with evidence of fetal movement, cardiac activity,
and breathing activity Adequate amniotic fluid volume
Normal fetal intracranial, thoracic, and abdominopelvic
anatomy; four limbs visualized
Procedure
1. Have t he pregnant w oman lie on her back w it h her abdomen exposed during
t he t est . This may cause some short ness of breat h and supine hypot ensive
syndrome, w hich can be relieved by elevat ing t he upper body or t urning t he
pat ient ont o her side.
2. Perf orm t he t ransabdominal scan in t he second t rimest er w hile t he pat ient
has a f ull bladder. Except ions are made w hen t he scan is perf ormed t o
locat e t he placent a bef ore amniocent esis, f or evaluat ion of an incompet ent
cervix, or during labor and delivery. A f ull bladder allow s t he examiner t o
assess t he t rue posit ion of t he placent a, reposit ions t he ut erus, and act s as
a sonic w indow t o t he pelvic organs.
3. Apply a coupling agent (special t ransmission gel, lot ion, or mineral oil)
liberally t o t he skin t o prevent air f rom absorbing sound w aves. The
sonographer slow ly moves t he t ransducer over t he ent ire abdomen t o obt ain
a pict ure of t he ut erine cont ent s.
4. Perf orm an endovaginal (t ransvaginal) scan during t he f irst t rimest er. Most
laborat ories use a t ransvaginal approach w hen perf orming obst et ric
sonograms at t his t ime. This met hod does not require a f ull bladder. A slim
t ransducer, properly covered and lubricat ed, is gent ly int roduced int o t he
vagina. Because t he sound w aves do not need t o t raverse abdominal t issue,
exquisit e image det ail is produced. Check w it h your laborat ory t o det ermine
t he approach t o be used.
5. Tell t he pat ient t hat t he examining t ime is about 30 t o 60 minut es.

1. During t he f irst t rimest er, t he f ollow ing inf ormat ion can be obt ained:
a. Number, size, and locat ion of gest at ional sacs
b. Presence or absence of f et al cardiac act ivit y and body movement
c. Presence or absence of ut erine abnormalit ies (eg, bicornuat e ut erus,
f ibroids) or adnexal masses (eg, ovarian cyst , ect opic pregnancy)
d. Pregnancy dat ing (eg, bipariet al diamet er, crow nrump lengt h)
e. Presence and locat ion of an I UD
2. During t he second and t hird t rimest ers, ult rasound can be perf ormed t o
obt ain t he f ollow ing inf ormat ion:
a. Fet al viabilit y, number, posit ion, gest at ional age, grow t h pat t ern, and
st ruct ural abnormalit ies
b. Amniot ic f luid volume
c. Placent al locat ion, mat urit y, and abnormalit ies
d. Ut erine f ibroids and anomalies
e. Adnexal masses
f. Early diagnosis of f et al st ruct ural abnormalit ies makes t he f ollow ing
choices possible:
1. I nt raut erine surgery or ot her prenat al t herapy
2. Discont inuat ion of pregnancy
3. Preparat ion of t he f amily f or care of a child w it h a disorder or
planning of ot her opt ions
3. Fetal vi abi l i ty: Fet al heart act ivit y can be demonst rat ed at 5 w eeks'
gest at ion in most cases. This inf ormat ion is helpf ul in est ablishing dat es and
in t he management of vaginal bleeding. Molar pregnancies and incomplet e,
complet e, and missed abort ions can be diff erent iat ed.
4. G estati onal age: I ndicat ions f or gest at ional age evaluat ion include uncert ain
dat es f or t he last menst rual period, recent discont inuat ion of oral hormonal
suppression of ovulat ion, bleeding episode during t he f irst t rimest er,
amenorrhea of at least 3 mont hs' durat ion, ut erine size t hat does not agree
w it h dat es, previous cesarean birt h, and ot her high-risk condit ions.
5. Fetal growth: The condit ions t hat serve as indicat ors f or ult rasound
assessment of f et al grow t h include poor mat ernal w eight gain or pat t ern of
w eight gain, previous int raut erine grow t h ret ardat ion (I UG R), chronic
inf ect ion, ingest ion of drugs such as ant iconvulsant s or heroin, mat ernal
diabet es, pregnancy-induced or ot her hypert ension, mult iple pregnancy, and
ot her medical or surgical complicat ions. Serial evaluat ion of bipariet al
diamet er and limb lengt h can help diff erent iat e bet w een w rong dat es and
I UG R. Doppler evaluat ion of t he umbilical art ery, ut erine art ery, and f et al
aort a can also assist in t he det ect ion of I UG R. I UG R can be symmet ric (t he
f et us is small in all measurement s) or asymmet ric (head and body grow t h
vary). Symmet ric I UG R may be caused by low genet ic grow t h pot ent ial,
int raut erine inf ect ion, mat ernal undernut rit ion, heavy smoking by t he mot her,
or chromosomal aberrat ion. Asymmet ric I UG R may ref lect placent al
insuff iciency secondary t o hypert ension, cardiovascular disease, or renal
disease. Depending on t he probable cause, t he t herapy varies.
6. Fetal anatomy: Depending on t he gest at ional age, t he f ollow ing st ruct ures
may be ident if ied: int racranial anat omy, neck, spine, heart , st omach, small
bow el, liver, kidneys, bladder, and ext remit ies. St ruct ural def ect s may be
ident if ied bef ore delivery. The f ollow ing are examples of st ruct ural def ect s
t hat may be diagnosed by ult rasound: hydrocephaly, anencephaly, and
myelomeningocele are of t en associat ed w it h polyhydramnios. Pot t er's
syndrome (renal agenesis) is associat ed w it h oligohydramnios def ect s
(dw arf ism, achondroplasia, ost eogenesis imperf ect a) and diaphragmat ic
hernias. O t her st ruct ural anomalies t hat can be diagnosed
by ult rasound are pleural eff usion (af t er 20 w eeks), int est inal at resias or
obst ruct ion (early pregnancy t o second t rimest er), hydronephrosis, and
bladder out let obst ruct ion (second t rimest er t o t erm w it h f et al surgery
available). Tw o-dimensional st udies of t he heart , t oget her w it h
echocardiography, allow diagnosis of congenit al cardiac lesions and prenat al
t reat ment of cardiac arrhyt hmias.
7. Detecti on of f etal death: I nabilit y t o visualize t he f et al heart beat ing and
separat ion of bones in t he f et al head are signs of deat h. Wit h real-t ime
scanning, t he absence of cardiac mot ion f or 3 minut es is diagnost ic of f et al
demise.
8. Pl acental posi ti on and f uncti on: The sit e of implant at ion (eg, ant erior,
post erior, f undal, in low er segment ) can be described, as can locat ion of t he
placent a on t he ot her side of midline. The pat t ern of ut erine and placent al
grow t h and t he f ullness of t he bladder inf luence t he apparent locat ion of t he
placent a. For example, w hen ult rasound scanning is done in t he second
t rimest er, t he placent a seems t o be overlying t he os in 15% t o 20% of all
pregnancies. At t erm, how ever, t he evidence of placent a previa is only 0. 5%.
Theref ore, t he diagnosis of placent a previa can seldom be conf irmed unt il
t he t hird t rimest er. Placent a abrupt io (premat ure separat ion of placent a) can
also be ident if ied. A t ransverse scan t hrough t he umbilical cord conf irms t he
number of vessels. Doppler of t he cord det ect s f low abnormalit ies.
9. Fetal wel l -bei ng: Ult rasound f indings are a major component of t he
biophysical prof iles. The f ollow ing physiologic measurement s can be
accomplished w it h ult rasound: heart rat e and regularit y, f et al breat hing
movement s, urine product ion (af t er serial measurement s of bladder volume),
f et al limb and head movement s, and analysis of vascular w ave f orms f rom
f et al circulat ion. Fet al breat hing movement s are decreased w it h mat ernal
smoking and alcohol use and increased w it h hyperglycemia. Fet al limb and
head movement s serve as an index of neurologic development . I dent if icat ion
of amniot ic f luid measuring at least 1 cm is associat ed w it h normal f et us
st at us. The presence of one pocket measuring < 1 cm or t he absence of a
pocket is abnormal; it is associat ed w it h increased risk f or perinat al deat h.
10. Assessment of mul ti pl e pregnancy: Tw o or more gest at ional sacs, each
cont aining an embryo, may be seen af t er 6 w eeks. O f t w in pregnancies
diagnosed in t he f irst t rimest er, only about 30% w ill deliver t w ins, ow ing t o
loss or absorpt ion of one f et us. O f value is assessment of t he relat ive f et al
grow t h of t w ins w hen I UG R or t w in-t o-t w in t ransf usion t o suspect ed. O ne
cannot unequivocally diagnose w het her t w ins are monozygot es or
het erozygot es w it h ult rasound alone unless f et uses of opposit e sex are
evident . Rout ine ult rasound cannot t ot ally be relied on t o exclude t he
possibilit y of t riplet s or quadruplet s, inst ead of only t w ins.
11. I f t he f et al posit ion and amniot ic f luid volumes are f avorable, f et al sex can
be det ermined by visualizat ion of t he genit alia. I t must be caut ioned,
how ever, t hat sex det erminat ion is not t he purpose of obst et ric sonography.
Interfering Factors
1. Art if act s may be produced w hen t he t ransducer is moved out of cont act w it h
t he skin. This can be resolved by adding more coupling agent t o t he skin and
repeat ing t he scan.
2. Art if act s (reverberat ion) may be produced by echoes emanat ing f rom t he
same surf ace several t imes. This can be avoided by caref ul posit ioning of
t he t ransducer.
3. A post erior placent al sit e may be diff icult t o ident if y because of t he
angulat ion of t he ref lect ing surf ace or insuff icient penet rat ion of t he sound
beam ow ing t o t he pat ient 's size.
Interventions
1. A brief explanat ion of t he procedure t o be perf ormed is given, emphasizing
t hat it is not uncomf ort able or painf ul and does not involve ionizing radiat ion
t hat might be harmf ul t o t he mot her or f et us. The st udies can be repeat ed
w it hout harm, but t he procedure is being
st udied caref ully t o det ermine w het her t here are any long-t erm adverse side
eff ect s. Benef it s of t he procedure should be explained.
2. Most st udies are perf ormed by a t ransabdominal approach w it h a f ull
bladder. The pat ient is asked t o drink f ive t o six glasses of f luid (w at er or
juice) about 1 t o 2 hours bef ore t he examinat ion. I f she is unable t o do so,
int ravenous f luids may be administ ered. She is asked t o ref rain f rom voiding
unt il t he examinat ion is complet e. Tell t he pat ient t hat she w ill have a st rong
urge t o void during t he examinat ion. Discomf ort caused by pressure applied
over a f ull bladder may be experienced. I f t he bladder is not suff icient ly
f illed, t hree t o f our 8-oz glasses of w at er should be ingest ed, w it h
rescanning done 30 t o 45 minut es lat er.
3. Most laborat ories use a t ransvaginal (endovaginal) approach during t he f irst
t rimest er of pregnancy. No pat ient preparat ion is required f or t his met hod.
Cont act t he laborat ory perf orming t he st udy t o det ermine t he met hod t o be
used.
4. Explain t hat a liberal coat ing of coupling agent must be applied t o t he skin so
t hat t here is no air bet w een t he skin and t he t ransducer and t o allow f or
easy movement of t he t ransducer over t he skin. A sensat ion of w armt h or
w et ness may be f elt . Alt hough t he acoust ic couplant does not st ain, advise
t he pat ient not t o w ear good clot hing f or t he examinat ion.
5. The w oman may f ace t he screen, and t he sonographer may explain t he
images in basic t erms. I n some inst it ut ions, t he f at her is encouraged t o
observe t he t est ing. A phot ograph or videot ape f or t he f amily t o keep is
somet imes provided.
6. See Chapt er 1 guidelines f or saf e, eff ect ive inf ormed pretest care.
Clin ical Alert

1. A f ull bladder may not be needed or desired f or pat ient s in t he lat e st ages
of pregnancy or act ive labor. How ever, if a f ull bladder is required and t he
w oman has not been inst ruct ed t o report w it h a f ull bladder, at least
anot her hour of w ait ing t ime may be needed bef ore t he examinat ion can
2.
3.
4.
5.
begin.
A t ransvaginal (endovaginal) scan does not require t he pat ient t o have a
f ull bladder. Cont act t he laborat ory t o det ermine met hod t o be used.
Endovaginal st udies t ypically involve t he use of a lat ex condom t o sheat h
t he t ransducer bef ore it is insert ed int o t he vaginal vault . Cont act t he
laborat ory if t he pat ient has know n or suspect ed lat ex sensit ivit y.
Fet al age det erminat ions are most accurat e during t he crow nrump st age
in t he f irst t rimest er. The next most accurat e t ime f or age est imat ion is
during t he second t rimest er. Sonographic dat ing during t he t hird t rimest er
has a large margin of error (up t o 3 w eeks).
I f f et al deat h is suspect ed, caref ul and considerat e counseling and
support are off ered t o parent s.

1. I nt erpret t est out comes and counsel appropriat ely. Explain possible need f or
f ollow -up t est ing (eg, f et al echocardiography) and/ or t reat ment : medical
(st imulat e early onset of labor) or surgical (f et al surgery or immediat e
surgery f or ect opic pregnancy).
Fetal Echocardiography (Fetal Doppler) Fetal

echocardiography is performed after the detection of a
potential cardiac abnormality during an obstetric
sonogram or in patients with a strong history of
congenital cardiovascular
disease. Additionally, women exposed to cardiac
teratogens are usually advised to have this study. Not
a screening procedure, fetal echocardiograms are most
commonly performed in specialized laboratories or
teaching hospitals. The heart is imaged in numerous
planes, using pulsed Doppler and M-mode tracings (see
Heart Sonogram, page 895), similar to an
electrocardiogram. Valves and other cardiac structures
are measured, and blood velocities and volumes are

calculated.
Reference Values
Normal Sonogram
Normal st ruct ure of heart and great vessels Normal heart rat e and rhyt hm, w it h
proper hemodynamic f low t hrough heart and great valves
Procedure
1. Perf orm t he f et al echocardiogram in t he same manner as a rout ine obst et ric
scan, w hich also requires similar pat ient preparat ion. The pregnant pat ient
lies on her back w it h t he abdomen exposed. Couplant is applied t o t he skin,
and a t ransducer is moved across t he abdomen. Unless combined w it h an
obst et ric sonogram, t he f et al echocardiogram does not require t he mot her t o
have a f ull bladder.
Abnormalit ies det ect ed during f et al echocardiography include:
1. Cardiac arrhyt hmias
2. Sept al def ect s, including t et ralogy of Fallot
3. Hypoplast ic heart syndrome
4. Valvular abnormalit ies, including Ebst ein's anomaly
5. Cardiac t umors
6. Vessel abnormalit ies, including coarct at ion of aort a, t ransposit ion, aort ic
st enosis, t runcus art eriosus, and pulmonary st enosis
Clin ical Alert

O pt imal f et al echocardiographic st udies are perf ormed bet w een 18 and 22
gest at ional w eeks. Bef ore 18 w eeks, t he f et al heart is t oo small, and af t er 22
w eeks, image qualit y may be degraded by overlying st ruct ures.
Interfering Factors
Same as f or obst et ric sonogram.
Interventions
Pretest Patient Preparation Same as for obstetric
sonogram.
Posttest Patient Aftercare Same as for obstetric
sonogram.
Pelvic Gynecologic (GYN) Sonogram; Pelvic (Uterine
Mass) Ultrasound Diagnosis; Intrauterine Device (IUD)
Localization The pelvic gynecologic ultrasound study
examines the area from the umbilicus to the pubic bone
in women. It may be used in the evaluation of pelvic
masses, to determine the position of an IUD, to
evaluate postmenopausal bleeding, or to aid in the
diagnosis of cysts and tumors. Information can be
provided on the size, location, and structure of
masses. Spectral or color Doppler can be applied to
pelvic vessels, demonstrating normal flow changes
associated with the menstrual cycle, and can evaluate
abnormal flow patterns to masses/tumors. The
examination cannot provide a definitive diagnosis of
pathology but can be used as an adjunct procedure
when the diagnosis is not readily apparent. It is also
used in treatment planning and follow-up radiation
therapy for gynecologic cancer. Additionally, follicle
development after infertility treatment can be
monitored.
This t est may be perf ormed by a t ransvaginal met hod w hereby a slim, covered,
lubricat ed t ransducer is gent ly int roduced int o t he vagina. A f ull bladder is not
required. Because t he sound w aves do not need t o t ransverse abdominal t issue,
exquisit e image det ail is produced. This approach is most advant ageous f or
examining t he obese pat ient , t he pat ient w it h a ret rovert ed ut erus, or t he pat ient
w ho has diff icult y maint aining bladder dist ent ion. The t ransvaginal met hod is t he
approach of choice in monit oring f ollicular size during f ert ilit y w orkups and during
aspirat ion of f ollicles f or in vit ro f ert ilizat ion.
For pelvic sonograms using t he t ransabdominal approach, a f ull bladder is
necessary. The dist ended bladder serves f our purposes: it act s as a w indow
f or t ransmission of t he ult rasound beam; it pushes t he ut erus aw ay f rom t he
pubic symphysis, t hereby providing a less obst ruct ed view ; it pushes t he bow el
out of t he pelvis; and it may be used as a ref erence f or comparison in evaluat ing
t he int ernal charact erist ics of a mass under st udy.
Reference Values
Normal Sonogram
Normal pat t ern image of bladder, ut erus, f allopian t ubes, vagina, and surrounding
st ruct ures
Procedure
Transabdominal Method
1. Have t he pat ient lie on t he back on t he examining t able during t he t est .
2. Apply a coupling agent t o t he area under st udy.
3. Place t he act ive f ace of t he t ransducer in cont act w it h pat ient 's skin and
sw eep across t he area being st udied.
4. Tell t he pat ient t hat t he examinat ion t ime is about 30 minut es.
Transvaginal (Endovaginal) Method

1. Have t he pat ient lie on an examining t able w it h hips slight ly elevat ed in a
modif ied lit hot omy posit ion. Drape t he pat ient .
2. Lubricat e and int roduce a slim vaginal t ransducer, prot ect ed by a condom or
st erile sheat h, int o t he vagina. Some laborat ories pref er t hat t he pat ient
insert t he t ransducer herself . Dept h < 8 cm is all t hat is usually required.
3. Perf orm scans by using a slight rot at ion or movement of t he handle and by
varying t he degree of t ransducer insert ion. Typically, t he t ransducer is
insert ed only a f ew inches int o t he vaginal vault .
4. Tell pat ient t hat t he examinat ion t ime is about 15 t o 30 minut es.
1. Ut erine abnormalit ies such as f ibroids, int raut erine f luid collect ions, and
variat ions in st ruct ure such as bicornuat e ut erus can be det ect ed. Ut erine
and cervical carcinomas may be visualized, alt hough def init ive diagnosis of
cancer cannot be made by sonography alone.
2. Endomet rial abnormalit ies such as polyps can be visualized by sonography.
This procedure involves dist ent ion of t he endomet rial canal w it h saline and
subsequent ult rasound scanning. Very small adnexal masses may not be
demonst rat ed by ult rasound st udies. Masses ident if ied on ult rasound may be
evaluat ed in t erms of size and consist ency.
3. Cyst s
a. O varian cyst s (t he most common ovarian mass det ect ed by ult rasound)
appear as smoot hly out lined, w ell-def ined masses. Cyst s cannot be
conf irmed as eit her malignant or benign, but ult rasound st udies can
increase t he suspicion t hat a part icular mass is malignant .
b. A corpus lut eum cyst is a single, simple cyst commonly visualized in early
pregnancy.
c. Theca-lut ein cyst s are associat ed w it h hydat if orm mole,
choriocarcinoma, or mult iple pregnancy.
d. Because normal ovaries of t en have numerous visible small cyst s, t he
diagnosis of polycyst ic ovaries is diff icult t o make on t he basis of
ult rasound alone.
e. Dermoid cyst s or benign ovarian t erat omas may be f ound in young adult
w omen and have an ext remely variable appearance. Because of t heir
echogenicit y, t hey are of t en missed on ult rasound. The only init ial clue
may be an indent at ion of t he urinary bladder. When a dermoid cyst is
suspect ed on ult rasound, a pelvic radiograph should be obt ained.
4. Solid ovarian t umors such as f ibromas, f ibrosarcomas, Brenner's t umors,
dysgerminomas, and malignant t erat omas are not diff erent iat ed by diagnost ic
ult rasound. Ult rasound document s t he presence of a solid lesion but can go
no f urt her in narrow ing t he diagnosis.
5. Met ast at ic t umors of t he ovary are common and may be solid or cyst ic in
ult rasonic appearance. They are variable in size and are usually bilat eral.
Because ascit es is of t en present , t he pelvis and remainder of t he abdomen
should be scanned f or f luid.
6. Pel vi c i nf l ammatory di sease: Ult rasound diff erent iat ion bet w een pelvic
inf lammat ory disease and endomet riosis is diff icult . Evaluat ion of laborat ory
result s and t he clinical hist ory leads t o correct diagnosis. O t her ent it ies t hat
may have similar ult rasonic present at ion include appendicit is w it h rupt ure int o
t he pelvis, chronic ect opic pregnancy, post t raumat ic hemorrhage int o t he
pelvis, and pelvic abscesses f rom various causes (eg, Crohn's disease,
divert iculit is).
7. Bl adder di storti on: Any dist ort ion of t he bladder raises t he possibilit y of an
adjacent mass. Tumor, inf ect ion, and hemorrhage are t he major causes of
increased t hickness of t he urinary bladder w all. Masses such as calculi and
cat het ers may be seen w it hin t he bladder lumen. Urinary bladder calculi are
highly echogenic. A urinary bladder divert iculum appears as a cyst ic mass
adjacent t o t he urinary bladder. I t may be mist aken f or a cyst ic mass arising
f rom some ot her pelvic st ruct ure, so at t empt s are made t o demonst rat e it s
communicat ion t o t he bladder.
8. Ult rasound st udies can help t o det ermine w het her a pelvic mass is mobile.
9. Solid pelvic masses such as f ibroids and malignant t umors may be
diff erent iat ed f rom cyst ic masses, w hich show sound pat t erns similar t o
t hose of t he bladder.
10. Lesions may be show n t o have met ast asized.
11. St udies may aid in t he planning of t umor radiat ion t herapy.
12. The posit ion of an I UD may be det ermined.
Interfering Factors
1. Result s may be only f air, may vary w it h t he pat ient 's habit s and preparat ion
(as described in Clinical I mplicat ions), and can be used only in conjunct ion
w it h ot her st udies. How ever, masses 1 cm and smaller can be seen w it h
high-resolut ion equipment .
2. The success of a t ransabdominal scan depends on f ull bladder dist ent ion.
Interventions
1. Explain t he purpose, benef it s, and procedure of t he t est . Fast ing is not
required.
2. Have t he pat ient drink f our glasses of w at er or ot her liquid 1 hour bef ore
t ransabdominal scans. Advise t he pat ient not t o void unt il t he t est is over.
3. Cont act t he laborat ory perf orming t he st udy t o det ermine met hod t o be used.
I f a t ransvaginal (endovaginal) approach is t o be used, no pat ient

preparat ion is required.
5. Det ermine w het her t he pat ient has a lat ex sensit ivit y and communicat e such
sensit ivit ies t o t he examining laborat ory, if a t ransvaginal (endovaginal)
approach is t o be used. See lat ex precaut ions in Appendix B.
6. Reassure t he pat ient t hat she w ill have no pain or discomf ort .
Clin ical Alert

1. I f t he pat ient is t aking not hing by mout h (NPO ) or in cert ain emergency
sit uat ions, t he pat ient may be cat het erized and t he bladder f illed t hrough
t he cat het er if a t ransabdominal approach is required.
2. Endovaginal st udies, w hen indicat ed, t ypically involve t he use of a lat ex
condom t o sheat h t he t ransducer bef ore it is insert ed int o t he vaginal
vault . Cont act t he laborat ory if t he pat ient has a know n or suspect ed lat ex
sensit ivit y. See Appendix B regarding lat ex precaut ions.

1. I nt erpret t est out comes and counsel appropriat ely about possible f urt her
t est ing (biopsy w it h cyt ologic and hist ologic exam) and/ or t reat ment
(medical, pharmacologic, or surgical int ervent ions).
ABDOM INAL SONOGRAM S

Kidney (Renal) Sonogram
The kidney sonogram is a noninvasive t est used t o visualize kidney parenchyma
and associat ed st ruct ures, including renal blood vessels. This procedure is of t en
perf ormed af t er an int ravenous pyelogram (I VP) t o def ine and charact erize mass
lesions or t he cause of a nonvisualized kidney. Because no cont rast medium is
administ ered, renal ult rasound is valuable f or visualizing t he kidneys of pat ient s
w it h iodine hypersensit ivit ies. This procedure is also helpf ul in monit oring t he
st at us of a t ransplant ed kidney, guiding st ent and biopsy needle placement , and
evaluat ing t he progression of chronic condit ions. Renal sonography is t he
pref erred met hod f or evaluat ing possible hydronephrosis in spinal cord injury
pat ient s.
Reference Values
Normal
Normal pat t ern image indicat ing normal size and posit ion of kidneys, appropriat e
f low in renal vessels
Procedure
1. Have t he pat ient lie quiet ly on an examining t able. Scans are of t en perf ormed
w it h t he pat ient in t he decubit us posit ion.
2. Apply w arm oil or gel t o t he pat ient 's skin.
3. Ask t he pat ient t o inspire as deeply as possible f or visualizat ion of t he upper
part s of t he kidney.
4. Tell t he pat ient t hat t he t ot al st udy t ime varies f rom 15 t o 30 minut es.
1. Abnormal pat t ern readings reveal:
a. Cyst s
b. Solid masses
c. Hydronephrosis
d. O bst ruct ion of uret ers

e. Calculi
2. Result s provide inf ormat ion on t he size, sit e, and int ernal st ruct ure of a
nonf unct ioning kidney.
3. Result s diff erent iat e bet w een bilat eral hydronephrosis, polycyst ic kidneys,
and t he small, end-st age kidneys of glomerulonephrit is or pyelonephrit is.
4. Result s may be used t o monit or kidney development in children w it h
congenit al hydronephrosis. This approach is saf er t han repeat ed I VP st udies.
5. Perineal f luid collect ions such as t hose associat ed w it h complicat ions of
t ransplant at ion may be det ect ed. These collect ions include abscesses,
hemat omas, urinomas, and lymphoceles.
6. Solid lesions may be diff erent iat ed f rom cyst ic lesions.
7. The spread of cancerous condit ions f rom t he kidney int o t he renal vein or
inf erior vena cava can be det ect ed.
8. I f ult rasound is combined w it h Doppler evaluat ions, t he pat ency and f low
charact erist ics of t he renal vessels may be scrut inized.
Interfering Factors
1. Ret ained barium f rom radiology st udies causes poor result s.
2. O besit y adversely aff ect s t issue visualizat ion.
Interventions
2. Assure t he pat ient t hat t here is no pain involved and t hat t he only discomf ort
is t hat caused by lying quiet ly f or a long period.
4. Explain t hat t he pat ient w ill be inst ruct ed t o cont rol breat hing pat t erns w hile
t he images are being made.
5. Check w it h your ult rasound depart ment f or guidelines about f ast ing. I t
usually is not necessary but may be required in cert ain laborat ories.

1. I nt erpret t est out comes and counsel appropriat ely about f urt her t est ing (CAT
scans, biopsies) and/ or t reat ment of chronic condit ions.
Clin ical Alert

1. Scans cannot be done over open w ounds or t hrough dressings.
2. This examinat ion must be perf ormed bef ore radiographic st udies involving
barium. I f such scheduling is not possible, at least 24 hours must elapse
bet w een t he barium procedure and t he renal echogram.
3. Biopsies or drainage procedures are of t en done w it h ult rasound as a
guide. I f an invasive procedure is t o be done, a surgical permit must be
signed by t he pat ient .
Urinary Bladder Sonogram The urinary bladder

sonogram is done as part of the investigation of
possible bladder tumor and provides a simple method
of estimating postvoid residual urine volume. This test
reduces the need for urinary catheterization and the
risk for subsequent urinary tract infection.
Reference Values
Normal
Normal pat t ern image of t he exact dimensions and cont our of t he bladder and
lit t le residual volume
Procedure
1. I nst ruct t he pat ient t o lie, w it h bladder f ully dist ended, on t he back on an
examinat ion t able.

2. Apply a coupling agent t o t he ant erior pelvic region t o allow maximum
penet rat ion of t he ult rasound beam.
3. Place t he act ive f ace of t he t ransducer in cont act w it h t he pat ient 's skin and
sw eep across t he area being st udied.
4. I nst ruct t he pat ient t o void. This is t ypically done w hen t he f ull-bladder scans
are complet ed. Take addit ional images t hen t o check f or residual volume.
5. Tell pat ient t hat t ot al examinat ion t ime is about 10 t o 20 minut es.
Abnormal result s reveal t he f ollow ing:
1. Tumors of bladder
2. Cancerous ext ension t o urinary bladder
3. Thickening of bladder w all
4. Masses post erior t o bladder
5. Uret erocele
Interfering Factors
1. Residual barium f rom previous radiology st udies aff ect s t est result s.
2. O verlying gas or f at t issue aff ect s t est result s.
Interventions
1. Explain t he purpose, benef it s, and procedure of t he t est .
2. Ask t he pat ient t o have a f ull bladder at t he beginning, w hich is t hen empt ied
t o complet e t he examinat ion.
3. Assure t he pat ient t hat t here is no pain involved. Some discomf ort may be
experienced f rom maint aining a f ull urinary bladder.

1. Pat ient may ret urn t o normal rout ines.
2. I nt erpret t est out comes and counsel about bladder abnormalit ies and
possible f urt her t est s (cyst oscopy) and t reat ment : medical (drugs) or
surgical int ervent ions.
care.
Hepatobiliary Sonogram; Gallbladder (GB) Ultrasound;

Liver Ultrasound These tests are helpful in
differentiating hepatic disease from biliary obstruction.
Unlike the oral cholecystogram, this procedure allows
visualization of the gallbladder and ducts in patients
with impaired liver function. Stones and evidence of
cholecystitis are readily visualized. This procedure is
indicated as an initial study for patients with right
upper quadrant pain. It is also useful as a guide for
biopsy or other interventional procedures.
Posttransplantation color Doppler sonography of the
reconstructed vessels is an important diagnostic tool.
Reference Values
Normal
Normal size, posit ion, and conf igurat ion of t he gallbladder and bile duct s Normal
adjacent liver t issue
Procedure
1. Ask t he pat ient t o lie quiet ly on an examinat ion t able. Scans usually are
perf ormed w it h t he pat ient in t he supine and decubit us posit ions.
2. Cover t he skin w it h a layer of coupling gel, oil, or lot ion.
3. Ask t he pat ient t o regulat e breat hing pat t erns as inst ruct ed during t he
examinat ion.
4. Tell pat ient t hat t ot al examinat ion t ime is about 10 t o 30 minut es.
1. G al l bl adder abnormal pat t erns reveal:
a. Size variat ions
b. Thickened w all, indicat ive of cholecyst it is, adenomyomat osis, or t umor
and commonly seen as a manif est at ion of cholecyst opat hy in pat ient s
w it h t he acquired immunodef iciency syndrome (AI DS)
c. Benign and malignant lesions such as polyps
d. G allst ones
2. Bi l e duct abnormalit ies reveal:
a. Dilat ion of duct s
b. Duct obst ruct ion by calculi, t umor, or parasit es
c. Congenit al abnormalit ies such as choledochal cyst s
3. Adjacent l i ver pat hologies may include:
a. Parenchymal disease such as cirrhosis
b. Masses, including cyst s, solid lesions, and met ast at ic t umors
4. I f combined w it h Doppler evaluat ion, port al hypert ension and hepat of ugal
(port al blood f low aw ay f rom t he liver) f low can be det ect ed.
Post t ransplant at ion st enoses or f low variances can be monit ored.
Clin ical Alert

Result s of sonograms alone cannot diff erent iat e cancers f rom benign
processes.
Interfering Factors
1. I nt est inal gas overlying t he area of int erest int erf eres w it h sonographic
visualizat ion.
2. Barium f rom recent radiographic st udies compromises t he st udy.
Interventions
2. I nst ruct t he pat ient t o remain NPO at least 8 hours bef ore t he examinat ion t o
f ully dilat e t he gallbladder and t o improve anat omic visualizat ion. Some
laborat ories pref er t hat t he last meal bef ore t he st udy cont ain low quant it ies
of f at .
3. Assure t he pat ient t hat t here is no pain involved. How ever, t he pat ient may
f eel uncomf ort able lying quiet ly f or a long period.

1. I nt erpret t est out comes and counsel appropriat ely about f urt her t est ing
(biopsy).
Clin ical Alert

bet w een t he barium procedure and t he sonogram.
3. The gallbladder's abilit y t o cont ract may be t est ed by administ ering a f at t y

subst ance and rescanning.
Abdominal Aorta Sonogram The abdominal aorta

sonogram is a noninvasive examination used to
evaluate the abdominal aorta and its major tributaries
for structural abnormalities such as aneurysms and the
presence of thrombus. Many laboratories include
Doppler evaluations to characterize blood flow through
vessels. Typically, the path of the abdominal aorta is
traced from its most proximal portion to the region of
its bifurcation into the iliac arteries.
Reference Values
Normal
Normal pat t ern image show ing regular cont our and diamet er of t he aort a The
w alls st rongly ref lect ing echoes, w hereas t he blood-f illed lumen is echo f ree.
Procedure
1. Ask t he pat ient t o lie quiet ly on an examinat ion t able. Scans are generally
3. Ask t he pat ient t o regulat e breat hing pat t erns as inst ruct ed during t he
examinat ion.
4. Tell t he pat ient t hat t he t ot al examinat ion t ime is about 30 minut es.
1. The t ypical abnormal pat t ern reveals aort ic aneurysms w it h or w it hout
t hrombus. I nt imal dissect ions and leaks also may be det ect ed.
2. Barium f rom recent radiographic st udies compromises t he st udy.
Interventions
2. I nst ruct t he pat ient t o remain NPO f or at least 8 hours bef ore t he
examinat ion t o f ully dilat e t he gallbladder and t o improve anat omic
visualizat ion of all st ruct ures.
t hat t here is no air bet w een t he skin and t he t ransducer over t he skin. A
sensat ion of w armt h or w et ness may be f elt . Alt hough t he acoust ic couplant
does not st ain, advise t he pat ient not t o w ear good clot hing f or t he
examinat ion.
Clin ical Alert


1. The pat ient may resume normal diet and f luids.
2. I nt erpret t est out comes and counsel appropriat ely about possible f urt her
t est ing (art eriogram) and t reat ment (surgery).
Abdominal Ultrasound
This noninvasive procedure visualizes all solid organs of t he upper abdomen,
including t he liver, gallbladder, bile duct s, pancreas, kidneys, spleen, and large
abdominal blood vessels. Some diagnost ic laborat ories may perf orm organspecif ic st udies, such as renal or hepat obiliary ult rasound, t oget her w it h
abdominal ult rasound. This st udy is valuable in det ect ing a variet y of
pat hologies, including f luid collect ions, masses, inf ect ions, and obst ruct ions.
Reference Values
Normal
Normal size, posit ion, and appearance of t he liver, gallbladder, bile duct s,
pancreas, kidneys, adrenals, and spleen, as w ell as t he abdominal aort a and
inf erior vena cava and t heir major t ribut aries
Procedure
1. Ask t he pat ient t o lie quiet ly on t he examinat ion t able. Scans are generally
3. Explain t hat t he pat ient w ill be asked t o regulat e breat hing pat t erns as
inst ruct ed during t he examinat ion.
4. Tell t he pat ient t hat t ot al examinat ion t ime is about 30 t o 60 minut es.
1. Li ver abnormalit ies reveal:
a. Cyst s, abscesses, t umors, and met ast ases
b. Parenchymal disease (eg, cirrhosis)
c. Variat ions in port al venous f low
d. Hepat ic art erial and venous f low pat t erns
2. G al l bl adder and bi l e duct abnormalit ies reveal:
a. Duct dilat ion or obst ruct ion
b. G allst ones
c. Cholecyst it is
d. Tumors
3. Pancreas abnormalit ies reveal:
a. Pancreat it is
b. Pseudocyst
c. Cyst s and t umors, including adenocarcinoma
4. Ki dney abnormalit ies reveal:
a. Hydronephrosis
b. Cyst s, t umors, abscesses
c. Abnormal size, number, locat ion of kidneys
d. Calculi
e. Perirenal f luid collect ions
f. Pat ency and f low t hrough renal art ery; pat ency of renal vein
5. Adrenal abnormalit ies reveal:
a. Pheochromocyt oma
b. Adrenal hemorrhage
c. Met ast ases
6. Spl een abnormalit ies reveal:
a. Splenomegaly
b. Evidence of lymphat ic disease, lymph node enlargement
c. Evidence of t rauma
7. Vascul ar abnormalit ies in t he upper abdomen reveal:
a. Aneurysm
b. Thrombi
c. Abnormal blood f low pat t erns
8. Miscellaneous pat hologies include:
a. Ascit es
b. Mesent eric or oment al cyst s or t umors
c. Congenit al absence or malplacement of organs
d. Ret roperit oneal t umors
e. Hemat omas
Clin ical Alert

The result s of sonograms alone cannot diff erent iat e malignant f rom benign
condit ions.
Interfering Factors
1. I nt est inal gas overlying t he area of int erest int erf eres w it h sonographic
visualizat ion.
2. Barium f rom recent radiology st udies compromises t he st udy.
Interventions
1. Explain t est purpose, benef it s, and procedure.
2. I nst ruct pat ient t o remain NPO f or a minimum of 8 hours bef ore t he
examinat ion t o f ully dilat e t he gallbladder and t o improve anat omic
visualizat ion of all st ruct ures. Some laborat ories pref er t hat t he last meal
bef ore t he st udy cont ain low quant it ies of f at .
Clin ical Alert


1. Normal diet and f luids are resumed.
OTHER BODY STRUCTURE SONOGRAM S

Breast Sonogram (Sonomammography) Ultrasound
mammography is useful for differentiating cystic, solid,
and complex lesions; in the diagnosis of disease in
women with very dense breasts; and in the follow-up
care of women with fibrocystic breast disease. It is
recommended as the initial method of examination in a
young woman with palpable mass and in a pregnant
woman with a newly palpable mass. The pregnant
patient presents a dilemma because malignancies in
pregnancy grow rapidly and the increased glandular
tissue causes difficulties in mammography. Ultrasound
may be used to evaluate women who have silicone
prostheses in their breasts. The prosthesis is readily
penetrated by the ultrasound beam, and tissues behind
the prosthesis can be examined. Such prostheses are
known to obscure masses on physical examination;
they also absorb x-ray beams, obscuring portions of
the breast parenchyma.
Breast sonography is a valuable guide during breast biopsies and needle
localizat ion procedures. Alt hough not opt imal, sonographic visualizat ion of t he
breast is an alt ernat ive f or w omen w ho ref use t o have a radiographic
mammogram and f or t hose w ho should not be exposed t o radiat ion.
Reference Values
Normal
Symmet ric echo pat t ern in bot h breast s, including subcut aneous, mammary, and
ret romammary layers
Procedure
1. Ask t he pat ient t o lie on an examinat ion t able.
2. Apply a coupling medium, usually a gel, t o t he exposed breast t o promot e
t he t ransmission of sound.
3. Move a t ransducer slow ly across t he breast . I n most laborat ories, a
handheld t ransducer is used, w hereas in some, an aut omat ed breast scanner
is used. The aut omat ed examinat ion requires t he pat ient t o assume a
posit ion w it h t he breast immersed in a t ank of w at er. The t ank cont ains
t ransducers t hat are moved by remot e cont rol t o image t he breast .
4. Tell pat ient t hat t he t ot al examining t ime is 15 minut es.
Unusual and dist inct ive echo pat t erns may indicat e t he presence of :
1. Cyst s
2. Benign solid grow t hs
3. Malignant t umors
4. Tumor met ast asis t o muscles and lymph nodes
5. Duct al ect asia
6. Enlarged lymph nodes
Interventions
1. Explain t he purpose and procedure of t he examinat ion. There is no
discomf ort involved. Many diagnost ic depart ment s show t he pat ient a
videot ape t hat explains t he t est .
2. Ask t hat t he pat ient w ear a 2-piece out f it on t he day of examinat ion because
t he garment s on t he t orso are removed bef ore t he examinat ion.
3. Explain t hat a liberal coat ing of a coupling agent must be applied t o t he skin
so t hat t here is no air bet w een t he skin and t he t ransducer and t o allow f or
Clin ical Alert

1. I f t he breast sonogram is t o be perf ormed on t he same day as a
radiographic mammogram, advise t he pat ient not t o apply any pow ders,
lot ions, or ot her cosmet ics t o t he upper body on t he day of t he
examinat ion.
2. I f t he breast sonogram is t o be used f or guidance during a biopsy, make
cert ain t hat a signed inf ormed consent is secured.
3. Sonomammography is not an appropriat e met hod f or visualizing
microcalcif icat ions.

1. The breast s are cleaned and dried, and t he pat ient is advised t o cont act her
ref erring clinician f or out comes.
2. Answ er t he pat ient 's quest ions regarding procedures and explain need f or
possible f urt her t est ing (biopsy) and t reat ment : medical, diet eliminat ion of
caff eine, or surgical (mast ect omy or lumpect omy).
Prostate Sonogram (Transurethral Ultrasound [TRUS])

The prostate sonogram is used to visualize the
prostate gland, typically in response to an elevated
concentration of prostate-specific antigen (PSA) on a
blood test or as a complement to a digital rectal
examination. Ultrasound of the prostate is also used as
a guidance mechanism for biopsy procedures and to
assist in placement of radiation seeds. Carcinoma of
the prostate is the second most common cause of
cancer-related death in American men.
The pat ient t ypically is inst ruct ed t o prepare by administ ering a Fleet enema
bef ore t he procedure. The pat ient usually is examined w it h t he use of a small
endorect al t ransducer t hat is insert ed w hile t he pat ient is in t he lef t lat eral
decubit us posit ion w it h t he knees f lexed t ow ard t he
chest . Mult iple images of t he prost at e, rect al w alls, prost at e uret hra, and
ejaculat ory duct s are t aken. Prost at ic volumes are calculat ed f rom t w odimensional (2-D) measurement s. Doppler evaluat ion is used t o assess blood
f low t hrough t he prost at e or any mass t hat might be det ect ed.
Reference Values
Normal
Normal size, volume, shape, locat ion, and echo t ext ure of prost at e and adjacent
st ruct ures
Procedure
1. Ask t he pat ient t o void and t o remove clot hing f rom t he w aist dow n.
2. Posit ion t he pat ient on an examinat ion t able in t he lef t lat eral decubit us
posit ion, w it h his knees f lexed t ow ard t he chest . The pat ient is draped.
3. Perf orm a digit al rect al examinat ion bef ore insert ing t he rect al t ransducer.
4. Caref ully insert a slim endorect al t ransducer, lubricat ed and sheat hed w it h a
condom, a f ew cent imet ers int o t he rect um.
5. Perf orm scans by using a slight rot at ion of t he probe handle. Tot al
examinat ion t ime is about 15 t o 20 minut es.
Abnormalit ies t hat may be det ect ed include:
1. Prost at ic enlargement increased volume measurement s may indicat e:
a. Benign prost at ic hypert rophy (BPH)
b. Space-occupying lesion (t umor, cyst , abscess)
2. Prost at ic calcif icat ions
3. Prost at it is
4. Prost at e cancer, classically seen as a low -level echo st ruct ure w it hin t he
out er gland (peripheral and cent ral zones)
Interfering Factors
Excess f ecal mat t er in t he rect um compromises t he st udy.
Interventions
2. Assure t he pat ient t hat no pain is involved. How ever, a sensat ion of f ullness
w it hin t he rect um is t o be expect ed. Because t he t ransducer is t ypically
draped w it hin a condom, check f or lat ex sensit ivit ies.
3. Many laborat ories require administ rat ion of a Fleet enema about 1 hour
bef ore t he st udy.
4. Advise t he pat ient t o empt y t he bladder immediat ely bef ore t he st udy.
Clin ical Alert

1. I f t he prost at e examinat ion is perf ormed in conjunct ion w it h a prost at ic
biopsy, be cert ain t o obt ain a signed inf ormed consent .
2. I f t he pat ient is lat ex sensit ive, cont act t he laborat ory.

1. I nt erpret t est out comes and counsel about any ident if ied prost at ic
abnormalit ies and need f or possible f urt her t est ing (t issue biopsy w it h
cyt ologic or hist ologic exam) and t reat ment .
Scrotal Sonogram
This noninvasive ult rasound st udy is usef ul in diagnosing t est icular masses,
varicoceles, hydroceles, spermat oceles, and diff use processes. Doppler
ult rasound or color-f low Doppler evaluat ion is helpf ul in demonst rat ing t he
presence of t orsion of t he t est es. Test icular ult rasound is used t o evaluat e
scrot al pain and t o demonst rat e t he scope of scrot al t rauma.
Reference Values
Normal
Normal scrot al st ruct ures, t est icles, epididymis, and spermat ic cord Normal
scrot al blood f low
Procedure
1. Ask t he pat ient t o lie on his back. The penis is gent ly ret ract ed, and t he
scrot um is support ed on a rolled t ow el.
2. Apply an acoust ic gel t o t he skin, t hen pass t he t ransducer repeat edly over
t he scrot um. Sonographic images are generat ed.
3. Tell pat ient t hat t ot al examinat ion t ime is about 30 minut es.
4. Use color Doppler st udies t o assess presence, absence (as in t orsion), or
increase (as in inf ect ion and cert ain neoplasms) of blood f low in t he t est icle.
Abnormal result s are associat ed w it h:
1. Abscess
2. I nf arct ed t est es (t orsion)
3. Tumor (primary and met ast at ic)
4. Hydrocele
5. Spermat ocele
6. Adherent scrot al hernia
7. Crypt orchism
8. Epididymit is (chronic or acut e), orchit is
9. Hemat oma (associat ed w it h t rauma)
10. Tuberculosis inf ect ion (associat ed w it h AI DS)
11. Test icular microlit hiasis
Interventions

2. Assure t he pat ient t hat t here is no pain involved.
3. Explain t hat a liberal coat ing of coupling media must be applied t o t he
scrot um. A sensat ion of w armt h or w et ness may be f elt . Alt hough t he
acoust ic couplant does not st ain, advise t he pat ient not t o w ear good
clot hing f or t he examinat ion.

1. I nt erpret t est out comes and counsel appropriat ely about f urt her t est ing
(nuclear scan), t reat ment , medicat ions f or inf ect ion (TB, HI V) and/ or surgery.
care.
Eye and Orbit Sonograms

Ult rasound can be used t o describe bot h normal and abnormal t issues of t he eye
w hen no alt ernat ive visualizat ion is possible because of opacit ies caused by
inf lammat ion or hemorrhage. This inf ormat ion is valuable in t he management of
eyes f or kerat oprost hesis. O rbit al lesions can be det ect ed and dist inguished
f rom inf lammat ory and congest ive causes of exopht halmos w it h a high degree of
reliabilit y. An ext ensive preoperat ive evaluat ion bef ore vit rect omy or surgery f or
vit reous hemorrhages is also done. I n t his case, t he vit reous cavit y is examined
t o rule out ret inal and choroidal det achment s and t o det ect and localize
vit reoret inal adhesions and int raocular f oreign bodies. Also, pat ient s w ho are t o
have int raocular lens implant s af t er removal of cat aract s must be measured f or
t he exact lengt h of t he eye (w it hin 0. 1 mm).
Reference Values
Normal
Pat t ern image indicat ing normal sof t t issue of eye and ret robulbar orbit al areas,
ret ina, choroid, and orbit al f at
Procedure
1. Place a small, very-high-f requency t ransducer on t he eye direct ly, or posit ion
it over a w at er st andoff pad placed ont o t he eye surf ace. Mult iple images
and measurement s are t aken.

2. Anest het ize t he eye area by inst illing eye drops.
3. Ask t he pat ient t o f ix t he gaze and hold very st ill.
4. Place a probe gent ly on t he corneal surf ace.
5. Tell t he pat ient t hat if a lesion in t he eye is det ect ed, as much as 30 minut es
may be required t o diff erent iat e t he pat hologic process accurat ely.
O t herw ise, orbit al examinat ions can be done in 8 t o 10 minut es.
1. Abnormal pat t erns are seen in:
a. Alkali burns w it h corneal f lat t ening and loss of ant erior chamber
b. Det ached ret ina
c. Kerat oprost hesis
d. Ext raocular t hickening in t hyroid eye disease
e. Pupillary membranes
f. Cyclot ic membranes
g. Vit reous opacit ies
h. O rbit al mass lesions
i. I nf lammat ory condit ions
j. Vascular malf ormat ions
k. Foreign bodies
2. Abnormal pat t erns are also seen in t umors of various t ypes based on
specif ic ult rasonic pat t erns:
a. Solid t umors (eg, meningioma, glioma, neurof ibroma)
b. Cyst ic t umors (eg, mucocele, dermoid, cavernous hemangioma)
c. Angiomat ous t umors (eg, diff use hemangioma)
d. Lymphangioma
e. I nf ilt rat ive t umors (eg, met ast at ic lymphoma, pseudot umor)
Interfering Factors
I f at some t ime t he vit reous humor in a part icular pat ient has been replaced by a
gas, no result can be obt ained.
Interventions
2. I nst ill t opical anest het ic drops int o t he eyes bef ore t he examinat ion is
perf ormed; t his usually is done in t he examining depart ment .

1. I nst ruct t he pat ient t o ref rain f rom rubbing t he eyes unt il t he eff ect s of
anest het ic have disappeared. This t ype of f rict ion could cause corneal
abrasions.
2. Advise t he pat ient t hat minor discomf ort and blurred vision may be
experienced f or a short t ime. Counsel regarding possible f urt her t est ing
and/ or t reat ment f or inf ect ion (medical or surgical f or det ached ret ina).
Clin ical Alert

When a rupt ured globe is suspect ed, opht halmic ult rasound should not be
perf ormed. Excessive pressure applied t o t he globe may cause expulsion of
t he cont ent s and increases t he risk f or int roduct ion of bact eria.
Thyroid Sonogram (Neck Ultrasound) This ultrasound

study is used to evaluate a neck mass or to determine
the size of the thyroid and reveal the depth and
dimension of thyroid goiters and nodules. The
response of a mass in the thyroid to suppressive
therapy can be monitored by successive examinations.
Theoretically, this technique offers the possibility of a
good estimation of thyroid weightinformation that is
important in radioiodine therapy for Graves' disease.
The examinat ion is easy t o do, is of t en done bef ore surgery, and gives 85%
accuracy. O f t en, t hese st udies are done in conjunct ion w it h radioact ive iodine
upt ake t est s. Wit h pregnant pat ient s, ult rasound st udies are t he met hod of
choice because radioact ive iodine is harmf ul t o t he developing f et us.
Reference Values
Normal
Normal, homogenous pat t ern of t hyroid and adjacent st ruct ures, including st rap
muscles and blood vessels
Procedure
1. Have t he pat ient lie on t he back on t he examining t able, w it h t he neck
hyperext ended.
2. Place a pillow under t he shoulders f or comf ort and t o bring t he t ransducer
int o bet t er cont act w it h t he t hyroid.
3. Apply an acoust ic couplant (gel, lot ion, or oil) t o t he pat ient 's neck. This
aff ords good cont act bet w een t he t ransducer and t he pat ient 's skin and
allow s t he t ransducer t o be moved easily across t he neck's surf ace. An
alt ernat e procedure involves separat ion of t he neck surf ace f rom t he
t ransducer by a gel-f illed pad t hat permit s proper t ransmission of t he
ult rasound w aves t hrough t he t hyroid.
1. An abnormal pat t ern may consist of a cyst ic, complex, or solid echo pat t ern.
2. Solit ary cold nodules ident if ied on radioisot ope scans may appear as echof ree cyst s on ult rasound. Most of t en, cyst s are benign. Solid-appearing
lesions may represent benign adenomas or malignant t umors. A biopsy is t he
only def init ive met hod t o det ermine t he nat ure of such t umors.
3. O verall gland enlargement is indicat ive of goit er or t hyroidit is.
4. Sonographic st udies of t he neck may also reveal parat hyroid lesions or
evidence of changed lymph nodes.
5. Cert ain congenit al def ormit ies relat ed t o t he embryologic development of
neck st ruct ures may be det ect ed, most commonly t hyroglossal duct cyst ,
brachial clef t cyst , or cyst ic hygroma.
Interfering Factors
1. Nodules < 1 cm in diamet er may escape det ect ion.
2. Cyst s not originat ing in t he t hyroid may show t he same ult rasound
charact erist ics as t hyroid cyst s.
3. Lesions > 4 cm in diamet er f requent ly cont ain areas of cyst ic or hemorrhagic
degenerat ion and give a mixed echogram t hat is diff icult t o correlat e w it h
specif ic disease.
Interventions
f eel uncomf ort able maint aining t he neck posit ion during t he examinat ion.
4. Advise t he pat ient t o ref rain f rom w earing necklaces t o t he laborat ory.
Clin ical Alert

Thyroid or neck biopsies are of t en perf ormed w it h ult rasound guidance. I f a
biopsy is perf ormed, a w it nessed, inf ormed consent must be signed in
advance by t he pat ient .

1. I nt erpret t est out comes and counsel about f ollow -up t est ing (t hyroid nuclear
scans) or t reat ment f or t hyroid (surgical removal) or neck abnormalit ies.
care.
VASCULAR ULTRASOUND STUDIES (DUPLEX SCANS)
Overview of Duplex Scans The

combination of anatomic imaging of blood
vessels and hemodynamic information
provided by Doppler ultrasound results in
duplex scans. These noninvasive studies
can be performed on literally any area of
human anatomy. Blood velocity is detected
by positioning the Doppler sample gate
within the lumen of the desired vessel. The
resultant spectral trace (Fig. 13.1) also
provides information as to the direction,
phase, pulsatile rhythm, and resistivity of
flow. Antegrade flow is demonstrated
above the baseline. Retrograde flow (ie,
flow in the direction opposite then
expected) is demonstrated by a spectral
trace below the baseline. Flow that is
antegrade through all phases (systole as
well as diastole) demonstrates a lowresistive profile, which is normally
associated with many visceral blood
vessels (eg, renal artery, internal carotid
artery). High-resistance, or triphasic, flow

is typically associated with peripheral
arteries (eg, femoral artery, brachial artery)
and shows a forward-backward-forward
pattern in each cycle. Spectral broadening
occurs when the sample contains blood
cells moving at many velocities; this is
generally associated with a flow
disturbance. Mathematical ratios that
contrast peak or mean velocities at various
stages in the cycle can give further clues
to the integrity of the vascular system
examined. Color Doppler ultrasound
generally is used to code flow velocities
and direction with color and can readily
differentiate the patency of vessels. B-flow
is a technique that images the blood itself
and has an enhanced ability to display
plaque margins.
FI G URE 13. 1 Blood velocit y t racings show direct ion, phasicit y, pulsat ilit y,
and resist ivit y of f low.
Cerebrovascular Ultrasound (Carotid and Vertebral

Arteries) Duplex Scans Carotid duplex scans examine
the major extracranial arteries supplying the brain to

gain information about cerebrovascular blood flow.
Carotid scans are used in the evaluation of ischemia,
headache, dizziness, hemiparesis, paresthesias, and
speech and visual disturbances. Testing is commonly
performed before major cardiovascular surgery and as
a follow-up to many surgeries.
Reference Values
Normal
Normal vascular anat omy and course of common carot id art ery, int ernal and
ext ernal carot ids, and vert ebral art eries No evidence of st enosis or occlusion;
normal f low pat t erns
Procedure
1. Ask t he pat ient t o lie on t he examining t able w it h t he neck slight ly ext ended.
The head t ypically is t urned aw ay f rom t he side being examined.
2. Apply an acoust ic coupling gel t o t he neck area t o enhance t he t ransmission
of sound. During Doppler evaluat ion, an audible signal, represent ing blood
f low, can be heard.
3. Move a handheld t ransducer gent ly up and dow n t he neck w hile images of
appropriat e blood vessels are made. Examine bot h sides of t he neck.
4. Tell pat ient t hat t he examinat ion t ime is 30 t o 60 minut es.
Abnormal images and Doppler signals may provide evidence of t he f ollow ing:
1. Plaque
2. St enosis
3. O cclusion
4. Dissect ion
5. Aneurysm
6. Carot id body t umor
7. Art erit is
Interfering Factors
1. Severe obesit y and pat ient movement compromise examinat ion qualit y.
2. Cardiac arrhyt hmias and disease may cause changes in hemodynamic
pat t erns.
Interventions
1. Explain t he t est purpose, benef it s, and procedure. Pat ient should ref rain
f rom smoking or consuming caff eine f or at least 2 hours bef ore t he st udy.
Assure t he pat ient t hat no radiat ion is employed, t ypically no cont rast
medium is inject ed, and no pain is involved. Some slight discomf ort may be
experienced f rom lying w it h head ext ended.
2. Advise t he pat ient t hat a liberal coat ing of coupling gel must be applied t o
t he skin t o promot e sound t ransmission. A sensat ion of w armt h or w et ness
may be f elt during applicat ion. Alt hough t he acoust ic couplant does not st ain,
advise t he pat ient not t o w ear good clot hing f or t he examinat ion. Necklaces
and earrings must be removed bef ore t he st udy.

1. Remind t he pat ient t o remove any residual gel f rom t he skin.
2. I nt erpret t est out comes, provide support , and counsel appropriat ely should
an abnormalit y be det ect ed. Monit or and counsel f or art erial disease and
possible f urt her t est ing (art eriogram) and t reat ment (surgery).
Peripheral Arterial Doppler Studies; Lower Extremity

Arterial (LEA) and Upper Extremity Arterial (UEA)
Duplex Scans Peripheral arterial studies visualize and

document the arterial blood flow in the extremities.
Duplex ultrasound scans can determine the presence,
amount, and location of plaques and are helpful in
assessing the cause of claudication. Graft patency and
condition may also be evaluated. Ultrasound analysis
is used to evaluate the site of a prior surgical or
percutaneous intervention. Some institutions also
incorporate segmental blood pressure readings into
these examinations. Flow characteristics of upper
versus lower extremities can be contrasted by
calculating a mathematical ratio between pressures
(see Ankle-Brachial Index and Segmental Pressures,
page 892).
Reference Values
Normal
Normal art erial anat omy of t he ext remit y Normal t riphasic blood f low and f low
velocit ies No evidence of plaques or ot her pat hologic processes
Procedure
1. Ask t he pat ient t o lie on t he examining t able w it h t he leg or arm t urned out
slight ly and t he knee or elbow part ially bent .
2. Apply an acoust ic coupling gel t o t he leg f rom groin dow n or t o t he arm f rom
shoulder dow n t o enhance t he t ransmission of sound. During Doppler
evaluat ion, an audible signal, represent ing blood f low, can be heard.
3. Move a handheld t ransducer gent ly up and dow n t he limb w hile images of
appropriat e blood vessels are made. Examine bot h sides.
5. For all procedures, see Chapt er 1 guidelines f or i ntratest.
Abnormal t racings (see Fig. 13-1) and Doppler signals may provide evidence of
t he f ollow ing:
1. Plaque or calcif icat ion (part icularly in t he diabet ic pat ient )
2. St enosis (hemodynamically signif icant lesions produce > 50% st enosis)
3. O cclusion
4. Art erit is
5. Aneurysm
6. Pseudoaneurysm
7. G raf t diamet er reduct ion
8. Abnormal communicat ion bet w een art ery and vein
Interfering Factors
1. Severe obesit y compromises examinat ion qualit y.
pat t erns.
Interventions
1. Explain t he t est purpose, benef it s, and procedure. I nst ruct t he pat ient t o
ref rain f rom smoking or consuming caff eine f or at least 2 hours bef ore t he
t est . Assure t he pat ient t hat no radiat ion is employed, t ypically no cont rast
medium is inject ed, and no pain is involved. Some slight discomf ort may be
experienced f rom lying w it h t he ext remit y ext ended or if segment al blood
pressures are t aken.
advise t he pat ient not t o w ear good clot hing f or t he examinat ion.

possible f urt her t est ing (art eriogram or venogram) and t reat ment (surgery).
Ankle-Brachial Index (ABI) and Segmental Pressures In

some laboratories, as an adjunct to duplex scanning,
blood pressures throughout the extremities are
measured and contrasted. In the typical four-cuff
technique, pneumatic cuffs are applied to the upper
thigh, the lower thigh, the upper calf, and the area just
above the ankle. Additionally, cuffs are applied to the
upper arms to determine brachial pressures. Segmental
pressures provide physiologic information that can
confirm a vascular cause for ischemic rest pain and
claudication.
The ankle-brachial index (ABI) is calculated by dividing
the ankle pressure (in mm Hg) by the brachial
pressure. Many laboratories perform a resting ABI
followed by an exercise ABI.
Reference Values
Normal
ABI > 1. 0 w hen a normal mult iphasic w avef orm is present A diff erence of 20 mm
Hg (or 20 t orr) bet w een t he right and lef t brachial pressures may indicat e
proximal art erial obst ruct ion on t he side w it h reduced pressure
The gradual pressure drop, as measured f rom upper t high or arm t o ankle or
w rist , should not exceed 20 mm Hg (or 20 t orr) bet w een any t w o segment s
Procedure
1. Ask t he pat ient t o lie on t he t able w it h t he ext remit y ext ended.
2. Place pneumat ic cuff s (usually f our) at int ervals along t he ext remit y.
3. Place a f low -sensing device (of t en a cont inuous-w ave Doppler device) dist al
t o a cuff . I nf lat e t he cuff (t his is of t en done aut omat ically) t o suprasyst olic
values and t hen slow ly def lat e unt il f low resumes. Record t he pressure at
w hich f low resumes.
4. Repeat t his t echnique, dist al t o each cuff , unt il t he ent ire ext remit y has been
evaluat ed. Measure brachial pressures as w ell.
5. Examine bot h ext remit ies.
6. Tell t he pat ient t hat t he t ot al examinat ion t ime (f or pressures only) is
generally < 15 minut es. I f an exercise/ st ress ABI is ordered, t he at -rest
st udy w ill be f ollow ed by exercise. Af t er w alking f or 5 minut es on a t readmill,
t he ABI procedure is repeat ed.
1. Asymmet ry in brachial pressure > 10 mm Hg (>10 t orr) is suspicious f or
art erial disease.
2. ABI < 1. 0 is suspicious f or disease. The low er t he numeric value f or t his
index, t he more severe t he disease may be (eg, ABI < 0, associat ed w it h
impending t issue loss).
3. G enerally speaking, pressure gradient s bet w een successive segment s on t he
same ext remit y should vary by < 20 mm Hg (<20 t orr). Variat ions t hat
exceed t his value suggest signif icant disease (occlusion or st enosis).
4. A diff erence of > 20 mm Hg (>20 t orr) bet w een similar segment s on opposit e
sides may suggest obst ruct ive vascular disease.
Clin ical Alert

1. Segment al pressures are a screening t ool t hat cannot dist inguish st enosis
f rom t ot al occlusion and cannot be specif ic in det ermining t he exact
locat ion of disease.
2. Vessel calcif icat ions (commonly seen in t he diabet ic pat ient ) can f alsely
elevat e syst olic pressures.
Interfering Factors

pat t erns.
Interventions
ref rain f rom smoking or consuming caff eine f or at least 2 hours bef ore t he
st udy. Assure pat ient t hat no radiat ion is employed, t ypically no cont rast
medium is inject ed, and no pain is involved. Some discomf ort may be
experienced f rom lying w it h t he ext remit y ext ended or w hen pneumat ic cuff s
are inf lat ed.

explain need f or possible f urt her t est ing (art eriogram) and t reat ment
(medical or surgical).
Peripheral Venous Doppler Studies; Lower Extremity

Venous (LEV) and Upper Extremity Venous (UEV)
Duplex Scans This procedure examines venous blood
flow in the selected extremity (upper or lower). It is
most commonly used to assess deep venous
thrombosis and can also be used to map veins to be
harvested and used for grafts. Peripheral ultrasound is
also used to locate veins for venous access and to
assess dialysis access grafts. This examination has
replaced contrast venography in many institutions.
Reference Values
Normal Duplex Scan
Normal venous anat omy of t he ext remit y Spont aneous phasic f low pat t ern (rises
and f alls w it h respirat ion) Normal venous augment at ion (exhibit s increased f low
proximal t o t he sit e of venous compression) Compet ent , int act valves, w it h no
evidence of t hrombi
Procedure
1. Ask t he pat ient t o lie on t he examining t able w it h t he leg or arm t urned out
slight ly and t he knee or elbow part ially bent .
2. Apply an acoust ic coupling gel t o t he leg f rom t he groin dow n or t o t he arm
f rom t he shoulder area dow n t o enhance t he t ransmission of sound. During
Doppler evaluat ion, an audible signal, represent ing blood f low, can be heard.
3. Move a handheld t ransducer gent ly up and dow n t he limb w hile images of
appropriat e blood vessels are made. At int ervals, apply gent le compression
t o t he vessel. Examine bot h sides.
Abnormal images and Doppler signals may provide evidence of t he f ollow ing:
1. Acut e or chronic deep venous t hrombosis
2. O cclusive venous disease
3. Valvular incompet ence
4. Clot t ed graf t s
Interfering Factors
pat t erns.
Interventions
ref rain f rom smoking f or at least 2 hours bef ore t he st udy. Assure t he pat ient
t hat no radiat ion is employed, t ypically no cont rast medium is inject ed, and
no pain is involved. Some slight discomf ort may be experienced f rom lying
w it h t he ext remit y ext ended or w hen compression is applied.
advise t he pat ient not t o w ear good clot hing f or t he examinat ion.

an abnormalit y be det ect ed. Monit or and counsel f or venous disease and
need f or possible f urt her t est ing and/ or t reat ment (medical, drugs, or
surgical).
HEART ULTRASOUND STUDIES

Heart Sonogram (Echocardiogram; Doppler
Echocardiography) This noninvasive technique for
examining the heart can provide information about its
position and size, movements of the valves and
chamber, and velocity of blood flow. Echoes from
pulsed high-frequency sound waves are used to locate
and study the movements and dimensions of cardiac
structures. Because the heart is a blood-filled organ,
sound can be transmitted through it readily to the
opposite wall and to the heart-lung interface. This test
is commonly used to determine biologic and prosthetic
valve dysfunction, to evaluate a pericardial effusion, to
evaluate the velocity and direction of blood flow, to
furnish direction for further diagnostic study, and to
monitor cardiac patients over an extended period.
Echocardiography is also used to monitor heart failure
patients relying on a left ventricular assist device
(LVAD). One of the advantages of this diagnostic
technique is that it can be performed at the bedside
with mobile equipment or can be done in the
laboratory.
The various modes of echocardiography are capable of providing a great range
of inf ormat ion concerning cardiac st ruct ure and f unct ion. The f ollow ing are
common t ypes of echocardiograms: Two-di mensi onal (2-D): used t o produce
gray-scale, cross-sect ional images of t he heart 's anat omy M-mode: used t o
generat e depict ions of rapidly moving st ruct ures such as valves and f or
st andardized dimensional measurement s Conti nuous-wave Doppl er and pul sedwave Doppl er: used t o det ermine velocit y of blood f low
Col or 2-D: used f or ident if ying areas of dist urbed or eccent ric blood f low Col or
M-mode: used f or evaluat ing movement of cardiac st ruct ures Specialized t ypes
of echocardiography include: Stress echocardi ography: used t o provide
inf ormat ion relat ing t o t he f unct ion of heart st ruct ures during high cardiac out put
st at es. A t readmill or upright bicycle may be used, or t he heart can be st ressed

by an inf usion of dobut amine.
Transesophageal echocardi ography (TEE): A miniat ure ult rasound t ransducer is
placed at t he end of a t ube insert ed int o t he esophagus t o provide a closer view
of cardiac st ruct ures w it hout int erf erence f rom superf icial chest t issues (see
page 897).
Fetal echocardi ography: perf ormed t hrough t he pregnant w oman's abdomen
w hen t here is a quest ion of congenit al cardiac def ect (see page 870).
Contrast echocardi ography: A liquid cont aining nont oxic microbubbles is inject ed
int o a vein t o opacif y cardiac st ruct ures.
These special t echniques may require a signed, inf ormed consent bef ore
perf ormance and involve more complicat ed procedures. Check w it h t he individual
laborat ory f or specif ic guides and prot ocols.
Reference Values
Normal
Normal posit ion, size, and movement of heart valves and chamber w alls as
visualized in 2-D, M-mode, and Doppler mode Color M-mode and color Doppler
assessment s of heart st ruct ures w it hin normal limit s
Procedures
1. Ensure t hat a specif ic diagnosis accompanies t he request f or t he t est (eg,
rule out pericardial eff usion, det ermine severit y of mit ral st enosis). I f a
st ress echocardiogram is ordered, t he pat ient 's abilit y t o perf orm exercise
must be indicat ed.
2. Ask t he pat ient t o lie on t he examining t able in a slight side-lying posit ion.
3. Apply an acoust ic gel t o t he skin surf ace over t he chest t o permit maximum
penet rat ion of t he ult rasound beam. Hold t he t ransducer over various regions
of t he chest and upper abdomen t o obt ain t he appropriat e view s of t he heart .
4. Tell t hat pat ient t hat t here should be no pain or discomf ort involved. Leads
may be at t ached f or a simult aneous elect rocardiogram reading during t he
ult rasound procedure.
5. Tell t he pat ient t hat t he examinat ion t ime is 30 t o 45 minut es.
Abnormal values help t o diagnose:

1. Acquired cardiac disease
a. Valvular disease, st enosis insuff iciency, prolapse, and regurgit at ion
b. Cardiomyopat hies
c. Evidence of coronary art ery disease
d. Pericardial disease, including eff usion, t amponade, and pericardit is
e. Endocardit is
f. Cardiac neoplasm
g. I nt racardiac t hrombi
2. Prost het ic valve f unct ion
3. Congenit al heart disease
Interfering Factors
1. Dysrhyt hmias int erf ere w it h t he t est .
2. Hyperinf lat ion of t he lungs w it h mechanical vent ilat ion, especially w it h
posit ive end-expirat ory pressure (PEEP) > 10 cm H2 O , precludes adequat e
ult rasound imaging of t he heart .
3. False-negat ive and f alse-posit ive diagnoses have been ident if ied (especially
in M-mode echocardiograms), including diagnoses of pleural eff usion, dilat ed
descending aort a, pericardial f at pad, t umors encasing t he heart , clot t ed
blood, and loculat ed eff usions.
4. Doppler st udy result s can vary great ly if t he t ransducer posit ion does not
provide sat isf act ory angles f or t he beam.
Interventions
2. Assure t he pat ient t hat no pain is involved. How ever, some discomf ort may
be f elt f rom lying quiet ly f or a long period.
t hat t here is no air bet w een t he skin and t he t ransducer and t o permit easy
movement of t he t ransducer over t he skin. A sensat ion of w armt h or w et ness

may be f elt . Alt hough t he acoust ic couplant does not st ain, advise t he pat ient
not t o w ear good clot hing f or t he examinat ion.
Clin ical Alert

Cert ain specialized echocardiographic procedures, such as st ress
echocardiography and TEE, may require individualized pat ient preparat ion.
Check w it h t he laborat ory t o det ermine specif ic prot ocols and preparat ion.

1. I nt erpret t est out comes and counsel appropriat ely about cardiac disorders
and explain need f or possible f urt her t est ing and/ or t reat ment (medical,
drugs, or surgical).
Transesophageal Echocardiogram (TEE) TEE permits

optimal ultrasonic visualization of the heart when
traditional transthoracic (noninvasive)
echocardiography fails or proves inconclusive. A
miniaturized high-frequency ultrasound transducer is
mounted on an endoscope and coupled with an
ultrasound instrument to display and record ultrasound
images from the heart. Endoscope controls allow
remote manipulation of the transducer tip. Various
images of heart anatomy can be displayed by rotating
the tip of the instrument and by varying the depth of
insertion into the esophagus.
I ndicat ions f or TEE include t he f ollow ing:
1. To assess f unct ion of prost het ic valves, diagnose endocardit is, evaluat e
valvular regurgit at ion and congenit al abnormalit ies, and examine t he aort a f or
dissect ing aneurysms
2. To monit or lef t vent ricular w all mot ion int raoperat ively
3. To measure eject ion f ract ion in select ed pat ient s

4. Sit uat ions in w hich a t ranst horacic echocardiogram has not been sat isf act ory
(eg, obesit y, chest w all t rauma, chronic obst ruct ive pulmonary disease)
5. When result s of t radit ional t ranst horacic echocardiography do not agree or
correlat e w it h ot her clinical f indings
Reference Values
Normal
Normal posit ion, size, and f unct ion of heart valves and heart chambers
Procedure
1. Apply a t opical anest het ic t o t he pharynx. I nsert a bit e block int o t he mout h.
This reduces t he risk f or damage t o t he pat ient 's t eet h and oral st ruct ures
and accident al damage t o t he endoscope.
2. Ask t he pat ient t o assume a lef t lat eral decubit us posit ion w hile t he
lubricat ed endoscopic inst rument is insert ed t o a dept h of 30 t o 50 cm. Ask
t he pat ient t o sw allow t o f acilit at e advancement of t he device.
3. Manipulat e t he ult rasound t ransducer t o provide a number of image planes.
4. For all procedures, see Chapt er 1 guidelines f or i ntratest care.
Procedu ral Alert

A variet y of medicat ions may be used during t his procedure. G enerally, t hese
drugs are int ended t o sedat e, anest het ize, reduce secret ions, and serve as
cont rast agent s f or t he ult rasound. (See Appendix A. )
Abnormal TEE f indings include:
1. Heart valve disease: st enosis, insuff iciency, prolapse, and regurgit at ion
2. Pericardial eff usion, pericardit is, t amponade
4. Aort ic dissect ion
5. Lef t vent ricular dysf unct ion
6. Endocardit is
7. I nt racardiac t umors or t hrombi
Interventions
1. Explain t he purpose, procedure, and t he benef it s and risks of t he t est .
2. The pat ient must remain NPO f or at least 4 t o 8 hours bef ore t he procedure
t o reduce t he risk f or aspirat ion. Pret est medicat ion such as analgesics or
sedat ives may be ordered. Check w it h t he laborat ory or physician f or
specif ic inst ruct ions.
3. O bt ain baselines vit al signs.
4. Est ablish an int ravenous access line t o administ er medicat ions or cont rast
agent s.
5. Remove dent ures and any loose object s f rom pat ient 's mout h.
Patient Posttest Aftercare

1. I nt erpret t est result s; monit or vit al signs and level of consciousness (if t he
pat ient is sedat ed). Ensure pat ent airw ay. Explain need f or possible f urt her
t est ing and/ or t reat ment : medical (drugs) or surgical (eg, cardiac
cat het erizat ion).
2. Posit ion t he pat ient on t he side, if sedat ed, t o prevent risk f or aspirat ion.
3. Ascert ain ret urn of sw allow ing, coughing, and gag ref lexes bef ore allow ing
pat ient t o t ake oral f ood or f luids. G enerally, t he pat ient should remain NPO
f or at least 1 hour af t er t he t est .
Clin ical Alert

Sw allow ing ref lexes may be diminished f or several hours because of t he
eff ect s of t he t opical anest het ic.
BIBLIOGRAPHY
Allen M, Kaw amura DM, Craig M, Berman MC: Diagnost ic Medical
Sonography: Echocardiography. Philadelphia, Lippincot t Williams & Wilkins,
1998
Berman MC: Diagnost ic Medical Sonography: O bst et rics and G ynecology, 2nd
ed. Philadelphia, Lippincot t -Raven Publishers, 1997
Blut h EI : Ult rasound: A Pract ical Approach t o Clinical Problems. New York,
Thieme, 2000
D'Cruz I A: Echocardiographic Anat omy. St amf ord, CT, Applet on & Lange,
1996
Drose JA: Fet al Echocardiography. Philadelphia. WB Saunders, 1998
Fleischer AC: Sonography in O bst et rics and G ynecology, 6t h ed. New York,
McG raw -Hill, 2001
G oroll AH, May LA, Mully AG : Primary Care Medicine, O ff ice Evaluat ion and
Management of Adult Pat ient , 4t h ed. Philadelphia, Lippincot t Williams &
Wilkins, 2001
Herrera CJ, Wagner C: The Pract ice of Clinical Echocardiography, 2nd ed.
Kaw amura DM: Diagnost ic Medical Sonography: Abdomen and Superf icial
St ruct ures. Philadelphia, Lippincot t -Raven Publishers, 1997
Kremkaw FW: Diagnost ic Ult rasound Principles and I nst rument s, 6t h ed.
Kurjak A, Kupesic S: Clinical Applicat ion of 3D Sonography. New York, CRC
Press, 2000
Kurt z AB, Middlet on WD: Ult rasound: Radiology Requisit es Series. St . Louis,
Mosby, 1996
Lanf ranchi ME: Breast Ult rasound. New York, Marban Books, 2000
Leeman LM, Wendland CL: Cervical ect opic pregnancy: Diagnost ic w it h

endovaginal ult rasound examinat ion and successf ul t reat ment w it h
met hot rexat e. Arch Fam Med, 9: 7277, 2000
Madden ME: I nt roduct ion t o Sect ional Anat omy. Philadelphia, Lippincot t
Rumak CM, Charboneau JW, Wilson SR: Diagnost ic Ult rasound, 2nd ed. St .
Louis, CV Mosby, 1998
Sanders RC: Ult rasound. Philadelphia, Lippincot t Williams & Wilkins, 2001
INTERNET SITES
w w w. acr. org
w w w. aunt minnie. com
w w w. int elihealt h. com
w w w. w ebmd. com

Wilkins
> Table of C ontents > 14 - P ulm onar y Func tion, Ar ter ial B lood Gas es ( AB Gs ) , and E lec tr olyte S tudies
14
Pulmonary Function, Arterial Blood Gases
(ABGs), and Electrolyte Studies
OVERVIEW OF BLOOD GASES, ACID-BASE BALANCE,
AND OXYGENATION STATUS (TISSUE OXYGENATION,
GAS EXCHANGE IN LUNGS) Diagnostic evaluations of
body fluid balance, electrolytes, lung ventilatory
function, blood gas exchange in the lungs, oxygen
tissue saturation by pulse oximetry, and acid-base
balance are important determinants of normal body
function (homeostasis). Homeostatic mechanisms are
affected by a variety of exogenous (originating from
w ithout, eg, stress) and endogenous (originating from
w ithin, eg, immune system) factors. Evidence supports
a strong association betw een stress and altered
immune function, w hich can subsequently lead to
abnormal pathophysiology observable by a w ide array
of diagnostic tests. Abnormal test outcomes in
hospitalized patients, as w ell as w hen complications of
treatment occur (as in kidney and respiratory diseases,
diabetes, anemia), gastric fluid loss, medication
diuretics, sepsis, and fever, for this reason are
discussed in this chapter. Other factors that need to be
assessed include respiratory rate, fluid intake, urine
output, amount of w ater diarrhea, emesis, w eight gain
or loss, presence of burned or excoriated skin, food
intake, and evidence of dehydration edema.
PULM ONARY FUNCTION TESTS

Pulmonary Physiology
There are t hree aspect s of pulmonary f unct ion: perf usion, diff usion, and
vent ilat ion. Perf usi on relat es t o blood f low t hrough pulmonary vessels; di f f usi on
ref ers t o movement of oxygen and carbon dioxide across alveolar capillary
membranes; and venti l ati on relat es t o air exchange bet w een alveolar spaces and
t he at mosphere.
During breat hing, t he lung-t horax syst em act s as a bellow s t o provide air t o t he
alveoli f or adequat e gas exchange t o t ake place. Like a spring or rubber band,
t he lung t issue also possesses t he propert y of elast icit y. When t he inspirat ory
muscles cont ract , t he t horax and lungs expand; w hen t he same muscles relax
and t he f orce is removed, t he t horax and lungs ret urn t o t heir rest ing posit ion.
Also, w hen t he t horax and lungs expand, t he alveolar pressure is low ered below
at mospheric pressure. This permit s air t o f low int o t he t rachea, bronchi,
bronchioles, and alveoli. Expirat ion is mainly passive. I t occurs because t he
t horax and lungs recoil t o t heir rest ing posit ion: t he alveolar pressure increases
above at mospheric pressure, and air f low s out t hrough t he respirat ory t ract . The
major f unct ion of t he lung is t o provide adequat e vent ilat ion t o meet t he
met abolic demands of t he body during rest and during exercise. The primary
purpose of pulmonary blood f low is t o conduct mixed venous blood t hrough t he
capillaries of t he alveoli so t hat oxygen (O2 ) can be t aken up by t he blood and
carbon dioxide (CO2 ) can be removed f rom t he blood.
Purpose of Tests
Pulmonary f unct ion t est s det ermine t he presence, nat ure, and ext ent of
pulmonary dysf unct ion caused by obst ruct ion, rest rict ion, or bot h. When
vent ilat ion is dist urbed by an increase in airw ay resist ance, t he vent ilat ory def ect
is called an obstructi ve vent ilat ory impairment . When vent ilat ion is dist urbed by a
limit at ion in chest w all excursion, t he def ect is ref erred t o as a restri cti ve
vent ilat ory impairment . When vent ilat ion is alt ered by bot h increased airw ay
resist ance and limit ed chest w all excursion, t he def ect is t ermed a combi ned or
mi xed def ect . Table 14. 1 present s t he condit ions t hat aff ect vent ilat ion.
Table 14.1 Conditions That Affect Ventilation
Exam ples
Causes
REST RICT IVE

VENT ILATORY
IMPAIRMENT S*
Chest wall disease
Injury, kyphoscoliosis,
spondylitis, muscular
dystrophy, other neuromuscular
diseases
Extrathoracic
conditions
Obesity, peritonitis, ascites,

pregnancy
Interstitial lung
disease
Interstitial pneumonitis, fibrosis,

pneumoconioses
(eg, asbestosis, silicosis),
granulomatosis,
edema, sarcoidosis
Pleural disease
Pneumothorax, hemothorax,
pleural effusion,
fibrothorax
Space-occupying
lesions
Tumors, cysts abscesses
OBST RUCT IVE

VENT ILATORY
IMPAIRMENT S
Peripheral airway
disease
Bronchitis, bronchiectasis,
bronchiolitis, bronchial
asthma, cystic fibrosis
Pulmonary
parenchymal
disease
Emphysema
Upper airway
disease
Pharyngeal, tracheal or
laryngeal tumors, edema,
infections, foreign bodies,
collapsed airway,
stenosis
MIXED-DEFECT
VENT ILATORY
IMPAIRMENT S
Pulmonary
congestion
Both increased airway

resistance and limited
expansion of chest cavity and/or
chest wall;
obstruction caused by bronchial
edema,
compression of respiratory
airway owing to
increased interstitial (and
intravenous fluid)
pressure; restriction caused by
impaired
elasticity, anatomic deformity

(eg, kyphosis,
lordosis, scoliosis)
*Characterized by interference with chest wall or lung

movement, "stiff lung," and an actual reduction in the
volume of air that can be inspired.
Characterized by the need for increased effort to
produce airflow; respiratory muscles must work harder
to overcome obstructive forces during breathing;
prolonged and impaired airflow during expiration; airway
resistance increases and lungs become very compliant.
Combined or mixed; exhibits components of both
obstructive and restrictive ventilatory impairments.
Pulmonary f unct ion st udies may reveal locat ions of abnormalit ies in t he airw ays,
alveoli, and pulmonary vascular bed early in t he course of a disease, w hen t he
physical examinat ion and radiographic st udies st ill appear normal.
Indications for Tests

1. Early det ect ion of pulmonary or cardiogenic pulmonary disease (see Table
14. 1)
2. Diff erent ial diagnosis of dyspnea
3. Presurgical assessment (eg, abilit y t o t olerat e int raoperat ive anest het ics,
especially during t horacic procedures)
4. Evaluat ion of risk f act ors f or ot her diagnost ic procedures
5. Det ect ion of early respirat ory f ailure
6. Monit oring progress of bronchopulmonary disease
7. Periodic evaluat ion of w orkers exposed t o mat erials harmf ul t o t he

respirat ory syst em
8. Epidemiologic st udies of select ed populat ions t o det ermine risks f or or
causes of pulmonary diseases
9. Workers' compensat ion claims
10. Monit oring af t er pharmacologic or surgical int ervent ion
Classification of Tests Pulmonary function tests

evaluate the ventilatory system and alveoli in an
indirect, overlapping way. The patient's age, height,
weight, ethnicity, and gender are recorded before
testing because they are the basis for calculating
predicted values.
Pulmonary f unct ion t est s are generally divided int o t hree cat egories:
1. Ai rway f l ow rates t ypically include measurement s of inst ant aneous or
average airf low rat es during a maximal f orced exhalat ion t o assess airw ay
pat ency and resist ance. These t est s also assess responses t o inhaled
bronchodilat ors or bronchial provocat ions.
2. Lung vol umes and capaci ti es measure t he various ai r-contai ni ng
compartments of t he lung t o assess air-t rapping (hyperinf lat ion,
overdist ent ion) or reduct ion in volume. These measurement s also help t o
diff erent iat e obst ruct ive f rom rest rict ive vent ilat ory impairment s.
3. G as exchange (di f f usi on capaci ty) measures t he rat e of gas t ransf er across
t he alveolar capillary membranes t o assess t he diff usion process. I t can also
monit or f or side eff ect s of drugs, such as bleomycin (ant ineoplast ic) or
amiodarone (ant iarrhyt hmic), w hich can cause int erst it ial pneumonit is or
pulmonary f ibrosis. Diff usion capacit y in t he absence of lung disease (eg,
anemia) can also be evaluat ed.
Symbols and Abbreviations Pulmonary function studies

and blood gas analyses measure quantities of gas
mixtures and their components, blood and its
constituents, and various factors affecting these
quantities. The symbols and abbreviations given here
are based on standards developed by American
physiologists. Familiarity with the major and secondary

symbols facilitates interpretation of any combination of
these symbols (see Chart 14.1,Chart 14.2,Chart 14.3
and Chart 14.4).
Ch art 14.1 Gas Volumes: Symbols and Abbreviations Large
capital letters den ote primary symbols for gases:
Symbols an d Abbreviation s
V
G as volume
[V with dot above]
G as volume per unit t ime (t he dot over t he symbol indicat es t he f act or per unit
t ime, as in f low )
P
G as pressure or part ial pressure of a gas in a gas mixt ure (exhaled air) or in
a liquid (blood)
F
Fract ional concent rat ion of a gas
Small capit al let t ers indicat e t he t ype of gas measured in relat ion t o
respirat ory t ract locat ion or f unct ion:
A
Alveolar gas
D
Dead space gas
E
Expired gas
I
I nspired gas
T
Tidal gas
Chemical symbols f or gases may be placed af t er t he small capit al let t ers:
O2
O xygen
CO
Carbon monoxide
CO 2
Carbon dioxide
N2
Nit rogen
Combin ation s of Symbols T h e follow in g are some examples of

th e w ays th ese symbols may be combin ed:
F 1 CO 2
Fract ional concent rat ion of inspired oxygen
Vt
Tidal volume
Ve
Volume of expired gas

PACO
Part ial pressure of carbon dioxide in alveolar gas
Blood Gas Symbols

Large capit al let t ers are used as primary symbols f or blood det erminat ions:
C
Concent rat ion of a gas in blood
S
Percent sat urat ion of hemoglobin
Q
Volu me of blood
[ Q w it h dot above]
Volume of blood per unit t ime (blood f low )
To indicat e w het her blood is capillary, venous, or art erial, low ercase let t ers
are used:
v
Venous blood
a
Art erial blood
c
Capillary blood
s
Shunt ed blood
Ch art 14.2 Combinations of Symbols and Abbreviations Blood

gas symbols may be combin ed in th e follow in g w ays:
PO 2
O xygen t ension or part ial pressure of oxygen
PaO 2
Art erial oxygen t ension or part ial pressure of oxygen in art erial blood
PAO 2
Alveolar oxygen t ension or part ial pressure of oxygen in t he alveoli
PCO 2
Carbon dioxide t ension or part ial pressure of carbon dioxide
PaCO 2
Part ial pressure of carbon dioxide in art erial blood
PvCO 2
Part ial pressure of carbon dioxide in venous blood
pH
Hydronium ion concent rat ion
pHa
Hydronium ion concent rat ion in art erial blood
SO 2
O xygen sat urat ion
SaO 2
Percent sat urat ion of oxygen in art erial blood as measured by hemoximet ry
(direct met hod)
SpO 2
Percent sat urat ion of oxygen in art erial blood as det ermined by pulse oximet ry
(indirect met hod)
SvO 2
Percent sat urat ion of oxygen in venous blood
T CO 2
Tot al carbon dioxide cont ent
Ch art 14.3 Lung Volume Symbols: Pulmonary Function

Terminology T h is list in dicates terms u sed in measu rin g lu n g
volu mes an d th e u n its th at express th ese measu remen ts.
FVC = Forced vit al capacit y: maximum amount of air t hat can be exhaled
f orcibly and complet ely af t er a maximal inspirat ion (lit ers)
FEV t = Forced expirat ory volume at specif ic t ime int ervals (eg, 1, 2,
and/ or 3 seconds): volume of air expired during t he f irst , second, t hird,
et c. , seconds of FVC maneuver (lit ers)
FEV t / FVC = Rat io of a t imed f orced expirat ory volume t o t he f orced vit al
capacit y (eg, FEV1 / FVC) (percent )
FEF 2001200 = Forced expirat ory f low bet w een 200 mL and 1200 mL:
average f low of expired air measured af t er t he f irst 200 mL and average
during t he next 1000 mL of t he FVC maneuver (lit ers/ second)
FEF 2575 = Forced expirat ory f low bet w een 25% and 75%: average f low of
expired air measured bet w een 25% and 75% of t he FVC maneuver
(lit ers/ second)
PEFR = Peak expirat ory f low rat e: maximum f low of expired air at t ained
during an FVC maneuver (lit ers/ second or lit ers/ minut e)
PI FR = Peak inspirat ory f low rat e: maximum f low of inspired air achieved
during a f orced maximal inspirat ion (lit ers/ second or lit ers/ minut e)
FEF 25 = Forced inst ant aneous expirat ory f low rat e at 25% of lung volume
achieved during an FVC maneuver (lit ers/ second or lit ers/ minut e)
FI VC = Forced inspirat ory vit al capacit y: maximum amount of air t hat can
be inhaled f orcible and complet ely af t er a maximal expirat ion (lit ers)
FRC = Funct ional residual capacit y: volume of air remaining in t he lung at
t he end of a normal expirat ion (ie, end-t idal expirat ion) (lit ers)
I C = I nspirat ory capacit y: maximum amount of air t hat can be inspired
f rom end-t idal expirat ion (lit ers)
I RV = I nspirat ory reserve volume: maximum amount of air t hat can be
inspired f rom end-t idal inspirat ion (lit ers)
ERV = Expirat ory reserve volume: maximum amount of air t hat can be
expired f rom end-t idal expirat ion (lit ers)
RV = Residual volume: volume of gas lef t in t he lung af t er a maximal
expirat ion (lit ers)
VC = Vit al capacit y: maximum volume of air t hat can be expired af t er a
maximal inspirat ion (lit ers)
TLC = Tot al lung capacit y: volume of gas cont ained in t he lungs af t er a
maximal inspirat ion (lit ers)
DLCO = Carbon monoxide diff using capacit y of t he lung: rat e of diff usion
of carbon monoxide across t he alveolar capillary membrane (ie, rat e of
gas t ransf er across t he alveolar capillary membrane) (millilit ers/ minut e per
millimet er of mercury)
DL/ V A = Carbon monoxide diff using capacit y per lit er of alveolar volume
(millilit ers/ minut e per millimet er of mercury per lit er of alveolar volume)
CV = Closing volume: volume at w hich t he low er lung zones cease t o
vent ilat e, presumably as a result of airw ay closure (percent of vit al
capacit y)
MVV = Maximum volunt ary vent ilat ion: maximum number of lit ers of air a
pat ient can breat he per minut e by a volunt ary eff ort (lit ers/ minut e)
VI SO [ V w it h dot above] = Volume of isof low : volume f or w hich f low is t he
same w it h air and w it h helium during an FVC maneuver (percent )
Ch art 14.4 Miscellaneous Symbols T h is list sh ow s some of th e

oth er symbols fou n d in th is ch apter.
f = Frequency (of breat hing)

CL = Compliance of t he lung
D = Diff using capacit y
CO Hb = Carboxyhemoglobin
DLO 2 = O xygen diff using capacit y of t he lung
A-aDO 2 = Alveolar-t o-art erial oxygen gradient
BSA = Body surf ace area (square met ers)
H2 CO 3 = Carbonic acid
HCO 3 - = Bicarbonat e ion
TG V = Thoracic gas volume (also expressed as VTG )
R aw = Airw ay resist ance
G aw = Airw ay conduct ance
sG aw = Specif ic airw ay conduct ance
F-V = Flow -volume
V-T = Volume-t ime
Airway Flow Rates

Airw ay f low rat es provide inf ormat ion about t he severit y of airw ay obst ruct ion
and serve as an index of dynamic f unct ion. The lung volume at w hich t he f low
rat es are measured is usef ul f or ident if ying a cent ral or peripheral locat ion of
airw ay obst ruct ion.
Spirometry, Forced Expiratory M aneuver Volume-Time

Spirogram (V-T Tracing); Flow -Volume Spirogram (F-V
Loop) Lung capacities, volumes, and flow rates are
clinically measured by a mechanical device called a
spirometer. The mechanical signal is converted to an
electrical signal, w hich records the amounts of gas
breathed in and out and produces a spirogram.
Spirometers can be grouped into tw o major categories:
(1) the mechanical or volume-displacement types
(w ater-filled, dry-rolling seal, w edge, or bellow s), and
(2) the electronic or flow -sensing types
(pneumotachometer or hot-w ire anemometer) (Fig.
14.1). Spirometry determines the effectiveness of the

various mechanical forces involved in lung and chest
w all movement. The values obtained provide
quantitative
information about the degree of obstruction to airflow
or the degree of restriction of inspired air. The forced
expiratory maneuver (spirometry) is useful to quantify
the extent and severity of airw ay obstruction. It
measures the maximum amount of air that can be
exhaled rapidly and forcibly, after a maximal deep
inspiration. The results are a measure of airw ay
function and the patency of the airw ay.
FI G URE 14. 1 MedicAI R Plus elect ronic spiromet er. (Court esy of Q RS
Diagnost ic, LLC, Plymout h, MN)
The f orced expirat ory volumes exhaled w it hin 1, 2, or 3 seconds are somet imes
ref erred t o ti med vi tal capaci ti es (FEV 1 , FEV2 , and FEV3 , respect ively). These
measurement s are usef ul f or evaluat ing a pat ient 's response t o bronchodilat ors.
G enerally, if t he FEV1 is < 80% (<0. 80) of predict ed
and/ or t he FEF2575 is < 60% (<0. 60) of predict ed, bronchodilat ors are
administ ered w it h a handheld nebulizer, and t he spiromet ry is repeat ed.
Recent ly, combinat ion bronchodilat ors (albut erol and iprat ropium) have been
int roduced. St udies have show n a bet t er bronchodilat or response w it h t he
combined drugs t han eit her alone. An increase in t hese values of 20% or more
(>0. 20) above t he prebronchodilat or level suggest s a signif icant response t o t he
bronchodilat or and is consist ent w it h a diagnosis of reversible obst ruct ive airw ay
disease (eg, ast hma). Persons w it h emphysema t ypically do not demonst rat e
t his t ype of response t o bronchodilat or. Measured (act ual) spiromet ry values are
compared w it h predict ed values by means of regression equat ions using age,
height , w eight , et hnicit y, and gender and are expressed as a percent age of t he
predict ed value. Typically, a value >80% (>0. 80) of predict ed is considered
w it hin normal limit s.
Reference Values
Normal
FVC: >80% (>0. 80) of predict ed value FEVt : FEV1 , FEV2 , FEV3 , >80% (>0. 80)
of predict ed value FEVt / FVC:
FEV 1 , 80%85% (0. 800. 85) of FVC
FEV 2 , 90%94% (0. 900. 94) of FVC
FEV 3 , 95%97% (0. 950. 97) of FVC
Predict ed values are based on t he pat ient 's age, height , et hnicit y, and gender.
Procedure
1. Have t he pat ient eit her sit or st and. Place nose clips on t he nose and inst ruct
t he pat ient t o breat he normally t hrough a mout hpiece/ f ilt er (bact erial/ viral)
combinat ion int o t he spiromet er.
2. Ask t he pat ient t o t ake a maximal inspirat ion and t hen f orcibly and
complet ely exhale int o t he spiromet er.
3. Have t he pat ient repeat t his maneuver a minimum of t hree t imes. The t w o
best t racings should compare w it hin 5% (0. 05) of one anot her, or addit ional
f orced expirat ory eff ort s w ill be needed.
4. Administ er bronchodilat ors w it h a handheld nebulizer, and repeat spiromet ry
if indicat ed.
Clin ical Alert
Spiromet ry is a pat ient eff ort dependent t est ; as such, if t he pat ient does not
provide his or her best eff ort , t he result s may be inconclusive.
Clin ical Alert

1. Bef ore t est ing, assess t he pat ient 's abilit y t o comply w it h breat hing
requirement s.
2. The pat ient may experience light headedness, short ness of breat h, or ot her
slight discomf ort s. These sympt oms are generally t ransit ory. An
appropriat e rest period is usually all t hat is needed. I f sympt oms persist ,
t est ing is t erminat ed.
3. Rarely, moment ary loss of consciousness (caused by anoxia during f orced
expirat ion) may occur. Follow est ablished prot ocols f or t est ing t his.
4. Assess f or cont raindicat ions such as pain or alt ered ment al st at us.
1. Wit h obst ruct ive vent ilat ory impairment s such as ast hma, airw ay collapse
occurs during f orced expirat ory eff ort . This leads t o decreases in airw ay
f low rat es and also, in t he more severe f orms, t o apparent loss of volumes.
2. Decreased values occur in chronic lung diseases t hat cause t rapping of air
such as emphysema, chronic bronchit is, cyst ic f ibrosis, or ast hma.
3. Wit h rest rict ive vent ilat ory impairment s, t he FVC is reduced; how ever, f low
rat es can be normal or elevat ed.
Interfering Factors
1. Bronchodilat ors (eg, albut erol) should be w it hheld f or at least 4 hours if
t olerat ed.
2. Respirat ory inf ect ions may decrease airf low during t he maneuver.
Interventions
1. Explain t he purpose and procedure of t he spiromet ry t est . Explain t hat t he
pat ient w ill be asked t o perf orm a maximal f orced inspirat ion in addit ion t o
t he f orced expirat ions.

2. Remind pat ient t hat a light meal may be eat en bef ore t he t est . How ever, no
caff eine should be t aken bef ore t est ing. Specif ic inst ruct ions w ill be given
regarding t he use of bronchodilat ors or inhaler medicat ions bef ore t he t est .

1. Evaluat e f or dizziness, short ness of breat h, or chest discomf ort . Usually
t hese sympt oms are t ransit ory and subside af t er a short rest . I f sympt oms
persist , use est ablished f ollow -up prot ocols.
Peak Inspiratory Flow Rate (PIFR) The peak inspiratory

flow rate (PIFR) measures the function of the airw ays,
identifies reduced breathing on inspiration, and is
totally dependent on the effort the patient makes to
inspire. The PIFR is the maximum flow of air achieved
during a forced maximal inspiration.
Reference Values
Normal
Approximat ely 300 L/ min or 5 L/ sec Predict ed values are based on age, sex, and
height .
Procedure
2. Ask t he pat ient t o t ake a maximal inspirat ion, f orcibly and complet ely exhale
int o t he spiromet er, and t hen inspire f orcibly and complet ely again.
3. Have t he pat ient repeat t his maneuver a minimum of t hree t imes. Report t he
highest value.
1. PI FR is reduced in neuromuscular disorders, w it h w eakness or poor eff ort ,
and in ext rat horacic airw ay obst ruct ion (ie, subst ernal t hyroid, t racheal
st enosis, and laryngeal paralysis).
2. The PI FR is decreased in upper airw ay obst ruct ion.
Interfering Factors
Poor pat ient eff ort compromises t he t est .
I nabilit y t o maint ain an airt ight seal around t he mout hpiece
Interventions
1. Explain t he purpose and procedure of t he t est . Assess t he pat ient 's abilit y t o
comply.

1. See Chapt er 1 guidelines f or saf e, eff ect ive inf ormed posttest care.
2. See af t ercare guidelines f or volume-t ime spirogram on page 908.
Peak Expiratory Flow Rate (PEFR) The peak expiratory

flow rate (PEFR) measurement is used as an index of
large airw ay function. It is the maximum flow of
expired air attained during a forced expiratory
maneuver.
Reference Values
Normal
Approximat ely 450 L/ min or 7. 5 L/ sec Predict ed values are based on age, sex,
and height .
Procedure
2. Ask t he pat ient t o t ake a maximal inspirat ion, f orcibly and complet ely exhale
int o t he spiromet er, and t hen inspire f orcibly and complet ely again.
3. Have t he pat ient repeat t his maneuver a minimum of t hree t imes. Report t he
highest value.
4. Be aw are t hat PEFR can also be measured w it h a handheld peak f low met er.
1. The PEFR usually is decreased in obst ruct ive disease (eg, emphysema),
during acut e exacerbat ions of ast hma, and in upper airw ay obst ruct ion (eg,
t racheal st enosis).
2. The PEFR usually is normal in rest rict ive lung disease but is reduced in
severe rest rict ive sit uat ions.
Interfering Factors
Poor pat ient eff ort compromises t he t est .
I nabilit y t o maint ain an airt ight seal around t he mout hpiece
Interventions
1. Explain t he purpose and procedure of t he t est . Assess t he pat ient 's abilit y t o
comply.
2. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest care
guidelines.

1. Monit or pat ient f or dizziness, light headedness, or chest pain f ollow ing t he
t est . G enerally, t hese sympt oms are t ransient and w ill subside quickly. I f not ,
f ollow est ablished prot ocols.
2. See af t ercare f or volume-t ime spirograms on page 908.

Lung Volumes and Capacities Lung volumes can be

considered as basic subdivisions of the lung (not
actual anatomic subdivisions). They may be subdivided
as follows:
1. Tot al lung capacit y (TLC)
2. Tidal volume (VT )
3. I nspirat ory capacit y (I C)
4. I nspirat ory reserve volume (I RV)
5. Residual volume (RV)
6. Funct ional residual capacit y (FRC)
7. Expirat ory reserve volume (ERV)
8. Vit al capacit y (VC)
Combinat ions of t w o or more volumes are t ermed capaci ti es. These volumes and
capacit ies are show n graphically in Figure 14. 2. Also show n are t he values f ound
in normal adult
men. Measurement of t hese values can provide inf ormat ion about t he degree of
air-t rapping or hyperinf lat ion.
FI G URE 14. 2 Subdivisions of lung volume in t he normal adult . (Source:

G eschickt er CF: The Lung in Healt h and Disease. Philadelphia, JB Lippincot t ,
1973)
Functional Residual Capacity (FRC) Functional residual

capacity (FRC) is used to evaluate both restrictive and
obstructive lung defects. Changes in the elastic
properties of the lungs are reflected in the FRC. The
FRC is the volume of gas contained in the lungs at the
end of a normal quiet expiration (see Fig. 14.2).
Reference Values
Normal
Approximat ely 2. 503. 50 L
Predict ed values are based on age, height , w eight , et hnicit y, and gender.
The observed value should be 75%125% (0. 751. 25) of t he predict ed value.
Procedure
1. Fit t he pat ient w it h nose clips, t hen inst ruct t he pat ient t o breat he t hrough
t he mout hpiece/ f ilt er (bact erial/ viral) combinat ion t hat is at t ached t o t he
lung volume apparat us. The pat ient is generally in t he seat ed posit ion.
2. Be aw are t hat t here are t w o met hods, depending on t he inst rument used:
a. Nit rogen w ashout or open-circuit t echnique
b. Helium dilut ion or closed-circuit t echnique
3. Have t he pat ient breat he normally f or about 37 minut es.
4. Perf orm t he t est a second t ime. Remember t hat result s f or FRC should vary
by not more t han 5% t o 10% (0. 05 t o 0. 10). Report t he average of t he t est
values.
1. A value < 75% (<0. 75) of t he predict ed is consist ent w it h rest rict ive
vent ilat ory impairment .

2. A value > 125% (>1. 25) of predict ed demonst rat es air-t rapping
(hyperinf lat ion), consist ent w it h obst ruct ive airw ay disease (eg, emphysema,
ast hma, bronchiolar obst ruct ion).
Interventions
1. Explain t he purpose and procedure of t he t est . Explain t hat t his is a
noninvasive t est requiring pat ient cooperat ion. Assess t he pat ient 's abilit y t o
comply.
2. Record t he pat ient 's age, gender, w eight , and height .

1. Explain t est out comes; allow t he pat ient t o rest if necessary.
2. See Chapt er 1 f or saf e, eff ect ive, inf ormed posttest guidelines .
Residual Volume (RV)

Residual volume (RV) can help t o dist inguish bet w een rest rict ive and obst ruct ive
vent ilat ory def ect s. I t is t he volume of gas remaining in t he lungs af t er a maximal
exhalat ion. Because t he lungs cannot be complet ely empt ied (ie, a maximal
expirat ory eff ort cannot expel all of t he gas), RV is t he only lung volume t hat
cannot be measured direct ly f rom t he spiromet er. I t is calculat ed mat hemat ically
by subt ract ing t he expirat ory reserve volume (ERV) f rom t he FRC (see Fig.
14. 2).
Reference Values
Normal
Approximat ely 12001500 mL
Predict ed values are based on age, gender, and height .
Procedure
1. Remember t hat t he RV is det ermined indirect ly f rom ot her t est s, ie, it is

mat hemat ically derived by subt ract ing t he measured expirat ory reserve
volume (ERV) f rom t he FRC.
1. An increase in t he RV (>125% [ >1. 25] of predict ed) indicat es t hat , despit e a
maximal expirat ory eff ort , t he lungs st ill cont ain an abnormally large amount
of gas (air-t rapping). This t ype of change occurs in young ast hmat ic pat ient s
and usually is reversible. I n emphysema, t he condit ion is permanent .
2. I ncreased RV is charact erist ic of emphysema, chronic air-t rapping, and
chronic bronchial obst ruct ion.
3. The RV and t he FRC usually increase t oget her, but not alw ays.
4. The RV somet imes decreases in diseases t hat occlude many alveoli.
5. An RV < 75% (<0. 75) of predict ed is consist ent w it h rest rict ive disorders
(eg, int erst it ial pulmonary f ibrosis).
Interfering Factors
Residual volume normally increases w it h age.
Interventions
1. Explain t he purpose of t he t est and how t he result s are calculat ed.

1. I nt erpret t est result s and monit or as necessary.
Expiratory Reserve Volume (ERV) Expiratory reserve

volume (ERV) is the largest volume of gas that can be
exhaled from end-tidal expiration. This measurement
identifies lung or chest w all restriction. The ERV can

be estimated mathematically by subtracting the
inspiratory capacity (IC) from the vital capacity (VC).
The ERV accounts for approximately 25% of the VC and
can vary greatly in patients of comparable age and
height (see Fig. 14.2).
Reference Values
Normal
Approximat ely 12001500 mL (1. 201. 50 L) Predict ed values are based on age,
height , and gender.
Procedure
t he pat ient t o breat he normally t hrough a mout hpiece/ f ilt er (bact erial/ f ilt er)
2. Ask t he pat ient t o exhale complet ely and resume normal breat hing. Record
result s on graph paper.
3. Have t he pat ient repeat t his maneuver a minimum of at least t w ice. The
measured volumes should be w it hin 5%10% (0. 050. 10) of one anot her.
Report t he average value.
1. A decreased ERV indicat es a chest w all rest rict ion result ing f rom
nonpulmonary causes.
2. Decreased values are associat ed w it h an elevat ed diaphragm (eg, massive
obesit y, ascit es, pregnancy). Decreased values also occur w it h massive
enlargement of t he heart , pleural eff usion, kyphoscoliosis, or t horacoplast y.
3. Decreases in ERV also are seen in obst ruct ion result ing f rom an increase in
t he RV impinging on t he ERV.
Interventions
1. Explain t he purpose and procedure of t he spiromet ry t est . I nf orm t he pat ient

t hat t he t est is noninvasive. Assess t he pat ient 's abilit y t o comply w it h t est
procedures.

1. I nt erpret t est out comes and counsel about respirat ory abnormalit ies.
Inspiratory Capacity (IC) Inspiratory capacity (IC)

measures the largest volume of air that can be inhaled
from the end-tidal expiratory level. This measurement
is used to identify lung or chest w all restrictions.
M athematically, the IC is the sum of the tidal volume
(VT) and the inspiratory reserve volume (IRV) (see Fig.
14.2).
Reference Values
Normal
Approximat ely 30003300 mL (3. 003. 30 L) Predict ed values are based on age,
height , and gender.
Procedure
2. Af t er several breat hs, ask t he pat ient t o inhale maximally, expanding t he
lungs as much as possible f rom end-t idal expirat ion. Have t he pat ient t he
resume normal breat hing. Record t he result s on graph paper.
3. Repeat st ep 2 t w o or more t imes unt il t he t w o best values are w it hin 5% of
each ot her. Select t he largest inspired volume value.
1. Changes in t he I C usually parallel increases or decreases in t he vit al

capacit y (VC).
2. Decreases in I C can be relat ed t o eit her rest rict ive or obst ruct ive vent ilat ory
impairment s.
Interventions
1. I nst ruct t he pat ient about t he purpose and procedure of t he t est and t he
need f or pat ient cooperat ion.

1. I nt erpret t est out comes and monit or pat ient .
Vital Capacity (VC)

Measurement of t he vit al capacit y (VC) ident if ies def ect s of lung or chest w all
rest rict ion. The VC is t he largest volume of gas t hat can be expelled f rom t he
lungs af t er t he lungs are f irst f illed t o t he maximum ext ent and t hen slow ly
empt ied t o t he maximum ext ent . Mat hemat ically, it is t he sum of t he I C and t he
ERV (see Fig. 14. 2).
Reference Values
Normal
Predict ed values are based on age, gender, height , and et hnicit y.
Procedure
2. I nst ruct t he pat ient t hen t o inhale as deeply as possible and t hen t o exhale
complet ely, w it h no f orced or rapid eff ort .
3. Record result s on graph paper.
4. Repeat t he procedure unt il t he measurement s are w it hin about 5% of each
ot her.
Clin ical Alert

I nadequat e pat ient eff ort causes low er VC values.
1. A reduced VC is def ined as a value < 80% (<0. 80) of predict ed.
2. The VC can be low er t han expect ed in eit her a rest rict ive or an obst ruct ive
disorder.
3. A decreased VC can be relat ed t o depression of t he respirat ory cent er in t he
brain, neuromuscular diseases, pleural eff usion, pneumot horax, pregnancy,
ascit es, limit at ions of t horacic movement , scleroderma, kyphoscoliosis, or
t umors.
4. The VC increases w it h physical f it ness and great er height .
5. The VC decreases w it h age (af t er age 30 years).
6. The VC is generally less in w omen t han in men of t he same age and height .
7. The VC is decreased by approximat ely 15% in Af rican Americans and by 20%
t o 25% in Asians, compared w it h Caucasians of t he same age, height , and
gender.
Interventions
1. Explain t he purpose and procedure of t he t est and need f or pat ient
cooperat ion. Assess f or int erf ering f act ors.
1. I nt erpret out comes, monit or pat ient signs and sympt oms, and f ollow up if
necessary.
2. See Chapt er 1 f or saf e, eff ect ive, inf ormed posttest care guidelines.
Total Lung Capacity (TLC) Total lung capacity (TLC) is

used mainly to evaluate obstructive defects and to
differentiate restrictive from obstructive pulmonary
disease. It measures the volume of gas contained in the
lungs at the end of a maximal inspiration.
M athematically, it is the sum of the VC and the RV, or
the sum of the primary lung volumes (see Fig. 14.2).
This value is calculated indirectly from other tests.
Reference Values
Normal
Predict ed values are based on age, height , gender, and et hnicit y.
All pulmonary volumes and capacit ies are about 20%25% less in w omen t han in
men.
Procedure
2. Ask t he pat ient t o inspire maximally and exhale maximally. The t ot al amount
of air exhaled is t he VC.
3. Use t he f ollow ing f ormula t o derive t he TLC mat hemat ically: TLC = VC + RV.
1. An obst ruct ive impairment is charact erized by an i ncreased TLC. How ever, a
normal or increased TLC does not mean t hat vent ilat ion or t he surf ace area
f or diff usion is normal. The TLC may be normal or increased in bronchiolar
obst ruct ion w it h hyperinf lat ion and in emphysema.
2. The TLC is decreased in edema, at elect asis, neoplasms, pulmonary

congest ion, pneumot horax, and t horacic rest rict ion.
3. A decreased TLC is t he hallmark of a restri cti ve vent ilat ory impairment .
Interventions
1. Explain t he purpose and procedure of t he t est . Even t hough it is noninvasive,
it does require pat ient eff ort and cooperat ion.

1. I nt erpret out comes (see Fig. 14. 3), monit or pat ient signs and sympt oms, and
f ollow up if necessary.
FI G URE 14. 3 Pulmonary f unct ion report of a 47-year-old f emale w hose

chief complaint is short ness of breat h. The report includes spiromet ry,
lung volumes, diff usion capacit y, maximum volunt ary vent ilat ion, and
maximal respirat ory pressures. Not e: The shape or conf igurat ion of t he
f low -volume loop (low er lef t corner of report ) is signif icant f or airf low
obst ruct ion (ie, obst ruct ive vent ilat ory impairment ). The current f low volume loop is essent ially normal in appearance. (Court esy of Pulmonary
Diagnost ic Laborat ory, Froedt ert Hospit al, Milw aukee, WI )
Gas Exchange (Diffusing Capacity) Gas exchange in the

lungs is referred to as respiration, whereas the
movement of gas in and out of the lung is ventilation.

In Europe, the diffusing capacity is termed the transfer
factor. Gas exchange involves the movement of oxygen
(O 2 ) from the alveolus (gas exchange units in the lung)
to the blood (ie, diffusion across the alveolar/capillary
membrane) and movement of carbon dioxide (CO2 ) from
the blood into the alveolus for subsequent removal.
Carbon M onoxide Diffusing Capacity (DLCO) The
diffusing capacity measurement determines the rate of
gas transfer across the alveolar capillary membranes.
Carbon monoxide (CO) combines w ith hemoglobin
about 210 times more readily than does O2 . If there is a
normal amount of hemoglobin in the blood, the only
other significant limiting factor to CO uptake is the
state of the alveolar capillary membranes. Normally,
the amount of CO in the blood is insufficient to affect
the test. Tw o categories of factors (ie, physical and
chemical) determine the rate of gas (CO) transfer
across the lung. The physical determinants are CO
driving pressure, surface area, thickness of capillary
w alls, and diffusion coefficient for CO. The chemical
determinants are red blood cell volume and reaction
rate w ith hemoglobin.
This t est is used t o diagnose pulmonary vascular disease, emphysema, and
pulmonary f ibrosis and t o evaluat e t he ext ent of f unct ional pulmonary capillary
bed in cont act w it h f unct ional alveoli. The alveolar volume (VA) can also be
det ermined. The DLCO measures t he diff using capacit y of t he lungs f or CO . The
DLO 2 is obt ained by mult iplying t he DLCO by 1. 23.
Reference Values
Normal
Approximat ely 25 mL/ min/ mmHg (8. 4 mmol/ min/ kPa) Predict ed values are based
on t he pat ient 's height , age, and gender.
Procedure
combinat ion int o t he diff usion inst rument .
2. Ask t he pat ient t o expire maximally and t hen inspire maximally (a diff usion
gas mixt ure), hold breat h f or 10 seconds, and t hen exhale, at w hich t ime a
sample of exhaled gas is obt ained.
3. Tw o t echniques are used by laborat ories:
a. Single-breat h or breat h-holding t echnique
b. St eady-st at e t echnique
1. Decreased values are associat ed w it h:
a. Mult iple pulmonary emboli
b. Emphysema
c. Lung resect ion
d. Pulmonary f ibroses:
1. Sarcoidosis
3. Asbest osis
4. Pneumonia
e. Anemia
f. I ncreased levels of carboxyhemoglobin (CO Hb)
g. Pulmonary resect ion
h. Scleroderma
2. Increased values are observed in polycyt hemia, lef t -t o-right shunt s,
pulmonary hemorrhage, and exercise.
3. The value is relat ively normal in chronic bronchit is.
Interfering Factors
Exercise (w it h an increased cardiac out put ) and polycyt hemia increase t he value.
Because increased levels of CO Hb (as seen in smokers) and anemia decrease
t he value, t he DLCO is correct ed f or CO Hb levels > 10% (>0. 10) and hemoglobin
(Hb) values < 8 g/ dL (<80 g/ L).
Interventions
1. Explain t he purpose and procedure. Assess f or int erf ering f act ors and
explain t hat t his noninvasive t est requires pat ient cooperat ion. Assess t he
pat ient 's abilit y t o comply.

1. Explain t est out comes (see Fig. 14. 3) and possible need f or f ollow -up t est ing
t o monit or course of t herapy (eg, ant i-inf lammat ory drugs, bronchodilat ors,
and some ant iarrhyt hmics and ant ineoplast ics).
M aximum Voluntary Ventilation (M VV) M aximum

voluntary ventilation (M VV) measures several
physiologic phenomena occurring at the same time,
including thoracic cage compliance, lung compliance,
airw ay resistance, and available muscle force. It is the
number of liters of air that the patient can breathe per
minute w ith maximal voluntary effort.
Reference Values
Normal
Approximat ely 160180 L/ min Predict ed values are based on t he pat ient 's age,
height , and gender. A healt hy person may vary by as much as 25%35% f rom
mean group values.
Procedure
2. I nst ruct t he pat ient t o breat he int o t he spiromet er as deeply and rapidly as
possible f or 10 t o 15 seconds. Usually, t he f requency reaches 40 t o 70
breat hs per minut e, and t he t idal volumes are about 50% of VC.
3. Ext rapolat e act ual values f rom t he 10- t o 15-second t ime int erval t o a 1minut e t ime period.
4. Be aw are t hat t ypically, t he maneuver is perf ormed t w ice. Report t he largest
value.
Interfering Factors
Poor pat ient eff ort can be ruled out by using t he f ollow ing f ormula t o predict t he
MVV of t he pat ient : Predict ed MVV = 35 FEV1 . This is a usef ul check t o
det ermine w het her t he recorded
MVV is indicat ive of adequat e pat ient eff ort . Low values can be relat ed t o
pat ient eff ort and not t o pat hophysiology.
1. O bst ruct ive vent ilat ory impairment s of moderat e t o severe degree, abnormal
neuromuscular cont rol, and poor pat ient eff ort are causes of low values.
2. I n rest rict ive disease, t he value is usually normal; how ever, in more severe
f orms, MVV may be decreased.
Interventions
1. Explain t he purpose and procedure of t he t est . Explain t hat it is a
noninvasive t est t hat requires pat ient cooperat ion. Assess t he pat ient 's
abilit y t o comply.
2. Record t he pat ient 's age, height , and gender.

1. Explain t est out come (see Fig. 14. 3) and possible need f or f ollow -up t est ing
and t reat ment .
2. See Chapt er 1 regarding saf e, eff ect ive, inf ormed posttest care guidelines.
M aximal Respiratory Pressure (M RP) The maximal

respiratory pressure (M RP) measurements assess
ventilatory muscle strength in persons w ith
neuromuscular disorders such as poliomyelitis,
emphysema, and pulmonary fibroses. The maximal
expiratory pressure (M EP) is the greatest pressure that
can be generated at or near total lung capacity after a
maximal inspiration, w hereas the maximal inspiratory
pressure (M IP) is measured at or near the residual
volume after a maximal expiration.
Reference Values
Normal
Maximal expirat ory pressure (MEP): approximat ely 100250 cm H2 O
Maximal inspirat ory pressure (MI P): approximat ely 40125 cm H2 O
Predict ed values are based on t he pat ient 's age and gender.
Procedure
1. I nst ruct t he pat ient , w ho should be in a seat ed posit ion and w earing a nose
clip, t o inspire maximally. Place t he mout hpiece of t he handheld pressure
manomet er int o t he mout h and have t he pat ient perf orm a f orced expirat ion.
Record t his maximal sust ained (1 t o 3 seconds) pressure against t he int ernal
occlusion of t he manomet er as t he MEP.
2. Repeat t his same procedure t o obt ain t he MI P, except t hat t his t ime t he
pat ient f ully exhales bef ore placing t he mout hpiece of t he manomet er in t he
mout h. Have t he pat ient t hen inspire f orcef ully, and record t he maximal
sust ained (1 t o 3 seconds) pressure.
3. Repeat each procedure, and record t he best of t hree measurement s f or
each.
Interfering Factors
The MI P and MEP measurement s depend on pat ient eff ort ; low values may be
caused by poor eff ort rat her t han loss of respirat ory muscle st rengt h. I f t he
pat ient does not inspire or expire maximally bef ore perf orming t he pressure
measurement , t he value may be low. Also, sust ained eff ort s longer t han 3
seconds should be avoided because t hey can cause a decrease in cardiac out put
as a result of increased int rat horacic pressures.
1. Decreases i n both MEP and MIP are seen in neuromuscular disorders (eg,
myast henia gravis, poliomyelit is).
2. Decreased MEP is common in bot h severe obst ruct ive disease (eg,
emphysema) and severe rest rict ive vent ilat ory impairment (eg, int erst it ial
pulmonary f ibrosis).
3. Decreased MIP is observed in pat ient s w it h chest w all abnormalit ies (eg,
kyphoscoliosis) and in hyperinf lat ion (eg, emphysema).
Interventions
1. Explain t he purpose and procedure of t he t est . Explain t hat it is a
noninvasive, eff ort -dependent maneuver t hat requires pat ient cooperat ion.
2. Record t he pat ient 's age and sex.

1. Explain t est out comes (see Fig. 14. 3) and possible need f or f ollow -up t est ing
and t reat ment .
Closing Volume (CV)

I n a healt hy person, t he concent rat ion of alveolar nit rogen, af t er a single breat h
of 100% O2 , rapidly increases near t he end of expirat ion. This rise is caused by
closure of t he small airw ays in t he bases of t he lung. The point at w hich t his
closure occurs is called t he cl osi ng vol ume (CV). CV is used as an index of
pat hologic changes occurring w it hin t he small airw ays (t hose < 2 mm in
diamet er). The convent ional pulmonary f unct ion t est s are not sensit ive enough t o
make t his det erminat ion. This t est relies on t he f act t hat t he upper lung zones
cont ain a proport ionat ely larger residual volume of gas t han t he low er lung zones
do; t here is a gradient of int rapleural pressure f rom t he t op t o t he bot t om of t he
lung. Addit ionally, t he unif ormit y of gas dist ribut ion w it hin t he lungs can be
measured.
Reference Values
Normal
Average is 10% t o 20% (0. 10 t o 0. 20) of t he pat ient 's vit al capacit y (VC)
Predict ed values are derived f rom mat hemat ical regression equat ions and are
based on t he pat ient 's age and gender.
Procedure
1. Have t he pat ient assume a seat ed posit ion. Place nose clips on t he nose and
inst ruct t he pat ient t o breat he normally t hrough a mout hpiece/ f ilt er
(bact erial/ viral) combinat ion int o t he spiromet er.
2. Ask t he pat ient t o exhale complet ely, t o inhale 100% O2 , and t hen t o exhale
complet ely at t he rat e of approximat ely 0. 5 L/ second.
3. During exhalat ion, monit or simult aneously bot h t he expired volume and
percent age of alveolar nit rogen on an X-Y recorder. Remember t hat a
sudden increase in nit rogen represent s t he closing volume.
1. Values are i ncreased f or t hose condit ions in w hich t he airw ays are narrow ed
(eg, bronchit is, early airw ay obst ruct ion, chronic smokers, old age).
2. A change in t he sl ope of t he nit rogen curve of > 2% is indicat ive of
maldist ribut ion of inspired air (ie, uneven alveolar vent ilat ion).
3. Congest ive heart f ailure, w it h subsequent edema, may also cont ribut e t o
decreasing pat ency of t he small airw ays leading t o an increase in t he CV.
Interfering Factors
1. The CV increases w it h age.
2. Pat ient s in congest ive heart f ailure may show an increased CV.
Interventions
1. Explain t he purpose and procedure of t he t est . Explain t hat t his is a
noninvasive t est t hat requires pat ient cooperat ion. Assess t he pat ient 's
abilit y t o comply w it h breat hing requirement and inst ruct ions. Assess f or
int erf ering f act ors.

1. Explain t he meaning of t est out comes and possible need f or f ollow -up t est ing
and t reat ment of early small airw ay disease.
Volume of Isoflow (VISO[V w ith dot above]) This test is

designed to detect pathologic changes occurring in the
small airw ays and may be more sensitive than
conventional pulmonary function tests. Helium has the
unique property of low ering gas density. Therefore,
after the patient breathes a helium-oxygen gas mixture,
the effects of convective acceleration and turbulence
are negated. Any abnormality observed in the F-V loop,
then, results from an increase in resistance to laminar
(nonturbulent) flow, w hich indicates small airw ay
abnormalities or lung disease.
Reference Values
Normal
Average is 10%25% of VC.
Predict ed values are based on age.
Procedure
1. Have t he pat ient assume a seat ed posit ion. Place nose clips on t he nose and
inst ruct t he pat ient t o breat he normally t hrough a mout hpiece/ f ilt er
2. Have t he pat ient perf orm a baseline F-V loop, w hich is recorded by a
spiromet er on an X-Y recorder.
3. Have t he pat ient next breat he a mixt ure of 80% He and 20% O2 f or several
breat hs and t hen perf orm anot her F-V loop maneuver; t his is t he HeliO x F-V
loop.
4. Superimpose t he F-V loop t racings, and measure t he volume of isof low at t he
point at w hich t he t w o loops int ersect .
An i ncreased volume of isof low is consist ent w it h early small airw ay obst ruct ion
(eg, ast hma).
Interventions
2. Follow guidelines in Chapt er 1 regarding saf e, eff ect ive, pretest care.

1. I nt erpret t est out comes and possible need f or f ollow -up t est ing and
t reat ment .
2. See Chapt er 1 guideline f or saf e, eff ect ive, inf ormed posttest care .
Body Plethysmography: Thoracic Gas Volume (VTG),

Compliance (CL), Airw ay Resistance (Raw ) This test
measures several parameters. Thoracic gas volume
(V T G ) composes all the air contained w ithin the thorax,
w hether or not it is in ventilatory communication w ith
the rest of the lung. Compliance of the lung (CL) is an
indication of its elasticity, and airw ay resistance (Raw )
is a measurement of the resistance to airflow in the
tracheobronchial tree.
The measurement of VTG via body plet hysmography is an applicat ion of Boyle's
law, w hich st at es t hat , f or a gas at const ant t emperat ure, pressure and volume
vary inversely (P1 V 1 = P2 V 2 ). Airw ay resist ance (Raw ) increases w it h decreased
lung volumes and decreases w it h higher lung volumes in a nonlinear, hyperbolic
f ashion. Compliance (CL) increases in obst ruct ive diseases (eg, emphysema)
and decreases in rest rict ive processes (eg, int erst it ial lung disease).
Reference Values
Normal
Thoracic gas volume (VTG ): approximat ely 2. 503. 50 L
Compliance (CL): 0. 2 L/ cm H2 O (2. 04 L/ kPa) Airw ay resist ance (Raw ): 0. 62. 4
L/ s/ cm H2 O
Predict ed values are based on t he pat ient 's age, height , w eight , and gender.
Procedure
1. Have t he pat ient sit in t he plet hysmograph (body box). Fit w it h nose clips,
and have t he pat ient breat he t hrough a mout hpiece/ f ilt er (bact erial/ viral)
combinat ion connect ed t o a t ransducer (Fig. 14. 4).
FI G URE 14. 4 Body plet hysmograph. (Source: SensorMedics Corp. , a

subsidiary of VI ASY S Healt hcare, Yorba Linda, CA, USA)
2. Ensure t hat t he body box door is secured. Delay t he t est f or a f ew minut es

t o allow t he box pressure t o st abilize.
3. I nst ruct t he pat ient t o perf orm a pant ing maneuver w hile holding t he cheeks
rigid and t he glot t is open against a closed shut t er locat ed w it hin t he
t ransducer assembly. Record box and mout h pressures on t he oscilloscope
t o provide dat a f or VTG .
4. Next , ask t he pat ient t o breat he rapidly and shallow ly. Record box pressure
changes versus f low on t he oscilloscope t o provide dat a f or Raw .
5. To det ermine CL, pass a balloon cat het er t hrough t he nose int o t he pat ient 's
esophagus. Ensure t hat t he inf lat ed balloon is connect ed t o a t ransducer,
and inst ruct t he pat ient t o breat he normally. Record t he changes in
int raesophageal pressure during normal respirat ion (w hich mimic changes in
int rapleural pressure) t o provide dat a f or CL.
6. See Chapt er 1 guidelines f or i ntratest t est .
1. An i ncreased VTG demonst rat es air-t rapping, consist ent w it h obst ruct ive
pulmonary disease.
2. An i ncreased R aw demonst rat es increased resist ance t o airf low t hrough t he

t racheobronchial t ree; t his is seen in ast hma, emphysema, bronchit is, and
ot her f orms of obst ruct ion. The Raw dist inguishes bet w een rest rict ive and
obst ruct ive vent ilat ory def ect s.
3. An i ncrease in CL (ie, lung is more dist ensible) is seen in obst ruct ive
diseases.
4. A decrease in CL (ie, lung is more st iff ) is seen in f ibrot ic diseases,
rest rict ive diseases, pneumonia, congest ion, and at elect asis.
Interventions
2. Assure t he pat ient t hat alt hough t he chamber is airt ight , t he t est only t akes a
f ew minut es. A t echnician w ill be in const ant at t endance t o open t he door
should t hat be necessary. Assess f or abilit y t o comply w it h t est requirement s
and inst ruct ions. Tact f ully assess f or predisposit ion t o claust rophobia, panic
at t acks, or ot her similar responses.

1. Allow t he pat ient t ime t o rest quiet ly if necessary.
2. Explain t he meaning of t est out comes.
Bronchial Provocation: M ethacholine, Histamine

Challenge Bronchial provocation challenge testing is
performed in patients w ith normal pulmonary function
tests w ho have suspected underlying bronchial
hyperreactivity. Additionally, the asthmatic patient is
more sensitive to the bronchoconstrictive effects of
cholinergic agents (eg, methacholine chloride) than is
the healthy person as observed on a spirometry test.
Airw ay resistance (Raw ) tests are also sensitive

monitors of response to bronchoconstrictive agents.
Reference Values
Normal
Posit ive response: >20% (or >0. 20) decrease in FEV1 f rom baseline or >35%
(>0. 35) increase in Raw
Negat ive response: <20% (or <0. 20) decrease in FEV1 f rom baseline or <35%
(<0. 35) increase in Raw
Procedure
1. Have t he pat ient assume t he seat ed posit ion. Place nose clips on t he nose
and inst ruct t he pat ient t o breat he normally t hrough a mout hpiece/ f ilt er
2. Have t he pat ient perf orm a f orced expirat ory maneuver, and measure and
record t he baseline FEV1 (or an Raw measurement ).
3. Have t he pat ient inhale increasing concent rat ions of met hacholine chloride
(0. 06216. 00 mg/ mL) or hist amine by nebulizer. Repeat t he FVC or Raw
maneuver af t er each successive concent rat ion is inhaled. Be aw are t hat a
20% reduct ion in t he FEV1 or 35% increase in Raw is considered a posit ive
response.
4. Administ er an inhaled bronchodilat or w hen or if a decrease of > 20% f rom
baseline is reached.
5. Be aw are t hat if a pat ient goes t hrough all dilut ion rat ios and a 20%
reduct ion in t he FEV1 or >35% increase in Raw is not reached, t he t est is
considered negat ive.
6. Remember t hat if t he met hacholine causes no change, hist amine t est ing may
be ordered.
7. See Chapt er 1 f or guidelines f or i ntratest care.
A posit ive response t o met hacholine or hist amine is consist ent w it h bronchial
hyperreact ivit y. Approximat ely 5% t o 10% of ast hmat ic persons do not respond
t o t he met hacholine challenge t est .
Interventions
1. Explain t he purpose and procedure of t he t est and t he need f or pat ient
cooperat ion. Assess t he pat ient 's abilit y t o comply.
2. Wit hhold bronchodilat ors f or 8 hours and ant ihist amines f or 48 hours bef ore
t est ing, if t olerat ed.
Clin ical Alert

1. I nhalat ion of met hacholine can cause bronchospasm, chest pain, short ness
of breat h, and general discomf ort .
2. These eff ect s can be reversed w it h a bronchodilat or.

1. Explain t he meaning of t est out comes.
2. I f t he t est is posit ive, advise t he pat ient t o avoid ant igens t hat may be
causing hypersensit ivit y react ion and bronchospasms.
Carbon Dioxide (CO2 ) Response This test evaluates the

respiratory response to increasing concentrations of
inspired CO2 . As alveolar levels of CO2 increase, so
does arterial CO2 . The central chemoreceptors respond
by initiating impulses to the respiratory control
centers. In the healthy person, this causes the rate and
depth of breathing to increase. The act of breathing
successively greater concentrations of CO2 should
result in an increase in minute volume (VE), w hen
compared w ith the VE during breathing of room air
alone. (Room air contains 0.03% CO2 .)
Reference Values
Normal
I ncrease in minut e vent ilat ion of 3 L/ min/ mmHg increase of CO2 (3 L/ min/ 0. 133
kPa)
Procedure
1. Remember t hat [ V w it h dot above] E is det ermined w hile t he pat ient breat hes
room air f or several minut es int o an inst rument (eg, spiromet er) t hat records
t he f requency of breat hing (f ) and t he t idal volume (VT). Use t he f ollow ing
f ormula t o calculat e t he minut e volume: [ V w it h dot above] E = f VT.
2. Have t he pat ient breat he a gas mixt ure of 2% CO2 in room air f or 5 minut es.
During t he last 2 minut es, record f and VT and calculat e t he [ V w it h dot
above] E.
3. Have t he pat ient breat he gas mixt ures of 4% CO2 and 6% in room air.
Mixt ures can be increased t o as much as 8% CO2 . Repeat t he ent ire process
w it h each successive concent rat ion.
4. Const ruct a graph t o plot t he changes in VE against t he concent rat ion of
inspired CO2 (FI CO 2 ).
Lack of response t o increasing inspired CO2 concent rat ions suggest s a
dist urbance in t he normal physiologic pat hw ay of vent ilat ory changes t o
hypercapnia. This may result f rom ingest ion of cent ral nervous syst em
depressant s (eg, anest het ics, barbit urat es, narcot ics) or f rom airf low obst ruct ion
(eg, chronic obst ruct ive pulmonary disease [ CO PD] ).
Interventions
1. Explain t he purpose and procedure of t he t est and need f or pat ient
cooperat ion. Assess t he pat ient 's abilit y t o comply.

1. I nt erpret t he t est out come and advise t hat pharmacologic int ervent ion may
be necessary t o sensit ize t he chemorecept ors.
2. See Chapt er 1 guidelines regarding saf e, eff ect ive, posttest care.
Exercise Stress Testing, M aximum Oxygen

Consumption ([V w ith dot above]O2 max) Test
Respiratory disease reduces the ability to perform
exercise. Dynamic exercise that involves large muscle
groups produces increases in metabolic O2
consumption ([V w ith dot above]O2 ) and CO2 production
([V w ith dot above]CO2 ). This increase in metabolic
demand leads to stresses on other mechanisms taking
part in O2 and CO2 transport. Exercise testing measures
the functional reserves of these mechanisms by testing
under load. Analysis of bronchogenic and
cardiovascular disorders includes procedures that
measure respiratory outcomes, blood gas values, and
cardiovascular responses during exercise. Ventilation
and gas exchange are altered during exercise in
healthy persons; how ever, specific abnormalities are
noted in the presence of cardiovascular or respiratory
impairment. Exercise tests are valuable for assessing
the severity and type of impairment in existing or
undiagnosed conditions.
The normal response t o graded exercise is an increase in vent ilat ion and cardiac
out put such t hat alveolar and art erial gases are maint ained at opt imal levels t o
meet met abolic demands. Measurement of t he pat ient 's vent ilat ory and alveolarart erial gas responses during exercise is t he primary object ive of a pulmonary
exercise st ress t est . No signif icant or abnormal changes in t he
elect rocardiographic (ECG ) complex, blood pressure, airf low pat t erns during
inspirat ion and expirat ion, art erial blood gases (ABG s) and chemist ry, or
hemodynamic pressures should occur. Exercise t est ing is done t o evaluat e
f it ness, f unct ional capacit y, and ot her limit ing f act ors in
persons w it h obst ruct ive or rest rict ive diseases. The eff iciency of t he
cardiopulmonary syst em may be alt ered during exercise; exercise t est ing
assesses vent ilat ion, gas exchange, and cardiovascular f unct ion during increased
demands. Dyspnea on exert ion due t o cardiovascular causes can be
diff erent iat ed f rom t hat due t o respirat ory causes. Precise inf ormat ion about
mechanisms t hat inf luence O2 and CO2 t ransport during exercise can be obt ained
by using a st aged approach.
An exercise t est can det ect or exclude many condit ions, even t hough t he
response may be nonspecif ic. For example, if t he pat ient complains of severe
short ness of breat h despit e a normal exercise response, a psychogenic cause is
likely. How ever, a f ew condit ions exhibit diagnost ic responses, eg, exerciseinduced ast hma or myocardial ischemia. These t est s can also reveal t he degree
of impairment in condit ions aff ect ing t he respirat ory and circulat ory syst ems and
may uncover unsuspect ed abnormalit ies (Table 14. 2).
Table 14.2 Normal Ventilatory and Arterial Blood Gas

Responses to Graded Exercise
Value
Change
O 2 consumption ([V with dot above]O 2 )
Increase
CO 2 production ([V with dot above]CO 2 )
Increase
Ventilatory equivalents for O2 and CO2
No change
Respiratory exchange ratio (RER)
Increase
Minute ventilation (VE)
Increase
Blood lactate
Increase
VD/VT ratio
Decrease
A-aDO 2
Slight
increase
Arterial blood gas tensions (eg, PaO2 ,

PaCO 2 )
No change
Bicarbonate concentration (HCO3 - )
Decrease
Oxygen saturation (SaO2 )
No change
The majorit y of clinical problems can be assessed during t he simple procedures

included in stage 1 (see Procedure sect ion f or descript ion) and should be done
bef ore more complex t est s. Abnormal result s indicat e t hat more precise
inf ormat ion is required t hrough stage 2 prot ocols. I f stage 3 prot ocols are
implement ed, art erial blood analysis is necessary. I n 75% of cases, st age 1 is
suff icient . O xygen t it rat ion can be done during graded exercise t o det ermine t he
oxygen needs f or improving exercise t olerance and increasing f unct ional
capacit y.
Clin ical Alert

1. Absol ute contrai ndi cati ons t o exercise t est ing include:
Acut e f ebrile illness
Pulmonary edema
Syst olic blood pressure >250 mm Hg (>33 kPa)
Diast olic blood pressure >120 mm Hg (>16 kPa)
Uncont rolled hypert ension
Uncont rolled ast hma
Unst able angina
2. Rel ati ve contrai ndi cati ons t o exercise t est ing include:
Recent myocardial inf arct ion (<4 w eeks)
Rest ing t achycardia (>120 bpm)
Epilepsy
Respirat ory f ailure
Rest ing ECG abnormalit ies
Reference Values
Normal
I ncrease in vent ilat ion, heart rat e, and blood pressure appropriat e t o t he level of
exercise No abnormal changes in t he ECG (no arrhyt hmias), ABG s, or
hemodynamic pressures
Procedure
1. Stage 1
a. Record blood pressure readings, ECG analysis, and vent ilat ion during
increment al cycle ergomet ry or t readmill w alking.
b. Take measurement s at t he end of each minut e. Remember t hat t he t est
cont inues unt il maximum-allow ed sympt oms occur (ie, t o a sympt omlimit ed maximum). Measure O2 upt ake ([ V w it h dot above] O2 ) and CO2
out put ([ V w it h dot above] CO2 ) if possible.
c. Alert pat ient t hat t ot al examinat ion t ime is approximat ely 30 minut es.
2. Stage 2
a. Be aw are t hat more complex analyt ic met hods are required.
b. Have exercise build t o a st eady st at e, usually 3 t o 5 minut es f or each
w orkload.
c. I n addit ion t o st age 1 measurement s, det ermine mixed venous CO2
t ension by means of rebreat hing t echniques.
3. Stage 3
a. Be aw are t hat blood gas sampling and analysis are required.
b. I nsert an indw elling cat het er int o t he brachial or radial art ery.
c. I n addit ion t o st age 2 t est s, det ermine measurement s f or cardiac out put ,
alveolar vent ilat ion, rat io of dead space t o t idal volume (VD/ VT),
alveolar-art erial O2 t ension diff erence (A-aDO 2 ), venous admixt ure rat io,
and lact at e concent rat ion.
Alt ered values may reveal:
1. Cardiac dysrhyt hmias or ischemia
2. Degree of f unct ional impairment caused by obst ruct ive or rest rict ive
vent ilat ory disease
3. Hypovent ilat ion
4. Workload level at w hich met abolic acidosis (lact ic acidosis) occurs
Interfering Factors
1. The exercise t olerance of any person is aff ect ed by t he degree of
impairment relat ed t o:
a. Mechanical f act ors
b. Vent ilat ory eff iciency
c. G as exchange f act ors
d. Cardiac st at us
e. Physical condit ion
f. Sensit ivit y of t he respirat ory cont rol mechanism
2. O bese persons have a higher-t han-normal oxygen consumpt ion at any given
w ork rat e, even t hough muscular and w ork eff iciency values are normal.
Interventions
1. Explain t he purpose and procedure f or exercise st ress t est ing and assess f or
cont raindicat ions, int erf ering f act ors, and abilit y t o comply.

1. Explain t he meaning of t est out comes and possible need f or lif est yle
changes.
Arterial Blood Gases (ABGs)
Overview of Arterial Blood Gas Tests

Measurements of arterial blood gases
(ABGs) are obtained to assess adequacy of
oxygenation and ventilation, to evaluate
acid-base status by measuring the
respiratory and nonrespiratory
components, and to monitor effectiveness
of therapy. They are also used to monitor
critically ill patients, to establish baseline
values in the perioperative and
postoperative period, to detect and treat
electrolyte imbalances, to titrate
appropriate oxygen flow rates, to qualify a
patient for use of oxygen at home, and in
conjunction with pulmonary function
testing.
Reasons f or using arteri al rat her t han venous blood t o measure blood gases
1. Art erial blood provides a bet t er w ay t o sample a mixt ure of blood f rom
various part s of t he body.
a. Venous blood f rom an ext remit y gives inf ormat ion most ly about t hat
ext remit y. The met abolism in t he ext remit y can diff er f rom t he
met abolism in t he body as a w hole. This diff erence is accent uat ed in t he
f ollow ing inst ances:
1. I n shock st at es, w hen t he ext remit y is cold or underperf used

2. During local exercise of t he ext remit y, as in opening and closing a
f ist
3. I f t he ext remit y is inf ect ed
b. Blood f rom a cent ral venous cat het er usually is an incomplet e mix of
venous blood f rom various part s of t he body. For a sample t o be
complet ely mixed, t he blood w ould have t o be obt ained f rom t he right
vent ricle or pulmonary art ery.
2. Art erial blood measurement s indicat e how w ell t he lungs are oxygenat ing
blood.
a. I f it is know n t hat t he art erial O2 concent rat ion is normal (indicat ing t hat
t he lungs are f unct ioning normally) but t he mixed venous O2 concent rat ion
is low, it can be inf erred t hat t he heart and circulat ion are f ailing.
b. O xygen measurement s of cent ral venous cat het er blood reveal t issue
oxygenat ion but do not separat e cont ribut ions of t he heart f rom t hose of
t he lungs. I f cent ral venous cat het er blood has a low O2 concent rat ion, it
means eit her t hat t he lungs have not oxygenat ed t he art erial blood w ell
or t hat t he heart is not circulat ing t he blood eff ect ively. I n t he lat t er
case, t he body t issues must t ake on more t han t he normal amount of O2
f rom each cardiac cycle because t he blood is f low ing slow ly and permit s
t his t o occur; t his produces a low venous O2 concent rat ion.
3. Art erial samples provide inf ormat ion about t he abilit y of t he lungs t o regulat e
acid-base balance t hrough ret ent ion or release of CO2 . Eff ect iveness of t he
kidneys in maint aining appropriat e bicarbonat e levels also can be gauged.
NOTE
Art erial punct ure sit es must sat isf y t he f ollow ing requirement s: (1) available
collat eral blood f low ; (2) superf icial or easily accessible locat ion; and (3)
relat ively nonsensit ive periart erial t issues.
The radial art ery is usually t he sit e of choice, but brachial and f emoral art eries
can also be used. Samples can be draw n f rom direct art erial st icks or f rom
indw elling art erial lines.
Clinical Alert
1. Bef ore obt aining an art erial blood sample, assess f or t he f ollow ing
cont raindicat ions t o an art erial st ick or indw elling line:
Absent palpable radial art ery pulse
Negat ive modif ied Allen's t est , indicat ing obst ruct ion in t he ulnar art ery
(ie, compromised collat eral circulat ion)do not at t empt t o use radial
art ery f or blood sample
Cellulit is or inf ect ion in t he area
Art eriovenous f ist ula or shunt
Severe t hrombocyt openia
Prolonged prot hrombin or part ial t hromboplast in t ime (relat ive
cont raindicat ion)
2. A Doppler probe or f inger-pulse t ransducer may be used t o assess
circulat ion. This may be especially helpf ul w it h dark-skinned or
uncooperat ive pat ient s.
3. Bef ore obt aining an art erial blood sample, record t he most recent
hemoglobin (Hb) concent rat ion, t he mode and f low of oxygen t herapy, and
t he t emperat ure. I f t he pat ient has recent ly undergone suct ioning or been
placed on mechanical vent ilat ion, or if t he inspired oxygen concent rat ion
has been changed, w ait at least 15 minut es bef ore draw ing t he sample.
This w ait ing period allow s circulat ing blood levels t o ret urn t o baseline.
Hypert hermia and hypot hermia also inf luence oxygen release f rom
hemoglobin at t he t issue level.
Reference Values
Normal
See Table 14. 3.
Table 14.3 Normal Values for Commonly Ordered

Arterial Blood Gas Studies
Adults
Pediatrics
pHa
7.357.45
7.327.42
Pa CO 2
3545 mmHg (4.65.9

kPa)
3040 mmHg (4.0

5.3 kPa)
Pa O 2
>80 mmHg (>10.6 kPa)
80100 mmHg
(10.613.3 kPa)
Sa O 2
>94% (>0.94)
CO 2
content
4551 vol% (19.322.4

mmol/L)
O2
content
1522 vol % (6.69.7

mmol/L)
Base
excess
>2 mEq/L (>2 mmol/L)
Base
deficit
< -2 mEq/L (< -2

mmol/L)
HCO 3 -
2226 mEq/L (2226

mmol/L)
Hb
1216 g/dL or 120160

g/L (women);
13.517.5 g/dL or 135
175 g/L (men)
Hct
37%47% (women);
40%54% (men)
COHb
<2% (<0.02)
[NA + ]
135148 mEq/L (135

148 mmol/L)
[K + ]
3.65.2 mEq/L (3.65.2

mmol/L)
[Ca ++ ]
4.25.1 mEq/L (2.12.5

mmol/L)
[Cl - ]
98106 mEq/L (98106

mmol/L)
Procedure
1. O bserve standard precauti ons and f ol l ow agency protocol s.
2. Have t he pat ient assume a sit t ing or supine posit ion.
3. Perf orm t he modif ied Allen's t est t o assess collat eral circulat ion bef ore
perf orming a radial punct ure, as f ollow s:
a. Use pressure t o oblit erat e bot h radial and ulnar pulses.
b. Make t he hand blanch, t hen release pressure over only t he ulnar art ery.
I n a posit ive t est , not e f lushing immediat ely; t he radial art ery may t hen
be used f or punct ure.
c. I f collat eral circulat ion f rom t he ulnar art ery is inadequat e (negat ive
t est ), choose anot her sit e.
4. Elevat e t he pat ient 's w rist w it h a small pillow, and ask t he pat ient t o ext end
t he f ingers dow nw ard (t his f lexes t he w rist and posit ions t he radial art ery
closer t o t he surf ace).
5. Palpat e t he art ery and maneuver t he pat ient 's hand back and f ort h unt il a
sat isf act ory pulse is f elt .
6. Sw ab t he area liberally w it h an ant isept ic agent (eg, an agent w it h an iodine
base).
7. O pt ional: Af t er assessing f or allergy, inject t he area w it h a small amount
(<0. 25 mL) of 1% plain lidocaine (Xylocaine) if necessary t o anest het ize sit e.
This allow s f or a second at t empt w it hout undue pain.
8. Prepare a 20- or 21-gauge needle on a preheparinized self -f illing syringe,
punct ure t he art ery, and collect a 3- t o 5-mL sample. During t he procedure,
if t he pat ient f eels a dull or sharp pain radiat ing up t he arm, w it hdraw t he
needle slight ly and reposit ion it . I f reposit ioning does not alleviat e t he pain,
t he needle should be w it hdraw n complet ely.
9. Wit hdraw t he needle and place a 4- 4-inch absorbent bandage over t he
punct ure sit e. Maint ain pressure over t he sit e w it h t w o f ingers f or a minimum
of 2 minut es or unt il no bleeding is evident ; it may be necessary t o use a
pressure dressing, secured t o t he sit e w it h elast ic t ape, f or several hours.
10. Meanw hile, ensure t hat all air bubbles in t he blood sample are expelled as
quickly as possible. Air in t he sample changes ABG values. Cap t he syringe
and gent ly rot at e t o mix heparin w it h t he blood.
11. Label t he sample w it h pat ient 's name, ident if icat ion number, dat e, t ime,
mode of O2 t herapy, and f low rat e.
12. Place t he sample on ice and t ransf er it t o t he laborat ory. This prevent s
alt erat ions in gas t ensions result ing f rom met abolic processes t hat cont inue
af t er blood is draw n.
Interventions
1. Explain t he purpose and procedure f or obt aining an art erial blood sample.
2. I f t he pat ient is apprehensive, explain t hat a local anest het ic can be used.

1. Evaluat e color, mot ion, sensat ion, degree of w armt h, capillary ref ill t ime, and
qualit y of pulse in t he aff ect ed ext remit y or at t he punct ure sit e.
2. Monit or punct ure sit e and dressing f or art erial bleeding f or several hours. No
vigorous act ivit y of t he ext remit y should be undert aken f or 24 hours.
Clin ical Alert

1. Some pat ient s experience light headedness, nausea, or vasovagal syncope
during art erial punct ure. Respond according t o est ablished prot ocols.
2. ABG measurement s do not indicat e t he degree of an abnormalit y. For t his
reason, t he vit al signs and ment al f unct ion of t he pat ient must be used as
guides t o det ermine adequacy of t issue oxygenat ion.
3. Pressure must be applied t o t he art erial punct ure sit e, and t he sit e must
be w at ched caref ully f or bleeding f or several hours. I nst ruct t he pat ient t o
report any bleeding f rom t he sit e.
4. I nf ormat ion f or t he laborat ory should include t he f ract ion of inspired
oxygen (FI O2 ), w hich is 0. 21 (21%) f or room air, and t he t ime w hen t he
sample w as obt ained. Do not use blood f or ABG measurement s if sample
is >3 hours old.
5. I n t he clinical set t ing (eg, perioperat ive or int ensive care environment ),
ABG st udies usually include t he f ollow ing: pH, PaCO2 , SaO2 , CO2 cont ent ,
O 2 cont ent , PaO2 , base excess or def icit , HCO3 - , hemoglobin, hemat ocrit ,
CO , Na+ , and K+ (see Table 14. 3).
Alveolar-to-Arterial Oxygen Gradient (A-aDO2 ); Arterialto-Alveolar Oxygen Ratio (a/A Ratio) This test gives an
approximation of the difference in the partial pressure
of O2 betw een the alveoli and arteries. The alveolar to
arterial oxygen gradient assesses oxygen delivery by

comparing the arterial oxygen level to the theoretical
maximum alveolar oxygen level. It identifies the cause
of hypoxemia and intrapulmonary shunting as either (1)
ventilated alveoli but no perfusion, (2) unventilated
alveoli w ith perfusion, or (3) collapse of both alveoli
and capillaries.
Reference Values
Normal
A-aDO 2 : <10 mm Hg (<1. 33 kPa) at rest (room air) A-aDO 2 : 2030 mm Hg (2. 7
4. 0 kPa) at maximum exercise (room air) a/ A rat io: 75%
Procedure
1. O bt ain and analyze an art erial blood sample. This gives t he arteri al part ial
pressures of oxygen (PaO2 ) and of carbon dioxide (PaCO2 ). The baromet ric
pressure (PB) and w at er vapor pressure (PH2 O ) are also know n, as is t he
f ract ional concent rat ion of inspired oxygen (FI O2 ), w hich is 0. 21 (21%) f or
room air.
2. From t hese, derive t he al veol ar oxygen t ension (PAO2 ), t he art erial-t o
alveolar oxygen rat io (a/ A rat io), and t he alveolar-t o-art erial diff erence f or
PO 2 (A-aDO 2 ) by use of f ormulas.
1. Increased values may be caused by:
a. Mucus plugs
b. Bronchospasm
c. Airw ay collapse, as seen in:
1. Ast hma
2. Bronchit is
3. Emphysema
2. Hypoxemia (increased A-aDO 2 ) is caused by:
a. At rial sept al def ect s

b. Pneumot horax
c. At elect asis
d. Emboli
e. Edema
Interfering Factors
Values increase w it h age (age in years +10 divided by 4 gives an est imat e of a
normal gradient ) and increasing O2 concent rat ion (gradient increases by 57 mm
Hg [ 0. 60. 9 kPa] f or every 10% increase in oxygen).
Interventions
1. Explain t he purpose, benef it s, and risks of art erial blood sampling (see page
928).

1. I nt erpret t est out come and assess, monit or, and int ervene appropriat ely f or
hypoxemia and vent ilat ory dist urbances.
2. Frequent ly observe t he punct ure sit e f or bleeding (see page 928).
Partial Pressure of Carbon Dioxide (PCO2 ) This test

measures the pressure or tension exerted by dissolved
CO2 in the blood (10% of CO2 is carried in plasma and
90% in red blood cells) and is proportional to the
partial pressure of CO2 in the alveolar air. The test is
commonly used to detect a respiratory abnormality and
to determine the alkalinity or acidity of the blood. To
maintain CO2 w ithin normal limits, the rate and depth of
respiration vary automatically w ith changes in

metabolism. This test is an index of the effectiveness
of alveolar ventilation; it is the most physiologically
reflective blood gas measurement. An arterial sample
directly reflects how w ell air is exchanged w ith blood
in the lungs.
CO 2 t ension in t he blood and in cerebrospinal f luid is t he major chemical f act or
regulat ing alveolar vent ilat ion. When t he CO2 t ension in art erial blood (PaCO2 )
rises f rom 40 t o 45 mmHg (5. 3 t o 6. 0 kPa), it causes a 3-f old increase in
alveolar vent ilat ion. A PaCO2 of 63 mmHg (8. 4 kPa) increases alveolar vent ilat ion
10-f old. When t he FI CO2 is > 0. 05 (5%), t he lungs can no longer be vent ilat ed
f ast enough t o prevent a dangerous rise of CO2 concent rat ion in t issue f luids.
Any f urt her increase in CO2 begins t o depress t he respirat ory cent er, causing a
progressive decline in respirat ory act ivit y rat her t han an increase.
Reference Values
Normal
PaCO 2 (art erial blood): 3545 mmHg (4. 76. 0 kPa) PvCO2 (venous blood): 41
57 mmHg (5. 47. 6 kPa)
Procedure
1. O bt ain an art erial blood sample (or venous sample if request ed) according t o
prot ocols. See page 929 f or art erial blood sample specimen collect ion and
Chapt er 2 f or venous blood sample specimen collect ion.
2. I nt roduce a small amount of t his blood int o a blood gas analyzing inst rument
(Fig. 14. 5), and measure t he CO2 t ension by a silversilver chloride
elect rode.
FI G URE 14. 5 Blood gas and elect rolyt e analyzer. (Source: Radi-omet er
Copenhagen, Radiomet er America, I nc. , West lake, O H, USA)
1. A ri se in PaCO2 (hypercapnia) usually is associat ed w it h hypovent ilat ion (CO2
ret ent ion); a decrease is associat ed w it h hypervent ilat ion (blow ing off
CO 2 ). A reduct ion in PaCO2 , t hrough it s eff ect on t he plasma bicarbonat e
concent rat ion, decreases renal bicarbonat e reabsorpt ion. For each 1-mm Hg
(0. 133-kPa) decrease in t he PaCO2 , t he plasma bicarbonat e w ill decrease by
approximat ely 1 mEq/ L (1 mmol/ L). Because HCO3 - and PaCO2 bear t his
close mat hemat ical relat ionship, and t his rat io, in t urn, def ends t he hydrogen
ion concent rat ion, t he out come is t hat t he st eady-st at e PaCO2 in simple
met abolic acidosis is equal t o t he last t w o digit s of t he art erial pH (pHa).
Also, addit ion of 15 t o t he bicarbonat e level equals t he last t w o digit s of t he
pHa. Failure of t he PaCO2 t o achieve predict ed levels def ines t he presence
of superimposed respirat ory acidosis on alkalosis.
2. Causes of decreased PaCO 2 include:
a. Hypoxia
b. Nervousness
c. Anxiet y
d. Pulmonary emboli
e. Pregnancy
f. Pain
g. O t her cause of hypervent ilat ion
3. Causes of i ncreased PaCO 2 include:

a. O bst ruct ive lung disease
1. Chronic bronchit is
2. Emphysema
b. Reduced f unct ion of respirat ory cent er
1. O verreact ion
2. Head t rauma
3. Anest hesia
c. O t her, less common causes of hypovent ilat ion (eg, pickw ickian
syndrome)
Clin ical Alert

I ncreased PaCO2 may occur, even w it h normal lungs, if t he respirat ory cent er
is depressed. Alw ays check laborat ory report s f or abnormal values. When
int erpret ing laborat ory report s, remember t hat PaCO2 is a gas and is
regulat ed by t he lungs, not t he kidneys.
Interventions
1. Explain t he purpose, benef it s, and risks of t he invasive art erial blood
sampling procedure. Assess t he pat ient 's abilit y t o cooperat e.

1. I nt erpret t he t est out come (see Fig. 14. 7). Assess, monit or, and int ervene
appropriat ely f or hypoxemia and vent ilat ory dist urbances.
FI G URE 14. 7 Art erial blood gas report of a 39-year-old male w it h

amyot rophic lat eral sclerosis (ALS). (Court esy of Pulmonary Diagnost ic
Laborat ory, Froedt ert Hospit al, Milw aukee, WI )
Oxygen Saturation (So2 ) This measurement is a ratio

betw een the actual O2 content of the hemoglobin and
the potential maximum O2 carrying capacity of the
hemoglobin. The SO2 is a percentage indicating the
relationship betw een O2 and hemoglobin; it does not
indicate the O2 content. The maximum amount of O2 that
can be combined w ith hemoglobin is called the oxygen
capacity. The combined measurements of SO2 , PO2 , and
hemoglobin (Hb) indicate the amount of O2 available to
tissues (tissue oxygenation). Pulse oximetry (SpO2 )
(Fig. 14.6) is a noninvasive technique that permits
continuous real-time monitoring and trending of
arterial oxygen saturation. How ever, it cannot
differentiate carboxyhemoglobin (COHb). As a result,
the SpO2 is generally higher than the actual arterial

oxygen saturation (SaO2 ) by the amount of COHb and a
more direct measurement involves taking an arterial
blood sample and measuring w ith a blood gas analyzer.
FI G URE 14. 6 Pulse oximet er. (Source: Nonin Medical, I nc, Plymout h, MN,
USA)
Reference Values
Normal
SaO 2 (art erial blood): >95% (>0. 95) SvO2 (mixed venous blood): 70%75%
(0. 700. 75) SaO2 (art erial) in new borns: 40%90% (0. 400. 90)
Procedure
1. O bt ain an art erial blood sample (see page 929 f or art erial and Chapt er 2 f or
venous). Tw o met hods are used f or det ermining SO2 :
a. Di rect method: I nt roduce t he blood sample int o hemoximet er, a
spect rophot omet ric device f or direct det erminat ion of SO2 .
b. Cal cul ated method: Calculat e SO2 f rom oxygen cont ent (t he volume of O2
act ually combined w it h hemoglobin) and oxygen capacit y (t he volume of
O 2 t o w hich hemoglobin could combine). Bot h of t hese values are
expressed as volume percent ages (vol%), or millilit ers per decilit er of
blood. Use t he f ollow ing f ormula:
2. Pul se oxi metry: A small, clip-like sensor is placed on a digit over t he

f ingernail (or t oenail or earlobe, if necessary). The inst rument , using
t ransmit t ed light w aves (in t he inf rared spect rum and sensors, det ermines
SO 2 noninvasively and is ref erred t o as t he SpO2 .
Limitations
1. SO 2 measures only t he percent age of oxygen being carried by hemoglobin; it
does not reveal t he act ual amount of oxygen available t o t he t issues (oxygen
cont ent ).
2. Pulse oximet ry equipment evaluat es pulsat ile blood f low. Many f act ors can
int erf ere w it h t he abilit y t o measure f low :
a. Digit mot ion
b. A decrease in blood f low t o t he digit (eg, cool ext remit y, decreased
peripheral pulses, vasoconst rict ion, nail bed t hickening, ambient light ,
digit malf ormat ion, vasoconst rict ive drugs, localized obst ruct ion)
c. Decreased hemoglobin (anemia) or abnormal hemoglobin (CO Hb)
d. Pulse rat e and rhyt hm
Interfering Factors
Recent smoking or exposure t o close second-hand smoke or t o CO can increase
t he level of CO Hb, as can use of cert ain paint and varnish-t ype st ripping agent s,
especially w hen t hey are
applied in closed or poorly vent ilat ed areas. The eff ect is t o decrease t he SaO2
w it h lit t le or no aff ect on t he PaO2 .
1. Abnormal result s occur in pulmonary diseases involving cyanosis and
eryt hrocyt osis.
2. Abnormal result s occur w it h venous-t o-art erial shunt s.
3. Values are abnormal in Rh incompat ibilit y caused by blocking ant ibodies.
4. Values usually are normal in polycyt hemic vera.
5. Values are decreased in vent ilat ion-perf usion mismat ching.
6. Values decrease w it h age.
Interventions
1. Explain t he purpose, benef it s, and risks of invasive art erial blood sampling.
Assess t he pat ient 's abilit y t o comply w it h t he procedure.

1. I nt erpret t est out comes. Assess, monit or, and int ervene appropriat ely f or
bleeding at punct ure sit e and f or hypoxemia or ot her respirat ory
dysf unct ions.
Oxygen Content (CO2 ) The actual amount of O2 in the

blood is termed the oxygen content (CO 2 ). Blood can
contain less O2 than it is capable of carrying. About
98% of all O2 delivered to the tissues is transported in
chemical combination w ith hemoglobin. One gram of
hemoglobin is capable of combining w ith 1.34 mL of O2 ,
w hereas 100 mL of blood plasma can carry a maximum

of only 0.3 mL of O2 (under normoxic conditions or
atmospheric conditions). The CO2 measurement is
determined mathematically.
Reference Values
Normal
CaO 2 (art erial blood): 1522 vol% or 1522 mL/ dL of blood (6. 69. 7 mmol/ L)
CvO 2 (venous blood): 1116 vol% or 1116 mL/ dL of blood (4. 97. 1 mmol/ L)
Procedure
1. O bt ain an art erial or venous blood sample.
2. Measure t he SO2 , PO2 , and hemoglobin concent rat ion (Hb).
3. Use t he f ollow ing f ormulas f or calculat ing O2 cont ent :
NOTE
0. 003 = Bunsen solubilit y f or oxygen in t he blood.
Decreased CaO 2 is associat ed w it h:
1.
COPD
2. Post operat ive respirat ory complicat ions

3. Flail chest
4. Kyphoscoliosis
5. Neuromuscular impairment
6. O besit y-caused hypovent ilat ion
7. Anemia
Interventions
1. Explain t he purpose, benef it s, and risks of invasive art erial blood sampling
(see page 928).

1. I nt erpret t est out come. Assess, monit or, and int ervene appropriat ely f or
bleeding at t he punct ure sit e and f or hypoxemia or vent ilat ory dist urbances.
Partial Pressure of Oxygen (PO2 ) Oxygen is carried in

the blood in tw o forms: dissolved in plasma (<2%) and
combined w ith hemoglobin (98%). The partial pressure
of a gas determines the force it exerts in attempting to
diffuse through the pulmonary membrane. The PO2
reflects the amount of O2 passing from the pulmonary
alveoli into the blood; it is directly influenced by the
fraction of inspired oxygen (FIO2 ).
This t est measures t he pressure exert ed by t he O2 dissolved in t he plasma. I t
evaluat es t he abilit y of t he lungs t o oxygenat e t he blood and is used t o assess
t he eff ect iveness of oxygen t herapy. The PO2 indicat es t he abilit y of t he lungs t o
diff use O2 across t he alveolar membrane int o t he circulat ing blood.
Reference Values
Normal
PaO 2 (art erial blood): >80 mm Hg (>10. 6 kPa) PvO2 (venous blood): 3040 mm
Hg (4. 05. 3 kPa)
Procedure
1. O bt ain an art erial (or venous, if request ed) blood sample (see page 929 f or
art erial and Chapt er 2 f or venous).
2. I nt roduce a small amount of t his blood int o a blood gas analyzing inst rument
(see Fig. 14. 5), and measure t he O2 t ension w it h a polargraphic elect rode
(developed by Leland Clark, somet imes ref erred t o as t he Clark elect rode).
1. Increased PaO 2 is associat ed w it h:
a. Polycyt hemia
b. I ncreased FI O2
c. Hypervent ilat ion
2. Decreased PaO 2 is associat ed w it h:
a. Anemias
b. Cardiac decompensat ion
c. I nsuff icient at mospheric O2
d. I nt racardiac shunt s
e.
COPD
f. Rest rict ive pulmonary disease

g. Hypovent ilat ion caused by neuromuscular disease
3. Decreased PaO 2 w it h normal or decreased PACO2 is associat ed w it h:
a. Diff use int erst it ial pulmonary inf ilt rat ion
b. Pulmonary edema
c. Pulmonary embolism
d. Post operat ive ext racorporeal circulat ion
Clin ical Alert

I n persons w it h CO PD, vent ilat ory eff ort s are st imulat ed by t he hypoxic st at e,
w hereas f or a healt hy person, t he respirat ory st imulus is t he buildup of CO2 .
Alt hough supplement al oxygen increases t he PaO2 in such pat ient s, it can also
result in less eff ect ive breat hing because vent ilat ory eff ort s are no longer
st imulat ed. The administ rat ion of oxygen knocks out t his hypoxic drive, and
CO 2 ret ent ion result s.
Interventions
1. Explain t he purpose, benef it s, and risks of art erial blood sampling. Assess
t he pat ient 's level of cooperat ion and underst anding.

1. I nt erpret t he t est out come (see Fig. 14. 7). Assess, monit or, and int ervene
appropriat ely f or bleeding at t he punct ure sit e and f or respirat ory or
vent ilat ory dist urbances.
Carbon Dioxide (CO2 ) Content; Total Carbon Dioxide
(TCO2 ) In normal blood plasma, >95% of the total CO2

content (TCO2 ) is contributed by bicarbonate ion (HCO3 ), w hich is regulated by the kidneys. The other 5% is
contributed by the dissolved CO2 gas and by carbonic
acid (H2 CO3 ). Dissolved CO2 gas, w hich is regulated by
the lungs, therefore contributes little to the TCO2 , and
the TCO2 gives little information about the lungs.
The HCO3 - in t he ext racellular spaces exist s f irst as CO2 , t hen as H2 CO 3 ; lat er,
much of it is changed t o sodium bicarbonat e (NaHCO3 ) by t he buff ers in t he
plasma and eryt hrocyt es. This t est is a general measure of t he alkalinit y or
acidit y of venous, art erial, or capillary blood. This t est measures t he CO2
cont ribut ions f rom dissolved CO2 gas, t ot al H2 CO 3 , HCO3 - , and
carbaminohemoglobin (CO2 HHb).
Reference Values
Normal
2330 mEq/ L or 2330 mmol/ L
Procedure
1. Collect a venous or art erial blood sample of 5 mL in a heparinized syringe.
2. Measure t he sample by a blood gas analyzer. I f t he collect ed blood sample
cannot be st udied immediat ely, place t he syringe in an iced cont ainer.
3. Use t he f ollow ing f ormula: TCO 2 = HCO3 - + H2 CO 3
1. Increased TCO 2 occurs in:
a. Severe vomit ing
b. Emphysema
c. Aldost eronism
d. Use of mercurial diuret ics
2. Decreased TCO 2 occurs in:

a. Severe diarrhea
b. St arvat ion
c. Acut e renal f ailure
d. Salicylat e t oxicit y
e. Diabet ic acidosis
f. Use of chlorot hiazide diuret ics
NOTE
I n diabet ic acidosis, t he supply of ket oacids exceeds t he demands of t he cell.
Blood plasma acids rise. Blood plasma HCO3 - decreases because it is used t o
neut ralize t hese excess acids.
Table 14. 4 present s t he changes in pH, HCO3 - , and PaO2 t hat occur in various
vent ilat ory dist urbances and acid-base imbalances.
Table 14.4 Summary of Ventilatory and Acid-Base C

Underlying Conditions of Acid-Base Imbal
Form of
Disturbance
pHa
Bicarbonate
(HCO 3 - )
PaCO 2 ||
Decrease
Normal
Increase
RESPIRATORY
ACIDOSIS
Acute: caused by
decreased alveolar
ventilation and
retention of CO2
Chronic:
compensated via
renal reabsorption
of the bicarbonate
ion
Normal
Increase
Increase
Increase
Normal
Decrease
RESPIRATORY
ALKALOSIS
Acute: caused by
increased alveolar
ventilation and
excessive blowing
off of CO2 and water
Chronic:
compensated via
glomerular filtration
of the
bicarbonate ion
Normal
Decrease
Decrease
Decrease
Decrease
Normal
NONRESPIRATORY
OR METABOLIC
ACIDOSIS
Acute: caused by
accumulation of
fixed body acids or
loss of bicarbonate
from the
extracellular fluid
Chronic:
compensated via
hyperventilation
through stimulation
of central
chemoreceptors
Normal
Decrease
Decrease
Increase
Increase
Normal
NONRESPIRATORY
OR METABOLIC
ALKALOSIS
Acute: caused by
loss of fixed body
acids or gain in
bicarbonate in
extracellular fluid
Chronic:
compensated via
hypoventilation
Normal
Increase
*Although these four basic imbalances occur

individually, a combination of two or more is
observed more frequently. These disturbances
may have an antagonistic or a synergistic effect
on each other.
Uncompensated disturbances are referred to
as acute and compensated ones as chronic.
Compensation occurs via the mechanism not
involved. Compensation is most efficient in
respiratory acidosis.
Acid-base disturbances force kidney and
lungs to compensate for changes in pH.
Hyperventilation or hypoventilation can restore
pH to normal within 15 minutes; the kidney,
however, can take 2 to 3 days to compensate.
The degree of hypoventilation is precisely
related to the degree of hypobicarbonatemia.
For each 1 mEq/L fall in bicarbonate, PCO 2 falls
Increase
by 1 to 1.3 mm Hg. A close mathematical

relationship prevails between bicarbonate and
PCO 2 ; their ratio defines the prevailing hydrogen
on concentration. For this reason, the steadystate PCO 2 in simple metabolic acidosis is equal
to the last two digits of the pH. Failure of the
PCO 2 to reach predicted levels defines the
presence of superimposed respiratory acidosis
or alkalosis.
||Decreases in PaO 2 are interpreted separately
and are referred to as hypoxemia.
Clin ical Alert
1. A double use of t he t erm CO2 is one of t he main reasons w hy
underst anding of acid-base problems may be diff icult . Use t he t erms CO 2
content and CO 2 gas t o avoid conf usion. Remember t he f ollow ing:
CO 2 content (ie, TCO 2 ) is mainly bicarbonat e and a base. I t is a
solut ion and is regulat ed by t he kidneys.
CO 2 gas is mainly acid. I t is regulat ed by t he lungs.
2. The panic value f or CO2 cont ent is <6. 0 mEq/ L (<6. 0 mmol/ L); it usually is
associat ed w it h severe met abolic acidosis, w it h t he pH of t en <7. 1. Thi s i s
a l i f e-threateni ng si tuati on.
Interfering Factors
A number of drugs can eit her increase or decrease TCO 2 .
Interventions
1. Explain t he purpose, benef it s, and risks of art erial blood sampling. Assess
t he pat ient 's abilit y t o comply w it h t he procedure.

1. I nt erpret t est out comes. Assess, monit or, and int ervene appropriat ely f or
acid-base imbalances.
2. Monit or and int ervene f or bleeding at t he punct ure sit e and f or respirat ory or
vent ilat orydist urbances.
Blood pH
The pH is t he negat ive logarit hm of t he hydrogen ion concent rat ion in t he blood.
The sources of hydrogen ions are volat ile acids, w hich can vary bet w een a liquid
and a gaseous st at e, and nonvolat ile acids, w hich cannot be volat ilized but
remain f ixed (eg, diet ary acids, lact ic acids, ket oacids).
NOTE
A pH value of 7 is neut ral; acidit y increases as t he pH f alls f rom 7 t o 1, and
alkalinit y increases as t he pH rises f rom 7 t o 14. Limit s of pH compat ible w it h
lif e f all w it hin t he range of 6. 9 t o 7. 8.
Blood pH measures t he body's chemical balance and represent s a rat io of acids
t o bases. I t is also an indicat or of t he degree t o w hich t he body is adjust ing t o
dysf unct ions by means of it s buff ering syst ems. I t is one of t he best w ays t o
det ermine w het her t he body is t oo acidic or t oo alkaline and is an indicat or of
t he pat ient 's met abolic and respirat ory st at us. The acid-base balance in t he
ext racellular f luid is ext remely delicat e and int ricat e and must be kept w it hin t he
very narrow range of 7. 35 t o 7. 45 (slight ly alkaline). Values < 7. 35 indicat e an
aci d state, w hereas pH values > 7. 45 indicat e an al kal i ne state.
Reference Values
Normal
pHa (art erial blood): 7. 357. 45
pHv (venous blood): 7. 317. 41
Procedure
1. O bt ain an art erial (or venous if request ed) blood sample.
2. Use one of t he f ollow ing t w o met hods t o det ermine t he pH:
a. Di rect method: Analyze a small amount of blood by a blood gas machine
(see Fig. 14. 5); measure t he pH by a modif ied Severinghaus elect rode.
b. Indi rect method: Solve t he Henderson-Hasselbalch equat ion f or t he pH of
a buff er syst em. I n t his equat ion, pK is t he negat ive logarit hm of t he acid
dissociat ion const ant (t he pH at w hich t he associat ed and unassociat ed
f orms of an acid exist in equal concent rat ions). [ A- ] is t he concent rat ion
of t he ionized f orm (in t his case HCO3 - , t he major blood base), and [ HA]
is t he concent rat ion of t he f ree acid (in t his case H2 CO 3 , t he major blood
acid), in milliequivalent s per lit er.
1. G enerally speaking, t he pH is decreased in acidemia (acidosis) because of
increased f ormat ion of acids, and pH is i ncreased in alkalemia (alkalosis)
because of a loss of acids.
2. When int erpret ing an acid-base abnormalit y, cert ain st eps should be
f ollow ed:
a. Check t he pH t o det ermine w het her an acid or an alkaline st at e exist s.
b. Check t he PCO2 t o det ermine w het her a respirat ory acidosis or alkalosis
is present . (PCO2 is t he breathi ng component . )
c. Check t he HCO3 - concent rat ion t o det ermine w het her a met abolic
acidosis or alkalosis is present . (HCO3 - is t he renal component . )
3. See Table 14. 4 f or a more complet e explanat ion of t he changes occurring in
acut e and chronic respirat ory and met abolic acidosis and alkalosis.
4. Met abolic acidemia (acidosis) occurs in:
a. Renal f ailure
b. Ket oacidosis in diabet es and st arvat ion
c. Lact ic acidosis
e. Severe diarrhea
5. Met abolic alkalemia (alkalosis) occurs in:
a. Hypokalemia
b. Hypochloremia
c. G ast ric suct ion or vomit ing
d. Massive doses of st eroids
e. Sodium bicarbonat e administ rat ion
f. Aspirin int oxicat ion
6. Respirat ory alkalemia (alkalosis) occurs in:
a. Acut e pulmonary disease
b. Myocardial inf arct ion
c. Chronic and acut e heart f ailure
d. Adult cyst ic f ibrosis
e. Third t rimest er of pregnancy and during labor and delivery

f. Anxiet y, neuroses, psychoses
g. Pain
h. Cent ral nervous syst em diseases
i. Anemia
j. Carbon monoxide poisoning
k. Acut e pulmonary embolus
l. Shock
7. Respirat ory acidemia (acidosis) occurs in:
a. Acut e or chronic respirat ory f ailure
b. Vent ilat ory f ailure
c. Neuromuscular depression
d. O besit y
e. Pulmonary edema
f. Cardiopulmonary arrest
Interfering Factors
A number of drugs may alt er t he component s of acid-base balance. See
Appendix J.
Clin ical Alert

1. Venti l atory f ai l ure i s a medi cal emergency. Aggressi ve and supporti ve
measures must be taken i mmedi atel y.
2. Rat e and dept h of respirat ions may give a clue t o blood pH.
Acidosis usually i ncreases respirat ions; t his is t he body's w ay of
adjust ing once t he st at e is est ablished.
P.
Alkalosis usually decreases respirat ions; t his is t he body's w ay of
adjust ing once t he st at e is est ablished.
3. Respirat ory alkalosis may ref lect hypervent ilat ion in response t o t reat ment
f or hypoxemia; how ever, correct ion of hypoxemia is essent ial.
4. Met abolic alkalosis, w hich is compensat ed t hrough hypovent ilat ion, may
produce hypoxemia.
Interventions
1. Explain t he purpose, benef it s, and risks of invasive blood sampling.

1. I nt erpret t est out come (see Fig. 14. 7). Assess, monit or, and int ervene
appropriat ely f or met abolic and respirat ory acidosis and alkalosis (see Table
14. 4).
2. Frequent ly observe t he art erial punct ure sit e f or bleeding (see page 929). Be
prepared t o init iat e proper int ervent ions in t he event of lif e-t hreat ening
sit uat ions.
Base Excess or Deficit

This t est quant if ies t he pat ient 's t ot al base excess or def icit so t hat clinical
t reat ment of acid-base dist urbances (specif ically t hose t hat are nonrespirat ory in
nat ure) can be init iat ed. I t is also
ref erred t o as t he whol e bl ood buf f er base and is t he sum of t he concent rat ion
of buff er anions (in milliequivalent s per lit er) cont ained in w hole blood. These
buff er anions are t he bicarbonat e ion (HCO3 - ) present in plasma eryt hrocyt es,
and t he hemoglobin, plasma prot eins, and phosphat es in plasma and red blood
cells.
The t ot al quant it y of buff er anions is 4550 mEq/ L (4550 mmol/ L), or about
t w ice t hat of HCO3 - alone (2226 mEq/ L or 2226 mmol/ L). Theref ore, t he
quant it y of HCO3 - ions account s f or only about half of t he t ot al buff ering capacit y
of t he blood. The base excess or def icit measurement provides a more complet e
pict ure of t he buff ering t hat is t aking place and is a crit ical index of
nonrespirat ory versus respirat ory changes in acid-base balance.
Reference Values
Normal
Normal values are bet w een 2 mEq/ L (2 mmol/ L) A posit ive value indicat es a
base excess (ie, nonvolat ile acid def icit ).

A negat ive value indicat es a base def icit (ie, nonvolat ile acid excess).
Procedure
1. Make calculat ions f rom t he measurement s of pH, PaCO2 , and t he hemat ocrit .
2. Plot t hese values on a nomogram, and read t he base excess or def icit .
1. A negati ve value (less t han -2 mEq/ L or -2 mmol/ L) ref lect s a nonrespirat ory
or met abolic dist urbance or t rue base def icit , or a nonvolat ile acid
accumulat ion caused by:
a. Diet ary int ake of organic and inorganic acids
b. Lact ic acid
c. Ket oacidosis
2. A posi ti ve value (higher t han +2 mEq/ L or +2 mmol/ L) ref lect s a nonvolat ile
acid def icit or t rue base excess.
Anion Gap (AG)

This t est measures t he diff erence bet w een t he sum of t he sodium (Na+ ) and
pot assium (K+ ) ion concent rat ions (t he measured cat ions) and t he sum of t he
chloride (Cl- ) and bicarbonat e (HCO3 - ) concent rat ions (t he measured anions).
This diff erence ref lect s t he concent rat ions of ot her anions t hat are present in t he
ext racellular f luid but are not rout inely measured, t he component s of w hich
include phosphat es, sulf at es, ket one bodies, lact ic acid, and prot eins. I ncreased
amount s of t hese unmeasured anions are produced in t he acidot ic st at e.
Primary hypobi carbonatemi a is brought about by any combinat ion of t hree
mechanisms: (1) overproduct ion of acids, w hich causes replacement of NaHCO3
by t he Na+ salt of t he off ending acid (eg, lact at e replaces HCO3 - in lact ic
acidosis); (2) loss of NaHCO3 t hrough diarrhea along w it h renal ret ent ion of
diet ary NaCl, w hich causes hyperchloremic met abolic acidosis; and (3)
generalized renal f ailure or specif ic f orms of renal t ubular acidosis, w hich cause
ret ent ion of acids t hat are normally produced by int ermediary met abolism or by
urinary excret ion of alkali (Table 14. 5).
Table 14.5 Subclassification of Anion Gap Metabolic

Acidosis (Hypobicarbonatemia) into High- and LowPotassium Forms*
High-Potassium Form
LowPotassium
Form
Acidifying agents
Diarrhea
Mineralocorticoid deficiency
Ureteral
sigmoidostomy
and
malfunctioning
ileostomy
Renal diseases such as systemic

lupus erythematosus, interstitial
nephritis, amyloidosis,
hydronephrosis, and sickle cell
nephropathy
Renal tubular
acidosis, both
proximal and
distal
Early nonspecific renal failure

*All metabolic acidoses can be classified on the basis
of how they affect the anion gap.
Hyperbi carbonatemi a w it h sust ained increases in HCO3 - levels is brought about

by a source of new alkali or by t he presence of f act ors t hat st imulat e renal
ret ent ion of excess HCO3 - . These mechanisms include excessive gast roint est inal
loss of acid, exogenous alkali in persons w hose kidneys avidly ret ain NaHCO3 ,
and renal synt hesis of HCO3 - in excess of daily consumpt ion. O t her
pat hophysiologic f act ors t hat aff ect renal reabsorpt ion of >25 mEq/ L (>25
mmol/ L) of HCO3 - and cont ribut e t o sust ained hyperbicarbonat emia include
ext racellular f luid volume cont ract ion, hypercapnia, hypokalemia,
hyperaldost eronemia, and hypoparat hyroidism (Table 14. 6).
Table 14.6 Classification of Anion Gap Metabolic

Alkalosis (Hyperbicarbonatemia) on the Basis of
Urinary Excretion
Saline-Responsive Urinary
SalineUnresponsive
Chloride
Chloride Excretion of <10

m Eq/day
Excretion of <10
m Eq/day
EXCESS BODY
BICARBONAT E CONT ENT
Renal alkalosis
Renal alkalosis
normotensive
conditions
Diuretic therapy
Poorly reabsorbable anion
therapy, (eg, carbenicillin,
penicillin, sulfate, phosphate)
Gastrointestinal alkalosis
Gastric alkalosis
Intestinal alkalosis (eg,

chloride diarrhea)
Bartter's syndrome
Severe potassium
depletion
Refeeding alkalosis
Hypercalcemia and
hypoparathyroidism
Hypertensive
conditions
endogenous
mineralocorticoids
Primary
aldosteronism
Exogenous alkali
Hyperreninism
Baking soda
Adrenal enzyme
deficiency: 11- and
17-hydroxylase
Sodium citrate, lactate,

gluconate, acetate
Liddle's syndrome
Transfusions
Exogenous
mineralocorticoids
Antacids
Licorice
Carbenoxolone
Chewing tobacco
NORMAL BODY
BICARBONAT E CONT ENT
Contraction alkalosisurinary loss of NaCl and water
without bicarbonate loss causes extracellular fluid
contraction around an unchanged body content of
alkali, resulting in hyperbicarbonatemia (especially
important in persons with edema and persons who have
excess body stores of water, sodium, bicarbonate, and
chloride).
Reference Values
Normal
Normal values are bet w een 12 4 mEq/ L or 12 mmol/ L.
I f pot assium concent rat ion is used in t he calculat ion, t he normal value is 16 4
mEq/ L or 16 4 mmol/ L.
Procedure
1. O bt ain t his measurement by calculat ing t he diff erence bet w een t he measured
serum cat ion concent rat ions (eit her w it h or w it hout K+ ) and t he measured
serum anion concent rat ions.
2. Use t he f ollow ing f ormulas:
1. An anion gap (AG ) occurs in acidosis t hat is caused by excess met abolic
acids and excess serum chloride levels. I f t here is no change in sodium
cont ent , anions such as phosphat es, sulf at es, and organic acids increase t he
AG because t hey replace bicarbonat e.
2. Increased AG is associat ed w it h an increase in met abolic acid w hen t here is
excessive product ion of met abolic acids, as in:
a. Alcoholic ket oacidosis
b. Diabet ic ket oacidosis
c. Fast ing and st arvat ion
d. Ket ogenic diet s
e. Lact ic acidosis
f. Poisoning by salicylat e, et hylene glycol (ant if reeze), met hanol, or propyl
alcohol
3. Increased AG is also associat ed w it h decreased loss of met abolic acids, as
in renal f ailure. I n t he absence of renal f ailure or int oxicat ion w it h drugs or
t oxins, an increase in AG is assumed t o be caused by ket oacidosis or lact at e
accumulat ion.
Anion gap includes t he det erminat ion of t hree gaps of t oxicology (inf luence of
drugs and heavy met als): (1) anion = t ype A lact ic acidosis due t o t issue
hypoxia; (2) osmolar gap; and (3) oxygen sat urat ion gap. A list of drugs and
t oxic subst ances t hat cause i ncreased anion gap (>12 mEq/ L or >12 mmol/ L)
including t he f ollow ing: nonaci doti c: carbenicillin and sodium salt s; metabol i c
aci dosi s: acet aminophen (ingest ion > 75100 g), acet azolamide, aluminum
phosphat e, amiloride, 4-aminopyridine, ammonium chloride, ascorbic acid,
benzalkonium chloride, bialaphos, 2-but oxyet hanol, carbon monoxide,
cent rimonium bromide, chloramphenicol, clozapine, cobalt , colchicine,
cyanide, dapsone, dimet hyl sulf at e, dinit rophenol, endosulan, epinephrine (I V
overdose), et hanol, et hylene dibromide, et hylene glycol, f enoprof en,
f luoroacet at e, f ormaldehyde, f ruct ose (I V), f unnel w eb spiders, glycol
et hers, glyphosale, hydrogen sulf ide, ibuprof en (ingest ion > 300 mg/ kg),
inorganic acid, iodine, iron, isoniazid, ket amine, ket oprof en, lime sulf ur,
margosa oil, met aldehyde, met f ormin, met hanol, met henamine mandelat e,
misoprost ol, monochloracet ic acid, nalidixic acid, naproxen, nef opam, niacin,
papaverine, paraldehyde, pennyroyal oil, pent aborane, pent achlorophenol,
phenelzine, phenf ormin (off t he market ), phenol, phenylbut azone, phosphoric
acid, polyet hylene glycol (low molecular w eight ), propof ol, propylene glycol,
salicylat es, sodium azide, sorbit ol (I V), st rychnine, sublimed sulf ur,
sult hiame, surf act ant herbicide, t et racycline
(out dat ed), t ienilic acid, t oluene, t ranylcypromine, vacor, valproic acid,
verapamil, zidovudine (chronic use > 6 mont hs), and zinc phosphide.
Toxins t hat cause osmolar gap > 10 mO sm f rom baseline include et hanol,
et hylene glycol, glycerol, hypermagnesemia (>9. 5 mEq/ L or >9. 5 mmol/ L),
isopropanol (acet one), iodine (quest ionable), mannit ol, met hanol, and
sorbit ol.
Drugs and t oxins t hat cause decreased anion gap (< 6 mEq/ L or < 6 mmol/ L)
include t he f ollow ing: aci dosi s: acet azolamide, amiloride, ammonium
chloride, amphot ericin B, bromide, f ialuridine (FI AU), iodide, kombucha t ea,
lit hium, polymyxin B, spironolact one, sulindac, t oluene, and t romet hamine.
Toxins t hat cause an oxygen sat urat ion gap (>5% diff erence bet w een
measured and calculat ed value) include carbon monoxide, cyanide
(quest ionable), hydrogen sulf ide (possible), met hemoglobin, and nit rat es.
4. I ncreased bicarbonat e loss w it h a normal AG is associat ed w it h
a. Decreased renal losses, as in
1. Renal t ubular acidosis
2. Use of acet azolamide
b. I ncreased chloride levels, as in
1. Alt ered chloride reabsorpt ion by t he kidney
2. Parent eral hyperaliment at ion
3. Administ rat ion of sodium chloride and ammonium chloride
c. Loss of int est inal secret ions, as in
1. Diarrhea
2. I nt est inal suct ion or f ist ula
3. Biliary f ist ula
5. Low AG is associat ed w it h
a. Mult iple myeloma
b. Hyponat remia caused by viscous serum
c. Bromide ingest ion (hyperchloremia)
Clin ical Alert

1. I nt erpret t est out comes and assess and monit or appropriat ely f or acidbase dist urbances.
2. The AG may provide evidence of a mixed rat her t han a simple acid-base
dist urbance.
3. Lact ic acidosis should be considered in any met abolic acidosis w it h
increased AG of >15 mEq/ L (>15 mmol/ L).
Lactic Acid
Lact at e is a product of carbohydrat e met abolism. Lact ic acid is produced during
periods of anaerobic met abolism w hen cells do not receive adequat e oxygen t o
allow conversion of f uel sources t o CO2 and w at er. Lact ic acid accumulat es
because of excess product ion of lact at e and decreased removal of lact ic acid
f rom blood by t he liver.
This measurement cont ribut es t o t he know ledge of acid-base volume and is used
t o det ect lact ic acidosis in persons w it h underlying risk f act ors such as
cardiovascular or renal disease t hat predispose t hem t o t his imbalance. Lact at e
is elevat ed in a variet y of condit ions in w hich hypoxia occurs and in liver disease.
Lact ic acidosis can occur in bot h diabet ic and nondiabet ic pat ient s. I t is of t en
f at al.
Reference Values
Normal
I n venous blood: 0. 52. 2 mEq/ L (0. 52. 2 mmol/ L) I n art erial blood: 0. 51. 6
mEq/ L (0. 51. 6 mmol/ L)
Procedure
1. O bt ain a venous or art erial blood sample of at least 5 mL.
2. Take t he specimen t o t he laborat ory immediat ely f or analysis.
1. Values are i ncreased in:
a. Lact ic acidosis
b. Cardiac f ailure
c. Pulmonary f ailure
d. Hemorrhage
e. Diabet es
f. Shock
g. Liver disease
2. Lact ic acidosis can be dist inguished f rom ket oacidosis by t he absence of

severe ket osis and hyperglycemia in t his st at e.
Interfering Factors
Lact ic acid levels normally rise during st renuous exercise, w hen blood f low and
oxygen cannot keep pace w it h t he increased needs of exercising muscle.
Clin ical Alert

An unexplained decrease in pH associat ed w it h a hypoxia-producing condit ion
is reason t o suspect lact ic acidosis.
Interventions
1. Explain t he purpose and procedure of art erial blood sampling. Assess pat ient
cooperat ion.

1. Frequent ly observe t he punct ure sit e f or bleeding. Manual pressure and a
pressure dressing should be applied t o t he punct ure sit e if necessary.
2. Base posttest assessment s on pat ient out comes; monit or and int ervene
appropriat ely f or vent ilat ory and acid-base dist urbances and hypoxemia.
Electrolyte Tests
Elect rolyt es (ions) are crit ical f or cellular react ions. These elect rolyt es provide
t he necessary inorganic chemicals f or a variet y of cellular f unct ions (eg, nerve
impulse t ransmission, muscular cont ract ion, w at er balance). Typically, t he
concent rat ion of cat ions (posit ively charged
elect rolyt es), eg, Na+ , K+ , Ca+ + and Mg+ , is higher in t he plasma t han in t he
int erst it ial f luid ow ing t o t he Donnan ef f ect (plasma prot eins have a net negat ive
charge), w hereas t he anions (negat ively charged), eg, Cl- , HPO4 - , t end t o be
higher in t he int erst it ial f luid t han t he plasma.
Calcium (Ca+ + ) The bulk of body calcium (99%) is stored

in the skeleton and teeth, w hich act as huge reservoirs
for maintaining blood levels of calcium. About 50% of
blood calcium is ionized; the rest is protein bound.
Only ionized calcium can be used by the body in such
vital processes as muscular contraction, cardiac
function, transmission of nerve impulses, and blood
clotting.
The amount of prot ein in t he blood also aff ect s calcium levels because 50% of
blood calcium is prot ein bound. Thus, a decrease in serum albumin w ill result in a
decrease in t ot al serum calcium. The decrease, how ever, does not alt er t he
concent rat ion of t he ionized f orm of calcium. Measurement s of ionized calcium
are done during open-heart surgeries, liver t ransplant at ions, and ot her
operat ions in w hich large volumes of blood ant icoagulat ed w it h cit rat e are given.
These t est s are also used t o monit or renal disease, renal t ransplant at ion,
hemodialysis, hyperparat hyroidism, hypoparat hyroidism, pancreat it is, and
malignancy. Parat hyroid hormone (PTH), calcit onin, vit amin D, est rogens,
androgens, carbohydrat es, and lact ose all are f act ors t hat inf luence calcium
levels.
This t est measures t he concent rat ion of t ot al and ionized calcium in t he blood t o
ref lect parat hyroid f unct ion, calcium met abolism, and malignancy act ivit y.
Clin ical Alert

Hyperparat hyroidism and cancer are t he most common causes of
hypercalcemia. Hypoalbuminemia is t he most common cause of decreased
t ot al calcium.
Reference Values
Normal
See Table 14. 7.
Table 14.7 Values for Calcium
Total
Calcium
Ionized
Calcium
Age
mg/dL
mmol/L
Age
mg/dL
mmol/L
010
d
7.610.4
1.90
2.60
Newborn
4.40
5.48
1.10
1.37
10
d3
yr
6.79.8
2.24
2.75
118 yr
4.80
5.52
1.20
1.38
39
yr
8.810.1
2.20
2.70
Adult
4.65
5.28
1.16
1.32
411
yr
8.910.1
2.30
2.70
11
13 yr
8.810.6
2.20
2.65
13
15 yr
9.210.7
2.30
2.55
15
18 yr
8.410.7
2.10
2.67
Adult
8.810.4
2.20
2.60
Procedure
1. O bt ain a 5-mL venous blood sample; t his w ill provide suff icient serum f or t his
t est .
2. O bserve st andard/ universal precaut ions. Be aw are t hat heparinized samples
are pref erred f or ionized calcium st udies.
3. Place specimens on ice, keep t ight ly capped, and deliver immediat ely t o t he
laborat ory.
Clin ical Alert

Cit rat ed et hylenediaminet et raacet ic acid (EDTA) and oxalat ed blood give
f alsely low values and should not be used in t he syringe.
1. Normal l evel s of total bl ood cal ci um, combined w it h ot her f indings, indicat e
t he f ollow ing condit ions:
a. Normal calcium levels w it h overall normal result s in ot her t est s indicat e
no problems w it h calcium met abolism.
b. Normal calcium and abnormal phosphorus values indicat e impaired
calcium absorpt ion ow ing t o alt erat ion of PTH act ivit y or secret ion (eg, in
ricket s, t he calcium level may be normal or slight ly low ered and t he
phosphorus level depressed).
c. Normal calcium and elevat ed blood urea nit rogen (BUN) levels indicat e
t he f ollow ing:
1. Possible secondary hyperparat hyroidism: init ially, low ered serum
calcium result s f rom uremia and acidosis. The reduced calcium level
st imulat es t he parat hyroid t o release PTH, w hich act s on bone t o
release more calcium.
2. Possible primary hyperparat hyroidism: excessive amount s of PTH
cause elevat ion in calcium levels, but secondary kidney disease
causes ret ent ion of phosphat e and concomit ant low er calcium levels.
d. Normal calcium and decreased serum albumin indicat es hypercalcemia.
Normally, a decrease in calcium is associat ed w it h a decrease in
albumin.
2. Hypercal cemi a (i ncreased total cal ci um l evel s [ >12 mg/ dL or >3 mmol / L] ) is
caused by or associat ed w it h t he f ollow ing condit ions:
a. Hyperparat hyroidism due t o parat hyroid adenoma, hyperplasia of
parat hyroid glands, or associat ed hypophosphat emia
b. Cancer (PTH-producing t umors)
1. Met ast at ic bone cancers; cancers of lung, breast , t hyroid, kidney,
liver, and pancreas
2. Hodgkin's lymphoma, leukemia, and non-Hodgkin's lymphoma
3. Mult iple myeloma w it h ext ensive bone dest ruct ion, Burkit t 's
lymphoma
4. Primary squamous cell carcinoma of lung, neck, and head
c. G ranulomat ous disease (eg, t uberculosis, sarcoidosis)
d. Thyroid t oxicosis
e. Paget 's disease of bone (also accompanied by high levels of alkaline
phosphat ase)
f. I diopat hic hypercalcemia of inf ancy
g. Bone f ract ures combined w it h bed rest , prolonged immobilizat ion
h. Excessive int ake of vit amin D, milk, ant acids
i. Renal t ransplant at ion
j. Milk-alkali syndrome (Burnet t 's syndrome)
3. Hypocal cemi a (decreased total cal ci um l evel s [ <4. 0 mg/ dL or <1. 0 mmol / L] )
are commonly caused by or associat ed w it h t he f ollow ing condit ions:
a. Pseudohypocalcemia, w hich ref lect s reduced albumin levels. The reduced
prot ein is responsible f or t he low calcium level because 50% of t he
calcium t ot al is prot ein bound.
b. Hypoparat hyroidism due t o surgical removal of parat hyroid glands,
irradiat ion, hypomagnesemia, gast roint est inal (G I ) disorders, or renal
w ast ing. The primary f orm is very rare.
c. Hyperphosphat emia due t o renal f ailure, laxat ive int ake, or cyt ot oxic
drugs
d. Malabsorpt ion due t o sprue, celiac disease, or pancreat ic dysf unct ion
(f at t y acids combine w it h calcium and are precipit at ed and excret ed in
t he f eces)
e. Acut e pancreat it is
f. Alkalosis (calcium ions become bound t o prot ein)

g. O st eomalacia (advanced)
h. Renal f ailure
i. Vit amin D def iciency, ricket s
j. Malnut rit ion (inadequat e nut rit ion)
k. Alcoholism, hepat ic cirrhosis
4. Increased i oni zed cal ci um l evel s occur in t he f ollow ing condit ions:
a. Hyperparat hyroidism
b. Ect opic PTH-producing t umors
c. I ncreased vit amin D int ake
d. Malignancies
5. Decreased i oni zed cal ci um l evel s occur in t he f ollow ing condit ions:
a. Hypervent ilat ion t o cont rol increased int racranial pressure (t ot al Ca+ +
may be normal)
b. Administ rat ion of bicarbonat e t o cont rol met abolic acidosis
c. Acut e pancreat it is (eg, diabet ic acidosis, sepsis)
d. Hypoparat hyroidism
e. Vit amin D def iciency
f. Magnesium def iciency
g. Mult iple organ f ailure
h. Toxic shock syndrome
Clin ical Alert

1. Severe hypocalcemia occurs w hen serum calcium is <3 mg/ dL (<0. 75
mmol/ L).
2. Excessive I V f luids decrease albumin levels and t hus decrease calcium
levels. Tot al serum prot ein and albumin should be measured at t he same
t ime as calcium f or proper int erpret at ion of calcium levels. I onized calcium
is not aff ect ed by albumin levels.
Clin ical Alert

Pan ic Valu es for Total Calciu m <4.4 mg/dL (<1.1 mmol/L) may
produ ce tetan y an d con vu lsion s.
>13 mg/ dL (>3. 25 mmol/ L) may cause cardiot oxicit y, arrhyt hmias, and coma.
Rapid t reat ment of hypercalcemia w it h calcit onin solut ion is indicat ed.
Pan ic Valu es for Ion ized Calciu m <2.0 mg/dL (<0.5 mmol/L) may
produ ce tetan y or life-th reaten in g complication s.
2. 03. 0 mg/ dL (<0. 50. 75 mmol/ L) in cases of mult iple blood t ransf usions
(t his is an indicat ion t o administ er calcium) >7. 0 mg/ dL (>1. 75 mmol/ L) may
cause coma.
Interfering Factors
1. Thiazide diuret ics may impair urinary calcium excret ion and result in
hypercalcemia (most common drug-induced f act or).
2. For pat ient s w it h renal insuff iciency undergoing dialysis, a calcium-ion
exchange resin is somet imes used f or hyperkalemia. This resin may increase
calcium levels.
3. I ncreased magnesium and phosphat e upt ake and excessive use of laxat ives
may low er blood calcium level because of increased int est inal calcium loss.
4. When decreased calcium levels are due t o magnesium def iciency (as in poor
bow el absorpt ion), t he administ rat ion of magnesium w ill correct t he calcium
def iciency.
5. I f a pat ient is know n t o have or suspect ed of having a pH abnormalit y, a
concurrent pH t est w it h ionized calcium level should be request ed.
6. Many drugs may cause increased or decreased levels of calcium. Calcium
supplement s t aken short ly bef ore specimen collect ion w ill cause f alsely high
values.
7. Elevat ed serum prot ein increases calcium; decreased prot ein decreases
calcium.
Interventions
1. Explain purpose and procedure. Encourage relaxat ion.
2. Be aw are t hat t ourniquet applicat ion should be as brief as possible w hen
draw ing ionized calcium t o prevent venous st asis and hemolysis.
3. Ensure t hat calcium supplement s are not t aken w it hin 8 t o 12 hours bef ore
t he blood sample is draw n.

2. I nt erpret t est result s and monit or appropriat ely f or calcium abnormalit ies.
Chloride (Cl2 ) Chloride, a blood electrolyte, is the major

anion that exists predominantly in the extracellular
spaces as part of sodium chloride or hydrochloric acid.
Chloride maintains cellular integrity through its
influence on osmotic pressure and acid-base and w ater
balance. It has the reciprocal pow er of increasing or
decreasing in concentration in response to
concentrations of other anions. In metabolic acidosis,
there is a reciprocal rise in chloride concentration
w hen the bicarbonate concentration drops. Similarly,
w hen aldosterone directly causes an increase in the
reabsorption of sodium (the positive ion), the indirect
effect is an increase in the absorption of chloride (the
negative ion).
Chlorides are excret ed w it h cat ions (posit ive ions) during massive diuresis f rom
any cause and are lost f rom t he G I t ract w hen vomit ing, diarrhea, or int est inal
f ist ulas occur.
Alt erat ion of sodium chloride level is seldom a primary problem. Measurement of
chlorides is usually done f or inf erent ial value and is helpf ul in diagnosing
disorders of acid-base and w at er balance. Because of t he relat ively high
chloride concent rat ions in gast ric juices, prolonged vomit ing may lead t o
considerable chloride loss and low ered serum chloride levels.
I n an emergency, chloride is t he least import ant elect rolyt e t o measure.
How ever, it is especially import ant in t he correct ion of hypokalemic alkalosis. I f
pot assium is supplied w it hout chloride, hypokalemic alkalosis may persist .
Reference Values
Normal
Adult s: 96106 mEq/ L or 96106 mmol/ L
New borns: 96113 mEq/ L or 96113 mmol/ L
Procedure
1. O bt ain a 5-mL venous blood sample in a heparinized Vacut ainer t ube. Serum
can also be used.
NOTE
Whenever serum chloride levels are much low er t han 100 mEq/ L (100 mmol/ L),
urinary excret ion of chlorides is also low.
1. Decreased bl ood chl ori de l evel s occur in t he f ollow ing condit ions:
a. Severe vomit ing
b. G ast ric suct ion
c. Chronic respirat ory acidosis
d. Burns
e. Met abolic alkalosis
f. Congest ive f ailure
g. Addison's disease
h. Salt -losing diseases (syndrome of inappropriat e ant idiuret ic hormone
[ SI ADH] )
i. O verhydrat ion or w at er int oxicat ion
j. Acut e int ermit t ent porphyria
k. Salt -losing nephrit is
2. Increased bl ood chl ori de l evel s occur in t he f ollow ing condit ions:
a. Dehydrat ion
b. Cushing's syndrome
c. Hypervent ilat ion, w hich causes respirat ory alkalosis
d. Met abolic acidosis w it h prolonged diarrhea
e. Hyperparat hyroidism (primary)
f. Select kidney disorders (eg, renal t ubular acidosis)
g. Diabet es insipidus
h. Salicylat e int oxicat ion
i. Head injury w it h hypot halamic damage
j. Eclampsia
Interfering Factors
1. The plasma chloride concent rat ion in inf ant s is usually higher t han t hat in
children and adult s.

2. Cert ain drugs may alt er chloride levels.
3. I ncreases are associat ed w it h excessive I V saline inf usions.
Clin ical Alert

Pan ic Valu es for Seru m Ch loride <70 or >120 mEq/L (<70 or >120
mmol/L)
Interventions
1. Explain t est purpose and blood collect ion procedure.
2. I f possible, ensure t hat t he pat ient f ast s at least 8 t o 12 hours bef ore t he
t est .

3. I f an elect rolyt e disorder is suspect ed, daily w eight and accurat e f luid int ake
and out put should be recorded.
Phosphate (P); Inorganic Phosphorus (PO4 ) Of the

human body's total phosphorus content, 85% is
combined w ith calcium in the bone, and the remainder
resides w ithin the cells. M ost of the phosphorus in the
blood exists as phosphates or esters. Phosphate is
required for generation of bony tissue and functions in
the metabolism of glucose and lipids, in the
maintenance of acid-base balance, and in the storage
and transfer of energy from one site in the body to

another. Phosphorus enters the red blood cells w ith
glucose and therefore is low ered in the plasma after
carbohydrate ingestion or infusion.
Phosphat e levels are alw ays evaluat ed in relat ion t o calcium levels because
t here is an inverse relat ion bet w een t he t w o element s. When calcium levels are
decreased, phosphorus levels are increased, and w hen phosphorus levels are
decreased, calcium levels are increased. An excess of one elect rolyt e in serum
causes t he kidneys t o excret e t he ot her elect rolyt e. Many of t he causes of
elevat ed calcium levels are also causes of decreased phosphorus levels. As w it h
calcium, t he cont rolling f act or is PTH.
Reference Values
Normal
Adult s: 2. 74. 5 mg/ dL or 0. 871. 45 mmol/ L
Children: 4. 55. 5 mg/ dL or 1. 451. 78 mmol/ L
New borns: 4. 59. 0 mg/ dL or 1. 452. 91 mmol/ L
Procedure
O bt ain a f ast ing, 5-mL, venous blood sample. Serum is pref erred, but
heparinized blood is accept able. Serum should be removed f rom clot as soon as
possible af t er collect ion.
1. Hyperphosphatemi a (increased blood phosphorus levels) is most commonly
f ound in associat ion w it h kidney dysf unct ion and uremia. This is because
phosphat e is so minut ely regulat ed by t he kidneys. These condit ions include
t he f ollow ing:
a. Renal insuff iciency and severe nephrit is (accompanied by elevat ed BUN
and creat inine) and renal f ailure
b. Hypoparat hyroidism (accompanied by elevat ed phosphorus, decreased
calcium, and normal renal f unct ion) and pseudohypoparat hyroidism
c. Hypocalcemia
d. Milk-alkali syndrome
e. Excessive int ake of vit amin D
f. Fract ures in t he healing st age

g. Bone t umors and met ast ases
h. Addison's disease
i. Acromegaly
j. Liver disease and cirrhosis
k. Cardiac resuscit at ion
2. Hypophosphatemi a (decreased phosphorus level) occurs in t he f ollow ing
condit ions:
a. Hyperparat hyroidism
b. Ricket s (childhood) or ost eomalacia (adult ) and vit amin D def iciency
c. Diabet ic coma (increased carbohydrat e met abolism)
d. Hyperinsulinism
e. Cont inuous administ rat ion of I V glucose in a nondiabet ic pat ient
(phosphorus f ollow s glucose int o t he cells)
f. Liver disease and acut e alcoholism
g. Vomit ing and severe diarrhea
h. Severe malnut rit ion and malabsorpt ion
i. G ram-negat ive sept icemia
j. Hypercalcemia of any cause
k. Prolonged hypot hermia
l. Respirat ory alkalosis due t o cellular use of phosphorus f or an
accelerat ed glucose met abolism
Interfering Factors
1. Phosphorus levels are normally high in children.
2. Phosphorus levels can be f alsely increased by hemolysis of blood; t heref ore,
separat e serum f rom cells as soon as possible.
3. Drugs can be t he cause of decreases in phosphorus.
4. The use of laxat ives or enemas cont aining large amount s of sodium
phosphat e w ill cause increased phosphorus levels. Wit h oral laxat ives, t he
blood phosphorus level may increase as much as 5 mg/ dL (1. 6 mmol/ L) 2 t o
3 hours af t er int ake. This increased level is only t emporary (56 hours), but
t his f act or should be considered w hen abnormal levels are seen t hat cannot
ot herw ise be explained.
5. Seasonal variat ions exist in phosphorus levels (maximum levels in May and
June, low est levels in w int er).
Interventions
1. Explain t est purpose and blood sampling procedures. The pat ient should f ast
2. Not e on t est requisit ion if any cat ast rophic st ressf ul event s have t aken place
w hich may cause high phosphorus levels.
3. Not e t ime of day t est is draw n; levels are highest in t he morning and low est
in t he evening.
care.

2. I nt erpret t est out comes and monit or as appropriat e f or calcium imbalances.
When phosphorus rises rapidly, calcium drops; w at ch f or arrhyt hmias and
muscle t w it ching. The signs
and sympt oms of phosphat e deplet ion may include manif est at ions in t he
neuromuscular, neuropsychiat ric, G I , skelet al, and cardiopulmonary syst ems.
Manif est at ions usually are accompanied by serum levels < 1 mg/ dL (<0. 32
mmol/ L).
Clin ical Alert

Pan ic Valu e for Ph osph ate <1.0 mg/dL (<0.32 mmol/L)
M agnesium (M g11 ) M agnesium in the body is

concentrated (40%60%) in the bone, 20% muscle, 30%
w ithin the cell itself, and 1% in the serum, and is
required for the use of adenosine triphosphate (ADP) as
a source of energy. It is therefore necessary for the
action of numerous enzyme systems such as

carbohydrate metabolism, protein synthesis, nucleic
acid synthesis, and contraction of muscular tissue.
Along w ith sodium, potassium, and calcium ions,
magnesium also regulates neuromuscular irritability
and the clotting mechanism.
Magnesium and calcium are int imat ely linked in t heir body f unct ions, and
def iciency of eit her one has a signif icant eff ect on t he met abolism of t he ot her
because of magnesium's import ance in t he absorpt ion of calcium f rom t he
int est ines and in calcium met abolism. Magnesium def iciency w ill result in t he drif t
of calcium out of t he bones, possible result ing in abnormal calcif icat ion in t he
aort a and t he kidney. This condit ion responds t o administ rat ion of magnesium
salt s. Normally, 95% of t he magnesium t hat is f ilt ered t hrough t he glomerulus is
reabsorbed in t he t ubule. When t here is decreased kidney f unct ion, great er
amount s of magnesium are ret ained, result ing in increased blood serum levels.
Magnesium measurement is used t o evaluat e renal f unct ion, elect rolyt e st at us,
and evaluat e magnesium met abolism.
Reference Values
Normal
Adult s: 1. 82. 6 mg/ dL or 0. 741. 07 mmol/ L
Children: 1. 72. 1 mg/ dL or 0. 700. 86 mmol/ L
New borns: 1. 52. 2 mg/ dL or 0. 620. 91 mmol/ L
Procedure
1. O bt ain a f ast ing (4 hours), 5-mL, venous blood sample.
2. Avoid hemolysis, and separat e serum f rom cells as soon as possible.
Heparinized blood may be used.
Clin ical Alert

Blood sample should be draw n w hile t he pat ient is in a prone posit ion,
because an upright posit ion increases t he magnesium level by 4%.
1. Reduced bl ood magnesi um l evel s (<1. 5 mg/ dL or <0. 62 mmol / L) occur in

t he f ollow ing condit ions:
a. Hypercalcemia of any cause
b. Diabet ic acidosis
c. Hemodialysis
d. Chronic renal disease (glomerulonephrit is)
e. Chronic pancreat it is
f. Hyperaldost eronism
g. Pregnancy (second and t hird t rimest er)
h. Hypoparat hyroidism
i. Excessive loss of body f luids (eg, sw eat ing, lact at ion, diuret ic abuse,
chronic diarrhea)
j. Malabsorpt ion syndromes
k. Chronic alcoholism (hepat ic cirrhosis)
l. Long-t erm hyperaliment at ion
m. Syndrome of inappropriat e secret ion of ant idiuret ic hormone (SI ADH)
2. Increased bl ood magnesi um l evel s occur in t he f ollow ing condit ions:
a. Renal f ailure or reduced renal f unct ion (acut e and chronic)
b. Dehydrat ion
c. Hypot hyroidism
e. Adrenalect omy (adrenocort ical insuff iciency)
f. Diabet ic acidosis (severe)
g. Use of ant acids cont aining magnesium (eg, Milk of Magnesia),
administ rat ion of magnesium salt s
h. O liguria
NOTE
I n magnesium def iciency st at es, urinary magnesium decreases bef ore t he
serum magnesium. Serum magnesium levels may remain normal even w hen
t ot al body st ores are deplet ed up t o 20%.
Interfering Factors
1. Prolonged salicylat e t herapy, lit hium, and magnesium product s (eg, ant acids,
laxat ives) w ill cause f alsely increased magnesium levels, part icularly if t here
is renal damage.
2. Calcium gluconat e, as w ell as a number of ot her drugs, can int erf ere w it h
t est ing met hods and cause f alsely decreased result s.
3. Hemolysis w ill invalidat e result s because about t hree f ourt hs of t he
magnesium in t he blood is f ound int racellularly in t he red blood cells.
Interventions
2. Ensure t hat pat ient is f ast ing f or at least 4 hours if possible and is in a prone
posit ion w hen blood is draw n.
care.

1. I nt erpret t est result s and monit or as appropriat e. Treat ment of diabet ic coma
of t en result s in low plasma magnesium levels. This change occurs because
magnesium moves w it h pot assium int o t he cells af t er insulin administ rat ion.
2. Measure serum magnesium in persons receiving aminoglycosides and
cyclosporine. There is a know n associat ion bet w een t hese t herapies and
hypermagnesemia. Treat ment of hypermagnesemia involves w it hholding
source of magnesium excess, promot ing excret ion, giving calcium salt s, and
perf orming hemodialysis.
3. Be aw are t hat magnesium def iciency may cause apparent ly unexplained
hypocalcemia and hypokalemia. I n t hese inst ances, pat ient s may have
neurologic and/ or G I sympt oms. O bserve f or t he f ollow ing signs and
sympt oms:
a. Muscle t remors, t w it ching, t et any
b. Hypocalcemia
c. Hyperact ive deep t endon ref lexes
d. Elect rocardiogram (ECG ): prolonged P-R and Q -T int ervals; broad, f lat T
w aves; premat ure vent ricular t achycardia and f ibrillat ion
e. Anorexia, nausea, vomit ing
f. I nsomnia, delirium convulsions
4. O bserve f or signs of t oo much magnesium (w hich act s as a sedat ive):
a. Let hargy, f lushing, nausea, vomit ing, slurred speech
b. Weak or absent deep t endon ref lexes
c. ECG : prolonged PR and Q -T int ervals; w idened Q RS; bradycardia
d. Hypot ension, drow siness, respirat ory depression
Clin ical Alert

Pan ic Valu es for Magn esiu m
1. Hypomagnesemia: <1. 2 mg/ dL (<0. 49 mmol/ L), t et any occurs
2. Hypermagnesemia: >5. 0 mg/ dL (>2. 1 mmol/ L)
a. 5. 010. 0 mg/ dL (2. 14. 1 mmol/ L): CNS depression, nausea, vomit ing,
f at igue
b. 1015 mg/ dL (4. 16. 2 mmol/ L): coma, ECG changes, respirat ory
paralysis
c. 30 mg/ dL (12. 3 mmol/ L): complet e heart block
d. 3440 mg/ dL (14. 016. 0 mmol/ L): cardiac arrest
Potassium (K1 ) Potassium is the principal electrolyte

(cation) of intracellular fluid and the primary buffer
w ithin the cell itself. Ninety percent of potassium is
concentrated w ithin the cell; only small amounts are
contained in bone and blood. Damaged cells release
potassium into the blood.

The body is adapt ed f or eff icient pot assium excret ion. Normally, 80% t o 90% of
t he cells' pot assium is excret ed in t he urine by t he glomeruli of t he kidneys; t he
remainder is excret ed in sw eat and in t he st ool. Even w hen no pot assium is
t aken int o t he body (as in a f ast ing st at e), 40 t o 50 mEq is st ill excret ed daily in
t he urine. The kidneys do not conserve pot assium, and w hen an adequat e
amount of pot assium is not ingest ed, a severe def iciency w ill occur. Pot assium
balance is maint ained in adult s on an average diet ary int ake of 80200 mEq/ day.
Normal int ake, minimal needs, and maximum t olerance f or pot assium are almost
t he same as t hose f or sodium.
Pot assium plays an import ant role in nerve conduct ion, muscle f unct ion, acidbase balance, and osmot ic pressure. Along w it h calcium and magnesium,
pot assium cont rols t he rat e and f orce of cont ract ion of t he heart and, t hus, t he
cardiac out put . Evidence of a pot assium def icit can be not ed on an ECG by t he
presence of a U w ave.
Pot assium and sodium ions are part icularly import ant in t he renal regulat ion of
acid-base balance because hydrogen ions are subst it ut ed f or sodium and
pot assium ions in t he renal t ubule. Pot assium is more import ant t han sodium
because pot assium bicarbonat e is t he primary int racellular inorganic buff er. I n
pot assium def iciency, t here is a relat ive def iciency of int racellular pot assium
bicarbonat e, and t he pH is relat ively acid. The respirat ory cent er responds t o t he
int racellular acidosis by low ering Pco2 t hrough t he mechanism of
hypervent ilat ion. The pot assium concent rat ion is great ly aff ect ed by t he adrenal
hormones. Pot assium def iciency w ill cause a signif icant reduct ion in prot ein
synt hesis.
This t est evaluat es changes in body pot assium levels and diagnoses acid-base
and w at er imbalances. The level of pot assium is not an absolut e value; it varies
w it h circulat ory volume and ot her f act ors. Because a t ot ally unsuspect ed
pot assium imbalance can suddenly prove let hal, it s development must be
ant icipat ed. Thus, it is import ant t o check t he pot assium level in severe cases of
Addison's disease, uremic coma, int est inal obst ruct ion, acut e renal f ailure, G I
loss in t he administ rat ion of diuret ics, st eroid t herapy, and cardiac pat ient s on
digit alis. Pot assium levels should be monit ored during t reat ment of acidosis,
including ket oacidosis of diabet es mellit us.
Reference Values
Normal
Adult s: 3. 55. 2 mEq/ L (3. 55. 2 mmol/ L) Children (118 years): 3. 44. 7 mEq/ L
(3. 44. 7 mmol/ L) I nf ant s: (7 days1 year): 4. 15. 3 mEq/ L (4. 15. 3 mmol/ L)
Neonat es (07 days): 3. 75. 9 mEq/ L (3. 75. 9 mmol/ L)
Procedure
1. G eneral procedure f or pot assium (K+ )
a. Collect a 5-mL venous blood sample using serum or heparinized
Vacut ainer t ube. O bserve st andard/ universal precaut ions. Avoid
hemolysis in obt aining t he sample.
b. Deliver t he sample t o t he laborat ory and cent rif uge immediat ely t o
separat e cells f rom serum. Pot assium leaks out of t he cell and levels in
t he sample w ill be f alsely elevat ed lat er t han 4 hours af t er collect ion.
2. Procedure f or hyperkalemia (excess K+ )
a. Record f luid int ake and out put . Check blood volume and venous
pressure, w hich w ill give clues t o dehydrat ion or circulat ory overload.
I dent if y ECG changes. I n hyperkal emi a, t hese include t he f ollow ing:
1. Elevat ed T-w ave heart block
2. Flat t ened P w ave
3. Cardiac arrest may occur w it hout w arning ot her t han ECG changes.
b. O bserve f or slow pulse, oliguria, neuromuscular alt erat ions such as
muscle irrit abilit y and impaired muscle f unct ion, f laccid paralysis,
t remors, and t w it ching preceding act ual paralysis.
c. Hyperkalemia can be t reat ed w it h sodium bicarbonat e, glucose, and
insulin. Kayexalat e, a sodium-pot assium exchange resin, can be
administ ered orally, nasogast rically, or rect ally.
3. Procedure f or hypokalemia (def iciency of K+ )
a. Record f luid int ake and out put . Check blood volume and venous
pressure, w hich w ill give clues t o circulat ory overload or dehydrat ion.
I dent if y ECG changes. I n hypokal emi a, t hese include t he f ollow ing:
1. Depressed T w aves
2. Peaking of P w aves
b. O bserve f or dehydrat ion caused by severe vomit ing, hypervent ilat ion,
sw eat ing, diuresis, or nasogast ric t ube w it h gast ric suct ion. Accurat ely
record st at e of hydrat ion or dehydrat ion.
c. O bserve f or neuromuscular changes such as f at igue, muscle w eakness,
muscle pain, f labby muscles, parest hesia, hypot ension, rapid pulse,
respirat ory muscle w eakness leading t o paralysis, cyanosis, respirat ory
arrest , anorexia, nausea, vomit ing, paralyt ic ileus, apat hy, drow siness,
t et any, and coma.
d. Hypokalemia may be t reat ed w it h a K+ rice diet and K+ -sparing diuret ics.

Use salt subst it ut es cont aining pot assium chloride and administ er I V oral
pot assium chloride supplement s.
Clin ical Alert

1. Be on t he alert f or t he f ollow ing arrhyt hmias, w hich may occur w it h
hyperkalemia:
a. Sinus bradycardia
b. Sinus arrest
c. First -degree at riovent ricular block
d. Nodal rhyt hm
e. I diovent ricular rhyt hm
f. Vent ricular t achycardia
g. Vent ricular f ibrillat ion
h. Vent ricular arrest
2. Be on t he alert f or t he f ollow ing arrhyt hmias, w hich may occur w it h
hypokalemia:
a. Vent ricular premat ure beat s
b. At rial t achycardia
c. Nodal t achycardia
d. Vent ricular t achycardia
e. Vent ricular f ibrillat ion
1. Decreased bl ood potassi um (hypokal emi a) levels are associat ed w it h
shif t ing of K+ int o cells, K+ loss f rom G I and biliary t ract s, renal K+ excret ion,
and reduced K+ int ake, as can occur in t he f ollow ing condit ions:
a. Diarrhea, vomit ing, sw eat ing
b. St arvat ion, malabsorpt ion
c. Bart t er's syndrome
d. Draining w ounds
e. Cyst ic f ibrosis
f. Severe burns
g. Primary aldost eronism
h. Alcoholism, chronic
i. O smot ic hyperglycemia
j. Respirat ory alkalosis
k. Renal t ubular acidosis
l. Diuret ic, ant ibiot ic, and mineralocort icoid administ rat ion
m. Barium chloride poisoning
n. Treat ment of megaloblast ic anemia w it h vit amin B12 or f olic acid
2. Pot assium levels of 3. 5 mEq/ L (3. 5 mmol/ L) are more commonly associat ed
w it h def iciency rat her t han normalit y. A f alling t rend (0. 10. 2 mEq/ day or
0. 10. 2 mmol/ day) is indicat ive of a developing pot assium def iciency.
a. The most f requent cause of pot assium def iciency is G I loss.
b. The most f requent cause of pot assium deplet ion is I V f luid administ rat ion
w it hout adequat e pot assium supplement s
3. Increased potassi um l evel s (hyperkal emi a) occur w hen K+ shif t s f rom cells
t o int racellular f luid, w it h inadequat e renal excret ion and w it h excessive K+
int ake, as can occur in t he f ollow ing condit ions:
a. Renal f ailure, dehydrat ion, obst ruct ion, and t rauma
b. Cell damage, as in burns, accident s, surgery, chemot herapy,
disseminat ed int ravascular coagulat ion (damaged cells release pot assium
int o t he blood)
c. Met abolic acidosis (drives pot assium out of t he cells), diabet ic
ket oacidosis
e. Pseudohypoaldost eronism
f. Uncont rolled diabet es, decreased insulin
g. Primary acquired hyperkalemia, such as syst emic lupus eryt hemat osus,
sickle cell disease, int erst it ial nephrit is, and t ubular disorders
h. Kidney t ransplant reject ion
Interfering Factors
1. Hemolyzed blood may not be used; K+ values are elevat ed t o as much as
50% over normal w it h moderat e hemolysis. O pening and closing t he f ist 10
t imes w it h a t ourniquet in place result s in an increase in pot assium level by
10% t o 20%. For t his reason, it is recommended t hat t he blood sample be
obt ained w it hout a t ourniquet , or t hat t he t ourniquet be released af t er t he

needle has ent ered t he vein.
2. Drug usage
a. I V administ rat ion of pot assium penicillin may cause hyperkalemia;
penicillin sodium may cause increased excret ion of pot assium.
b. G lucose administ ered during t olerance t est ing or t he ingest ion and
administ rat ion of large amount s of glucose in pat ient s w it h heart disease
may cause a decrease of as much as 0. 4 mEq/ L (0. 4 mmol/ L) in
pot assium blood levels.
c. A number of drugs raise pot assium levels, especially pot assium-sparing
diuret ics and nonst eroidal ant i-inf lammat ory drugs, especially in t he
presence of renal disease.
d. Excessive int ake of licorice decreases pot assium levels.
3. Leukocyt osis, as occurs in leukemia, raises pot assium levels.
4. Pat ient s w ho have t hrombocyt osis due t o polycyt hemia vera or a
myeloprolif erat ive disease may have spuriously high pot assium levels. This
f alsely elevat ed level is caused by a high number of plat elet s, w hich release
pot assium during coagulat ion. Theref ore, heparinized samples, rat her t han
clot t ed serum samples, should be used in t hese pat ient s.
Interventions
1. Explain t est purpose and blood-draw ing procedure. Do not have pat ient open
and close f ist w hile draw ing blood.

1. I nt erpret t est result s, monit or changes in body pot assium, and int ervene as
appropriat e.
2. Be aw are t hat recognizing signs and sympt oms of hypokalemia and
hyperkalemia is very import ant . Many of t hese originat e in t he nervous and
muscular syst ems and are usually nonspecif ic and similar.
3. Remember t hat t he pot assium blood level rises 0. 6 mEq/ L (0. 6 mmol/ L) f or
every 0. 1 decrease in blood pH.
Clin ical Alert

1. Panic values f or pot assium:
a. <2. 5 mEq/ L (<2. 5 mmol/ L) causes vent ricular f ibrillat ion.
b. >8. 0 mEq/ L (>8. 0 mmol/ L) causes muscle irrit abilit y, including
myocardial irrit abilit y.
2. The most common cause of hypokalemia in pat ient s receiving I V f luids is
w at er and sodium chloride administ rat ion w it hout adequat e replacement
f or K+ lost in urine and drainage f luids. A pat ient receiving I V f luids needs
K + every day. The minimum adult daily dose should be 40 mEq, but t he
opt imum daily dose ranges bet w een 60 and 120 mEq. (Pediat ric dose,
0. 51 mEq/ kg of body w eight / 24 h, not t o exceed 40 mEq/ d or 10 mEq/ h. )
Pot assium needs are great er in persons w it h t issue injury, w ound
inf ect ion, and gast ric int est inal or biliary drainage. I f adequat e amount s of
pot assium (40 mEq/ d) are not given in I V solut ion, hypokalemia w ill
event ually develop. Pat ient s receiving > 10 mEq KCl in 100 mL of I V
solut ion should be monit ored by ECG f or pot ent ial arrhyt hmia if t he I V rat e
is 100/ h. Concent rat ed doses of I V pot assium should alw ays be
administ ered via volume-cont rolled I V inf usion devices. A burning sensat ion
may be f elt at t he sit e of needle insert ion. NS can be inf used along w it h
t he pot assium, or t he I V rat e can be reduced. Some physicians order a
small dose of lidocaine t o be added t o I V pot assium t o eliminat e t he
burning sensat ion some pat ient s experience. Alw ays be sure t o check f or
lidocaine allergies bef ore administ rat ion of t his local anest het ic.
3. Closely monit or f or hypokalemia in pat ient s t aking digit alis and diuret ics
because cardiac arrhyt hmias can occur. Hypokalemia enhances t he eff ect
of digit alis preparat ions, creat ing t he possibilit y of digit alis int oxicat ion
f rom even an average maint enance dose. Digit alis, diuret ics, and
hypokalemia are a pot ent ially let hal combinat ion.
Sodium (Na1 ) Sodium is the most abundant cation (90%

of the electrolyte fluid) and the chief base of the blood.
Its primary functions in the body are to maintain
osmotic pressure and acid-base balance chemically
and to transmit nerve impulses. The body has a strong
tendency to maintain a total base content, and only
slight changes are found even under pathologic
conditions. M echanisms for maintaining a constant

sodium level in the plasma and extracellular fluid
include renal blood flow, carbonic anhydrase enzyme
activity, aldosterone, action of other steroids w hose
plasma level is controlled by the anterior pituitary
gland, renin enzyme secretion, ADH, and vasopressin
secretion.
Det erminat ions of plasma sodium levels det ect changes in w at er balance rat her
t han sodium balance. Sodium levels are used t o det ermine elect rolyt es, acidbase balance, w at er balance, w at er int oxicat ion, and dehydrat ion.
Reference Values
Normal
Adult s: 136145 mEq/ L (136145 mmol/ L) Children (116 years): 136145
mEq/ L (136145 mmol/ L) Full-t erm inf ant s: 133142 mEq/ L (133142 mmol/ L)
Premat ure inf ant s: 132140 mEq/ L (132140 mmol/ L)
Procedure
1. O bt ain a 5-mL venous blood sample. Heparinized blood can be used. Avoid
hemolysis.
2. O bserve st andard/ universal precaut ions.
1. Hyponatremi a (decreased sodium levels) ref lect a relat ive excess of body
w at er rat her t han low t ot al body sodium. Reduced sodium levels
(hyponat remia) are associat ed w it h t he f ollow ing condit ions:
a. Severe burns
b. Congest ive heart f ailure (predict or of cardiac mort alit y)
c. Excessive f luid loss (eg, severe diarrhea, vomit ing, sw eat ing)
d. Excessive I V induct ion of nonelect rolyt e f luids (eg, glucose)
e. Addison's disease (impairs sodium reabsorpt ion)
f. Severe nephrit is (nephrot ic syndrome)
g. Pyloric obst ruct ion

h. Malabsorpt ion syndrome
i. Diabet ic acidosis
j. Drugs such as diuret ics
k. Edema (dilut ional hyponat remia)
l. Large amount s of w at er by mout h (w at er int oxicat ion)
m. St omach suct ion accompanied by w at er or ice chips by mout h
n. Hypot hyroidism
o. Excessive ADH product ion
2. Hypernatremi a (increased sodium levels) is uncommon, but w hen it does
occur, it is associat ed w it h t he f ollow ing condit ions:
a. Dehydrat ion and insuff icient w at er int ake
b. Conn's syndrome
c. Primary aldost eronism
d. Coma
e. Cushing's disease
f. Diabet es insipidus
g. Tracheobronchit is
Clin ical Alert

Pan ic Valu es for Sodiu m
1. <125 mEq/ L (<125 mmol/ L) causes w eakness, dehydrat ion.
2. 90105 mEq/ L (90105 mmol/ L) causes severe neurologic sympt oms,
vascular problems.
3. >152 mEq/ L (>152 mmol/ L) result s in cardiovascular and renal sympt oms.
4. >160 mEq/ L (>160 mmol/ L) can cause heart f ailure.
Interfering Factors
1. Many drugs aff ect levels of blood sodium.
a. Anabolic st eroids, cort icost eroids, calcium, f luorides, and iron can cause
increases in sodium level.
b. Heparin, laxat ives, sulf at es, and diuret ics can cause decreases in sodium
level.
2. High t riglycerides or low prot ein causes art if icially low sodium values.
Interventions

1. I nt erpret t est out comes and monit or f or f luid and sodium imbalances.
2. Remember t hat I V t herapy considerat ions are as f ollow s:
a. Sodium balance is maint ained in adult s w it h an average diet ary int ake of
90 t o 250 mEq/ day. The maximum daily t olerance t o an acut e load is
400 mEq/ day. A pat ient w ho is given 3 L of isot onic saline in 24 hours w ill
receive 465 mEq of sodium. This amount exceeds t he average, healt hy
adult 's t olerance level. I t w ill t ake a heal thy person 24 t o 48 hours t o
excret e t he excess sodium.
b. Af t er surgery, t rauma, or shock, t here is a decrease in ext racellular f luid
volume. Replacement of ext racellular f luid is essent ial if w at er and
elect rolyt e balance is t o be maint ained. The ideal replacement I V
solut ion should have a sodium concent rat ion of 140 mEq/ L.
3. Monit or f or signs of edema or hypert ension, and record and report t hese if
present .
care.
Osmolality and Water-Load Test (Water-Loading

Antidiuretic Hormone Suppression Test) Osmolality,
w hich is the measure of the number of dissolved solute
particles in solution, increases w ith dehydration and
decreases w ith overhydration. In general, the same
conditions that reduce or increase serum sodium affect
osmolality.
This t est is used as an evaluat ion of w at er and elect rolyt e balance. I t is helpf ul
in assessing hydrat ion st at us, seizures, liver disease, ADH f unct ion, and coma,
and it is used in t oxicology w orkups f or et hanol, et hylene glycol, isopropanol,
and met hanol ingest ions.
Clin ical Alert

1. Simult aneous det erminat ion of urine and serum osmolalit ies f acilit at es
int erpret at ion of result s. High urinary/ serum (U/ S) rat io is seen in
concent rat ed urine. Normal ranges f or t he U/ S rat io are 0. 2 t o 4. 7 and
may be >3 w it h overnight dehydrat ion. Wit h poor concent rat ing abilit y, t he
rat io is low but is st ill >1. I n SI ADH, sodium and urine osmolalit ies are
high f or t he serum osmolalit y.
2. Det erminat ion of t he urine osmolar gap is used t o charact erize met abolic
acidosis and is described as t he sum of urinary concent rat ions of sodium,
pot assium, bicarbonat e, chloride, glucose, and urea compared w it h
measured urine osmolalit y.
Reference Values
Normal
Serum osmol al i ty Adult s: 280303 mO sm/ kg H2 O (280303 mmol/ kg H2 O )
New borns: as low as 266 mO sm/ kg H2 O (266 mmol/ kg H2 O ) Uri ne osmol al i ty
Adult s:
24-hour: 300900 mO sm/ kg H2 O (300900 mmol/ kg H2 O ) Random: 501400
mO sm/ kg H2 O (501400 mmol/ kg H2 O )
Af t er 12-hour f luid rest rict ion: >850 mO sm/ kg H2 O (>850 mmol/ kg H2 O ) Rat io of
urine/ serum osmolalit y: 0. 24. 7 (average, 1. 03. 0) Rat io af t er f luid rest rict ion:
3: 1 or a range of 0. 24. 7: 1
O smol al gap Serum: 510 mO sm/ kg H2 O (510 mmol/ kg H2 O ) Urine: 80100
mO sm/ kg H2 O (80100 mmol/ kg H2 O )
Procedure
1. Det ermining osmolalit y
a. O bt ain a 5-mL venous blood sample. Serum or heparinized plasma is
accept able. O bserve st andard/ universal precaut ions.
b. Collect a 24-hour urine specimen concurrent ly and keep on ice.

c. Det ermine osmolalit y in t he laborat ory using t he f reezing point
depression met hodology f or bot h serum and urine.
2. Det ermining w at er-loading ant idiuret ic hormone suppression
a. Be aw are t hat t he ideal posit ion during t he t est ing period is t he
recumbent posit ion because t he response t o w at er loading is reduced in
persons in t he upright posit ion.
b. O ne hour bef ore t est ing, t he pat ient is given 300 mL of w at er t o replace
f luid lost during t he overnight f ast . Do not count t his w at er as part of t he
t est load.
c. Have t he pat ient drink a t est load of w at er (20 mL/ kg body w eight ) w it hin
30 minut es.
d. Af t er t he t est load of w at er is consumed, collect all urine f or t he next 4
t o 5 hours, and check each voiding f or volume osmolalit y and specif ic
gravit y. O bt ain hourly blood samples f or osmolalit y, and check t he ent ire
volume of urine obt ained f or osmolalit y.
3. Remember t hat normal values f or w at er-loading ant idiuret ic hormone
suppression t est are excret ion of > 90% of w at er load w it hin 4 hours. Urine
osmolalit y f alls t o < 100 mO sm/ kg (<100 mmol/ kg). Specif ic gravit y f alls t o
1. 001.
4. Det ermine plasma ADH at hourly int ervals.
Clinical Implications of Decreased Renal Function

1. I n decreased renal f uncti on, < 80% of f luid is excret ed, and urine specif ic
gravit y may not f all below 1. 010. This phenomenon occurs in t he f ollow ing
condit ions:
a. Adrenocort ical insuff iciency
b. Malabsorpt ion syndrome
c. Edema
d. Ascit es
e. O besit y
f. Hypot hyroidism
g. Dehydrat ion
h. Congest ive heart f ailure
i. Cirrhosis
2. Disorders w it h i ncreased ADH secreti on (SIADH) give an inadequat e

response; <90% of w at er is excret ed, and urine osmolalit y remains > 100
mO sm/ kg H2 O (>100 mmol/ kg H2 O ). Plasma ADH measured at 90 minut es
conf irms diagnosis of SI ADH.
Interventions
Pretest Patien t Care: Decreased Ren al Fu n ction
1. Explain t he t est purpose and procedure. The t est t akes 5 t o 6 hours t o
complet e.
2. Do not allow f ood, alcohol, medicat ions, or smoking f or 8 t o 10 hours bef ore
t est ing. No muscular exercise is allow ed during t he t est .
3. Be aw are t hat t he pat ient may experience nausea, abdominal f ullness,
f at igue, and desire t o def ecat e.
4. Discard f irst morning urine specimen.
Clin ical Alert

I n pat ient s w it h impaired abilit y t o t olerat e t he w at er-loading t est , seizures or
f at al hyponat remia may occur.
Posttest Patien t Aftercare: Decreased Ren al Fu n ction

1. O bserve f or adverse react ions t o w at er-loading t est such as ext reme
abdominal discomf ort , short ness of breat h, or chest pain.
2. Remember t hat if w at er clearance is impaired, t he w at er load w ill not induce
diuresis, and maximum urinary dilut ion w ill not occur.
3. Be aw are t hat accurat e result s may not be obt ained if nausea, vomit ing, or
diarrhea occur or if a dist urbance in bladder empt ying is present . Not e on
chart if any of t hese eff ect s occur.
care.
Clinical Implications of Hyperosmolality and

Hypoosmolality
1. Increased val ues (hyperosmol al i ty) are associat ed w it h t he f ollow ing

condit ions:
a. Dehydrat ion
b. Hypercalcemia
c. Diabet es mellit us, hyperglycemia, diabet ic ket oacidosis
d. Hypernat remia
e. Cerebral lesions
f. Alcohol ingest ion (et hanol, met hanol, et hylene glycol)
g. Mannit ol t herapy
h. Azot emia
i. I nadequat e w at er int ake
j. Chronic renal disease
2. Decreased val ues (hypoosmol al i ty) are associat ed w it h t he f ollow ing
condit ions:
a. Loss of sodium w it h diuret ics and low -salt diet (hyponat remia)
b. Renal f ailure
c. Adrenocort ical insuff iciency
d. I nappropriat e secret ion of ADH, as may occur in t rauma and lung cancer
e. Excessive w at er replacement (overhydrat ion, w at er int oxicat ion)
f. Panhypopit uit arism
g. Diabet es insipidus (cent ral or nephrogenic)
h. Pyelonephrit is
Clinical Implications of Osmolal Gap

1. Abnormal levels (>10 mO sm/ kg H2 O or >10 mmol/ kg H2 O ) can occur in t he
a. Met hanol
b. Et hanol
c. I sopropyl alcohol
d. Mannit ol
e. Severely ill pat ient s, especially t hose in shock, lact ic acidosis, and renal
f ailure
2. Et hanol glycol, acet one, and paraldehyde have relat ively small osmolal gaps,
even at let hal levels.
Interfering Factors
1. Decreases in osmolal gap are associat ed w it h alt it ude, diurnal variat ion w it h
w at er ret ent ion at night , and some drugs.
2. Some drugs also cause increases in osmolal gap.
3. Hypert riglyceridemia and hyperprot einemia cause an elevat ed osmolal gap.
4. Radiographic cont rast medium w it hin 3 days
Interventions
Pretest Patien t Care: Hyperosmolality, Hypoosmolality, Osmolar
Gap
2. Ensure t hat no alcohol is ingest ed during t he 24 hours bef ore t he t est .
Posttest Patien t Aftercare: Hyperosmolality, Hypoosmolality,

Osmolar Gap
1. I nt erpret t est result s and monit or appropriat ely. A pat ient receiving I V f luids
should have a normal osmolalit y. I f t he osmolalit y increases, t he f luids
cont ain relat ively more elect rolyt es t han w at er. I f it f alls, relat ively more
w at er t han elect rolyt es is present .
2. Remember t hat if t he rat io of serum sodium t o serum osmolalit y f alls below
0. 43, t he out look is guarded. This rat io may be dist ort ed in cases of drug
int oxicat ion.
Clin ical Alert

1. Panic serum osmolalit y values are result s <240 or >321 mO sm/ kg H2 O
(<240 or >321 mmol/ kg H2 O ). A value of 385 mO sm/ kg H2 O (385 mmol/ kg

H2 O ) relat es t o st upor in hyperglycemia. Values of 400420 mO sm/ kg H2 O
(400420 mO sm/ kg H2 O ) are associat ed w it h grand mal seizures. Values
>420 mO sm/ kg H2 O (>420 mmol/ kg H2 O ) are f at al.
2. A w at er-loading ADH suppression t est may be ordered t o invest igat e
impaired renal excret ion of w at er.
Sw eat Test
This t est is done t o diagnose cyst ic f ibrosis. Abnormally high concent rat ions of
sodium and chloride appear in t he secret ions of eccrine sw eat glands in persons
w it h cyst ic f ibrosis. This condit ion is present at birt h and persist s t hroughout lif e.
This st udy uses sw eat -inducing t echniques (eg, pilocarpine iont ophoresis)
f ollow ed by chemical analysis t o det ermine sodium, chloride, and cont ent of
collect ed sw eat .
Reference Values
Normal
Sweat sodi um Normal: <70 mEq/ L (<70 mmol/ L) Cyst ic f ibrosis: >90 mEq/ L (>90
mmol/ L)
Sweat chl ori de Normal: <50 mEq/ L (<50 mmol/ L) Cyst ic f ibrosis: >60 mEq/ L
(>60 mmol/ L)
Procedure
1. Be aw are t hat t he f orearm is t he pref erred sit e f or st imulat ion of sw eat ing,
but in t hin or small babies, t he t high, back, or leg may be used. I t may be
necessary t o st imulat e sw eat ing in t w o places t o obt ain suff icient sw eat f or
t est ing, especially in young inf ant s. At least 100 L of sw eat is necessary. I n
cold w eat her, or if t he t est ing room is cold, a w arm covering should be
placed over t he arm or ot her sit e of sw eat collect ion.
2. St imulat e sw eat product ion by applying gauze pads or f ilt er paper sat urat ed
w it h a measured amount of pilocarpine and at t achment of elect rodes t hrough
w hich a current of 4 t o 5 mAmp is delivered at int ervals f or a t ot al of 5
minut es (a t ot al of 512 minut es, according t o NI H).
3. Remove t he elect rodes and pad, and t horoughly w ash t he area w it h dist illed
w at er; dry caref ully.
4. Remember t hat successf ul iont ophoresis is indicat ed by a red area about 2. 5
cm in diamet er t hat appears w here t he elect rode w as placed.

5. Scrub t he skin t horoughly w it h dist illed w at er and dry caref ully. The area f or
sw eat collect ion must be complet ely dry, f ree f rom cont aminat ion by pow der
or ant isept ic, and f ree of any area t hat might ooze.
6. Be aw are t hat collect ion of sw eat occurs by applying prew eighed f ilt er or
sw eat collect ion cups t hat are t aped securely over t he red spot . The inside
surf aces of t he collect ing device should never be t ouched.
7. Leave t he paper on f or at least 1 hour bef ore removing and t hen place in a
prew eighed f lask t o avoid evaporat ion. Weigh t he f lask again. The desired
volume of sw eat is 200 mg; t he minimum volume necessary is 100 mg.
8. I f a cup is used, leave in place f or 1 hour and t hen caref ully remove by
scraping it across t he iont ophoresed area. This puddles t he sw eat in t he
cup t o reduce evaporat ion and t o redissolve any salt s lef t by t he
evaporat ion. Use suct ion capillary t ubes t o remove sw eat f rom t he collect ion
cups.
1. Children w it h cyst ic f ibrosis have sodium and chloride values of >90 mEq/ L
and >60 mEq/ L (>90 mmol/ L and >60 mmol/ L), respect ively.
2. Borderline or gray-zone cases are t hose w it h values of 7090 mEq/ L (7090
mmol/ L) f or sodium and 5060 mEq/ L (5060 mmol/ L) f or chloride. These
persons require ret est ing. Pot assium values do not assist in diff erent iat ing
borderline cases.
3. I n adolescence and adult hood, chloride levels > 80 mEq/ L (>80 mmol/ L)
usually indicat e cyst ic f ibrosis.
4. Elevat ed sw eat elect rolyt es also can be associat ed w it h t he f ollow ing
condit ions:
a. Addison's disease
b. Congenit al adrenal hyperplasia
c. Vasopressin-resist ant diabet es insipidus
d. G lucose-6-phosphat ase def iciency (G 6PD)
e. Hypot hyroidism
f. Familial hypoparat hyroidism
g. Alcoholic pancreat it is
Interfering Factors
1. The sw eat t est is not valuable af t er pubert y because levels may vary over a
very w ide range among individuals.
2. Dehydrat ion and edema, part icularly of areas w here sw eat is collect ed, may
int erf ere w it h t est result s.
3. A gap of > 30 mEq/ L (>30 mmol/ L) bet w een sodium and chloride values
indicat es calculat ion or analysis error or cont aminat ion of t he sample.
4. Sw eat t est ing is not considered accurat e unt il t he t hird or f ourt h w eek of lif e
because inf ant s < 3 w eeks of age may not sw eat enough t o provide a
suff icient sample.
5. Test may be f alsely normal in pat ient s w it h salt deplet ion, as in periods of
hot w eat her.
Clin ical Alert

1. The t est should alw ays be repeat ed if t he result , t he clinical f eat ures, or
ot her diagnost ic t est s do not f it t oget her.
2. The t est can be used t o exclude t he diagnosis of cyst ic f ibrosis in siblings
of diagnosed pat ient s.
3. There have been report s of cyst ic f ibrosis pat ient s w it h normal sw eat
elect rolyt e levels.
4. Sw eat pot assium t est ing is not diagnost ically valuable.
Interventions
1. Explain t est purpose and procedure. The sw eat t est is indicat ed f or t he
f ollow ing persons:
a. I nf ant s w ho pass init ial meconium lat e; w ho have int est inal obst ruct ion,
f ailure t o t hrive, st eat orrhea, chronic diarrhea, rapid respirat ion and
ret ract ion w it h chronic cough, ast hma, hypoprot einemia (especially on
soybean f ormula), at elect asis, or hyperaerat ion on x-ray,
hyperprot hrombinemia, or rect al prolapse; w ho t ast e salt y; or w ho are
off spring of a parent w it h cyst ic f ibrosis (ie, t he obligat e het erozygot e)
b. Persons suspect ed of having cyst ic f ibrosis or celiac disease, all siblings
of pat ient s w it h cyst ic f ibrosis, or persons w it h disaccharide int olerance,
recurrent pneumonia, chronic at elect asis, chronic pulmonary disease,

bronchiolect asis, chronic cough, nasal polyposis, cirrhosis of liver, and
hypert ension
c. Any parent s w ho request a sw eat t est on t heir child
2. I nf orm t he pat ient t hat a slight st inging sensat ion is usually experienced,
especially in f air-skinned persons.
care.

1. Af t er t he cup is removed, caref ully w ash and dry t he skin t o prevent irrit at ion
caused by collect ion cups.
3. I nt erpret t est result s and counsel and monit or pat ient as appropriat e.
Provide genet ic counseling. Cyst ic f ibrosis is t ransmit t ed as an aut osomal
recessive t rait . The Caucasian carrier rat e is 1 in 20, and t he Af rican
American carrier rat e is 1 in 60 t o 1 in 100.
BIBLIOGRAPHY
American Thoracic Societ y: G uidelines f or met hacholine and exercise
challenge t est ing Am J Respir Crit Care Med 161: 309329, 2000
American Thoracic Societ y: Single breat h carbon monoxide diff using capacit y
(t ransf er f act or): Recommendat ion f or a st andard t echnique. Am J Respir Crit
Care Med 152: 21852198, 1995
American Thoracic Societ y: St andardizat ion of spiromet ry: 1994 updat e. Am J
Respir Crit Care Med 152: 11071136, 1995
American Thoracic Societ y: Lung f unct ion t est ing: Select ion of ref erence
values and int erpret ive st rat egies. Am Rev Respir Dis 144: 12021218, 1991
Dunning MB: Respirat ory physiology. I n: Raff H (ed), Physiology Secret s, 2nd
ed. Philadelphia, Hanly & Balf us, 2002
G ale Encyclopedia of Medicine. Farming Hills, MI , G ale, 1999
G roer M: Advanced Pat hophysiology: Applicat ions t o Clinical Pract ice.
G uyt on AC & Hall J: Text book of Medical Physiology, 10t h ed. Philadelphia,
WB Saunders, 2000
Locat elli F, et al: Elect rolyt e disorders and subst it ut ion f luid in cont inuous
renal replacement t herapy. Kidney I nt ernat ional Supplement 66: S151S155,
1998
Madama VC: Pulmonary f unct ion t est ing and cardiopulmonary st ress t est ing,
2nd ed. Albany, NY, Delmar Publishers, 1998.
Mart in L: What You Really Need t o Know t o I nt erpret Art erial Blood G ases,
2nd ed. Philadelphia, Lippincot t Williams & Wilkins, 1999
McCance K, Huet her S: Pat hophysiology, 4t h ed. St . Louis, CV Mosby, 2002
Medline Plus: Healt h I nf ormat ion. U. S. Nat ional Library of Medicine. (O nline).
Available at : w w w. nlm. nih. gov/ medlineplus
Port h CM: Pat hophysiology: Concept s in Alt ered Healt h St at es, 6t h ed.
Ruppel G : Manual of Pulmonary Funct ion Test ing, 7t h ed. St . Louis, CV
Mosby, 1997
Shapiro BA, Peruzzi WT, Templin RK: Clinical Applicat ion of Blood G ases, 5t h
ed. St . Louis, CV Mosby, 1994
Universit y of Calif ornia at San Diego Library.
Wasserman K, Hansen JE, Sue DY, Whipp BJ, Casaburi R: Principles of
Exercise Test ing and I nt erpret at ion, 2nd ed. Philadelphia, Lea & Febiger,
1994
Weismann I M, Zeballos RJ: Clinical Exercise Test ing, Vol 32. Basel,
Sw it zerland, Karger, 2002

Wilkins
> Table of C ontents > 15 - P r enatal D iagnos is and Tes ts of Fetal W ell- B eing
15
Prenatal Diagnosis and Tests of Fetal Well-Being
OVERVIEW OF PRENATAL DIAGNOSIS

Fet al w ell-being depends on mat ernal healt h. Many rout ine prenat al t est s assess
mat ernal healt h and w ell-being. Prenat al t est ing usually includes a complet e
blood count or hemoglobin and hemat ocrit , Rh t ype and ABO blood group, red
cell ant ibody screening, rubella immunit y st at us, glucose challenge t est ing (see
Chap. 6), urinalysis, mat ernal serum alpha-f et oprot ein (MS-AFP) or mat ernal
t riple screen, hepat it is B t est ing, cult ure f or sexually t ransmit t ed diseases, t he
Venereal Disease Research Laborat ory (VDRL) t est , and surveillance f or group
B st rept ococci. Screening f or human immunodef iciency virus (HI V) inf ect ion is
recommended f or all pregnant w omen t o improve t he care of HI V-posit ive w omen
and t o ident if y inf ant s at risk; perinat al t ransmission is t he primary rout e of HI V
inf ect ion in children.
Test s in t his chapt er monit or t he st at us of t he mat ernal-f et al unit , ident if y t he
f et us at risk f or int raut erine asphyxia, aid in t he early diagnosis of inf ect ion, and
ident if y genet ic and biochemical disorders and major anomalies. (See Chap. 11
f or more on genet ic disorders. ) Test s are also perf ormed t o predict normal f et al
out come or t o ident if y t he f et us at risk f or asphyxia during labor.
M ATERNAL TRIPLE SCREEN

The mat ernal t riple screen t est s are off ered t o pregnant w omen t o ident if y risks
f or chromosome disorders such as Dow n's syndrome (t risomy 21); major birt h
def ect s, including open neural t ube def ect s such as spina bif ida; placent al
insuff iciency; and oligohydramnios. The evaluat ion consist s of t hree separat e
blood prot ein t est s done on mat ernal serum bet w een 14 and 19 w eeks of
gest at ion: MS-AFP is decreased in Dow n's syndrome and neural t ube def ect s,
est riol (E3 ) in Dow n's syndrome, and bet a-human chorionic gonadot ropin (hCG )
in Dow n's syndrome. Result s are report ed as mul ti pl es of the medi an (MoM).
The mat ernal t riple screen is a screening t est ; t heref ore, an abnormal (posit ive)
result is not diagnost ic, and f urt her t est ing w it h ult rasound, amniocent esis, and
genet ic counseling is indicat ed. The markers can be posit ive in normal variat ions
such as mult iple birt hs or miscalculat ed gest at ional age.
Ult rasound t est ing is a met hod of assessing f et al w ell-being t hat has become a
diagnost ic t ool f or assessment of f et al age, healt h, grow t h, and ident if icat ion of
anomalies. Level I ult rasound assesses gest at ional age, number of f et uses, f et al
deat h, and t he condit ion of t he placent a. Level I I ult rasound assesses specif ic
congenit al anomalies or abnormalit ies. I n some diagnost ic cent ers, f et al
echocardiography is also available. Color-enhanced Doppler sonography is used
t o measure t he velocit y and direct ion of blood f low in f et al and ut erine anat omy,
t o provide inf ormat ion about placent al f unct ion, and as an especially good
predict or of out come f or f et uses t hat are small f or gest at ional age (see Chap.
13).
Alt hough magnet ic resonance imaging (MRI ) is used at some prenat al cent ers, it
is st ill under invest igat ion f or diagnost ic evaluat ion in pregnancy, especially in
t he f inal t rimest er (see Chap. 16). Some of t he advant ages of MRI during
pregnancy are t hat it is a noninvasive t echnique, it permit s easy diff erent iat ion
bet w een f at and sof t t issue, it does not require a f ull bladder, and it can show
t he ent ire f et us in one scan. Current ly, MRI conf irms f et al abnormalit ies f ound by
ult rasound and can be used f or pelvimet ry, placent al localizat ion, and
det erminat ion of size. Fet al MRI is used at medical cent ers t hat specialize in
f et al diagnosis and t reat ment (part icularly t hose t hat perf orm f et al surgery).
Ult raf ast MRI is used f or evaluat ion of congenit al anomalies t hat are pot ent ially
correct able, such as congenit al diaphragmat ic hernia, neck masses t hat result in
airw ay obst ruct ion, and myelomeningocele. MRI is especially usef ul f or
def init ion of mat ernal anat omy in cases of suspect ed int raabdominal or
ret roperit oneal disease. Also under invest igat ion is t he combined use of a blood
t est f or pregnancy-associat ed plasma prot ein A (PAPPA), w hich is increased in
Dow n's pregnancy, and ult rasound measurement of neck membrane t hickness,
w hich is increased in Dow n's syndrome.
Maternal Serum Alpha-Fetoprotein (MS-AFP) AFP, a

product of the fetal liver, is normally found in fetal
serum, maternal serum, and amniotic fluid. MS-AFP
testing is routinely offered between 15 and 18 weeks of
gestation to all pregnant women as a screen for neural
tube defects; only 5% to 10% of neural tube defects
occur in families with previous occurrences.
Reference Values
Normal
25 ng/ mL (25 g/ L) At 1518 w eeks' gest at ion: 10150 ng/ mL or 10150 g/ L
Procedure
1. O bt ain a 10-mL venous blood sample (red-t opped t ube). O bserve st andard
2. Plan t he f irst screening at 15 t o 18 w eeks. I f t he result is normal, no f urt her
screening is necessary. I f MS-AFP is low, consider ult rasound st udies t o
det ermine exact f et al age. A second screening may be done af t er an init ial
elevat ed MS-AFP. I f t he result is normal, no f urt her screening is necessary.
Clinical Implications Abnormal levels should be

follow ed by ultrasound and amniocentesis.
1. El evated MS-AFP can indicat e:
a. Neural t ube def ect s of spina bif ida (a vert ebral gap) or anencephaly
(>2. 5 MoM)
b. Underest imat ion of gest at ional age
c. Mult iple gest at ion (>4. 5 MoM)
d. Threat ened abort ion
e. O t her congenit al abnormalit ies
2. El evated MS-AFP early in pregnancy is associat ed w it h:
a. Congenit al nephrosis
b. Duodenal at resia
c. Umbilical hernia or prot rusion

d. Sacrococcygeal t erat oma
3. El evated MS-AFP in t he t hird t rimest er is associat ed w it h:
a. Esophageal at resia
b. Fet al t erat oma
c. Hydroencephaly
d. Rh isoimmunizat ion
e. G ast roint est inal t ract obst ruct ion
4. Low MS-AFP is associat ed w it h:
a. Long-st anding f et al deat h
b. Dow n's syndrome (t risomy 21)
c. O t her chromosome abnormalit ies (t risomy 13, t risomy 18)
d. Hydat idif orm mole
e. Pseudopregnancy
Interfering Factors
1. O besit y causes low MS-AFP.
2. Race is a f act or: MS-AFP levels are 10% t o 15% higher in blacks and are
low er in Asians.
3. I nsulin-dependent diabet es result s in low MS-AFP.
Clin ical Alert

1. The incidence of neural t ube def ect is 1 per 1000 birt hs in t he Unit ed
St at es, 1 per 5000 in England.
2. Know ledge of t he precise gest at ional age is paramount f or t he accuracy of
t his t est .
3. I f t he MS-AFP is elevat ed and no f et al def ect is demonst rat ed (ie, by
ult rasound or amniocent esis), t hen t he pregnancy is at an increased risk
(eg, premat ure birt h, low -birt h-w eight inf ant , f et al deat h).
Interventions

1. Explain t he reason f or t est ing t he mot her's blood.

f urt her t est ing (eg, ult rasound, amniocent esis).
Hormone Testing Normally, the amounts of all steroid

hormones increase as pregnancy progresses. The
maternal unit responds to altered hormone levels even
before the growing uterus is apparent. Serial testing
may be done to monitor rising levels of a particular
hormone over a period of time. Decreasing levels
indicate that the maternal-placental-fetal unit is not
functioning normally. Biochemical analyses of several
hormones can be used to monitor changes in the status
of the maternal-fetal unit (See Chap. 3 and Chap. 6).
1. I n early pregnancy, hCG in mat ernal blood provides evidence of a viable
pregnancy. The hCG in mat ernal serum is measured as a sensit ive pregnancy
t est (t he hCG level doubles every 48 hours during pregnancy). Also, it is
used t o monit or t he success of in vit ro f ert ilizat ion or inseminat ion, t o
diagnose t rophoblast ic t umor, t o diagnose ect opic pregnancy (indicat ed by
decrease in hCG over a 48-hour period), and t o screen f or Dow n's syndrome
in pregnancy. For f urt her discussion of pregnancy t est s, see Chapt er 6.
2. The hCG , t oget her w it h prolact in and lut einizing hormone (LH), prolongs t he
lif e of t he corpus lut eum once t he ovum is f ert ilized. hCG st imulat es t he
ovary f or t he f irst 68 w eeks of pregnancy, bef ore placent al synt hesis of
progest erone begins. I t s f unct ion lat er in pregnancy (in mat ernal blood) is
unknow n.
3. PAPPA, a circulat ing placent al prot ein, has been show n t o increase t he
st imulat ory eff ect s of placent al insulin-like grow t h f act ors. Decreased serum
levels in t he mat ernal circulat ion in t he f irst 10 w eeks af t er concept ion are
associat ed w it h uncomplicat ed f ull-t erm low birt h w eight s. PAPPA levels are
det ect able w it hin 30 days af t er concept ion and slow ly increase t hroughout
t he f irst 30 w eeks of gest at ion. Mat ernal serum levels are 0. 43 g/ L (12
pmol/ L). I ncreased PAPPA occurs in Dow n's pregnancy.
4. Lat e in pregnancy, t he levels of est riol (E3 ) and human placent al lact ogen
(hPL) in mat ernal blood ref lect f et al homeost asis. hPL is a prot ein hormone
produced by t he placent a. Test ing of hPL evaluat es only placent al
f unct ioning. Blood t est ing of t he mot her usually begins af t er t he 30t h w eek
and may be done w eekly t hereaf t er. A concent rat ion of 1 g/ mL (46 nmol/ L)
hPL may be det ect ed at 68 w eeks of gest at ion. The level slow ly increases
t hroughout pregnancy and reaches 7 g/ mL (324 nmol/ L) at t erm bef ore
abrupt ly dropping t o zero af t er delivery. hPL f unct ions primarily as a f ail-saf e
mechanism t o ensure nut rient supply t o t he f et us, f or example, at t imes of
mat ernal st arvat ion. How ever, it does not appear t o be required f or a
successf ul pregnancy out come (see Chap. 6).
Estriol (E3 ) E3 is the predominant estrogen in the blood

and urine of pregnant women and is of fetal origin.
Normal production serves as a measure of the integrity
of the maternal-fetal unit and of fetal well-being.
This t est is used during pregnancy t o evaluat e f et al disorders and is part of t he
mat ernal t riple screen. Declining serial values indicat e f et al dist ress. E3 is
decreased in Dow n's syndrome and in t risomy 18.
Reference Values
Normal
W eeks of Gestation
E 3 (ng/mL)
SI Units (nmol/L)
2830
38140
132485
32
35330
1211144
34
45260
156901
36
46350
159277
38
59570
2141976
40
90460
3061595
Levels peak in t he middle or lat e af t ernoon. The day-t o-day variat ion is 12%
15%.
Procedure
1. O bt ain a 5-mL serum sample by venipunct ure using a red-t opped t ube. Draw
t he specimen at same t ime of day on each visit . O bserve st andard
precaut ions. Record w eeks of gest at ion on t he requisit ion or comput er
screen. Serial measurement s may be recommended t o est ablish a t rend.
2. Collect 24-hour urine specimens (Est riol: 1342 mg/ 24h or 46164 nmol/ d)
during t he t hird t rimest er.
1. Decreased E 3 is associat ed w it h risk f or:
a. G row t h ret ardat ion
b. Fet al deat h
c. Fet al anomalies (Dow n's syndrome, f et al encephalopat hy)
d. Fet us past mat urit y
e. Preeclampsia
f. Rh immunizat ion
2. Decreased E 3 also occurs in:
a. Anemia
b. Diabet es
c. Malnut rit ion
d. Liver disease
e. Hemoglobinopat hy
Interfering Factors Administration of radioactive

isotopes w ithin the previous 48 hours interferes w ith
this test.
Interventions
1. Explain t est purpose and procedures. Serial t est ing may be required. See
Hormone Test ing on page 976.
2. No f ast ing is necessary.
Clin ical Alert

1. A single det erminat ion cannot be int erpret ed in a meaningf ul f ashion.
2. I n some high-risk pregnancies, E3 is not reduced.

1. I nt erpret t est result s and monit or appropriat ely. Cont inuously low E3 values
are somet imes seen in normal pregnancy. A decreasing t rend is indicat ive of
f et al dist ress. Provide counseling and support .
Human Placental Lactogen (hPL) (Chorionic

Somatomammotropin) hPL is a growth-promoting
hormone of placental origin and is similar to hCG (see
Hormone Testing on page 976).
This t est is used t o evaluat e placent al f unct ion as an index of f et al w ell-being in
at -risk pregnancies. Low hPL levels are associat ed w it h int raut erine grow t h
ret ardat ion. Falling levels indicat e a poor prognosis. The level of hPL correlat es
best w it h placent al w eight , but t he clinical signif icance of t his hormone is
cont roversial.
Reference Values
Normal
Normal mat ernal serum: <0. 5 g/ mL (mg/ L or <25 nmol/ L) Men and nonpregnant
w omen: nondet ect able
Procedure
1. O bt ain a serum sample of at least 1 mL in t w o separat e vials (red-t opped
t ube) by venipunct ure. O bserve st andard precaut ions.
2. Record t he w eek of gest at ion or last menst rual period (LMP) on t he t est
requisit ion or comput er screen. These t est s are usually done as serial
measurement s.
1. Normal values are associat ed w it h normal int raut erine grow t h but do not
ensure lack of complicat ions.
2. Decreased or f al l i ng values are associat ed w it h:
a. G row t h ret ardat ion
b. Placent al disease
c. Fet al deat h
d. Hypert ensive st at e
3. Low levels are also associat ed w it h some normal pregnancies.
4. Increased values are f ound in t rophoblast ic t umors.
Interfering Factors Administration of

radiopharmaceuticals 24 hours before venipuncture
interferes w ith this test.
Interventions
1. Explain t he reason f or t est ing t he mot her's blood.

serial blood t est ing if result s are abnormal.
2. Use ult rasound st udies t o assess any abnormal result s.
Fetal Fibronectin (fFN) Fetal fibronectin is abundant in

amniotic fluid and may be useful in the diagnosis of
ruptured membranes. The detection of fFN in vaginal
secretions before membrane rupture may be a marker
for impending preterm labor within the next 7 to 14
days.
This t est helps t o predict a pret erm delivery w hen t he present ing sympt oms are
quest ionable so t hat early int ervent ion (eg, t ocolyt ics, cort icost eroids, t ransport
t o a t ert iary cent er) can be init iat ed w hen indicat ed. This t est is f or w omen w it h
int act membranes and cervical dilat at ion of <3 cm. f FN is secret ed in early
pregnancy t o help at t ach t he f ert ilized egg t o t he implant at ion sit e in t he ut erus,
but it is not secret ed af t er 22 w eeks unt il near t erm. This t est det ect s pret erm
labor f rom 24 unt il 34 w eeks' gest at ion.
Reference Values
Normal
Negat ive (<0. 050 g/ mL): delivery is unlikely t o occur w it hin 14 days.
Posit ive (>0. 050 g/ mL): delivery w it hin 714 days.
Procedure
1. Using a st erile speculum, obt ain secret ions f rom t he cervix and vagina by
rot at ing a st erile Dacron sw ab near t he out side of t he cervix and t he
post erior f ornix of t he vagina. O bserve st andard precaut ions.
2. Place specimen in a biohazard bag and send t he specimen t o laborat ory.
Result s may t ake 24 t o 48 hours.
Clinical Implications A level of fFN equal to or greater

than a reference value (0.050 g/mL) is considered
positive and means that preterm labor is imminent.
Transvaginal cervical ultrasonography may be used
along w ith fFN to assess risk for preterm birth. A short
cervix (<25 mm) w ith a positive fFN is a strong
predictor of preterm delivery. The greatest value of this
testing is a negative result in order to avoid
unnecessary interventions.
Interventions
1. Explain t est purpose and procedure t o t he pat ient .
2. Ref er t o Chapt er 1 f or saf e, eff ect ive, inf ormed pretest care .

1. Counsel t he pat ient regarding t est result s and need f or f ollow -up medicat ion,
t ocolysis (inhibit ion of cont ract ions), or preparat ion f or probable delivery.
2. Be sure t he mot her know s t he w arning signs of pret erm labor.
a. Uteri ne contracti onsa hard f eeling over t he ent ire surf ace of t he ut erus
t hat last s 20 seconds or longer. The cont ract ions can be painless. I f
more t han f our are f elt per hour, not if y clinician.
b. Menstrual -l i ke cramps f elt low in abdomen; may be const ant or come
and go
c. Pel vi c pressure or f ullness in t he pelvic area or back of t he t highs
d. Backachea dull pain in t he low er back, eit her const ant or rhyt hmic, t hat
is not relieved by changing posit ions
e. Persi stent di arrhea
f. Intesti nal cramps w it h or w it hout diarrhea
g. Vagi nal di scharge t hat is great er t han normal or changes in consist ency
or color (especially if it is pink, bloody, or greenish)
h. A general f eel i ng or sense that somethi ng i s wrong

3. Explain t he possible causes and increased risks associat ed w it h pret erm
labor and birt h:
a. Past pret erm birt h
b. Spont aneous abort ion in second t rimest er
c. Ut erine anomaly
d. Diet hylst ilbest rol exposure
e. I ncompet ent cervix
f. Hydramnios
g. Bleeding in second and t hird t rimest er
h. Pret erm labor
i. Premat ure rupt ure of membrane
j. Mult iple gest at ion
k. Pret erm cervical dilat at ion > 2 cm (mult ipara) or > 1 cm (primipara)
l. Pregnancy w eight < 115 pounds
m. Mot her < 15 years of age
TESTS TO PREDICT FETAL OUTCOM E AND RISK FOR

INTRAUTERINE ASPHYXIA
Contraction Stress Test (CST) This test is

done in a hospital or clinic setting to
assess fetal heart rate (FHR) in response
to uterine contractions via electronic fetal
monitoring.
Reference Values
Normal
The t est result is negat ive if t here are no lat e decelerat ions associat ed w it h at
least t hree cont ract ions w it hin a 10-minut e period.
A normal (negat ive) CST implies t hat placent al support is adequat e; t hat t he
f et us is probably able t o t olerat e t he st ress of labor, should it begin w it hin 1
w eek; and t hat t here is a low risk f or int raut erine deat h due t o hypoxia.
Procedure
1. O bt ain t he FHR by using an ext ernal t ransducer.
2. Monit or ut erine act ivit y by a t ocodynamomet er.
Clinical Implications A positive result indicates

increased risk for intrauterine death due to hypoxia.
See further discussion of results and contraindications
under Oxytocin Challenge Test (discussed below ).
Interventions
1. Explain t he reason f or t est ing.

f ollow -up t est ing.
Oxytocin Challenge Test (OCT); Nipple Stimulation

Test; Breast Stimulation Test (BST) These tests are
performed after 28 weeks of gestation, when a
nonstress test (NST) is nonreactive or a contraction
stress test (CST) is either positive or unsatisfactory.
Continuous external fetal monitoring is used. Because
uterine contractions are associated with a reduction in
uteroplacental blood flow, spontaneous, oxytocininduced (OCT), or nipple stimulation-induced

contractions with a frequency of 3 in 10 minutes may
be used clinically as a standard test of fetoplacental
respiratory function. Stress of this magnitude has been
proven clinically useful in separating fetuses with
suboptimal oxygen reserve from those with adequate
reserve (the vast majority), and it does not significantly
compromise the normal fetus.
Reference Values
Normal
The t est result is negat ive if t here are no lat e decelerat ions associat ed w it h at
least t hree cont ract ions w it hin a 10-minut e period.
A normal (negat ive) result is reassuring; it implies t hat placent al reserve is
suff icient should labor begin w it hin 1 w eek. There is a f alse-normal rat e of 1 t o 2
per 1000 pregnancies. The procedure is usually repeat ed w eekly.
Procedure
1. Be aw are t hat cont ract ions may occur spont aneously, af t er breast
st imulat ion (BST), or af t er administ rat ion of int ravenous oxyt ocin (O CT) t o
produce t hree good-qualit y cont ract ions of at least 40 seconds' durat ion
each, w it hin a 10-minut e period.
2. Monit or t he FHR f or react ion t o t his st ress.
1. The presence of consist ent and persist ent lat e decelerat ions w it h most
ut erine cont ract ions, regardless of t heir f requency, const it ut es a posit ive
(abnormal) O CT result . This is of t en associat ed w it h decreased baseline
FHR variabilit y, a lack of FHR accelerat ion w it h f et al movement , and a f et us
at risk f or int raut erine asphyxia.
2. The result s of O CT can be cat egorized as f ollow s:
a. Negati ve: no lat e decelerat ions
b. Posi ti ve: lat e decelerat ions f ollow ing 50% or more of cont ract ions, even
if t he f requency of t he cont ract ions is less t han t hree in 10 minut es
c. Equi vocal : int ermit t ent , lat e, or variable decelerat ions
d. Unsati sf actory: less t han t hree cont ract ions w it hin 10 minut es or a poorqualit y t racing
Interventions
Clin ical Alert

1. Wit h all met hods of O CT/ CST, t here is a risk f or hyperst imulat ion, w hich
could result in ext ended FHR decelerat ions t hat could be hypoxic f or t he
f et us.
2. Cont raindicat ions f or O CT/ CST include:
a. Third-t rimest er bleeding (unexplained vaginal bleeding)
b. Pret erm labor (premat ure)
c. Presence of classic ut erine incision
d. Placent a previa

1. I nt erpret t est out comes and counsel accordingly about meaning of f et al heart
act ivit y and movement .
Nonstress Test (NST) The NST can be performed in a

hospital, clinic, or possibly home care setting. Test
results reflect the functions of the fetal brain stem,
autonomic nervous system, and heart.
Reference Values
Normal
Negat ive result : react ive NST
American College of O bst et ricians and G ynecologist s (ACO G ) crit eria f or a
react ive NST (w it h or w it hout st imulat ion): t w o or more accelerat ions of FHR,
peaking at least 15 beat s/ minut e above t he baseline FHR and last ing at least 15
seconds f rom baseline t o baseline, w it hin a 20-minut e period
Procedure
1. Assess mat ernal vit al signs, last oral int ake (including medicines or st reet
drugs), smoking hist ory, and f et al movement hist ory.
2. Apply ext ernal f et al monit or w it h w oman posit ioned off her back in lat eral t ilt
posit ion.
3. Af t er 26 w eeks of gest at ion, t his assessment of t he FHR pat t ern w it hout
cont ract ions evaluat es f et al oxygenat ion. Fet al movement may or may not be
ident if ied by t he w oman during t he t est . I f gest at ion is < 26 t o 30 w eeks, t he
f et us may not meet t he crit eria f or a react ive NST yet st ill be a healt hy
f et us.
4. I t is no longer recommended t o f eed t he w oman bef ore t his t est because of
t he possibilit y of emergency delivery. G lucose does not alt er t he FHR
pat t ern.
5. I f unable t o elicit f et al heart rat e accelerat ions during NST, acoust ic
st imulat ion of a f et us t hat is not acidot ic may evoke f et al heart rat e
accelerat ions t hat seem t o predict f et al w ell-being. An art if icial larynx
(vibroacoust ic st imulat or) t hat is designed f or f et al monit oring is placed on
t he mot her's abdomen, and t he st imulus is act ivat ed f or 1 t o 2 seconds. The
st imulus may be repeat ed up t o t hree t imes f or gradually increased durat ions
up t o 3 seconds t o bring about f et al heart rat e accelerat ions. Use of
acoust ic st imulat ion can short en t ime needed f or react ive NST and reduce
f alse-posit ive t est result s.
Clinical Implications A nonreactive NST (positive test)

consists of few er than tw o accelerations of FHR (ACOG
criteria). If the fetus does not react w ithin the first 20
minutes, stimulation should be applied. The test is
considered nonreactive if, after extension to 40

minutes, the ACOG criteria are not met. This extended
testing minimizes the possibility of lack of activity
ow ing to fetal sleep. If the FHR pattern is unclear, the
test is considered inconclusive or unsatisfactory.
Clin ical Alert
1. The NST is a screening t est and can easily and saf ely be done once a
w eek.
2. A nonreact ive NST (posit ive t est ) should be f ollow ed by a CST.
3. Ult rasound st udies and a f et al biophysical prof ile (FBP) may be needed
af t er a nonreact ive NST.
4. Nonrepet it ive, brief (less t han 30 seconds) variable decelerat ions may be
not ed in up t o 50% of NSTs and do not indicat e a compromised f et us or a
need f or int ervent ions.
5. Repet it ive variable decelerat ions (t hree in 20 minut es) or decelerat ions
t hat last 60 seconds or longer indicat e nonreassuring f et al heart rat e
pat t ern and increased risk f or cesarean delivery.
Interfering Factors A false-positive result may be

caused by fetal sleep, preterm gestation, smoking
before the NST, congenital anomalies, or maternal use
of drugs such as central nervous system depressants
or beta blockers.
Interventions

1. I nt erpret t est out come; counsel appropriat ely.
2. Advise t he pat ient regarding need f or w eekly or t w ice-w eekly t est ing
according t o physician's orders, if pregnancy hist ory indicat es risk f act ors
f or ant epart um f et al demise. I f NST is perf ormed f or a single occurrence of
decreased f et al movement in uncomplicat ed pregnancy and react ive NST
result s, reassure pat ient t hat t est need not be repeat ed.
Fetal Activity-Acceleration Determination (FAD) The

fetal activity-acceleration determination (FAD) test
often is not distinguished from NST, but it is different.
In the FAD, both acceleration of FHR and fetal
movement are evaluated.
Reference Values
Normal
Negat ive result : react ive t est Crit eria are similar t o t hose f or NST, but f et al
movement is also required: more t han t hree discret e body or limb movement s
w it hin 30 minut es. I n a react ive t est (w ell-oxygenat ed f et us), spont aneous
accelerat ions of FHR begin at about t he t ime of onset of f et al movement . This
eff ect expresses t he condit ion of t he neurologic syst em and it s eff ect on f et al
movement and FHR.
Procedure
1. Remember t hat t he procedure is t he same as f or t he NST.
2. G ive t he w oman a but t on t o push w hen f et al movement occurs; pushing t he
but t on causes a mark t o appear on t he monit or st rip.
1. A nonreact ive FAD is ascert ained in t he same manner as is t he NST. Result s
are of quest ionable validit y bef ore 30 w eeks' gest at ion. Follow -up f or a
nonreact ive t est should include an ult rasound st udy t o assess f et al movement
and t one.
2. A nonreact ive FAD (posit ive result ) is associat ed w it h great er risk f or
hypoxia.
Clin ical Alert

Fet al movement t ends t o decrease as gest at ion progresses.
Interventions
1. Explain reason f or t est ing and f et al heart rat e monit oring.
2. This t est may be perf ormed in a hospit al or clinic set t ing.

1. I nt erpret t est out come and counsel appropriat ely. Explain need f or possible
f ollow -up ult rasound.
Continuous Fetal Heart Rate (FHR) Monitoring

Continuous FHR monitoring is done (both before and
during labor) to evaluate postterm pregnancy (>42
weeks); after a nonreactive stress or nonstress test;
and in the presence of diabetes, preeclampsia, chronic
hypertension, or intrauterine growth retardation.
Normally, the rate is 100 to 150 beats/minute;
accelerations occur with fetal movement, and a return
of variable decelerations to baseline occurs with no
evidence of decreasing baseline variability or
increasing baseline rate.
Fetal Biophysical Profile (FBP) (Biophysical Profile
[BPP]) The biophysical profile measurements, used in
the later stages of pregnancy, assess fetal well-being.
The BPP or FBP is more accurate and provides more
information than does the NST

alone. It can identify the fetus affected by hypoxia that
is at risk for intrauterine distress or death. In high-risk
pregnancies, testing usually begins by 32 to 34 weeks
of gestation; those with severe complications may
require earlier testing, at 26 to 28 weeks.
The FBP uses ult rasound imaging t o evaluat e f ive dist inct paramet ers: (1)
evidence of FHR (cardiac rat e) accelerat ions (NST); (2) muscle t one; (3) f et al
movement ; (4) f et al breat hing; and (5) volume of amniot ic f luid. Based on
sonographic evidence during a t ypical 20- t o 30-minut e survey, each paramet er
is assigned a value of 0 t o 2 point s (2 is opt imal). The maximum number of
point s obt ainable is 10; a score of 10 indicat es a normal t est w it hout evidence of
f et al dist ress. G enerally, a score > 8 indicat es f et al w ell-being. The FBP also
provides t he clinician w it h valuable inf ormat ion regarding f et al size and posit ion,
number of f et uses, placent al locat ion and grade, and evidence of specif ic f et al
act ivit ies such as mict urit ion and eye movement s.
Anot her version of t he FBP, t ermed t he modi f i ed bi ophysi cal prof i l e, has
become a primary mode of ant epart um f et al t est ing. The modif ied version
includes t he NST as a measure of f et al acid-base st at us and t he amniot ic f luid
index (AFI ) as a long-t erm placent al f unct ion assessment . The modif ied FBP is
normal if t he NST is react ive and if t he AFI is > 5. Abnormal result s include
nonreact ive NST and AFI 5.
I n some laborat ories, Doppler examinat ions of t he umbilical vessels assess
ut ero-f et al blood f low. Abnormal Doppler blood f low st udies (umbilical art ery
velocimet ry) may be det ect ed bef ore changes in NST, CST, or FBP are
det ect able. Abnormal Doppler umbilical art ery w avef orms become indicat ive of
acidosis, hypoxia, and int raut erine grow t h ret ardat ion, w hich result in a poor
out come. Doppler velocimet ry has demonst rat ed benef it s f or f et uses w it h
suspect ed int raut erine grow t h ret ardat ion.
Reference Values
Normal
Fet al w ell-being score: >8 point s, based on normal NST, normal f et al muscle
t one, movement , and breat hing; and normal volume of amniot ic f luid
Procedure
2. Posit ion t he pat ient on her back (as f or an obst et ric sonogram). Apply a gel
(coupling agent ) t o t he skin of t he low er abdomen. Then, move t he
ult rasound t ransducer across t he low er abdominal area t o visualize t he f et us
and surrounding st ruct ures.
3. Examining t ime is usually 30 minut es but may vary because of f et al age or
f et al st at e.
4. A CST or NST is also done at t his t ime (see pages 980 and 982).
1. Variables t hat inf luence FBP include f et al age, f et al behavioral st at es,
mat ernal or f et al inf ect ion, hypoglycemia, hyperglycemia, and post mat urit y.
2. I f a f et us < 36 w eeks of gest at ion does not have st able behaviors, a longer
t est may be needed. I nf ect ion may cause absence of FHR react ivit y and f et al
breat hing movement s. Frequency of f et al breat hing increases during mat ernal
hyperglycemia and decreases w it h mat ernal hypoglycemia. O t her variables
t hat inf luence FBP include use of t herapeut ic or nont herapeut ic chemicals.
Magnesium sulf at e may decrease or eliminat e f et al breat hing movement s and
decrease FHR variabilit y. Nicot ine can decrease t he prof ile paramet ers, and
cocaine may also decrease t he FBP score.
3. When t he f ive major biophysical prof ile paramet ers can be observed, t he
f et us is considered t o be f ree of dist ress. G enerally, a score of 8 point s
indicat es f et al w ell-being.
4. A score of 6 point s is equivocal, and ret est ing should be done in 12 t o 24
hours.
5. A score < 4 indicat es t he pot ent ial f or or t he exist ence of f et al dist ress. This
w arrant s f urt her t est ing or t he considerat ion of delivery.
Clin ical Alert

To assess t he f et al st at e properly, a sonographic det erminat ion of eye
movement and respirat ion must be done. I f no eye movement s and no
respirat ions are evident , t he f et us is most likely asleep. O n t he ot her hand, if
rapid eye movement is evident but breat hing is absent , t he f et us is probably in
dist ress.
Interventions

1. Explain t he t est purpose and procedure and include inf ormat ion regarding
each part of t he t est and how it relat es t o f et al w ell-being.

1. I nt erpret t est out comes, counsel appropriat ely, and inf orm about f urt her
t est ing.
2. I nst ruct t he pat ient regarding need f or w eekly or t w ice-w eekly t est ing, if
pregnancy hist ory indicat es risk f or ant epart um f et al demise.
care.
Fetoscopy
Fet oscopy allow s direct observat ion of t he f et us and f acilit at es f et al blood or
skin sampling. I t provides direct visualizat ion of t he f et us in 2- t o 4-cm segment s
so t hat development al def ect s can be more accurat ely ident if ied. The f et al blood
sample allow s early diagnosis of disorders such as hemophilia A and B t hat are
not amenable t o det ect ion t hrough ot her means. Fet oscopy can also be used f or
t herapeut ic int ervent ions such as shunt placement .
Reference Values
Normal
Normal f et al development ; no evidence of f et al development al def ect s Negat ive
f or hemophilia t ypes A and B and sickle cell anemia
Procedure
1. O bt ain a properly signed and w it nessed consent f orm.
2. Apply a local anest het ic t o t he mot her's abdominal w all. Meperidine
(Demerol), w hich crosses t he placent a, may be given t o t he mot her t o quiet
t he f et us.
3. Use real-t ime ult rasound t o locat e t he proper mat ernal abdominal area
t hrough w hich t o make a small incision, and t hen insert t he cannula and t he
t rocar int o t he ut erus.

4. Af t er cannulat ion int o t he ut erus, insert an endoscope (f et oscope), consist ing
of a f iberopt ic light source and a self -f ocusing lens, and t hen manipulat e f or
opt imal view s and f et al t issue sampling (eg, skin, blood, amniot ic f luid).
Clinical Implications Abnormal results reveal:

1. Fet al malf ormat ion
2. Neural t ube def ect s
3. Sickle cell anemia
4. Hemophilia
Clin ical Alert

1. Fet oscopy poses an increased risk f or spont aneous abort ions (5%10%),
pret erm delivery (10%), amniot ic f luid leakage (1%), and int raut erine f et al
deat h.
2. Fet oscopy is off ered only w hen t he w oman has a signif icant risk f or
producing a child w it h a major birt h def ect t hat can be diagnosed only by
t his met hod.
Interventions
1. The w oman (or couple) should receive genet ic counseling and a t horough
explanat ion of t he procedure and it s benef it s, risks, and limit at ions.
2. Ant ibiot ics may be ordered bef ore t he procedure t o prevent amnionit is.
Assess f or possible allergies t o t he drug.

1. Monit or mot her and f et us f or several hours af t er t he procedure. I nst it ut e
proper prot ocols f or dealing w it h mat ernal blood pressure and pulse
changes, FHR abnormalit ies, ut erine act ivit y, vaginal bleeding, or amniot ic
f luid leakage. Rh-negat ive mot hers should receive human Rho(D) immune
globulin (RhoG AM) unless t he f et us is also know n t o be Rh negat ive. Repeat
ult rasound st udies should be done t o check amniot ic f luid volume and f et al
viabilit y.
2. I nst ruct t he pat ient t o report any pain, bleeding, inf ect ed cannulat ion sit e,
amniot ic f luid leakage, or f ever (amnionit is).
Percutaneous Umbilical Blood Sampling (PUBS)

(Cordocentesis) Percutaneous umbilical blood
sampling (PUBS) has somewhat replaced fetoscopy
because of the risk factors associated with the latter
test. PUBS, for which research is ongoing, is probably
a safer and easier way to sample blood from the
umbilical cord of the fetus in utero. Fetal blood can be
examined for hemophilia, hemoglobinopathies, fetal
infections, chromosomal abnormalities, fetal distress,
fetal drug levels, and other blood studies.
Reference Values
Normal
No abnormalit ies not ed (see explanat ion of t est)
Procedure
1. Scan w it h a real-t ime ult rasound t ransducer (placed int o a st erile glove) t o
provide landmarks as a 20- t o 25-gauge spinal needle is f irst insert ed int o
t he mat ernal abdomen and t hen guided int o t he f et al umbilical vein, 1 t o 2 cm
f rom t he cord insert ion sit e on t he placent a.
2. Aspirat e t he f et al blood sample int o a syringe cont aining ant icoagulant t o
prevent clot t ing of t he sample.
Clin ical Alert

Risks include t ransient f et al bradycardia, mat ernal inf ect ion, premat ure labor,
and a 1% t o 2% incidence of f et al loss.
Clinical Implications Abnormal blood results reveal:

1. Hemoglobinopat hies
2. Hemophilia A or B, ot her coagulat ion disorders
3. Fet al inf ect ion
4. Chromosome abnormalit ies, genet ic diseases
5. I soimmunizat ion
6. Met abolic disorders
7. Fet al hypoxia
Interventions
1. Explain t he procedure and it s purpose, benef it s, and risks. O bt ain a properly
signed and w it nessed consent f orm.
2. Assist w it h relaxat ion exercises during t he procedure. Ant ibiot ics may be
given bef ore t he t est t o prevent inf ect ion.

1. Monit or mat ernal vit al signs and perf orm ext ernal f et al monit oring or an NST.
O bserve f or signs of f et al dist ress.
2. Perf orm an ult rasound 1 hour af t er t he procedure t o ensure t hat t here is no
bleeding at t he punct ure sit e.
3. I nt erpret t est out comes and counsel appropriat ely about f et al t herapy (eg,
red blood cell and plat elet t ransf usion and drug t reat ment ).
Chorionic Villus Sampling (CVS) Chorionic villus

sampling (CVS) can provide very early diagnosis of
fetal genetic or biochemical disorders. CVS involves
extraction of a small amount of tissue from the villi of
the chorion fondosum. This tissue is composed of
rapidly proliferating trophoblastic cells that ultimately
form the placenta. Although not a part of the fetus,
these villi cells are genetically identical to the fetus
and are considered fetal rather than maternal in origin.
CVS diff ers f rom amniocent esis in several respect s. I n amniocent esis, t he cells
examined are desquamat ed f et al cells; t he cells sampled in CVS divide rapidly
and are easier t o cult ure. For t his reason, karyot yping (see Chap. 11) can be
perf ormed much more rapidly, and diagnost ic inf ormat ion can be provided w it hin
24 hours, much f ast er t han w it h amniot ic f luid cells. Also, CVS can be perf ormed
much earlier in pregnancy, t ypically at 7 t o 11 gest at ional w eeks, w hereas
amniocent esis usually is perf ormed af t er 16 w eeks' gest at ion, w it h result s
available several w eeks lat er. CVS, t heref ore, has t he advant age of providing
f irst -t rimest er diagnosis,
w hich is of part icular value w hen t he choice is made t o abort an aff ect ed f et us
because f irst -t rimest er t erminat ions of pregnancy are medically saf er.
CVS reveals chromosome abnormalit ies and f et al met abolic or blood disorders.
How ever, because CVS cannot be used t o measure AFP, it cannot det ect neural
t ube def ect s or ot her disorders associat ed w it h increased AFP levels.
I ndicat ions f or CVS include t he f ollow ing:
1. Abnormal ult rasound t est
2. Fet us at risk f or det ect able mendelian disorders:
a. Tay-Sachs disease
b. Hemoglobinopat hies
c. Cyst ic f ibrosis
d. Muscular dyst rophy
3. Birt h of previous child w it h evidence of chromosome abnormalit y
4. Parent w it h know n st ruct ural chromosomal rearrangement
5. Diagnosis of f et al inf ect ion
Reference Values
Normal
Negat ive f or chromosomal and DNA abnormalit ies No f et al met abolic enzyme or
blood disorders
Procedure (Transcervical M ethod)

1. Posit ion t he mot her on her back t o permit ult rasound document at ion of t he
number of f et uses in ut ero and t heir viabilit y and localizat ion of t rophoblast ic
t issue. Ask t he pat ient eit her t o maint ain a f ull bladder or t o empt y t he
bladder so as t o opt imize t he sampling pat h. A bimanual pelvic examinat ion is
of t en perf ormed concurrent ly w it h t his preliminary ult rasound examinat ion.
2. Have t he pat ient assume a lit hot omy posit ion. I nsert a st erile speculum af t er
t he vagina has been cleansed w it h an iodine-based ant isept ic.
3. I nt roduce a st erile f lexible cat het er w it h a st ainless-st eel obt urat or int o t he
vaginal canal and advance t hrough t he cervical canal int o t he t rophoblast ic
t issue. The cat het er is visually t racked by t he ult rasound device.
4. O nce t he cat het er is in place, at t ach syringe t o t he end of t he cat het er t o
ext ract approximat ely 5 mL of t issue. I mmediat ely examine t he t issue sample
under a low -pow er microscope t o det ermine t hat bot h quant it y and t issue
qualit y are accept able.
5. Make up t o t hree passes of t he cat het er. Use a new, st erile cat het er each
t ime. Af t er suff icient t issue has been gat hered, use ult rasound again t o
monit or f et al viabilit y. Use t he t issue sample f or chromosome and enzyme
analysis and f or ot her t est s.
6. Be aw are t hat a t ransabdominal met hod may also be used. This met hod is
similar t o amniocent esis, except t hat t he t hin-w alled needle is insert ed int o
t he chorionic bed.
Clinical Implications Abnormal CVS results indicate:

1. Abnormal f et al t issue
2. Chromosome abnormalit ies
3. Fet al met abolic and blood disorders
4. Fet al inf ect ion
Interventions
1. Be aw are t hat genet ic counseling t ypically proceeds any CVS procedure.
2. Explain t he purpose, procedure, and risks of t he t est .
3. Ensure t hat a legal consent f orm is signed by t he mot her and t he f at her of
t he baby and is properly w it nessed.
4. Have t he pat ient drink f our 8-ounce glasses of w at er about 1 hour bef ore t he
examinat ion. The pat ient should not void unt il inst ruct ed t o do so.
5. O bt ain baseline measurement s of mat ernal vit al signs and FHR.
6. Advise t he pat ient t hat she may experience cramping as t he cat het er passes
t hrough t he cervical canal.
7. Help t he pat ient t o relax.

1. Monit or mat ernal vit al signs and FHR every 15 minut es f or t he f irst hour af t er
t est complet ion.
2. I nst ruct t he pat ient t o not if y her physician if she experiences abdominal pain,
vaginal bleeding or abnormal discharge, elevat ed t emperat ure, chills, or
amniot ic f luid leakage.
3. I nt erpret t est out comes and counsel appropriat ely. Rh-negat ive w omen
usually receive RhoG AM.
4. Support t he mot her and signif icant ot hers during decision making. Provide
opport unit y f or quest ions and discussion.
Clin ical Alert

1. CVS is not considered a rout ine alt ernat ive t o amniocent esis. The saf et y
of t he CVS procedure is relat ed t o t he experience and skill of t he
examiner. I n experienced hands, t he rat es of complicat ions and f et al loss
are only slight ly great er t han f or amniocent esis. Risks include leakage of
amniot ic f luid, bleeding, int raut erine inf ect ion, spont aneous abort ion,
mat ernal t issue cont aminat ion of specimen, Rh isoimmunizat ion, and f et al
2.
3.
4.
5.
deat h (5%).
Transcervical CVS is diff icult in pat ient s w ho have a f undal placent al
implant at ion sit e or an ext remely ret rof lexed or ant ef lexed ut erus. I n such
pat ient s, a t ransabdominal approach similar t o t hat used f or amniocent esis
is employed.
CVS cannot det ect neural t ube def ect s or ot her disorders associat ed w it h
abnormal mat ernal serum.
Some specialist s advise t hat t his procedure be reserved f or evaluat ion of
condit ions t hat present relat ively high genet ic risks (eg,
hemoglobinopat hies).
An increased risk f or severe limb def ormit ies is associat ed w it h t his
procedure.
AM NIOTIC FLUID STUDIES

The f luid f illing t he amniot ic sac serves several import ant f unct ions. I t provides a
medium in w hich t he f et us can readily move, cushions t he f et us against possible
injury, helps maint ain an even t emperat ure, and provides usef ul inf ormat ion
concerning t he healt h and mat urit y of t he
f et us. The origin of amniot ic f luid is not complet ely underst ood. I n early
pregnancy, it is produced by t he amniot ic membrane covering t he placent a and
t he cord. As t he pregnancy progresses, it is believed t o be primarily a byproduct
of f et al pulmonary secret ions, urine, and met abolic product s f rom t he int est inal
t ract .
I nit ially, amniot ic f luid is produced f rom t he amniot ic membrane cells. Lat er, most
of it is derived f rom t he mat ernal blood. The volume increases f rom about 30 mL
at 2 w eeks' gest at ion t o 350 mL at 20 w eeks. Af t er 20 w eeks, t he volume
ranges f rom 500 t o 1000 mL. The volume of amniot ic f luid changes cont inuously
because of f luid movement in bot h direct ions t hrough t he placent al membrane.
Lat er in pregnancy, t he f et us cont ribut es t o amniot ic f luid volumes t hrough
excret ion of urine and sw allow ing of amniot ic f luid. The f et us also absorbs up t o
400 mL of amniot ic f luid every 24 hours t hrough it s gast roint est inal t ract ,
bloodst ream, and umbilical art ery exchanges across t he placent a. Probably,
some f luid is also absorbed by direct cont act w it h t he f et al surf ace of t he
placent a. Amniot ic f luid cont ains cast off cells f rom t he f et us and resembles
ext racellular f luid w it h suspended, undissolved mat erial. I t is slight ly alkaline and
cont ains albumin, urea, uric acid, creat inine, lecit hin, sphingomyelin, bilirubin,
f at , f ruct ose, epit helial cells, leukocyt ic enzymes, and lanugo hair.
When amniocent esis is advised early in pregnancy (15 t o 18 w eeks), t he purpose
is t o st udy t he f et al genet ic makeup and t o det ermine development al
abnormalit ies. Fet al cells are separat ed f rom t he amniot ic f luid by cent rif ugat ion
and are placed in a t issue cult ure medium so t hat t hey can be grow n and
harvest ed f or subsequent karyot yping t o ident if y chromosome disorders. Test ing
in t he t hird t rimest er is done t o det ermine f et al age and w ell-being, t o st udy
blood groups, or t o det ect amnionit is.
Amniocentesis
Amniot ic f luid is aspirat ed by means of a needle guided t hrough t he mot her's
abdominal and ut erine w alls int o t he amniot ic sac. Amniocent esis is pref erably
perf ormed af t er t he 15t h w eek of pregnancy. By t his t ime, amniot ic f luid levels
have expanded t o 150 mL, so t hat a 10-mL specimen can be aspirat ed. I f t he
purpose of amniocent esis is t o ascert ain f et al mat urit y, it should be done af t er
t he 35t h w eek of gest at ion.
Amniocent esis provides a met hod t o det ect f et al abnormalit ies in sit uat ions in
w hich t he risk f or an abnormalit y may be high. The t est can evaluat e f et al
hemat ologic disorders, f et al inf ect ions, inborn errors of met abolism, and sexlinked disorders. I t is not done t o det ermine t he sex of t he f et us simply out of
curiosit y.
Chromosomal abnormalit ies and neural t ube def ect s such as anencephaly,
encephalocele, spina bif ida, and myelomeningocele can be det ermined, as can
est imat es of f et al age, f et al w ell-being, and pulmonary mat urit y.
The development of signif icant mat ernal Rh ant ibody t it ers or a hist ory of
previous eryt hroblast osis can be an indicat ion f or amniocent esis.
High-Risk Parents Who Should Be Offered Prenatal

Diagnosis
1. Women of advanced mat ernal age (>35 years) w ho are at risk f or having a
child w it h a chromosome abnormalit y, especially t risomy 21. At mat ernal age
35 t o 40 years, t he risk f or Dow n's syndrome is 1% t o 3%; at age 40 t o 45,
it is 4% t o 12%; and at > 45 years, t he risk is 12% or great er.
2. Women w ho have previously borne a t risomic child or a child w it h anot her
kind of chromosome abnormalit y.
3. Parent s of a child w it h spina bif ida or anencephaly or a f amily hist ory of
neural t ube disorders.
4. Couples in w hich eit her parent is a know n carrier of a balanced t ranslocat ion
chromosome f or Dow n's syndrome.
5. Couples in w hich bot h part ners are carriers f or a diagnosable met abolic or
st ruct ural aut osomal recessive disorder. More t han 70 inherit ed met abolic
disorders can be diagnosed by amniot ic f luid analysis.
6. Couples in w hich eit her part ner or a previous child is aff ect ed w it h a
diagnosable met abolic or st ruct ural dominant disorder.
7. Women w ho are presumed carriers of a serious X-linked genet ic disorder.
8. Couples f rom f amilies w hose medical hist ory reveals ment al ret ardat ion,
ambiguous genit alia, or parent al exposure t o t oxic environment al agent s (eg,
drugs, irradiat ion, inf ect ions).
9. Couples w hose personal and f amily medical hist ory reveals mult iple
miscarriages, st illbirt hs, or inf ert ilit y.
10. Parent s w it h anxiet y about t he healt h st at us of pot ent ial off spring.
11. Women w it h abnormal ult rasound result s.
Clin ical Alert
The in ut ero diagnosis of many genet ic disorders may lead t he parent s t o

consider abort ion as an opt ion f or dealing w it h an unf avorable sit uat ion.
Because t his can be a very diff icult and cont roversial choice, communicat ion
bet w een t he parent s and t he healt h care t eam must t ake place in a
nonjudgment al, nont hreat ening manner.
Reference Values
Normal
Normal amniot ic f luid const it uent s and propert ies vary according t o t he age of
f et us and t he laborat ory met hods used; pH is slight ly alkaline. See descript ions
of individual t est s.
Procedure (in Combination w ith Ultrasound)

1. Posit ion t he pat ient on her back w it h her arms behind her head t o prevent
t ouching of t he abdomen and t he st erile f ield during t he procedure (see
O bst et ric Sonogram in Chap. 13).
2. Perf orm ult rasound scanning bef ore t he procedure t o assess f et al number,
viabilit y, and posit ion. An appropriat e pocket of amniot ic f luid is localized in
t he scan. The t ap sit e should be locat ed aw ay f rom t he f et us, f rom t he sit e
of umbilical cord insert ion, and f rom any t hick placent al segment s.
3. Cleanse t he skin t horoughly w it h an appropriat e ant isept ic solut ion and
properly drape w it h st erile drapes. I nject a local anest het ic slow ly at t he
punct ure sit e.
4. Advance a 3. 5-inch spinal needle (20- t o 22-gauge) w it h st ylet t hrough t he
abdominal and ut erine w alls int o t he amniot ic sac but aw ay f rom t he f et us
and, w hen possible, f rom t he placent a. Use cont inuous ult rasound
surveillance t o t rack t he posit ion of t he f et us. Should t he f et us move close t o
t he needle, w it hdraw t he needle.
5. O nce t he needle is properly posit ioned, remove t he st ylet and at t ach a
syringe t o t he needle t o permit aspirat ion of a 20- t o 30-mL specimen.
Discard t he f irst 0. 5 mL of aspirat ed f luid t o prevent cont aminat ion by
mat ernal cells or blood.
6. Wit hdraw t he needle, and place an adhesive bandage over t he punct ure sit e.
Post procedure ult rasound scanning conf irms f et al viabilit y.
7. Place t he amniot ic f luid specimen in a st erile brow n or f oil-covered silicone
cont ainer t o prot ect it f rom light and t hereby prevent breakdow n of bilirubin.
Label t he cont ainer properly.
I nclude t he est imat ed w eeks of gest at ion and t he expect ed delivery dat e.
Deliver t he sample t o t he laborat ory immediat ely.
8. Be aw are t hat t he laborat ory w orkup f or genet ic diagnoses usually t akes 2
t o 4 w eeks t o complet e. How ever, specimens obt ained f or det erminat ion of
f et al age (eg, creat inine) t ake 1 t o 2 hours; det erminat ions of t he lecit hin-t osphingomyelin (L/ S) rat io and phosphat idyl glycerol t ake 3 t o 4 hours; G ram
st ain t o rule out inf ect ion t akes one-half hour, and cult ures t ake 48 t o 72
hours.
9. The procedure may have t o be repeat ed if no amniot ic f luid is obt ained or if
t here is f ailure of cell grow t h or cult ure result s are negat ive.
10. Record t he t ype of procedure done, dat e, t ime, name of physician
perf orming t he t est , mat ernal-f et al response, and disposit ion of specimen.
1. Elevat ed amniot ic f luid alpha1 -f et oprot ein (AFP) can indicat e possible neural
t ube def ect s as w ell as mult iple gest at ions, f et al deat h, abdominal w all
def ect s, t erat omas, Rh sensit izat ion, and f et al dist ress.
2. Decreased AFP is associat ed w it h f et al t risomy 21 (Dow n's syndrome).
3. Creat inine levels are reduced in f et al premat urit y. At 37 w eeks of gest at ion,
creat inine in amniot ic f luid should be >2 mg/ dL (>15 mol/ L).
4. I ncreased or decreased t ot al amniot ic f luid volumes are associat ed w it h
cert ain t ypes of arrest ed f et al development .
5. I ncreased bilirubin levels are associat ed w it h impending f et al deat h. (See
page 1005 f or normal values. )
6. Amniot ic f luid color changes are associat ed w it h f et al dist ress and ot her
disorders such as chromosome abnormalit ies.
7. Sickle cell anemia and t halassemia can be det ect ed t hrough analysis of
amniot ic f ibroblast DNA.
8. X-linked disorders are not rout inely diagnosed in ut ero. How ever, because
t hese disorders aff ect only men, t he f et al sex may need t o be det ermined
w hen t he mot her is a know n carrier of t he X-linked gene in quest ion (eg,
hemophilia, Duchenne's muscular dyst rophy).
9. Screening f or carrier st at e or aff ect ed f et us is done t hrough chromosomal
t est ing.
10. The presence of some of t he more t han 100 det ect able met abolic disorders
can be det ect ed in t he amniot ic f luid sample. Examples include Tay-Sachs
disease, Lesch-Nyhan syndrome, Hunt er's syndrome, Hurler's syndrome, and
various hemoglobinopat hies. Heredit ary met abolic disorders are caused by
absence of an enzyme due t o delet ion or by alt erat ion of t he st ruct ure or
synt hesis of an enzyme due t o gene mut at ion. I f t he enzyme in quest ion is
expressed in amniot ic f luid cells, it can pot ent ially be used f or prenat al
diagnosis. An unaff ect ed f et us w ould have a normal enzyme concent rat ion, a
clinically normal carrier of t he gene def ect w ould have perhaps half of t he
normal enzyme level, and an aff ect ed f et us w ould have a very small amount
or none of t he enzyme.
11. For disorders in w hich an abnormal prot ein is not expressed in amniot ic f luid
cells, ot her t est procedures are necessary, such as DNA restri cti on
endonucl ease anal ysi s.
Interfering Factors
1. Fet al blood cont aminat ion can cause f alse-posit ive result s f or AFP.
2. False-negat ive and f alse-posit ive errors in karyot yping can occur.
3. Polyhydramnios may f alsely low er bilirubin values as a result of dilut ion.
4. Hemolysis of t he specimen can alt er t est result s.
5. O ligohydramnios may f alsely increase some amniot ic f luid analysis values,
especially bilirubin; t his can lead t o errors in predict ing t he clinical st at us of
t he f et us.
Interventions
1. Ensure t hat elect ive genet ic counseling includes a discussion of t he risk f or
having a child w it h a genet ic def ect and problems (eg, depression, guilt )
associat ed w it h select ive abort ion. The f at her should be present and should
be a part ner in t he decision-making process. I n genet ic counseling, do not
coerce t he parent s int o undergoing abort ion or st erilizat ion; t his should be an
individual choice.
2. Explain t est purpose, procedure, and risks; assess f or cont raindicat ions.
3. Ensure t hat a properly signed and w it nessed legal consent f orm is obt ained.
4. I nst ruct t he pat ient t o empt y her bladder just bef ore t he t est .
5. O bt ain baseline measurement s of f et al and mat ernal vit al signs. Monit or f et al
signs f or 15 minut es.
6. Alert t he pat ient t o t he possibilit y t hat t ransient f eelings of nausea, vert igo,
and mild cramping may occur during t he procedure. Help t he pat ient t o relax.

1. Check mat ernal blood pressure, pulse, respirat ion, and f et al heart t one every
15 minut es f or t he f irst half hour af t er t est complet ion. Palpat e t he ut erine
f undus t o assess f et al and ut erine act ivit y; monit or f or 20 t o 30 minut es w it h
an ext ernal f et al monit or, if one is available.
2. Posit ion t he mot her on her lef t side t o count eract supine hypot ension and t o
increase venous ret urn and cardiac out put .
3. I nst ruct t he pat ient t o not if y her physician if she experiences amniot ic f luid
loss, signs of onset of labor, redness and inf lammat ion at t he insert ion sit e,
abdominal pain, bleeding, elevat ed t emperat ure, chills, unusual f et al act ivit y,
or lack of f et al movement .
Clin ical Alert

1. Fet al loss at t ribut able t o t he procedure is <0. 5%. Repeat amniocent esis is
necessary in 0. 1% of cases.
2. Fet al complicat ions include:
a. Spont aneous abort ion
b. I njury t o t he f et us (f et al punct ure)
c. Hemorrhage
d. I nf ect ion
e. Rh sensit izat ion if f et al blood ent ers t he mot her's circulat ion
3. Mat ernal complicat ions include:
a. Hemorrhage
b. Hemat omas
4. This t est is cont raindicat ed in w omen w it h a hist ory of premat ure labor or
incompet ent cervix and in t he presence of placent a previa or abrupt io
placent ae. I f t he amniot ic f luid is bloody (blood is usually of mat ernal
origin) and if a signif icant number of f et al cells (Kleihauer-Bet keposit ive
smear) are present in t he amniot ic f luid of an Rh-negat ive mot her,
administ rat ion of RhoG AM should be considered. Some doct ors pref er t o
administ er RhoG AM t o all Rh-negat ive mot hers f or amniocent esis, unless
t hey are already sensit ized at t hat t ime.
P.
5. Families need t o know t hat prenat al diagnoses based on amniot ic f luid
assay are not inf allible; somet imes, result s do not ref lect t he t rue f et al
st at us. Findings f rom amniocent esis cannot guarant ee a normal or
abnormal child; t hey can only det ermine t he relat ive likelihood of specif ic
disorders w it hin t he limit s of laborat ory measurement s. Some condit ions
cannot be predict ed by t his met hod, including nonspecif ic ment al
ret ardat ion, clef t lip and palat e, and phenylket onuria (PKU).
6. Accurat e and opt imally saf e result s f rom amniocent esis are possible only
if t he f ollow ing prot ocols are observed:
a. G est at ion 15 w eeks
b. Ult rasound monit oring t o locat e suit able pools of amniot ic f luid, out line
t he placent a, exclude t he presence of a mult iple pregnancy, and
accurat ely est imat e f et al mat urit y. These considerat ions are necessary
t o correct ly int erpret AFP values in amniot ic f luid and mat ernal blood.
c. Precise and met iculous amniocent esis t echnique, including use of 20or 22-gauge needle
d. Maximum of t w o needle insert ion at t empt s f or a single t ap
e. Administ rat ion of RhoG AM f or t he Rh-negat ive w oman
7. Cyt ogenet ic analysis can produce result s t hat are 99. 8% accurat e.
8. Techniques have been developed f or perf orming amniocent esis in t he
presence of t w in f et uses. Amniot ic f luid is aspirat ed f rom one of t he
amniot ic sacs, and a small amount of cont rast mat erial is inject ed int o t he
sac. When t he adjacent sac is t apped and produces clear amniot ic f luid,
t he clinician is assured t hat each sac has been t apped and each f et us w ill
be accurat ely assessed.
9. An ant eriorly locat ed placent a does not preclude amniocent esis. A t hin
port ion of placent a can be t raversed during amniocent esis w it h no
apparent increase in post amniocent esis complicat ions.
Amniotic Fluid Alpha 1 -Fetoprotein (AFP) AFP is

synthesized by the embryonic liver and is the major
protein (glycoprotein) found in fetal serum. It
resembles albumin in molecular weight, amino acid
sequence, and immunologic characteristics. However,
it is not normally detectable after birth. Ordinarily, high
levels of fetoproteins are found in the developing fetus,
and low levels exist in maternal serum and amniotic
fluid.
The amniot ic f luid AFP t est is used t o diagnose f et al neural t ube def ect s
(malf ormat ions of t he cent ral nervous syst em); f et oprot ein leaks int o t he
amniot ic f luid during such pregnancies. The causes of neural t ube def ect s are
not know n; how ever, a genet ic component is assumed because an increased risk
f or recurrence exist s. Neural t ube def ect s usually exhibit polygenic
(mult if act ional) t rait s. I n cases of anencephaly and open spina bif ida, bot h
mat ernal serum alpha-f et oprot ein (MS-AFP) and amniot ic f luid AFP
concent rat ions are abnormal by t he 18t h w eek of gest at ion.
Addit ionally, AFP measurement s have been used as indicat ors of f et al dist ress;
in such cases, bot h amniot ic f luid AFP and MS-AFP may be increased. How ever,
f inal conf irmat ion must come f rom f urt her st udies.
Reference Values
Normal
1216 w eeks
Peak at 1216 w eeks is 14. 5 g/ L or 196 pmol/ L
Values vary considerably according t o age of f et us and laborat ory met hods used.
Values peak at 1216 gest at ional w eeks and t hen gradually decline t o t erm.
Procedure
I n t he laborat ory, amniot ic f luid is analyzed f or concent rat ion of AFP.
Clinical Implications Increased amniotic AFP levels are

associated w ith:
1. Neural t ube def ect s such as anencephaly (100% reliable), encephalocele,
spina bif ida, and myelomeningocele (90% reliable)
2. Congenit al nephrosis
3. O mphalocele
4. Turner's syndrome w it h cyst ic hydromas
5. G ast roint est inal t ract obst ruct ion
6. Missed abort ion
7. Fet al dist ress
8. I mminent or act ual f et al deat h
9. Severe Rh immunizat ion

10. Esophageal or duodenal at resia
11. Fet al liver necrosis secondary t o herpes virus inf ect ion
12. Sacrococcygeal t erat oma
13. Spont aneous abort ion
14. Trisomy 13
15. Urinary obst ruct ion (eg, f et al bladder neck obst ruct ion w it h hydronephrosis)
16. Cyst ic f ibrosis
Interfering Factors
1. Fet al blood cont aminat ion causes increased AFP.
2. I ncreased AFP is associat ed w it h mult iple pregnancies.
3. False-posit ive (0. 1%0. 2%) result s may be associat ed w it h f et al deat h,
t w ins, or genet ic anomalies, but somet imes no explanat ion can be given f or
t he result s.
Clin ical Alert

1. Any parent s w ho have already produced a child w it h a neural t ube def ect
should be off ered ant enat al st udies in ant icipat ion of f ut ure pregnancies. I f
one parent has spina bif ida, t he pregnancy should be closely monit ored.
2. High-resolut ion ult rasound st udies must be used t o conf irm increased AFP
levels.
Interventions
1. Explain t he t est purpose and t he meaning of posit ive and negat ive t est
result s.
2. Provide f or genet ic counseling.

1. I nt erpret t est out comes, counsel, and monit or appropriat ely.
Amniotic Fluid Total Volume Measurement of amniotic

fluid total volume is helpful for estimating the changes
in total amounts of certain substances that circulate in
the amniotic fluid, including bilirubin, creatinine, and
surface-active agents. Knowledge of total amniotic
fluid volume is important because marked changes in
the amount of amniotic fluid can decrease the
predictive value of serial concentration measurements
of specific substances. This measurement is most
important when test results do not agree with the
clinical picture.
Reference Values
Weeks of Gestation
Average Volume (mL)
12
Approximately 50
15
350
20
450
25
750
30 to 35
1500
Af t er 35 w eeks, values decrease t o 1250 mL at t erm.
Procedure
1. St udy a sample of amniot ic f luid w it h t he use of a solut ion of

paraaminohippuric acid (PAH) f or absorbency and dilut ion t o calculat e t he
probable amniot ic f luid volume in millilit ers.
2. Correct amniot ic f luid t ot al volume by mult iplying t he measured levels of
specif ic subst ance by t he act ual f luid volume divided by average volume (f or
gest at ion age).
1. Polyhydramnios (increased amniot ic f luid, >2000 mL) is suggest ed by a t ot al
int raut erine volume > 2 st andard deviat ions above t he mean f or a given
gest at ional age. I t is est imat ed t hat 18% t o 20% of f et uses in such
pregnancies have congenit al anomalies, t he t w o most common being
anencephaly and esophageal at resia (f et al sw allow ing is great ly impaired).
The remainder have involvement secondary t o Rh disease, diabet es, or
ot her, unknow n causes. Polyhydramnios is also associat ed w it h mult iple
birt hs (eg, t w ins).
2. O ligohydramnios (reduced volume of amniot ic f luid, <300 mL) is suggest ed
by a t ot al int raut erine volume > 2 st andard deviat ions below t he mean
occurring bef ore t he 25t h w eek of gest at ion. A dist urbance of kidney f unct ion
caused by renal agenesis or kidney at resia can result in oligohydramnios
(f et al urinat ion is impaired). Af t er 25 w eeks, t he suspect ed causes of
decreased amniot ic f luid volume are premat ure rupt ure of membranes,
int raut erine grow t h ret ardat ion, and post t erm pregnancy.
Clin ical Alert

I f eit her polyhydramnios or oligohydramnios is suspect ed, t he f et us should be
screened w it h ult rasound t o det ect physical anomalies.
Interventions
1. Explain t he reason f or amniot ic f luid t est ing and t he meaning of result s.
1. I nt erpret amniot ic f luid t est result s and monit or appropriat ely.

Amniotic Fluid Index (AFI)
Reference Values
Normal
At t erm, t he AFI is usually bet w een 8 and 18 cm. Values < 5 cm indicat e
oligohydramnios, and t hose > 24 cm indicat e polyhydramnios.
Procedure
1. The pregnant w oman lies supine w it h displacement of t he ut erus t o t he lef t .
The abdomen is divided int o f our quadrant s.
2. Ult rasound is used t o locat e t he largest pocket of amniot ic f luid in each of
t he f our quadrant s, and each pocket is measured vert ically. The f our values
are added t oget her t o obt ain t he AFI . The advant age of t his t est is t hat
serial f ollow -up measurement s can be done.
1. O ligohydramnios and polyhydramnios are indicat ors of poor out come in
pregnancy.
2. An AFI low er t han t he 2. 4 percent ile f or a cert ain gest at ional age is
considered t o represent oligohydramnios.
3. O ligohydramnios can indicat e chronic ut eroplacent al insuff iciency or renal
anomaly.
4. An AFI higher t han t he 97. 5 percent ile f or a cert ain gest at ional age is
considered t o indicat e polyhydramnios. Polyhydramnios is associat ed w it h
upper gast roint est inal t ract obst ruct ion or malf ormat ion (eg,
t racheoesophageal f ist ula, hydrops f et alis).
Interfering Factors False-positive results can occur in a

severely dehydrated w oman.
Interventions
1. Explain t he reason f or t he AFI procedure.

1. Explain t he t est result s t o t he pat ient . Prepare t he pat ient f or f ollow -up
procedures or need f or delivery of t he inf ant .
Amniotic Fluid Creatinine Creatinine, a byproduct of

muscle metabolism found in amniotic fluid, reflects
increased fetal muscle mass and the ability of the
maturing kidney (ie, glomerular filtrating system) to
excrete creatinine into the amniotic fluid. The amniotic
fluid creatinine concentration progressively increases
as pregnancy advances. The mother's blood creatinine
level should be known before the amniotic fluid
creatinine value is interpreted.
Creat inine indicat es f et al physical mat urit y and correlat es reasonably w ell w it h
t he level of lung mat urit y. Normal lung development is dependent on normal
kidney development . As pregnancy progresses, t he amniot ic f luid creat inine level
increases. A value of 2 mg/ dL (177 mol/ L) is accept ed as an indicat or t hat
gest at ion is at 37 w eeks or more. How ever, t he use of t his value
alone t o assess mat urit y is not advised f or several reasons. A high creat inine
concent rat ion may ref lect f et al muscle mass but not necessarily kidney mat urit y.
For example, a large f et us of a diabet ic mot her may have high creat inine levels
because of increased muscle mass. Conversely, a small, grow t h-ret arded inf ant
of a hypert ensive mot her may have low creat inine levels because of decreased
muscle mass. Creat inine levels can be misleading if t hey are used w it hout ot her
support ing dat a. So long as mat ernal blood creat inine levels are not increased,
amniot ic f luid creat inine measurement s have a cert ain degree of reliabilit y if t hey
are int erpret ed in conjunct ion w it h ot her mat urit y st udies.
Reference Values
Normal
A value > 2 mg/ dL or > 177 mol/ L indicat es f et al mat urit y (at 37 w eeks) if
mat ernal creat ine is normal.
Procedure
1. O bt ain an amniot ic f luid sample of at least 0. 5 mL.
2. Prot ect t he specimen f rom direct light .
3. O bt ain mat ernal venous blood sample.
Clinical Implications Creatinine levels low er than

expected may occur in the follow ing situations:
1. Early in t he gest at ional cycle (not yet at 37 w eeks)
2. Fet us smaller t han normal (grow t h ret arded)
3. Fet al kidney abnormalit ies
4. Premat urit y
Interfering Factors Causes of elevated amniotic fluid

creatinine concentrations that are not consistent w ith
gestational age include abnormal maternal creatinine,
diabetes, and preeclampsia.
Interventions
1. Explain t he purpose of t he t est .

Amniotic Fluid Lecithin-to-Sphingomyelin (L/S) Ratio

(Surfactant Components) Lecithin and sphingomyelin
have detergent (surfactant) ability. These substances,
produced by lung tissue, stabilize the neonatal alveoli
to prevent their collapse on expiration and consequent
atelectasis. The amount of lecithin in amniotic fluid is
less than the amount of sphingomyelin until 26 weeks
of gestation; at 30 to 32 weeks of gestation, the two
lipid values are about equal. At 35 weeks, lecithin level
rises abruptly, but sphingomyelin stays constant or
decreases slightly. Saturated phosphatidylcholine, a
subfraction of total lecithins, is a major surface-active
component of lung surfactant.
The relat ionship bet w een t he phospholipids and t he surf ace-act ive agent s,
lecit hin and sphingomyelin, is used as an index of f et al lung mat urit y. I f early
delivery is ant icipat ed because of condit ions such as diabet es, premat ure
rupt ure of membranes, mat ernal hypert ension, placent al insuff iciency, or
eryt hroblast osis (Rh disease), t he L/ S rat io can be used t o predict w het her t he
f et al lung w ill f unct ion properly at birt h. When early delivery is necessary f or
f et al viabilit y, t he result may be premat urit y, pulmonary immat urit y, or perinat al
mort alit y. The L/ S rat io should be det ermined on all repeat cesarean sect ions
bef ore delivery t o ascert ain w hen f et al lungs are f unct ionally mat ure.
Sphingomyelin exhibit s surf ace-act ive propert ies in t he lung but plays no role in
t he surf act ant syst em except t o be used as a convenient marker.
Reference Values
Normal
A rat io of 2: 1 or great er indicat es pulmonary mat urit y
Procedure
1. Wit hdraw at least 3 mL of amniot ic f luid, or collect f rom a f ree f low of f luid
f rom t he vagina in cases of rupt ured membranes.

2. Cent rif uge t he f luid and prepare f or analysis, and read t he result s in a
ref lect ance densit omet er. Calculat e t he L/ S rat io.
1. A decreased L/ S rat io (<1. 5: 1) is of t en associat ed w it h pulmonary immat urit y
and respirat ory dist ress syndrome (RDS).
2. An L/ S rat io > 2: 1 signif ies f et al lung mat urit y. The occurrence of RDS is
ext remely unlikely.
3. An L/ S rat io bet w een 1. 5: 1 and 1. 9: 1 indicat es possible mild-t o-moderat e
RDS (50% risk).
4. Fet uses of w omen w it h insulin-dependent diabet es develop RDS at higher
rat ios. The L/ S rat io should be >3. 5: 1 f or t hese inf ant s.
Clin ical Alert

1. I f t he L/ S rat io is < 1. 5: 1, it is pref erable t o delay induced delivery unt il
t he f et al lung becomes more mat ure.
2. Fet al lung mat urit y appears t o be regulat ed by hormonal f act ors, some
st imulat ory and ot hers possibly inhibit ory. For t his reason, hormones such
as bet amet hasone (Celest one) are given in t w o doses, administ ered 12 t o
18 hours apart , if premat ure labor occurs.
3. Under cert ain st ressf ul condit ions, premat ure f et al lung mat urat ion may be
seen. This accelerat ed f et al lung mat urat ion is t hought t o be a prot ect ive
mechanism f or t he pret erm f et us should delivery act ually occur.
a. Premat ure rupt ure of t he membranes. Prolonged rupt ure of t he
membranes (af t er 72 hours) has an acut e negat ive eff ect on lung
mat urat ion.
b. Acut e placent al f unct ion
c. Placent al insuff iciency
d. Chronic abrupt io placent ae
e. Renal hypert ensive disease caused by degenerat ive f orms of diabet es
f. Cardiovascular hypert ensive disease associat ed w it h drug abuse
g. Severe pregnancy-induced hypert ension
P.
4. Delayed f et al lung mat urat ion may be seen in t he f ollow ing condit ions; in
t hese inst ances, a higher L/ S rat io (>3: 5) may be necessary t o ensure
adequat e f et al lung mat urit y:
a. I nf ant s born t o mot hers w it h insulin-dependent diabet es

b. I nf ant s born t o mot hers w it h nonhypert ensive glomerulonephrit is
c. Hydrops f et alis
5. A l ung prof i l e of amniot ic f luid t o evaluat e lung mat urit y looks not only f or
lecit hin but also f or t w o ot her phospholipidsphosphat idyl glycerol (PG )
and phosphat idylinosit ol (PI ). PI increases in t he amniot ic f luid af t er 26 t o
30 w eeks of gest at ion, peaks at 35 t o 36 w eeks, and t hen decreases
gradually. PG appears af t er 35 w eeks and cont inues t o increase unt il
t erm; measurement s are classif ied as posit ive PG or negat ive PG . The
lung prof ile is a usef ul adjunct in evaluat ing t he L/ S rat io. I t appears t hat
lung mat urit y can be conf irmed in most pregnancies if PG is present
(posit ive) in conjunct ion w it h an L/ S rat io of 2: 1. PG may provide st abilit y
t hat makes t he inf ant less suscept ible t o RDS w hen experiencing
hypoglycemia, hypoxia, or hypot hermia. The PG measurement is especially
usef ul in borderline cases and in class A, B, and C diabet es w hen
pulmonary mat urat ion is delayed.
Interfering Factors
1. High f alse-negat ive result rat es
2. Unpredict abilit y or borderline values
3. Unpredict abilit y of cont aminat ed blood specimens
4. O ccasional f alse-posit ive values associat ed w it h condit ions such as Rh
disease, diabet es, or severe birt h asphyxia.
Interventions
1. Explain t he reason f or t est ing and t he meaning of result s.

Amniotic Fluid Shake Test (Foam Stability Test) The

shake test is a qualitative measurement of the amount
of pulmonary surfactant contained in the amniotic fluid.
It is quick and inexpensive. It is a bedside test of
lung maturity. In an obstetric emergency, an immediate
decision about delivery can be made. The advantage of
this test over the L/S ratio is that a physician,
technician, or nurse can perform it and the results are
highly reliable. The L/S ratio usually is not determined
when the shake test is positive because the shake test
also indicates fetal maturity. A table of dilutions is
used to determine the stage of lung maturity.
Reference Values
Normal
Posit ive: persist ence of a f oam ring f or 15 minut es af t er shaking (at an amniot ic
f luid-alcohol dilut ion of 1: 2) indicat es lung mat urit y
Procedure
1. Remember t hat t he t est is based on t he abilit y of amniot ic f luid surf act ant t o
f orm a complet e ring of bubbles on t he surf ace of t he amniot ic f luid in t he
presence of 95% et hanol.
2. Place a mixt ure of 95% et hanol and amniot ic f luid in an appropriat e cont ainer
and shake f or 15 seconds. A commercial kit may be used.
1. I f a complet e ring of f oam f orms and persist s f or 15 minut es, t he t est is
posit ive.
2. I f no ring of bubbles f orms, t he t est is negat ive.
3. The t est has a high f alse-negat ive rat e but a low f alse-posit ive rat e. The L/ S
rat io must be > 4: 1 f or t his t est t o be posit ive.
Interfering Factors
1. Blood or meconium cont aminat ion can alt er result s.
2. Cont aminat ion of glassw are or reagent s can alt er t est result s.
Interventions
1. Explain t he reason f or t est ing and t he meaning of result s.

Amniotic Fluid Foam Stability Index (FSI) The foam

stability index (FSI) is a modification of the shake test.
It provides a functional measurement of fetal lung
maturity based on the surface tension properties of
surfactant phospholipids.
Reference Values
Normal
FSI : >0. 47
Procedure
1. Mix a f ixed amount of undilut ed amniot ic f luid w it h increasing volumes of
et hanol.
2. Shake t he sample and observe f or f oam.
3. Document t he largest column of et hanol in w hich t he amniot ic f luid can f orm
and support f oam. This t est is almost as reliable as t he L/ S rat io in normal
pregnancies, and it seems t o have a low er f alse-posit ive rat e t han t he shake
t est .
Clinical Implications FSI of >0.48 is termed mature; a

value of <0.46 is termed immature.
Interfering Factors
1. Blood or meconium cont aminat ion can produce a f alse mat ure result .
2. The t est is not reliable f or amniot ic f luid collect ed f rom t he vagina.
Amniotic Fluid Fern Test Fern production is a result of

the concentration of electrolytes, especially sodium
chloride, in the cervical glands; it is under the control
of estrogen. Close to term, amniotic fluid shows a
typical
fern pattern similar to that seen in cervical mucus; this
indicates a predominantly estrogen effect rather than
progesterone.
This st udy diff erent iat es urine f rom amniot ic f luid. I t is done t o det ermine
w het her t he f luid passed is urine or premat urely leaked amniot ic f luid. This is a
relat ively f ast and inexpensive t est t hat can be easily done.
Reference Values
Normal
Posit ive t est f or presence of amniot ic f luid
Procedure
1. Perf orm a vaginal examinat ion w it h t he use of a st erile speculum.
2. Place a f ew drops of f luid on a slide and allow t o dry.
3. Look f or a f ern or palm leaf pat t ern (arborizat ion) under t he microscope.
1. A posit ive t est show s t he f ern pat t ern indicat ive of amniot ic f luid.
2. A negat ive t est show s no f erning or cryst allizat ion; t his indicat es lit t le or no
est rogen eff ect .
3. No f ern pat t ern is seen if t he specimen is urine.
Interfering Factors Blood contaminating the specimen

inhibits fern formation.
Clin ical Alert
Urine can also be diff erent iat ed f rom amniot ic f luid if t he f luid is t est ed f or t he
presence of urea, nit rogen, pot assium, and creat inine and t he absence of AFP.
Interventions

1. I nt erpret t est result s and counsel appropriat ely.
Amniotic Fluid Color Amniotic fluid specimens may

vary from no color to a pale straw-yellow color. White
particles of vernix caseosa from fetal skin and lanugo
hair may be present. In certain disorders such as
missed abortion, chromosomally abnormal fetus, and
fetal anencephaly, the amniotic fluid color is altered.
Clin ical Alert
Every amniot ic f luid specimen should be visually inspect ed f or color.
1. Yel l ow amniot ic f luid indicat es blood incompat ibilit y, eryt hroblast osis f et alis,
or presence of bile pigment released by red blood cell hemolysis (f et al
bilirubin).
2. Dark yel l ow aspirat e indicat es probable f et al involvement .
3. Red color indicat es blood, in w hich case it must be det ermined w het her t he
blood is f rom t he mot her or t he f et us. Fet al blood in t he amniot ic f luid is of
grave concern.
4. G reen, opaque f luid indicat es meconium cont aminat ion. The f et us passes
meconium because of hyperperist alsis in response t o a st ressor t hat may be
very t ransient or may be more serious and prot ract ed (eg, hypoxia). A very
good correlat ion st at es t hat t he more meconium present , t he more severe
and immediat e t he st ressor. Addit ional assessment s, such as amnioscopy
and amniography, must be made t o det ermine w het her t he f et us is
experiencing ongoing episodes of hypoxia or ot her st ressors. G reen color
can also indicat e eryt hroblast osis but is not necessarily indicat ive of it .
5. Yel l ow-brown, opaque f luid may indicat e int raut erine deat h and f et al
macerat ion (alt hough not necessarily f rom eryt hroblast osis), oxidized
hemoglobin, or mat ernal t rauma.
Reference Values
Normal
Sound: colorless or pale st raw -yellow color
Procedure
1. O bserve color changes and st aining t hrough amnioscopy bef ore t he amniot ic
membranes have rupt ured.
2. Place an amnioscope int o t he vagina and against t he f et al present ing part .
Visualize t he amniot ic f luid t hrough t he amniot ic membranes. Problems w it h
amnioscopy include inadvert ent rupt ure of membranes, insuff icient dilat at ion
of t he cervix and consequent diff icult y insert ing t he amnioscope, int raut erine
inf ect ion, and occasional diff icult y in int erpret ing amniot ic f luid color.
3. Be aw are t hat t he t est may also be diff icult t o perf orm if t he pat ient is in
act ive labor.
Clin ical Alert

1. Meconium st aining may also be observed w hen an amniocent esis is done.
Af t er t he membranes have rupt ured, meconium st aining may be observed
in t he vaginal discharge. O nce meconium st aining is ident if ied, more
assessment s (eg, FHR pat t erns) must be made bef ore delivery is
cont emplat ed t o det ermine w het her t he f et us is experiencing ongoing
episodes of hypoxia.
2. The presence of meconium in t he amniot ic f luid is normal in breech
present at ions.
Interventions
1. Explain t he purpose of t he t est and t he procedure if amnioscopy is done.

1. I nt erpret t he t est result s, counsel, and monit or appropriat ely.
Amniotic Fluid Bilirubin Optical Density (OD) Bilirubin

is a pigment acquired by the amniotic fluid during its
circulation through the gastrointestinal tract. Bilirubin
may be found in amniotic fluid as early as the 12th
week of gestation. It reaches its highest concentration
between 16 and 30 weeks. As the pregnancy continues,
the amount of bilirubin progressively decreases until it
finally disappears near term. Bilirubin levels increase
in the presence of erythroblastotic fetuses and fetuses
with anencephaly or intestinal obstruction.
This measurement is used t o monit or t he f et al st at e in an Rho-negat ive pregnant

w omen w ho has a rising ant i-Rho ant ibody t it er. The rising t it er is synonymous
w it h Rh eryt hroblast osis f et alis or hemolyt ic disease of t he new born (HDN). This
det erminat ion usually is not made bef ore 20 t o 24 w eeks' gest at ion because no
t herapy is available t o t he f et us bef ore t hat t ime. Close t o t erm, t he amniot ic
f luid bilirubin pigment concent rat ion normally decreases in t he absence of Rh
sensit izat ion.
Det erminat ion of opt ical densit y (O D) is only one of several laborat ory met hods
used t o measure bilirubin. The degree of hemolyt ic disease f alls int o t hree
zones, using O D measurement and a w avelengt h (absorbance) of 450 nm (t he
Liley or Diazo met hod).
1. I f O D = 0. 28 t o 0. 46 (zone 1, low zone 2+ O D) at 28 t o 31 w eeks, t he f et us
w ill not be aff ect ed or w ill have very mild hemolyt ic disease.
2. I f O D = 0. 47 t o 0. 90 (zone 2, middle zone, 3+ O D), t here is a moderat e
eff ect on t he f et us. The f et al age and t he t rend in O D indicat e t he need f or
int raut erine t ransf usion and early delivery.
3. I f O D = 0. 91 t o 1. 0 (zone 3, high zone, 4+ O D), t he f et us is severely
aff ect ed, and f et al deat h is a possibilit y. I n t his case, a decision concerning
delivery or int raut erine t ransf usion, depending on t he age of t he f et us, should
be made. Af t er 32 t o 33 w eeks of gest at ion, early delivery and ext raut erine
t reat ment are pref erred.
4. An O D < 0. 04 indicat es f et al mat urit y and w ell-being.
Reference Values
Normal OD < 0.02 mg/dL or < 0.34 mol/L at 450

nm absorbence wavelength by the Liley method,
or 0.025 mg/dL (0.43 mol/L) by the Diazo
method, indicates maturity
Procedure
1. Collect 5 t o 10 mL of amniot ic f luid in a light -proof cont ainer.
2. Send t he f luid t o t he laborat ory immediat ely.
3. Be aw are t hat t he specimen may be ref rigerat ed f or up t o 24 hours. I t can
be f rozen if a longer t ime w ill elapse bef ore analysis.
4. Avoid blood in t he specimen. I f init ial aspirat ion produces a bloody f luid, t he
needle should be reposit ioned t o obt ain a specimen f ree of red cells. I f a
blood-f ree specimen cannot be obt ained, t he specimen must be examined at
once, bef ore hemolysis occurs.
5. I ndicat e w eeks of gest at ion on laborat ory request f orm.
Clinical Implications Increased OD is found in:

1. Eryt hroblast osis f et alis
2. O t her f et al hemolyt ic diseases
3. Mat ernal inf ect ious hepat it is
4. Mat ernal sickle cell crisis
Interfering Factors
1. Blood, hemoglobin, or meconium in t he specimen can produce inaccurat e
result s.
2. Mat ernal use of st eroids int erf eres w it h t he t est .
3. Exposure of t he amniot ic f luid t o light compromises t he t est .
4. Fet al acidosis int erf eres w it h t he t est .
Clin ical Alert

1. Diff icult y in int erpret at ion occurs f requent ly. Findings must be int erpret ed
by a know ledgeable person w ho can recognize pit f alls. O bt ain clinical
inf ormat ion and st udy ot her laborat ory dat a.
2. Af t er 30 w eeks' gest at ion, t he Liley t est result is usually combined w it h an
assessment of f et al lung mat urit y (L/ S rat io) t o assist in t he decision of
w het her t o induce delivery.
3. A bilirubin level t hat f ails t o decline as expect ed or increases indicat es
t hat t he f et al st at us is det eriorat ing.
Interventions
1. Explain t he t est purpose and t he meaning of t est result s.


1. I nt erpret t est out come; monit or and counsel appropriat ely.
Amniotic Fluid and Desaturated Phosphatidylcholine

(DSPC) Desaturated phosphatidylcholine (DSPC) is the
major component (50%) of fetal pulmonary surfactant.
The concentration in amniotic fluid can be measured by
separating DSPC from unsaturated lecithin.
Phosphatidylcholine is the second most surface-active
component of surfactant.
This t est is a direct measure of primary phospholipid in surf act ant and is used in
t he assessment of f et al lung mat urit y.
Reference Values
Normal
Presence of DSPC is evidence t hat f et us is at least 3637 w eeks in development
Procedure
O bt ain and examine amniot ic f luid f or t he primary phospholipid (DSPC).
1. Normal levels are consist ent w it h f et al lung mat urit y and indicat e a negligible
risk f or RDS.
2. Low levels are associat ed w it h immat urit y and a high risk f or RDS.
Interfering Factors Results may be altered by changes

in amniotic fluid volume (oligohydramnios or
polyhydramnios).
Interventions
1. Explain t est purpose and t he amniot ic f luid sampling procedure.

1. I nt erpret t est out comes; monit or and counsel appropriat ely.
ADDITIONAL M EASUREM ENTS

Group B Streptococcal (GBS) Screening GBS is a
frequent cause of newborn pneumonia. Sepsis and
meningitis are also common problems of GBS disease.
Preterm infants are more susceptible to GBS disease,
but it occurs most often in full-term infants.
The Cent ers f or Disease Cont rol and Prevent ion guidelines recommend t hat all
pregnant w omen should be screened f or anogenit al group B st rept ococcal
colonizat ion at 3537 w eeks' gest at ion.
Reference Values
Normal
A negat ive vaginal and anorect al cult ure indicat es G BS has not colonized in t he
cult ured sit es.
A posit ive cult ure indicat es a G BS carrier and result s should be recorded on t he
prenat al record so t hat it is available t o t he healt h care providers at t he t ime and
place of delivery.
Procedure
1. Use a single st andard cult ure sw ab t o sw ab t he dist al vagina and anorect um,
or t w o separat e sw abs can be used. See Chapt er 7 f or more inf ormat ion.
Place sw abs in t ransport medium if laborat ory is off sit e.
2. Report result s on prenat al record and ensure t hat a copy is available at t he
hospit al w here delivery of t he inf ant is ant icipat ed.
1. I nt rapart um ant ibiot ic prophylaxis should be considered w it h posit ive cult ure
result s by w eighing t he risks and benef it s of t reat ment w it h each G BS carrier
w ho is pregnant .
2. I nt ravenous penicillin G is pref erred t reat ment , but ampicillin is an
alt ernat ive, and clindamycin and eryt hromycin can be used f or t hose w omen
w it h penicillin allergy.
3. Prophylaxis should be cont inued t hroughout act ive labor unt il delivery.
4. Women w ho previously have given birt h t o an inf ant w it h G BS disease do not

need t o be screened prenat ally but should receive int rapart um t reat ment .
Interventions
1. Explain t he screening t est t o t he pat ient , including t he risks of G BS disease
t o new born.
Clin ical Alert

1. O ral ant ibiot ics should not be used t o t reat pregnant w omen w it h a
posit ive anogenit al G BS cult ure because t hey are not eff ect ive in
eliminat ing t he carrier st at us or prevent ing neonat al disease. Treat ment
should t ake place int rapart um.
2. Also, if sympt omat ic or asympt omat ic G BS bact eria are det ect ed in
pregnancy, t reat ment should be considered at t he t ime of diagnosis
because t his usually indicat es a heavily colonized individual. (See Chap. 7
f or more inf ormat ion. ) I nt rapart um t reat ment is also indicat ed f or t his
individual.

1. I nt erpret t est out comes; monit or and counsel appropriat ely.
Fetal Oxygen Saturation Monitoring (FSpO2 ) FSpO2

monitoring is used with external fetal monitoring (EFM)
as an additional means of assessment when the FHR is
nonreassuring or not interpretable. The FSpO2
monitoring system involves a single-use sterile
disposable sensor that is inserted through the cervix
into the uterus and rests against the fetal temple,
cheek, or forehead. The sensor is a reflectance sensor

in which a light source and a photodetector are placed
next to each other. Back scatter of light (light
absorption by pulsing arterial blood) is measured from
a vascular bed under the sensor, and when it is
reflected back to photodetector, reflected light is
analyzed and displayed on the monitor and on the FHR
paper tracing. FSpO2 monitoring should only be used
after maternal membranes have ruptured and on a
singleton fetus in vertex presentation with a
gestational age of 36 weeks or greater.
Reference Values
Normal
Wit h FSpO2 of 30% or above bet w een ut erine cont ract ions w it h a nonreassuring
f et al heart rat e, t he f et us can be assumed t o be adequat ely oxygenat ed.
Normal range f or FSpO2 is 30%70%. Cont inued FSpO2 readings of below 30%
f or more t han 10 minut es are likely t o lead t o progressive f et al hypoxemia,
acidemia, and det eriorat ion in f et al w ell-being.
Procedure
1. Be aw are t hat FSpO2 is indicat ed if nonreassuring FHR pat t ern.
2. Perf orm Leopold's maneuvers t o det ermine f et al posit ion and st erile vaginal
exam t o assess dilat at ion, st at ion, and present at ion.
3. Apply sensors w hen membranes are rupt ured and cervical dilat at ion of 2 cm
or great er has been achieved w it h t he f et us at st at ion of -2 or below and
vert ex present at ion.
4. I nsert a single-use st erile sensor (prof iciency in f et al scalp elect rode
insert ion or int raut erine pressure cat het er insert ion is necessary). I nsert t he
sensor perpendicular t o sagit t al sut ure. I nsert ion should be done bet w een
ut erine cont ract ions.
5. At t ach t he sensor t o t he f et al oxygen sat urat ion monit or. This monit or may
be able t o int erf ace w it h a f et al heart rat e monit or and record as a
cont inuous line w it h ut erine act ivit y.
6. Document FSpO2 on labor f low sheet as a range (eg, 40%45%), and f ollow
st andard document at ion int ervals of ot her f et al assessment s such as FHR.
1. Single measurement s of FSpO2 are not usef ul; need t o t rack t rends.
2. FSpO 2 monit oring along w it h t he use of f et al monit oring provides t he abilit y
t o det ect a compromised f et us and a healt hy f et us w it h nonreassuring FHR.
3. Provides dat a t hat a f et us w it h a nonreassuring FHR pat t ern can saf ely
cont inue in labor and reduce unnecessary int ervent ions during labor and
birt h, t heref ore improving mat ernal-f et al out comes and decreasing cost s.
Interfering Factors
1. Vernix can cause int errupt ion in FSpO2 monit oring if present in signif icant
quant it y. Meconium does not int erf ere.
2. St rong ut erine cont ract ions may cause t emporary loss of t he signal f rom
sensor at peak of ut erine cont ract ions.
3. Fet al and mat ernal movement can displace sensor.
Clin ical Alert

Cont raindicat ions include t he f ollow ing:
1.
2.
3.
4.
Document ed or suspect ed placent a previa

O minous FHR pat t ern requiring immediat e int ervent ion
Need f or immediat e delivery not relat ed t o FHR pat t ern
Act ive genit al herpes, hepat it is B and E, or ot her inf ect ions t hat preclude
int ernal monit oring
5. Seroposit ivit y f or HI V
Interventions
1. Explain t he reason f or monit oring and t he procedure involved.

1. Evaluat e t est out comes; counsel and monit or appropriat ely during labor.
Treat accordingly.
care.
Fetal Nuchal Translucency (FNT) FNT is a noninvasive

prenatal screening tool used to alert health care
providers of potential fetal abnormalities.
Ultrasonography is used to assess for a fluid collection
at the nape of the fetal neck. An abnormal fluid
collection may be due to genetic disorders or fetal
physical abnormalities. The test is most accurate at
1014 weeks' gestation. This screening test cannot
identify fetal abnormalities; it is used as a screening
tool for pregnancies that need diagnostic testing. If the
FNT exceeds the normal range, then diagnostic genetic
testing is recommended. There is a relationship
between increased fluid in nuchal area and cardiac
abnormalities. The nuchal edema is thought to be a
compensation factor in the fetus. It may indicate
trisomy 18, trisomy 21 (Down's syndrome), or fetal
cardiac anomalies.
Reference Values Abnormal FNT during 1014 w eeks'
gestation that is greater than 2.5 mm of fluid in the
fetal neck is considered abnormal.
A nuchal t ranslucency measurement of 3 mm or more is highly suggest ive of f et al
abnormalit ies.
Procedure
FNT screening is perf ormed by specially t rained pract it ioners.
1. Explain t he t est purpose and t he procedure.
2. Posit ion t he pat ient on her back as you w ould f or obst et ric ult rasound. A
coupling gel is applied t o t he skin of t he low er abdomen, and t he ult rasound
t ransducer is moved across t he abdomen t o visualize t he f et al neck f or f luid
accumulat ion.
3. FNT is det ermined by ult rasound measurement of f luid in t he nape of t he
neck bet w een 10 and 14 w eeks' gest at ion.
1. FNT screening can alert clinicians t o pot ent ial f et al abnormalit ies.
2. Analyzing mat ernal serum level of bet a-hCG and PAPPA levels along w it h
FNT increases accuracy of t est ing f or pregnancy t hat is at risk f or f et al
abnormalit ies.
Interfering Factors
1. There is a small but signif icant diff erence in FNT of some et hnic groups
(Caucasian and Asian f et uses have larger measurement s t han Af rican and
Caribbean f et uses).
2. Nuchal cord w ill decrease accuracy. Color Doppler ult rasound needs t o be
used in t hese cases t o diff erent iat e cord f rom f luid.
3. I mproper caliper placement during ult rasound
Interventions
1. Explain t he t est purpose and procedure t o t he pat ient .
2. Ref er t o Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest care .
1. I nt erpret t est out comes; monit or and counsel appropriat ely. Educat e pat ient
about f urt her t est ing (genet ic) and genet ic counseling.
BIBLIOGRAPHY
American College of O bst et ricians and G ynecologist s, Washingt on, DC,
Ant epart um Fet al Surveillance, ACO G Pract ice Bullet in, No. 9, O ct ober 1999
American College of O bst et ricians and G ynecologist s, Washingt on, DC,
ACO G Pract ice Bullet in, No. 31, Vol. 98, No. 4, O ct ober 2001
American College of O bst et ricians and G ynecologist s, Washingt on, DC, First Trimest er Screening f or Fet al Anomalies w it h Nuchal Translucency. ACO G
Commit t ee O pinion, O ct ober 1999
Beamer LC: Fet al nuchal t ranslucency: A prenat al screening t ool. JO G NN
30(4): 376384, 2001
Cent ers f or Disease Cont rol and Prevent ion: Recommendat ions f or G BS
disease prevent ion. O nline:
w w w. cdc. gov/ mmw r/ preview / mmw rht ml/ 00043277. ht m
Children's Hospit al of PhiladelphiaCent er f or Fet al Diagnosis and Treat ment

O nline: ht t p: / / f et alsurgery. chop. edu/ f et alnew s. sht ml
Cunningham F, G rant N, Leveno K, G ilst rap L: Williams O bst et rics, 21st ed.
New York, McG raw -Hill, 2001
Hubbard AM, Hart y MP, St at es LS: A new t ool f or prenat al diagnosis:
Ult raf ast MRI . Semin Perinat ol 6: 437447, 1999
Lopez RL, Francis JA, G arit e TJ, Dubyak JM: Fet al f ibronect in det ect ion as a
predict or of pret erm birt h in act ual clinical pract ice. Am J O bst et G ynecol
182: 11031106, 2000
Murray M: Ant epart al and I nt rapart al Fet al Monit oring, 2nd ed. Albuquerque,
Learning Resources I nt ernat ional, 1997, pp. 461467
Simpson KR: I nt rapart um f et al oxygen monit oring. O ngoing clinical research
explores part nering new met hod w it h EFM. AWHO NN Lif elines 5(2): 2024,
1998.
Wisconsin Associat ion f or Perinat al Care: Laborat ory Test ing During
PregnancyRecommendat ions of Perinat al Test ing Commit t ee, Madison, WI ,

Sept ember 2000, pp. 625.

Wilkins
> Table of C ontents > 16 - S pec ial S ys tem s , O r gan Func tions , and P os tm or tem S tudies
16
Special Systems, Organ Functions, and
Postmortem Studies
OVERVIEW OF SPECIAL STUDIES

These special st udies have been select ed f or discussion because of t heir great
diagnost ic value in ident if ying diseases and disorders of cert ain organs and
syst ems. Test s af t er deat h serve t o ident if y previously undiagnosed disease;
evaluat e accuracy of predeat h diagnosis; provide inf ormat ion about sudden,
suspicious, or unexplained deat hs; assist in organ donat ion and post mort em legal
invest igat ions; and promot e qualit y cont rol in healt h care set t ings.
THE EYE
Visual Field Testing
This procedure is used in conjunct ion w it h basic eye t est s t o evaluat e and rule
out glaucoma. The visual f ield exam may det ect diseases t hat aff ect t he eye,
opt ic nerve, or brain. Small blind spot s in t he visual f ield begin t o appear early in
glaucoma.
Reference Values
Normal
Negat ive f or blind spot s
Procedure
1. Remember t hat t he visual f ield t est present s dimmer and dimmer t arget s of
w hat t he eye can see unt il t hey reach t he limit .
2. Check one eye at a t ime.
3. I nf orm pat ient t hat procedure t ime is about 45 minut es f or each eye.
1. Abnormal f indings show t he blind spot s t hat appear in glaucoma.
2. Repeat t est ing f or posit ive f indings w ill show larger spot s and progression of
disease (see Fig. 16. 1).
FI G URE 16. 1 Humphrey Field Analyzer I I and visual f ield grid. The darker
t he symbol (f rom a single dot t o a black square), t he less likely t he f ield
is normal in t hat locat ion. (Source: Zeiss Humphrey Syst ems, Dublin, CA,
USA)
Interventions
1. Explain purpose and procedure f or visual f ield t est ing.

2. Alert pat ient t hat no pain should be involved. The only discomf ort is relat ed
t o f eeling sleepy, f eeling like t he pat ient is being hypnot ized.
3. Be aw are t hat elevat ed int raocular pressure, f amily hist ory, age, and
et hnicit y are among t he risk f act ors f or developing glaucoma.

1. I nt erpret t est out comes (see Fig. 16. 2) and counsel appropriat ely, especially
about need f or f urt her t est ing and possible t reat ment .
FI G URE 16. 2 Pat ient report of a single visual f ield analysis of t he right
eye. The darker t he symbol (f rom a single dot t o a black square), t he
less likely t he f ield is normal in t hat locat ion. For example, a p value
<0. 5% means t hat t he deviat ion f rom normal at t hat locat ion occurs in
f ew er t han 0. 5% of normal pat ient s. (Source: Humphrey Field Analyzer I I
User's G uide, Zeiss Humphrey Syst ems, Dublin, CA, USA)
NOTE
For t he previous sect ion, inf ormat ion w as produced by t he Eye Clinic of
Wisconsin. Laser Diagnost ic Technologies of San Diego, Calif ornia, supplied
t he t echnical inf ormat ion.
Retinal Imaging
Ret inal imaging is a new t echnology (scanning laser opht halmoscope [ SLO ] )
perf ormed by an opt omet rist and used t o evaluat e t he back of t he eye. The
ret ina, or t he inside layer at t he back of t he eye, is responsible f or t he majorit y
of vision (see Fig. 16. 3).
FI G URE 16. 3 Diagram of t he int ernal eye cut in a horizont al sect ion.
(Source: St ein HA, Slat t BJ, and St ein RM: The O pht halmic Assist ant , 5t h
edit ion. Mosby, St . Louis, 1988)
Cause of vision changes and general healt h can be diagnosed by view ing t he
ret ina. SLO t echnology uses red and green lasers t o det ect eye disease and
monit or t reat ment . G reen laser
(532 mm) scans t he sensory ret ina t hrough t he pigment epit helium layers of t he
ret ina. Red laser (633 mm) scans t he deeper st ruct ures of t he ret ina, f rom t he
pigment epit helium deep int o t he choroid. Unlike convent ional imaging, O pt omap
ret inal images are made at varying dept hs, providing addit ional diagnost ic
inf ormat ion. This provides up t o a 200-degree int ernal view of t he ret ina and is
capt ured w it hin 0. 25 seconds. Even t hough t he pat ient may not be aw are vision
is aff ect ed, signs of syst emic disease such as diabet es, hypert ension, and
ret inal disease like macular degenerat ion may be seen.
Reference Values
Normal
Ret inal scan: healt hy eye w it h no diseases not ed
Procedure
1. Be aw are t hat no dilat ion is necessary. Through digit ally imaging t he back of
t he eye, SLO t echnology uses diff erent colored lasers t o scan a pict ure of
t he ret ina ont o a comput er screen (O pt omap). This exam allow s f or a more
t horough exam of t he ret ina t han t he rout ine opht halmoscope exam.
2. Recommend t his exam f or all pat ient s during rout ine eye exams t o f ollow t he
healt h of t he eyes more accurat ely.
3. Tell pat ient t hat procedure t ime is approximat ely 25 minut es.
Abnormal result s show evidence of bleeding in eye associat ed w it h (most of t en)
diabet es, hypert ension, or macular degenerat ion.
Interventions
1. Explain t he purpose of t he eye t est and procedure.
2. Do not administ er eye drops f or t est .
3. Remember t hat if pat ient has cont act lenses, t hese may be w orn during t he
procedure.
4. Be aw are t hat generally, t here is minimal or no discomf ort during t he
procedure. How ever, some individual's eyes may be sensit ive t o t he f lashing
of light of t he lasers.

1. I nt erpret t est result s. I f bleeding or relat ed problems t hat may require
surgery are ident if ied, t he doct or may ref er pat ient t o anot her eye specialist .
2. Ref er t he pat ient t o t he appropriat e medical specialist if problems relat ed t o
medical diagnosis, such as bleeding in eye relat ed t o diabet es or
hypert ension, are ident if ied.
3. I nst ruct t he pat ient t o ret urn f or f ollow -up a year lat er f or repeat t est s t o
evaluat e disease progression.
Retinal Nerve Fiber Analysis

This procedure evaluat es glaucoma by use of microscopic laser t echnology t o
precisely measure t he t hickness of t he ret inal nerve f iber of t he eye and is
recorded in comput erized dat a f or analysis. I t is t he nerve layer t hat receives
and t ransmit s images t hat gives us vision. The inst rument is port able, and an
opht halmologist is t he clinician w ho uses t his t echnology.
Reference Values
Normal
No abnormalit ies of ret inal nerve f iber
Normal t hickness of ret inal nerve layer
Procedure
1. Remember t hat no eye drops (dilat ion) are necessary.
2. Have t he pat ient sit upright in t he examining chair.
3. Place t he pat ient 's f orehead and chin in cuplike holders and check one eye at
a t ime. Tw ent y sect ional images are obt ained in less t han 1 second and t hen
analyzed t o det ermine t hickness of nerve layer.
Abnormal appearance of t he opt ic nerve is associat ed w it h changes in t he eye

t hat occur in glaucoma. Changes may be associat ed w it h vision loss.
Interventions
1. Explain t est purpose and procedure. No pain or discomf ort is associat ed w it h
t his t est . There are no bright f lashes of light .
2. Be aw are t hat cont act lenses may be lef t in place.

1. Evaluat e out comes, counsel appropriat ely, and explain if t here is need f or
f urt her t est ing and possible t reat ment of abnormal out comes.
Fluorescein Angiography (FA)

The purpose of t his t est is t o det ect vascular disorders of t he ret ina t hat may be
t he cause of poor vision. Fluorescein, a yellow -red cont rast subst ance, is
inject ed int ravenously over a 1015 second period. Under ideal condit ions,
ret inal capillaries 510 m in diamet er can be visualized using FA. I mages of t he
eye, t aken by a special camera, are st udied t o det ect t he presence of ret inal
disorders.
Reference Values
Normal
Normal ret inal vessels, ret ina, and circulat ion
Procedure
1. G ive a series of t hree drops t o dilat e t he pupil of t he eye.
a. Complet e dilat at ion occurs w it hin 30 minut es of giving t he last drop.
b. When dilat at ion is complet e, t ake a series of color phot ographs of bot h
eyes.
2. Have t he pat ient sit w it h t he head immobilized in a special headrest in f ront

of a f undus camera.
3. I nject f luorescein dye int ravenously.
4. Take a series of phot ographs as t he dye f low s t hrough t he ret inal blood
vessels over a period of 34 minut es.
5. Take a f inal series of phot ographs 810 minut es af t er t he inject ion.
Clin ical Alert

1. Choroidal circulat ion is not seen w it h color phot ographs.
2. Some pat ient s may experience nausea f or a short period of t ime f ollow ing
t he inject ion.
3. The eye drops may st ing or cause a burning sensat ion.
Abnormal result s reveal:
1. Diabet ic ret inopat hy
2. Aneurysm
3. Macular degenerat ion
4. Diabet ic neovascularizat ion
5. Blocked blood vessels
6. Leakage of f luid f rom vessels
Interventions
1. Det ermine w het her t he pat ient has any know n allergies t o medicat ions or
cont rast agent .
2. I nst ruct pat ient about t he purpose, procedure, and side eff ect s of t he t est .

1. I nf orm t he pat ient t hat t he pat ient may experience color changes in t he skin
(yellow ish) and urine (bright yellow or green) f or 3648 hours af t er t he t est .
2. Advise t he pat ient t o w ear dark glasses and not t o drive w hile t he pupils
remain dilat ed (48 hours). During t his t ime, pat ient s are unable t o f ocus on
nearby object s and react abnormally t o changes in light int ensit y.
Electro-oculography (EOG)
This t est of ret inal f unct ion is used in t he st udy of suspect ed heredit ary and
acquired degenerat ion of t he ret ina. As a measurement of ret inal f unct ion,
elect ro-oculography (EO G ) serves primarily t o complement elect roret inography
(ERG ) by det ermining t he f unct ional st at e of ret inal pigment epit helium, as in
ret init is pigment osa. EO G det ermines t he elect rical pot ent ial of t he eye at rest in
bot h darkness and light . Normally, t he pot ent ial diff erence bet w een t he f ront and
back of t he eye should increase as light int ensit y increases.
Reference Values
Normal
>1. 85 rat io (Arden rat io: maximum height of t he ret inal pot ent ial in light divided
by t he minimum height of t he pot ent ial in t he dark)
Procedure
1. Have t he pat ient sit in t he examining chair.
2. Place skin surf ace elect rodes in t he inner and out er cant hi of t he eye. The
elect rical pot ent ials are recorded on a polygraph unit .
3. Make t w o recordings:
a. Make recordings af t er 15 minut es w it h t he pat ient in t ot al darkness w it h
measurement of eye movement t hrough a know n angle.
b. Ask t he pat ient t o again move t he eyes t hrough t he same angle, t his t ime
w it h t he int egrat ing sphere light ed.
4. Tell pat ient t hat t ot al examinat ion t ime is 4045 minut es.
Clin ical Alert

I f FA and EO G are bot h ordered, t he EO G must be done f irst because t he eye
is dilat ed f or t he FA t est but not f or t he EO G t est . How ever, w hen an ERG
and an FA are perf ormed on t he same day, t he FA should be done f irst t o
avoid corneal edema caused by t he corneal elect rode used in t he ERG
procedure. The w ait ing t ime bet w een FA and ERG should be at least 2 hours.
1. An Arden rat ion of 1. 601. 84 is probably abnormal; a rat io of 1. 201. 59 is
def init ely abnormal; w hereas a rat io < 1. 20 is f lat . The out come is usually
report ed as normal or abnormal.
2. The EO G rat io decreases in most ret inal degenerat ion, eg, ret inal
pigment osa; t his somet imes parallels t he decrease on t he ERG examinat ion.
3. I n Best 's disease (congenit al macular degenerat ion), t he EO G is abnormal;
how ever, t he ERG is normal.
4. I n ret inopat hy, due t o t oxins such as ant imalarial drugs, t he EO G may show
abnormalit ies earlier t han t he ERG .
5. Supernormal EO G s have been not ed in albinism and aniridia (loss of all or
part of iris) in w hich t he common f act or seems t o be chronic excessive light
exposure result ing in ret inal damage.
Interventions
Clin ical Alert

For t he most part , t he pat ient w ill experience lit t le t o no discomf ort .

Electroretinography (ERG)
The elect roret inography (ERG ) is used t o st udy heredit ary and acquired
disorders of t he ret ina, including part ial and t ot al color blindness (achromat opia),
night blindness, ret inal degenerat ion, and det achment of t he ret ina in cases in
w hich t he opht halmoscopic view of t he ret ina is prohibit ed by some opacit y, eg,
vit reous hemorrhage, cat aract s, or corneal opacit y. When t hese disorders
exclusively involve eit her t he rod syst em or t he cone syst em t o a signif icant
degree, t he ERG show s corresponding abnormalit ies.
I n t his t est , an elect rode is placed on t he eye t o obt ain t he elect rical response
t o light . When t he eye is st imulat ed w it h a f lash of light , t he elect rode w ill record
pot ent ial (elect ric) change t hat can be displayed and recorded on an
oscilloscope. The ERG is indicat ed w hen surgery is considered in cases of
quest ionable ret inal viabilit y.
Reference Values
Normal
Normal A and B w aves
NOTE
A w aves are produced by phot orecept or cells and B w aves by Mller cells.
Procedure
1. Have pat ient hold eyes open during t he procedure.
2. Remember t hat t he pat ient may be sit t ing up or lying dow n.
3. I nst ill t opical anest het ic eye drops.
4. Place bipolar cot t on w ick elect rodes, sat urat ed w it h normal saline, on t he
cornea.
5. Use t w o st at es of light adapt at ion t o det ect rod and cone disorders along
w it h diff erent w avelengt hs of light t o separat e rod and cone f unct ion.
Normally, t he more int ense t he light , t he great er t he elect rical response.
a. Room (ambient ) light
b. Room darkened f or 20 minut es, t hen a w hit e light is f lashed
c. Bright f lash (I n cases of t rauma, w hen t here is vit reous hemorrhage, a
much more int ense f lash of light must be used. )
6. Use chloral hydrat e or a general anest hesia f or inf ant s and small children
w ho are being t est ed f or a congenit al abnormalit y.
7. Be aw are t hat t ot al examining t ime is about 1 hour.
1. Changes in t he ERG are associat ed w it h:
a. Diminished response in ischemic vascular diseases, eg, art eriosclerosis,
giant cell art erit is
b. Siderosis (poisoning of t he ret ina w hen copper is imbedded int raocularly
[ t his is not associat ed w it h st ainless st eel f oreign bodies] )
c. Drugs t hat produce ret inal damage, eg, chloroquine, quinine
d. Ret inal det achment
e. O pacit ies of ocular media
f. Decreased response, eg, in vit amin A def iciency or
mucopolysaccharidosis
2. Diseases of t he macula do not aff ect t he st andard ERG . Macular disorder

can be det ect ed using a f ocal ERG .
Interventions
Clin ical Alert

1. For t he most part , t he pat ient w ill experience lit t le t o no discomf ort . The
elect rode may f eel like an eyelash in t he eye.
2. Caut ion t he pat ient not t o rub his or her eyes f or at least 1 hour af t er
t est ing t o prevent accident al corneal abrasion.

Eye and Orbit Sonograms

Ult rasound can be used t o describe bot h normal and abnormal t issues of t he
eyes w hen no alt ernat ive visualizat ion is possible because of opacit ies caused
by inf lammat ion, hemorrhage, or dense cat aract s. This inf ormat ion is valuable in
t he management of eyes w it h large corneal leukomas or conjunct ival f laps and in
t he evaluat ion of t he eyes f or kerat oprost hesis. O rbit al lesions can be det ect ed
and dist inguished f rom inf lammat ory and congest ive causes of exopht halmus w it h
a high degree of reliabilit y. An ext ensive preoperat ive evaluat ion bef ore
vit rect omy or surgery f or vit reous hemorrhages is also done. I n t his case, t he
vit reous cavit y is examined t o rule out ret inal and choroidal det achment s and t o
det ect and localize vit reoret inal adhesions, choroidal lesions, and int raocular
f oreign bodies. I t can also be used t o det ect opt ic nerve drusen. Persons w ho
are t o have int raocular lens implant s af t er removal of cat aract s must be
measured f or t he lengt h of t he eye (w it hin 0. 1 mm).
Reference Values
Normal
Normal image pat t ern indicat ing normal sof t t issue of eye, ret robulbar orbit al
areas, ret ina, choroid, and orbit al f at
Procedure
1. Anest het ize t he eye area by inst illing eye drops.
2. Ask t he pat ient t o f ix t he gaze and hold very st ill. (I f imaging a lesion,
movement is required f or a ret inal det achment evaluat ion. )
3. Place a small, very-high-f requency t ransducer direct ly on t he eye, or posit ion
over a w at er st andoff pad placed ont o t he eye surf ace.
4. Take mult iple images.
5. Be aw are t hat if a lesion in t he eye is det ect ed, as much as 30 minut es may
be required t o diff erent iat e t he pat hologic process accurat ely.
6. Remember t hat orbit al examinat ion can be done in 810 minut es.
1. Abnormal pat t erns are seen in:
a. Alkali burns w it h corneal f lat t ening and loss of ant erior chamber
b. Det ached ret ina
c. Kerat oprost hesis
d. Ext raocular t hickening in t hyroid eye disease
e. Pupillary membranes
f. Cyclot ic membranes
g. Vit reous opacit ies
h. O rbit al mass lesions
i. I nf lammat ory condit ions
j. Vascular malf ormat ions
k. Foreign bodies
l. Hypot omy
m. O pt ic nerve drusen
n. Congenit al cat aract

o. Post erior vit reous det achment
p. Ret inoschisis
q. Choroidal hemorrhage/ det achment
r. Trauma
2. Abnormal pat t erns are also seen in t umors of various t ypes based on
specif ic ult rasonic pat t erns:
1. Solid t umors (eg, meningioma, glioma, neurof ibroma)
2. Cyst ic t umors (eg, mucocele, dermoid, cavernous hemangioma)
3. Angiomat ous t umors (eg, diff use hemangioma)
4. Lymphangioma
5. I nf ilt rat ive t umors (eg, met ast at ic lymphoma, pseudot umor)
Clin ical Alert

1. When a rupt ured globe is suspect ed or surgery has been perf ormed,
opht halmic ult rasound can be perf ormed over a closed eyelid.
2. Caut ion must be used t o avoid excessive pressure applied t o t he globe
causing expulsion of t he cont ent s and increased risk f or int roduct ion of
bact eria.
Interfering Factors
I f at some t ime t he vit reous humor in a part icular pat ient had been replaced by
gas or silicone oil, no result may be obt ained.
Interventions
Clin ical Alert
1. For t he most part , t he pat ient w ill experience lit t le t o no discomf ort .
2. Caut ion t he pat ient not t o rub his or her eyes unt il t he eff ect s of t he
anest hesia have disappeared t o prevent accident al corneal abrasion.
3. Minor blurred vision may be experienced f or a short t ime.

BRAIN AND NERVOUS SYSTEM

Electroencephalography (EEG) and Epilepsy/Seizure
Monitoring The EEG measures and records electrical
impulses from the brain cortex. It is used to investigate
causes of seizures, to diagnose epilepsy, and to
evaluate brain tumors, brain abscesses, subdural
hematomas, cerebral infarcts, and intracranial
hemorrhages, among other conditions. It can be a tool
for diagnosing narcolepsy, Parkinson's disease,
Alzheimer's disease, and certain psychoses. It is
common practice to consider the EEG pattern, along
with other clinical procedures, drug levels, body
temperature, and thorough neurologic examinations, to
establish electrocerebral silence, otherwise known as
brain death. The American Electroneurodiagnostic
Society sets guidelines for obtaining these recordings.
When an electrocerebral silence pattern is recorded in
the absence of any hope for neurologic recovery, the
patient may be declared brain dead despite
cardiovascular and respiratory support.
Epilepsy/ seizure monit oring using simult aneous video and EEG recordings (online
comput er) is done t o verif y a diagnosis of epilepsy, w hen seizures begin, and
how t hey appear. The result s diff erent iat e and def ine seizure t ype, localize
region of seizure onset , quant if y seizure f requency, and ident if y candidat es f or
medical implant at ion of vagus nerve st imulat or or surgical t reat ment of seizures.
Hospit al admission is required.
Reference Values
Normal
1. Normal, symmet ric pat t erns of elect rical brain act ivit y
2. Range of alpha: 811 Hert z (cycles per second)
3. Seizure monit oring: expect ed out come of at least t hree t ypical recorded
seizures t hat may be diff erent f rom w hat t he pat ient usually experiences
because medicat ions have been reduced; also, onset area and t ype of
seizures
4. No cross-circulat ion of int ernal carot id art eries
5. Evidence of hemispheres t o support language and memory
Procedure
1. Be aw are t hat an EEG can be done at any t ime. Scalp hair should be
recent ly w ashed.
2. Fast en elect rodes cont aining conduct ion gel t o t he scalp w it h a special skin
glue or past e. Sevent een t o 21 elect rodes are used according t o an
int ernat ionally accept ed measurement know n as t he 1020 Syst em. This
syst em correlat es elect rode placement w it h anat omic brain st ruct ure.
3. Place t he pat ient in a recumbent posit ion, inst ruct t o keep t he eyes closed,
and encourage t o sleep during t he t est (rest ing EEG ). (Seizure act ivat ing
procedure [ see number 4, number 5 and number 6] ).
4. Bef ore beginning t he EEG , some pat ient s may be inst ruct ed t o breat he
deeply t hrough t he mout h 20 t imes per minut e f or 3 minut es. This
hypervent ilat ion may cause dizziness or numbness in t he hands or f eet but is
not hing t o be alarmed about . This act ivat ing breat hing procedure induces
alkalosis, w hich causes vasoconst rict ion, w hich in t urn may act ivat e a
seizure pat t ern.
5. Place a light f lashing at f requencies of 1 t o 30 t imes per second close t o t he
f ace. This t echnique, called photi c sti mul ati on, may cause an abnormal EEG
pat t ern not normally recorded.
6. Be aw are t hat cert ain persons may be int ent ionally sleep deprived bef ore t he
t est t o promot e sleep during t he t est . Administ er an oral medicat ion t o
promot e sleep (eg, Valium chloral hydrat e). The sleep st at e is valuable f or
revealing abnormalit ies, especially diff erent f orms of epilepsy. Make
recordings w hile t he pat ient is f alling asleep, during sleep, and w hile t he
pat ient is w aking.
7. Remove elect rodes, glue, and past e af t er t he EEG . The pat ient may t hen
w ash t he hair.
Procedure for Seizure M onitoring
1. Apply elect rodes, t ake EEG , and explain video and EEG monit oring (f or up t o
6 days). An elect rode panel is applied and must be covered w hen pat ient
eat s. Pat ient remains in bed except t o use t he bat hroom; a helmet is w orn
w hen out of bed.
2. Perf orm neuropsychologic t est ing t o evaluat e memory (remember object s),
language (circles, squares), and problem solving (46 hours of t est ing).
3. A cerebral angiogram t o assess cross-circulat ion in carot ids is f ollow ed by a
Wada t est t o det ermine t he dominant hemisphere f or language and if
opposit e hemisphere can support memory. An int ravenous line is st art ed and
a cat het er is t hreaded t hrough t he f emoral art ery t o t he int ernal carot id t o
inject sodium amobarbit al t o put t he brain t o sleep f or 5 minut es in each
half of t he brain. The Wada t est is also know n as t he int racarot id amyt al t est
or t he Brevit al (w hen sodium met hohexit al is used) t est .
4. Perf orm a f unct ional brain MRI . Procedure t ime is about 90 minut es. Pat ient
w ears earphones and is asked t o respond t o quest ions, sounds, and pict ures
by pressing a special but t on.
5. A combined PET/ CT scan is of t en done t o provide f urt her inf ormat ion about
brain hemispheres.
1. Abnormal EEG pat t ern readings reveal seizure act ivit y (eg, grand mal
epilepsy, pet it mal epilepsy) if recorded during a seizure. I f a pat ient
suspect ed of having epilepsy show s a
normal EEG , t he t est may have t o be repeat ed using sleep deprivat ion or
special elect rodes. The EEG may also be abnormal during ot her t ypes of
seizure act ivit y (eg, f ocal [ psychomot or] , inf ant ile myoclonic, or jacksonian
seizures); bet w een seizures, 20% of pat ient s w it h pet it mal epilepsy and
40% w it h grand mal epilepsy show a normal EEG pat t ern, and t he diagnosis
of epilepsy can be made only be correlat ing t he clinical hist ory w it h t he EEG
abnormalit y, if one exist s.
2. An EEG may of t en be normal in t he presence of cerebral pat hology.
How ever, most brain abscesses and glioblast omas produce EEG
abnormalit ies.
3. Elect roencephalographic changes due t o cerebrovascular accident s depend
on t he size and locat ion of t he inf arct s or hemorrhages.
4. Follow ing a head injury, a series of EEG s may be helpf ul in predict ing t he
likelihood of post t raumat ic epilepsy, especially if a previous EEG is available
f or comparison.
5. I n cases of dement ia, t he EEG may be normal or abnormal.

6. I n early st ages of met abolic disease, t he EEG is normal; in t he lat er st ages,
it is abnormal.
7. The EEG is abnormal in most diseases or injuries t hat alt er t he level of
consciousness. The more prof ound t he change in consciousness, t he more
abnormal t he EEG pat t ern.
8. Abnormal procedure result s, eg, ident if icat ion of major connect ions bet w een
t he ant erior and post erior circulat ion, or abnormal connect ion bet w een t he
int ernal carot id art eries, or isolat ion of seizure onset and number and t ypes
of seizures.
Interfering Factors
1. Sedat ive drugs, mild hypoglycemia, or st imulant s can alt er normal EEG
t racings.
2. O ily hair, hair spray, and ot her hair care product s int erf ere w it h t he
placement of EEG pat ches and t he procurement of accurat e EEG t racings.
3. Art if act s can appear in t echnically w ell-perf ormed EEG s. Eye and body
movement s cause changes in brain w ave pat t erns and must be not ed so t hat
t hey are not int erpret ed as abnormal brain w aves.
Interventions
1. Explain t est purpose and procedure t o allay pat ient f ears and concerns.
Emphasize t hat t he EEG is not painf ul, t hat it is not a t est of t hinking or
int elligence, t hat no elect rical impulses pass t hrough t he body, and t hat it is
not a f orm of shock t herapy. The t ransmit t ed impulses are magnif ied at least
1 million t imes and t ranscribed t o permanent hard copy f or f urt her st udy.
2. Explain seizure monit oring procedures, purposes, and risks. Risks of
angiogram and Wada t est include allergy t o sodium amobarbit al, crosscirculat ion leading t o respirat ory arrest , and st roke relat ed t o allergy t o
cont rast agent used in angiogram.
3. Allow f ood if t he pat ient is t o be sleep deprived. How ever, no coff ee, t ea, or
cola is permit t ed w it hin 12 hours of t he t est . Emphasize t hat f ood should be
eat en t o prevent hypoglycemia.
4. Allow, but do not encourage, smoking bef ore t he t est .
5. Have pat ient w ash and t horoughly rinse hair w it h clear w at er t he evening
bef ore t he EEG so t hat t he EEG pat ches remain f irmly in place during t he
t est . Tell pat ient t o not apply condit ioners or oils af t er shampooing.
6. Be aw are t hat if a sleep st udy is ordered, t he adult pat ient should sleep as
lit t le as possible t he night bef ore (ie, st ay up past midnight ) so t hat sleep
can occur during t he t est .
7. Call t he EEG depart ment f or special inst ruct ions if a sleep-deprivat ion st udy
is ordered f or a child.
8. Medicat ions are generally reduced bef ore t he Wada t est . A liquid breakf ast
is permit t ed.
9. EEG and video monit oring of seizures occur f or up t o 6 days, w it h
medicat ions gradually reduced by 1/ 3 f or 3 days.
care.

1. Wash t he hair af t er t he t est . Applicat ion of oil t o t he adhesive bef ore
shampooing can ease it s removal.
2. Allow t he pat ient t o rest af t er t he t est if a sedat ive w as given during t he
t est . Put bedside rails in t he raised posit ion f or saf et y. Resume medicat ions
(if reduced preprocedure).
3. Be aw are t hat skin irrit at ion f rom t he elect rodes usually disappears w it hin a
f ew hours.
4. I nt erpret t est result s and monit or appropriat ely. I f a repeat t est ing is
necessary, provide explanat ions and support t o t he pat ient . Explain possible
t reat ment of uncont rolled seizures, eg, new er ant iseizure medicat ions,
surgical implant at ion of vagus nerve st imulat or. Explain role of f emale
hormones in epilepsy: seizures w orsened by hormones, adult epilepsy
involves areas of t he brain sensit ive t o reproduct ive hormone, and at
menopause, seizures t end t o increase, w orsen, or lessen.
Evoked Responses/Potentials: Brain Stem Auditory

Evoked Response (BAER); Visual Evoked Response
(VER); Somatosensory Evoked Response (SSER)
These t est s use convent ional EEG recording t echniques w it h specif ic elect rode
sit e placement f or each procedure and include comput er dat a processing t o

evaluat e elect rophysiologic int egrit y of t he audit ory, visual, and sensory
pat hw ays. These are brain responses t ime-locked t o some event . See Chart
16. 1 f or w ave and st andard deviat ion (SD) measurement s.
Ch art 16.1 Wave and Standard Deviation Measurements for

Evoked Response Potential
Normal Poten tials, Brain -Stem Au ditory Evoked Respon se
(BAER), an d Visu al Evoked Respon se (VER) Absolu te laten cy,
measu red in millisecon ds (msec), of th e first five w aveforms at
a sou n d stimu lation rate of 11 clicks/secon d
Wave
Mean Standard Devi ati on (SD)
1. 7 0. 15
II
2. 8 0. 17
III
3. 9 0. 19
IV
5. 1 0. 24
5. 7 0. 25
Normal Visu al Evoked Respon se (VER)

Absolut e lat ency, measured in milliseconds of t he f irst major posit ive peak
(P 100 )
Wave
Mean SD
Range
P100
102.3 5.1
89114
Normal Somatosen sory Evoked Respon se (SSER) Absolu te

laten cy of major w aveforms, measu red in millisecon ds at a
stimu lation rate of 5 impu lses/secon d
Wave
EP
Mean SD
9.7 0.7
11.8 0.7
13.7 0.8
II
11.3 0.8
III
13.9 0.9
N2
19.1 0.8
P2
22.0 1.2
Brain Stem Auditory Evoked Response. This st udy allow s evaluat ion of
suspect ed peripheral hearing loss, cerebellopont ine angle lesions, brain st em
t umors, inf arct s, mult iple sclerosis, and comat ose st at es. Special st imulat ing
t echniques permit recording of signals generat ed by subcort ical st ruct ures in t he
audit ory pat hw ay. St imulat ion of eit her ear evokes pot ent ials t hat can reveal
lesions in t he brain st em involving t he audit ory pat hw ay w it hout aff ect ing hearing.
Evoked pot ent ials of t his t ype are also used t o evaluat e hearing in new borns,
inf ant s, children, and adult s t hrough elect rical response audiomet ry.
Visual Evoked Response. This t est of visual pat hw ay f unct ion is valuable f or
diagnosing lesions involving t he opt ic nerves and opt ic t ract s, mult iple sclerosis,
and ot her disorders. Visual st imulat ion excit es ret inal pat hw ays and init iat es
impulses t hat are conduct ed t hrough t he cent ral visual pat h t o t he primary visual
cort ex. Fibers f rom t his area project t o t he secondary visual cort ical areas on
t he brain's occipit al convexit y. Through t his pat h, a visual st imulus t o t he eyes
causes an elect rical response in t he occipit al regions, w hich can be recorded
w it h elect rodes placed along t he vert ex and t he occipit al lobes. I t is also used t o
assess development of blue-yellow pat hw ay in inf ant s.
Somatosensory Evoked Response. This t est assesses spinal cord lesions,
st roke, and numbness and w eakness of t he ext remit ies. I t st udies impulse
conduct ion t hrough t he somat osensory pat hw ay. Elect rical st imuli are applied t o
t he median nerve in t he w rist or peroneal nerve near t he knee at a level near
t hat w hich produces t humb or f oot t w it ches. The milliseconds it t akes
f or t he current t o t ravel along t he nerve t o t he cort ex of t he brain is t hen
measured. Somat osensory evoked responses can also be used t o monit or
sensory pat hw ay conduct ion during surgery f or scoliosis or spinal cord
decompression and/ or ischemia. Loss of t he sensory pot ent ial can signal
impending cord damage.
Procedures
1. O bt ain brain st em audit ory evoked responses t hrough elect rodes placed on
t he vert ex of t he scalp and on each earlobe. St imuli in t he f orm of clicking
noises or t one burst s are delivered t o one ear t hrough earphones. Because
sound w aves delivered t o one ear can be heard by t he opposit e ear, a
cont inuous masking noise is simult aneously delivered t o t he opposit e ear.
2. Place elect rodes used in visually evoked response on t he scalp along t he
vert ex and occipit al lobes. Ask t he pat ient t o w at ch a checkerboard pat t ern
f lash f or several minut es, f irst w it h one eye, t hen w it h t he ot her, w hile brain
w aves are recorded.
3. Record somat osensory evoked responses t hrough several pairs of
elect rodes. Apply elect rical st imuli t o t he median nerve at t he w rist or t o t he
peroneal nerve at t he knee. Scalp elect rodes placed over t he sensory cort ex
of t he opposit e hemisphere of t he brain pick up t he
signals and measure, in milliseconds, t he t ime it t akes f or t he current t o
t ravel along t he nerve t o t he cort ex of t he brain.
1. Abnormal BAERs are associat ed w it h t he f ollow ing condit ions:
a. Acoust ic neuroma
b. Cerebrovascular accident s
c. Mult iple sclerosis
d. Lesions aff ect ing any part of t he audit ory nerve or brain st em area
2. Abnormal VERs are associat ed w it h t he f ollow ing condit ions:
a. Demyelinat ing disorders such as mult iple sclerosis

b. Lesions of t he opt ic nerves and eye (prechiasma def ect s)
c. Lesions of t he opt ic t ract and visual cort ex (post chiasma def ect s)
d. Abnormal visual evoked pot ent ials may also be f ound in persons w it hout
a hist ory of ret robulbar neurit is, opt ic at rophy, or visual f ield def ect s.
How ever, many pat ient s w it h proven damage t o t he post chiasma visual
pat h and know n visual f ield def ect s may have normal visual evoked
pot ent ials.
3. Abnormal SSERs are associat ed w it h t he f ollow ing condit ions:
a. Spinal cord lesions
b. Cerebrovascular accident s
c. Mult iple sclerosis
d. Cervical myelopat hy accident
Interfering Factors
1. Some diff icult y in int erpret ing brain st em evoked pot ent ials may arise in
persons w it h peripheral hearing def ect s t hat alt er evoked pot ent ial result s
(ie, subt hreshhold st imulat ion of peripheral nerves and inadequat e skin
preparat ion).
2. Maximum depolarizat ion st imulat ion is divided int o t w o prot ocols:
a. Brachial plexus (BP) prot ocol involves st imulat ion t he median, ulnar, and
superf icial sensory radial nerves just proximal t o t he w rist .
b. Lumbosacral (LS) prot ocol involves st imulat ing t he post erior t ibial and
common peroneal nerves, w hich are t he primary divisions of t he
lumbosacral plexus f orming t he sciat ic nerve.
Interventions
2. Have pat ient w ash and rinse hair bef ore t est ing. I nst ruct pat ient not t o apply
any ot her hair preparat ions.

1. Allow pat ient t o w ash hair (assist if necessary). Remove gel f rom ot her skin
areas.
2. I nt erpret t est result s and monit or appropriat ely f or neurologic problems.
Cognitive Tests: Event-Related Potentials (ERPs)

Event-related potentials are used as objective
measures of mental function in neurologic diseases
that produce cognitive defects. These measurements
use the method of auditory evoked response
testing in which sound stimuli are transmitted through
earphones. A rare tone is associated with a prominent
endogenous P3 component that reflects the differential
cognitive processing of that tone. Although a
systematic neurologic increase in P3 component
latency occurs as a function of increasing age in
normal persons, in many instances of neurologic
diseases associated with dementia, the latency of the
P 3 component has been reported to exceed
substantially the normal age-matched value.
This t est is usef ul in evaluat ing persons w it h dement ia or decreased ment al
f unct ioning. I t is also helpf ul in diff erent iat ing persons w it h real organic brain
def ect s aff ect ing cognit ive f unct ion f rom t hose w ho are unable t o int eract w it h
t he examiner because of mot or or language def ect s or t hose unw illing t o
cooperat e because of problems such as depression or schizophrenia.
Reference Values
Normal
No shif t of P3 component s t o longer lat encies ERP: absolut e lat ency of P3
w avef orm P3 w ave mean and SD 294 21 milliseconds
Procedure
1. Remember t hat t his procedure is t he same as t hat f or audit ory brain st em
response.
2. Ask pat ient s t o count t he occurrences of audible rare t ones t hey hear
t hrough t he earphones.
An increased or abnormal P3 lat ency is associat ed w it h neurologic diseases
producing dement ia such as t he f ollow ing:
1. Alzheimer's disease
2. Met abolic encephalopat hy such as t hat associat ed w it h hypot hyroidism or
alcoholism w it h severe elect rolyt e dist urbances
3. Brain t umor
4. Hydrocephalus
Interfering Factors
Lat ency of P3 component normally increases w it h age.
Interventions
1. Explain t he purpose and procedure of t he t est
care.

1. I nt erpret t est result s and monit or appropriat ely f or neurologic disease.
Brain Mapping: Computed Tomography
Brain mapping uses t ransit ional EEG dat a and specialized comput er digit izat ion
t o display t he diagnost ic inf ormat ion as a t opographic map of t he brain and
spinal cord. The comput er analyzes EEG signals f or amplit ude and dist ribut ion of
alpha, bet a, t het a, and delt a f requencies and displays t he analysis as a color
map. Specif ic and/ or minut e abnormalit ies are enhanced and
allow comparison w it h normal dat a. This met hodology is used f or assessing
cognit ive f unct ion and f or evaluat ing pat ient s w it h migraine headaches, t rauma,
or episodes of vert igo or dizziness. Persons w ho lose periods of t ime and select
pat ient s w it h generalized seizures, dement ia of organic origin, ischemic
abnormalit ies, or cert ain psychiat ric disorders are also candidat es f or t his
t est ing. Wit h t his procedure, it is possible t o localize a specif ic area of t he brain
t hat may ot herw ise show up as a generalized area of def icit in t he convent ional
EEG . Children or adult s w ho demonst rat e hyperact ivit y, dyslexia, dement ia, or
Alzheimer's disease may benef it f rom evaluat ion t hrough brain mapping.
Reference Values
Normal
Normal f requency signals and evoked responses present ed as a color-coded
map of elect rical brain act ivit y
Procedure
1. Ensure t hat t he pat ient is rest ed and aw ake f or t he t est so t hat no sleep
signals appear as indicat ors of bet a w ave act ivit y.
2. Af t er t he skin of t he scalp is cleansed w it h an abrasive solut ion, place 42
elect rodes at designat ed areas on t he scalp and hold in place w it h adhesive
or past e f ormulat ed f or t his purpose.
3. Place t he pat ient in a recumbent posit ion and inst ruct t o keep t he eyes
closed and t o ref rain f rom any movement .
Abnormal brain maps can pinpoint t he f ollow ing condit ions:
1. Areas of f ocal seizure discharge in persons w ho experience generalized
seizures
2. Areas of f ocal irrit at ion in persons w it h migraine
3. Areas of ischemia
4. Areas of dysf unct ion in st at es of dement ia

5. Areas of possible brain abnormalit ies associat ed w it h schizophrenia or ot her
psychot ic st at es
Interfering Factors
1. Tranquilizers may alt er result s.
2. Unw ashed hair or t he use of hair preparat ions can int erf ere w it h elect rode
placement .
3. Eye and body movement s cause changes in signals and w ave pat t erns.
Interventions
1. Explain t he t est purpose and procedure. There are no know n risks.
Emphasize t he f act t hat elect rical impulses pass f rom t he pat ient t o t he
machine and not t he opposit e.
2. Tell pat ient t hat f ood and f luids can be t aken bef ore t est ing. How ever, no
coff ee, t ea, or caff einat ed drinks should be ingest ed f or at least 8 hours
bef ore t est .
3. Ensure t hat hair has been recent ly w ashed.
4. Ensure t hat t ranquilizers are not t aken bef ore t est ing (check w it h physician).
O t her prescribed medicat ions such as ant ihypert ensives and insulin may be
t aken. I f in doubt , cont act t he t est ing laborat ory f or guidelines.

1. Remove t he conduct ion gel and encourage t he pat ient t o w ash his or her
hair. Provide supplies if possible.
2. I nt erpret t est result s and monit or appropriat ely f or seizure act ivit y and ot her
neurologic manif est at ions.
Electromyography (EMG); Electroneurography;

Electromyoneurogram (EMNG) Electromyoneurography
combines electromyography and electroneurography.
These studies, done to detect neuromuscular
abnormalities, measure nerve conduction and
electrical properties of skeletal muscles. Together with
evaluation of range of motion, motor power, sensory
defects, and reflexes, these tests can differentiate
between neuropathy and myopathy. The
electromyogram can define the site and cause of
muscle disorders such as myasthenia gravis, muscular
dystrophy, and myotonia; inflammatory muscle
disorders such as polymyositis; and lesions that
involve the motor neurons in the anterior horn of the
spinal cord. EMG can also localize the site of
peripheral nerve disorders such as radiculopathy and
axonopathy. Skin and needle electrodes measure and
record electrical activity. Electrical sound equivalents
are amplified and recorded on tape for later studies.
Reference Values
Normal
Normal EMG and EMNG
Procedure
1. Be aw are t hat t he t est is done in a copper-lined room t o screen out out side
int erf erence.
2. Remember t hat t he pat ient may lie dow n or sit during t he t est .
3. Apply a surf ace disk or lead st rap t o t he skin around t he w rist or ankle t o
ground t he pat ient . Choose t he muscles and nerves examined according t o
t he pat ient 's signs and sympt oms, hist ory, and physical condit ion (select
nerves innervat e specif ic muscles).
4. Encourage t he pat ient t o relax (massage cert ain muscles t o get t he pat ient
t o relax) or t o cont ract cert ain muscles (eg, t o point t o t oes) at specif ic
t imes during t he t est .
5. Remember t hat t est ing is divided int o t w o part s. The f irst t est det ermines
nerve conduct ion.
a. Coat met al surf ace elect rodes w it h elect rode past e and f irmly place over
a specif ic nerve area. Pass elect rical current (maximum, 100 mAmp f or 1
msec) t hrough t he area t o cause sensat ions, similar t o shock f rom
carpet ing or st at ic elect ricit y or t he equivalent of an AA bat t ery, t hat are
direct ly proport ional t o t he t ime t he current is applied. Pat ient s w it h mild
f orms of neuromuscular disorders may f eel mild discomf ort , w hereas
t hose w it h polyneuropat hies may experience moderat e discomf ort .
b. Read t he amplit ude w ave on an oscilloscope and record on magnet ic
t ape f or lat er st udies.
c. Be aw are t hat elect rical current leaves no mark but can cause unusual
sensat ions t hat are not usually considered unpleasant . How f ast and how
w ell a nerve t ransmit s messages can be measured. Nerves in t he f ace,
arms, or legs are appropriat e f or t est ing in t his w ay.
6. Remember t hat t he second t est det ermines muscle pot ent ial.
a. I nsert a monopolar elect rode (a 1. 25- t o 7. 5-cm long small-gauge
needle), and increment ally advance int o t he muscle. Manipulat e t he
needle w it hout act ually removing it t o see if readings change, or place
t he needle in anot her muscle area.
b. The elect rode usually causes no pain unless t he t ip is near a t erminal
nerve. Ten or more needle insert ions may be necessary. The needle
elect rode det ect s elect ricit y normally present in muscle.
c. O bserve t he oscilloscope f or normal w ave f orms and list en f or normal
quiet sounds at rest . A machine-gun popping sound or a rat t ling sound
like hail on a t in roof is normally heard w hen t he pat ient cont ract s t he
muscle.
d. I f t he pat ient complains of pain, remove t he needle because t he pain
st imulus yields f alse result s.
e. Tot al examining t ime is 45 t o 60 minut es if t est ing is conf ined t o a single
ext remit y; t est ing may t ake up t o 3 hours f or more t han one ext remit y.
There is no complet ely rout ine EMG . The lengt h of t he t est depends on
t he clinical problem.
care.
1. Abnormal neuromuscular act ivit y occurs in diseases or dist urbances of
st riat ed muscle f ibers or membranes in t he f ollow ing condit ions:
a. Muscle f iber disorders (eg, muscular dyst rophy)
b. Cell membrane hyperirrit abilit y; myot onia and myot ic disorders (eg,
polymyosit is, hypocalcemia, t hyrot oxicosis, t et anus, rabies)
c. Myast henia (muscle w eakness st at es) caused by t he f ollow ing
condit ions:
1. Myast henia gravis
2. Cancer due t o nonpit uit ary adrenocort icot ropic hormone (ACTH)
secret ion by t he t umor
a. Bronchial cancer
b. Sarcoid
3. Def iciencies
a. Familial hypokalemia
b. McArdle's phosphorylase
4. Hyperadrenocort icism
5. Acet ylcholine blocking agent s
a. Curare
b. Bot ulin
c. Kanamycin
d. Snake venom
2. Disorders or diseases of low er mot or neurons
a. Lesions involving mot or neuron on ant erior horn of spinal cord
(myelopat hy)
1. Tumor
2. Trauma
3. Syringomyelia
4. Juvenile muscular dyst rophy
5. Congenit al amyot onia
6. Ant erior poliomyelit is
7. Amyot rophic lat eral sclerosis
8. Peroneal muscular at rophy

b. Lesions involving t he nerve root (radiculopat hy)
1. G uillain-Barr syndrome
2. Ent rapment of t he nerve root
a. Tumor
b. Trauma
c. Herniat ed disk
d. Hypert rophic spurs
e. Spinal st enosis
c. Damage or disease t o peripheral or axial nerves
1. Ent rapment of t he nerve
a. Carpal or t arsal t unnel syndrome
b. Facial, ulnar, radial, or peroneal palsy
c. Neuralgia parest het ica
2. Endocrine
a. Hypot hyroidism
b. Diabet es
3. Toxic
a. Heavy met als
b. Solvent s
c. Ant iamebicides
d. Chemot herapy
e. Ant ibiot ics
d. Early peripheral nerve degenerat ion and regenerat ion.
Interfering Factors
1. Conduct ion can vary w it h age and normally decreases w it h increasing age.
2. Pain can yield f alse result s.
3. Elect rical act ivit y f rom ext raneous persons and object s can produce f alse
result s as a result of movement .
4. The t est is ineff ect ive in t he presence of edema, hemorrhage, or t hick
subcut aneous f at .
Interventions
1. Explain t he t est purpose and procedure. There is a risk f or hemat oma if t he
pat ient is on ant icoagulant t herapy.
2. Be aw are t hat sedat ion or analgesia may be ordered.

1. I f t he pat ient experiences pain, provide pain relief t hrough appropriat e
int ervent ions. O bt ain an order f or an analgesic if necessary.
2. Promot e rest and relaxat ion.
3. I nt erpret t est result s and monit or appropriat ely f or nerve and muscle
disease. Provide assist ance as necessary.
Clin ical Alert

1. When ordering t he t est , t he more inf ormat ion t hat is know n, t he more
precise t he int erpret at ion of f indings w ill be.
2. Enzyme levels t hat ref lect muscle act ivit y (eg, aspart at e
aminot ransf erase, lact at e dehydrogenase, creat ine phosphokinase) must
be det ermined bef ore act ual t est ing because t he EMG causes elevat ion of
t hese enzymes f or up t o 10 days post procedure.
3. Alt hough rare, hemat omas may f orm at needle insert ion sit es. Take
measures, such as applicat ion of pressure t o t he sit e, t o cont rol bleeding.
Not if y t he physician. Ascert ain w het her t he pat ient is t aking ant icoagulant s
or aspirin-like drugs.
Electronystagmogram (ENG)
This st udy aids in t he diff erent ial diagnosis of lesions in t he brain st em and
cerebellum. I t can conf irm t he causes of unilat eral hearing loss of unknow n
origin, vert igo, or ringing in t he ears. Evaluat ion of t he vest ibular syst em and t he
muscles cont rolling eye movement is based on measurement s of t he nyst agmus
cycle. I n healt h, t he vest ibular syst em maint ains visual f ixat ion during head
movement s by means of nyst agmus, t he involunt ary back-and-f ort h eye
movement caused by init iat ion of t he vest ibular-ocular ref lex.
Reference Values
Normal
Vest ibular-ocular ref lex: normal nyst agmus accompanying head t urning is
expect ed.
Procedure
1. Be aw are t hat t he t est is usually done in a darkened room w it h t he pat ient
sit t ing or lying.
2. Remove any earw ax bef ore t est ing.
3. Tape f ive elect rodes at designat ed posit ions around t he eye.
4. During t he st udy, ask t he pat ient t o look at diff erent object s, t o open and
close his or her eyes, t o change head posit ion.
5. Tow ard t he end of t he t est , gent ly blow air int o each ext ernal ear canal, f irst
on t he aff ect ed side. I nst ill cold w at er, t hen w arm w at er, int o t he ears during
t he t est t o record eye movement in response t o various st imuli.
Prolonged nyst agmus and post ural inst abilit y f ollow ing a head t urn is abnormal
and can be caused by lesions of t he vest ibular or ocular syst em, as in t he
1. Cerebellum disease
2. Brain st em lesion
3. Peripheral lesion occurring in elderly person; head t rauma; middle ear
disorders
4. Congenit al disorders
5. Mnire's disease
Interfering Factors
1. Test result s are alt ered by t he inabilit y of t he pat ient t o cooperat e, poor
eyesight , blinking of t he eyes, or poorly applied elect rodes.
2. The pat ient 's anxiet y or medicat ions such as cent ral nervous syst em
depressant s, st imulant s, or ant ivert igo agent s can cause f alse-posit ive t est
result s.
Interventions
1. Explain t he t est purpose and procedure. No pain or know n risks are
associat ed w it h t he t est . The procedures t o st imulat e involunt ary rapid eye
movement are uncomf ort able.
2. Have t he pat ient remove makeup.
3. Have t he pat ient abst ain f rom all caff einat ed and alcoholic beverages f or at
least 48 hours. Heavy meals should be avoided bef ore t est ing.
4. Be aw are t hat in most cases, medicat ions such as t ranquilizers, st imulant s,
or ant ivert igo agent s should be w it hheld f or 5 days bef ore t he t est . I f in
doubt , consult t he clinician w ho ordered t he t est .
Clin ical Alert

1. The t est is cont raindicat ed in persons w ho have pacemakers.
2. Wat er irrigat ion of t he ear canal should not be done w hen t here is a
perf orat ed eardrum. I nst ead, a f inger cot may be insert ed int o t he ear
canal t o prot ect t he middle ear.

1. Allow t he pat ient t o rest as necessary.
2. Be aw are t hat if present , nausea, vert igo, and w eakness may require
t reat ment and medicat ion. Check w it h t he clinician w ho ordered t he t est .
3. I nt erpret t est result s and monit or appropriat ely f or brain disease, w hich may
manif est as loss of balance, or middle ear disease, w hich may cause
spasmodic eye movement , vert igo, or hearing loss.
HEART
Electrocardiography (ECG or EKG), With Brief
Description of Vectorcardiogram An ECG records the
electrical impulses that stimulate the heart to contract.
It also records dysfunctions that influence the
conduction ability of the myocardium. The ECG is
helpful in diagnosing and monitoring the origins of
pathologic rhythms; myocardial ischemia; myocardial
infarction; atrial and ventricular hypertrophy; atrial,
atrioventricular, and ventricular conduction delays; and
pericarditis. It can be helpful in diagnosing systemic
diseases that affect the heart; determining cardiac drug
effects (especially digitalis and antiarrhythmic agents);
evaluating disturbances in electrolyte balance
(especially potassium and calcium); and analyzing
cardiac pacemaker or implanted defibrillator functions.
An ECG provides a cont inuous pict ure of elect rical act ivit y during a complet e
cycle. Heart cells are charged or polarized in t he rest ing st at e, but t hey
depolarize and cont ract w hen elect rically st imulat ed. The int racellular body f luids
are excellent conduct ors of elect rical current and are an import ant component of
t his process. When t he depolarizat ion (st imulat ion) process sw eeps in a w ave
across t he cells of t he myocardium, t he elect rical current generat ed is conduct ed
t o t he body's surf ace, w here it is det ect ed by special elect rodes placed on t he
pat ient 's limbs and chest . An ECG t racing show s t he volt age of t he w aves and
t he t ime durat ion of w aves and int ervals. By st udying t he amplit ude of t he w aves
and measuring t he durat ion of t he w aves and int ervals, disorders of impulse
f ormat ion and conduct ion can be diagnosed.
Reference Values
Normal
Normal posit ive and negat ive def lect ions in an ECG recording Normal cardiac
cycle component s (one normal cardiac cycle is represent ed by t he P w ave, Q RS
complex, and T w ave; addit ionally, a U w ave may be observed). This cycle is
repeat ed cont inuously and rhyt hmically.
The P w ave indicat es at rial depolarizat ion; Q RS complex indicat es vent ricular
depolarizat ion; T w ave indicat es vent ricular repolarizat ion/ rest ing st age bet w een
beat s; and U w ave indicat es nonspecif ic recovery af t er pot ent ials.
FI G URE 16. 4 Commonly measured complex component s. (Source: Smelt zer

SC, Bare BG : Brunner and Suddart h's Text book of Medical-Surgical Nursing,
8t h ed. Philadelphia: Lippincot t -Raven Publishers, 1996)
Normal Waves
Capit al let t ers ref er t o relat ively large w aves (>5 mm), and small let t ers ref er t o
relat ively small w aves (<5 mm).
1. The P w ave is normally upright ; it represent s at rial depolarizat ion and
indicat es elect rical act ivit y associat ed w it h t he original impulse t hat t ravels
f rom t he sinus node t hrough t he at rial sinus. I f P w aves are present ; are of
normal size, shape, and def lect ion; have normal conduct ion int ervals t o t he
vent ricles; and demonst rat e rhyt hmic t iming variances bet w een cardiac
cycles, it can be assumed t hat t hey began in t he sinoat rial node.
2. The Ta or Tp designat ion is used t o diff erent iat e at rial repolarizat ion, w hich
ordinarily is obscured by t he Q RS complex, f rom t he more convent ional T
w ave, w hich signif ies vent ricular repolarizat ion (see number 8).
3. The Q (q) w ave is t he f irst dow nw ard/ negat ive def lect ion in t he Q RS complex;
it result s f rom vent ricular depolarizat ion. The Q (q) w ave may not alw ays be
apparent .
4. The R(r) w ave is t he f irst upright / posit ive def lect ion af t er t he P w ave (or in
t he Q RS complex); it result s f rom vent ricular depolarizat ion.
5. The S(s) w ave is t he dow nw ard/ negat ive def lect ion t hat f ollow s t he R w ave.
6. The Q and S w aves are negat ive def lect ions t hat do not normally rise above
t he baseline.
7. The T w ave is a def lect ion produced by vent ricular repolarizat ion. There is a
pause af t er t he Q RS complex, and t hen a T w ave appears. The T w ave is a
period of no cardiac act ivit y bef ore t he vent ricles are again st imulat ed. I t
represent s t he recovery phase af t er t he vent ricular cont ract ion.
8. The U w ave is a def lect ion (usually posit ive) f ollow ing t he T w ave. I t
represent s lat e vent ricular repolarizat ion of Purkinje's f ibers or t he
int ravent ricular papillary muscles. This
w ave may or may not be present on an ECG . I f it appears, it may be
abnormal, depending on it s conf igurat ion.
Normal In tervals
1. The R-R int erval (normally, 0. 83 second at a heart rat e of 72 beat s/ minut e)
is t he dist ance bet w een successive R w aves. I n normal rhyt hms, t he int erval,
in seconds or f ract ions of seconds, bet w een t w o successive R w aves divided
int o 60 seconds provides t he heart rat e per minut e.
2. The P-P int erval (normally, 0. 83 second at a heart rat e of 72 beat s/ minut e)
w ill be t he same as t he R-R int erval in normal sinus rhyt hm. The
responsiveness of t he sinus node t o physiologic act ivit y (eg, exercise, rest ,
respirat ory cycling) produces a rhyt hmic variance in P-P int ervals.
3. The PR int erval (~0. 16 second) measures conduct ion t one and includes t he
t ime it t akes f or at rial depolarizat ion and normal conduct ion delay in t he
at riovent ricular node t o occur. I t t erminat es w it h t he onset of vent ricular
depolarizat ion. I t is t he period f rom t he st art of t he P w ave t o t he beginning
of t he Q RS complex. This int erval represent s t he t ime it t akes f or t he
impulse t o t raverse t he at ria, proceed t hrough t he at riovent ricular node, and
reach t he vent ricles and init iat e vent ricular depolarizat ion.
4. The Q RS int erval (normally, 0. 12 second) represent s vent ricular
depolarizat ion t ime and t racks t he elect rical impulse as it t ravels f rom t he
at riovent ricular node t hrough t he bundle branches t o Purkinje's f ibers and
int o t he myocardial cells. Normal w aves consist of an init ial dow nw ard
def lect ion (Q w ave), a large upw ard def lect ion (R w ave), and a second
dow nw ard def lect ion (S w ave). I t is measured f rom t he onset of t he Q w ave
(or R if no Q is visible) t o t he t erminat ion of t he S w ave.
5. Q T int erval measures t he durat ion of vent ricular act ivat ion and recovery. I t is
measured f rom t he beginning of t he Q RS complex t o t he end of t he T w ave.
The Q T int erval varies w it h t he heart rat e, gender, and t ime of day. Normal
Q T int erval is 350430 milliseconds.
Normal Segmen ts an d Ju n ction s

1. The PR segment is normally isoelect ric and is t he port ion of t he ECG t racing
f rom t he end of t he P w ave t o t he onset of t he Q RS complex.
2. The J junct ion (or J point ) is t he point at w hich t he Q RS complex ends and
t he ST segment begins.
3. The ST segment is t hat part of t he ECG f rom t he J point t o t he onset of t he
T w ave. Elevat ion or depression is det ermined by comparing it s locat ion w it h
t he port ion of t he baseline bet w een t he end of t he T w ave and t he beginning
of t he P w ave or relat ing it t o t he PR segment . This segment represent s t he
period bet w een t he complet ion of depolarizat ion and onset of repolarizat ion
(ie, recovery) of t he vent ricular muscles.
4. The TP segment (~0. 25 second) is t he port ion of t he ECG record bet w een
t he end of t he T w ave and t he beginning of t he next P w ave. I t is usually
isoelect ric.
Normal Voltage Measu remen ts

1. Volt age f rom t he t op of t he R w ave t o t he bot t om of t he S w ave is 1 mV.
Volt age of t he P w ave is ~0. 1 t o 0. 3 mV. Volt age of t he T w ave is ~0. 2 t o
0. 3 mV. Upright def lect ion volt age is measured f rom t he upper part of t he
baseline t o t he peak of t he w ave.
2. Negat ive def lect ion volt age is measured f rom t he low er port ion of t he
baseline t o t he nadir of t he w ave.
Recordin g th e Electrical Impu lses

1. Because cardiac elect rical f orces ext end in several direct ions at t he same
t ime, a comprehensive view of heart act ivit y is possible only if t he f low of
current in several diff erent planes is recorded.
2. For a 12-lead ECG , 12 leads are simult aneously used t o present t his
comprehensive pict ure:
a. Limb leads (I , I I , I I I , AVL, AVF, AVR) record event s in t he f ront al plane of
t he heart .
b. Chest leads (V1 , V2 , V3 , V4 , V5 , and V6 ) record a horizont al view of t he
heart 's elect rical act ivit y.

3. O ccasionally, an esophageal lead, w hich is sw allow ed or placed in t he
esophagus, can supply addit ional inf ormat ion. This t ype of lead is f requent ly
used during surgical procedures.
FI G URE 16. 5 His bundle elect rogram. Not e elect rophysiologic event s are
present ed in relat ion t o t he surf ace elect rocardiogram. (Source: Phillips RE,
Feeney MK: The Cardiac Rhyt hms, 3rd ed. Philadelphia, WB Saunders,
1990)
ECG Versu s Vectorcardiogram

The vect orcardiogram, like t he ECG , records t he elect rical f orces of t he heart .
The major diff erence bet w een t hese t w o met hods is t he w ay in w hich t hese
f orces are displayed. A vect orcardiogram records a t hree-dimensional display of
t he heart 's elect rical act ivit y, w hereas t he ECG is a single-plane represent at ion.
The f ollow ing are t he t hree planes of t he vect orcardiogram:
1. Front al plane (combines t he Y and X axes)
2. Sagit t al plane (combines t he Y and Z axes)
3. Horizont al plane (combines t he X and Z axes)
Procedure
The f ollow ing st eps apply t o bot h t he ECG and t he vect orcardiogram:
1. Have t he pat ient assume a supine posit ion; how ever, recordings can be t aken
during exercise.
2. Prepare t he skin sit es and, if necessary, shave, and place elect rodes on t he
f our ext remit ies and on specif ic chest sit es. Ensure t hat t he right leg is t he
ground.
3. Remember t hat all 12 leads can be recorded simult aneously by new er ECG
machines.
4. Remember t hat a rhyt hm st rip is a 2-minut e recording f rom a single lead,
usually lead I I . I t is f requent ly used t o evaluat e dysrhyt hmias.
Comparison of the ECG and Vectorcardiogram

ECG
Vectorcardiogram
Records electrical
forces as positive or
negative deflections on
a scale
Depicts electrical forces as

vector* loops, which show
the direction of electrical
flow
Records activity in the

frontal and horizontal
planes
Records activity in the

frontal, horizontal, and
sagittal planes
* The term vector indicates the directional flow of

electrical activity.
1.
ECG
a. The ECG does not depict t he act ual mechanical st at e of t he heart or
f unct ional st at us of t he valves.
b. An ECG may be normal in t he presence of heart disease unless t he
pat hologic process dist urbs t he elect rical f orces. I t cannot predict f ut ure
cardiac event s.
c. An ECG should be int erpret ed and t reat ment ordered w it hin t he cont ext
of a comprehensive clinical pict ure.
d. ECG abnormalit ies are cat egorized according t o f ive general areas:
1. Heart rat e
2. Heart rhyt hm
3. Axis or posit ion of t he heart
4. Hypert rophy
5. I nf arct ion/ ischemia
e. Typical abnormalit ies include t he f ollow ing:
1. Pat hologic rhyt hms
2. Conduct ion syst em dist urbances
3. Myocardial ischemia
4. Myocardial inf arct ion
5. Hypert rophy of t he heart
6. Pulmonary inf arct ion
7. Alt ered pot assium, calcium, and magnesium levels
8. Pericardit is
9. Eff ect s of drugs
10. Vent ricular hypert rophy
2. Vect orcardiogram
a. The vect orcardiogram is more sensit ive t han t he ECG f or diagnosing
myocardial inf arct ion; it is probably not any more specif ic.
b. Vect orcardiography is more specif ic t han t he ECG in det ermining
hypert rophy or vent ricular dilat at ion.
c. Diff erent iat ion of int ravent ricular conduct ion abnormalit ies is possible.
FI G URE 16. 6 ECG elect rode placement . (Source: Smelt zer SC, Bare BG :
Brunner and Suddart h's Text book of Medical-Surgical Nursing, 8t h ed.
Philadelphia, Lippincot t -Raven Publishers, 1996)
1. Chest pain, if present , should be not ed on t he ECG st rip.
2. The presence of a pacemaker and t he use of a magnet in t est ing should be
document ed.
3. Marking t he posit ion on t he chest w all in ink ensures a reproducible
precordial lead placement .
Interfering Factors
1. Race: ST elevat ion w it h T-w ave inversion is more common in Af rican
Americans but disappears w it h maximal exercise eff ort .
2. Food int ake: high carbohydrat e cont ent is especially associat ed w it h an
int racellular shif t of pot assium in associat ion w it h int racellular glucose
met abolism. Nondiagnost ic ST depression and T-w ave inversion are evident
w it h hypokalemia.
3. Anxiet y: episodic anxiet y and hypervent ilat ion are associat ed w it h prolonged
PR int erval, sinus t achycardia, and ST depression w it h or w it hout T-w ave
inversion. This may be due t o aut onomic nervous syst em imbalances.
4. Deep respirat ion: t he posit ion of t he heart in t he chest shif t s more vert ically
w it h deep inspirat ion and more horizont ally w it h deep expirat ion.
5. Exercise/ movement : st renuous exercise bef ore t he t est can produce
misleading result s. Muscle t w it ching can also alt er t he t racing.
6. Posit ion of heart w it hin t he t horacic cage: t here may be an anat omic cardiac
rot at ion in bot h horizont al and f ront al planes.
7. Posit ion of precordial leads: inaccurat e placement of t he bipolar chest leads
and t he t ransposit ion of right and lef t arm and lef t leg elect rodes w ill aff ect
t est result s. I n normal persons, lead reversal produces t he t ypical ECG
f indings of dext rocardia in f ront al plane leads and can mimic a myocardial
inf arct ion pat t ern.
8. A lef t w ard shif t in t he Q RS axis occurs w it h excess body w eight , ascit es,
and pregnancy.
9. Age: at birt h and during inf ancy, t he right vent ricle is hypert rophied because
t he f et al right vent ricle perf orms more w ork t han t he lef t vent ricle. T-w ave
inversion in leads V1 V 3 persist s int o t he second decade of lif e and int o t he
t hird decade in black persons.
10. G ender: w omen exhibit slight ST-segment depression.
11. Chest conf igurat ion and dext rocardia: in t his congenit al anomaly in w hich t he
heart is t ransposed t o t he right side of t he chest , t he precordial leads must
also be placed over t he right side of t he chest .
12. Severe drug overdose, especially w it h barbit urat es, and many ot her
medicat ions can inf luence ECG conf igurat ion. Ant iarrhyt hmics,
ant ihist amines, and ant ibiot ics can w iden Q T int ervals.
13. The serious eff ect s of elect rolyt e imbalances show up on t he ECG as
f ollow s:
a. I ncreased Ca+ + : short ened Q T; less f requent ly, prolonged PR int erval
and Q RS complex
b. Decreased Ca+ + : prolonged Q T
c. Alt erat ions in K+ may produce cardiac arrhyt hmias.
Interventions
1. Explain t he t est purpose, procedure (ECG is a graphic record of elect ric
pulses associat ed w it h t he cont ract ion and relaxat ion of heart ), and
int erf ering f act ors. Emphasize t hat ECG is painless and does not deliver
elect rical current t o t he body. A rest ing ECG is no more t han a 1-minut e
record of t he heart 's elect rical act ivit y (t he amount of volt age generat ed by
t he heart and t he t ime required f or t hat volt age t o t ravel t hrough t he heart ).
2. Have t he pat ient complet ely relax t o ensure a sat isf act ory t racing.
3. Be aw are t hat ideally, t he person should rest f or 15 minut es bef ore ECG
recording. Have t he pat ient avoid heavy meals and smoking f or at least 30
minut es bef ore t he ECG , and longer if possible.

1. Recognize t he limit at ions of an ECG . A normal ECG does not rule out
coronary art ery disease or areas of cardiac ischemia. Conversely, an
abnormal ECG in and of it self does not alw ays signif y heart disease.
2. I nt erpret t est result s and counsel and monit or t he pat ient appropriat ely. A
rest ing ECG is usually normal in t hose pat ient s w ho experience only angina.
I t can provide evidence of prior heart damage. The ECG is one diagnost ic
t ool w it hin a repert oire of diagnost ic modalit ies and should be view ed as
such. The presence or absence of heart disease should not be presumed
solely on t he basis of t he ECG .
Clin ical Alert

1. When an ECG show s changes t hat indicat e ischemia, injury, or inf arct ion,
t hese changes must be report ed and act ed on immediat ely. The goal of
diagnosis and t reat ment is t o increase myocardial blood supply and
reduce oxygen demand.
a. When ECG changes represent st ages of ischemia, injury, or necrosis
and sympt oms of possible myocardial inf arct ion appear, t he primary
concern is balancing myocardial oxygen supply and demand as
f ollow s:
1. Nit roglycerin dilat es blood vessels.
2. Narcot ics relieve pain and anxiet y.
3. Calcium channel blockers relieve coronary spasm.
4. O xygen increases O2 supply available t o t he myocardium.
5. Bet a-blocking drugs slow rapid heart rat es.
6. Ant iarrhyt hmic agent s correct abnormal rhyt hms.
7. Frequent reassurances alleviat e pat ient anxiet y.
b. Monit oring f or cardiac rhyt hm dist urbances is an essent ial component
of care. Pot ent ially let hal dysrhyt hmias, especially vent ricular
t achyarrhyt hmias, require immediat e int ervent ion and may signal t he
need f or possible cardiopulmonary resuscit at ion.
2. Serious diagnost ic errors can be made if t he ECG is not int erpret ed in t he
broader cont ext of t he pat ient 's hist ory, signs, and sympt oms.
3. The elect rical axis is not synonymous w it h t he anat omic posit ion of t he
heart .
Signal-Averaged Electrocardiogram (SAE) The signalaveraged ECG (SAE) is a noninvasive tool for
identifying patients at risk for malignant ventricular
dysrhythmias, particularly after myocardial infarction.
During the later phase of the QRS complex and ST
segment, the myocardium produces high-frequency,
low-amplitude signals termed late potentials. These
late potentials correlate with delayed activation of
certain areas within the myocardium, a condition that
predisposes to reentrant forms of ventricular
tachycardia.
Indications
SAEs are perf ormed t o evaluat e t he et iology of vent ricular dysrhyt hmias or as a
precursor t o elect rophysiologic st udies. Disorders t hat may produce regions of
delayed myocardial conduct ion include myocardial inf arct ion, nonischemic dilat ed
cardiomyopat hy, lef t vent ricular aneurysm, and some f orms of healed vent ricular
incisions (eg, scar f rom t et ralogy of Fallot surgical int ervent ion).
Reference Values
Normal
Normal Q RS complexes and ST segment s
Procedure
1. Remember t hat t he SAE, w hich is a modif icat ion of t he convent ional ECG ,
uses comput erized t echniques t o provide signal averaging, amplif icat ion, and
f ilt ering of elect rical pot ent ials.
2. Place elect rodes on t he abdomen and ant erior and post erior t horax. The
signals received are convert ed t o a digit al signal. A t ypical Q RS complex is
used as a t emplat e against w hich
subsequent cardiac cycles are compared. Typically, several hundred beat s
are averaged t o analyze f or lat e pot ent ials.
3. Be aw are t hat dat a collect ion usually t akes about 20 minut es. O pt imal
recordings require t hat t he pat ient be in a comf ort able posit ion and remain
quiet , t he proper applicat ion of elect rodes, and eliminat ion of int erf erence
f rom ot her elect rical equipment .
1. SAE provides predict ive values f or pot ent ial vent ricular t achycardias in
pat ient s w ho have a hist ory of myocardial inf arct ion or coronary art ery
disease.
2. Lat e pot ent ials are st ronger predict ors of sudden deat h or sust ained
vent ricular t achycardias t han are vent ricular dysrhyt hmias f rom a Holt er
monit or recording.
3. Evidence show s t hat lat e pot ent ials associat ed w it h vent ricular t achycardias
are abolished f ollow ing successf ul surgical int ervent ion.
4. Pat ient s w ho experience lat e pot ent ials have a 17% incidence of sust ained
vent ricular t achycardia or sudden deat h, compared w it h a 1% incidence in
pat ient s w it hout lat e pot ent ials. The incidence is even great er in t he
presence of decreased eject ion f ract ions.
5. SAE may explain t he cause of syncope subsequent ly ident if ied as vent ricular
t achycardia during elect rophysiologic st udy.
Interfering Factors
1. I ncreased t ime is required f or recording beat s in t he presence of slow heart
rat es or f requent vent ricular ect opics. Pat ient movement , t alking, and
rest lessness also delay dat a procurement .
2. Bundle-branch block can int erf ere w it h impulse averaging.
3. SAE does not provide inf ormat ion about ant iarrhyt hmic drug eff ect iveness.
4. Lat e pot ent ials do not occur in every pat ient w it h vent ricular t achycardia.
5. Vent ricular pacing prolongs vent ricular act ivat ion t ime and obscures lat e
pot ent ials. Conversely, at rial pacing, even at rapid rat es, does not alt er
vent ricular lat e pot ent ials.
Interventions

Cardiac Event Monitoring; ECG Continuous Monitoring;

Holter Monitoring; 30-Day Event Monitoring;
Implantable Monitor Cardiac event monitoring refers to
continuous ECG recording of cardiac rhythms, unusual
cardiac events, and patient activity. The patient wears
a special monitor (Holter) using a loop magnetic tape
recording for 2448 hours or a memory loop batteryoperated ECG recorder. These tracings are used to
record onset and termination of rhythm disturbances
and to diagnose the cause of dizziness, palpitations,
fainting (syncope), lightheadedness, and unexplained

fatigue. These procedures are also used to check
pacemaker function and automatic implantable
defibrillator function status and to trace drug and
treatment effectiveness.
Reference Values
Normal
Normal t racings of cardiac ECG sinus rhyt hms and heart rat e No hypoxic or
ischemic ECG changes
Procedure
1. Holt er, 2448 hour ECG monit or
a. Prepare t he sit e and apply t he leads. Areas may need t o be shaved,
cleansed w it h rubbing alcohol, and abraded w it h gauze.
b. I f and w hen t he pat ient experiences sympt oms, ask t he pat ient t o push
an indicat or marked t o save t he current ECG t racing. The t racings are
t ransmit t ed by t elephone f or analysis.
2. 30-Day cardiac event ECG monit oring
a. Prepare t he sit e appropriat ely (eg, shaving, cleansing).
b. Apply t w o-channel elect rodes, place leads, and connect t o t he monit or.
c. Ask t he pat ient t o press a record marker w hen any sympt oms (event s)
occur and also t o keep a diary of sympt oms.
3. I mplant able monit or
a. Surgically insert ed just beneat h t he skin in t he upper chest area
b. Follow ing a sympt om (eg, dizziness, f aint ing spell), a pager-sized device
is placed over t he implant ed monit or t o capt ure and save t he dat a.
c. Dat a are t hen analyzed by a physician or nurse.
Interfering Factors
1. I ncomplet e diary or event marker not pushed during sympt oms
2. Mechanical ineff ect iveness
3. Smoking, cert ain drugs
1. Abnormal t racings and record may indicat e unsuspect ed dist urbances, eg,
arrhyt hmias, f rict ion, scrat ching, t achycardia (at rial and vent ricular)
2. Brachycardia and bradycardia-t achycardia syndrome
3. Premat ure at rial and bradycardia-t achycardia syndrome
4. Heart blocks
5. Junct ional rhyt hms
6. Flut t er or f ibrillat ion
7. Premat ure at rial or vent ricular cont ract ions
8. Hypoxic/ ischemia changes
Interventions
1. Explain monit oring purpose and procedure. Holt er monit or is usually w orn f or
2448 hours and t hen removed. The loop recorders are usually w orn f or 12
w eeks and up t o 1 mont h. I mplant able monit ors can be used f or several days
up t o several mont hs.
2. I f t he pat ient experiences sympt oms such as dizziness, or palpit at ions, ask
t he pat ient t o push an indicat or and record t ime of event in a diary.
3. Encourage pat ient t o cont inue normal daily event s; do not get recorder w et .
4. I nst ruct pat ient t o avoid magnet s, met al det ect ors, high-volt age
environment s, and elect ric blanket s.
5. Be aw are t hat an it ching sensat ion under elect rodes is common. I nst ruct
pat ient s not t o adjust placement sit es unless t hey call in and receive proper
procedure.

1. Remove recorder and chart t ime monit or is discont inued.
2. Clean elect rode sit es w it h mild soap and w at er and dry t horoughly.
3. Evaluat e out comes and counsel t he pat ient appropriat ely about f urt her
t est ing and/ or possible t reat ment .
Stress Test/Exercise Testing (Graded Exercise

Tolerance Test), Submaximal Effort This test measures
the efficiency of the heart during a dynamic exercise
stress period on a motor-driven treadmill or ergometer.
It is valuable for diagnosing ischemic heart disease
and investigating physiologic mechanisms underlying
cardiac symptoms such as angina, dysrhythmias,
inordinate blood pressure elevations, and functionally
incompetent heart valves. Exercise testing can also
measure functional capacity for work, sports, or
participation in rehabilitation programs, and it can be a
predictor or potential response to medical or surgical
treatment. Additionally, upper limits of physiologically
responsive pacemakers can be evaluated.
Syst olic blood pressure normally increases w it h exercise, and diast olic pressure
normally remains essent ially unchanged. St ress exercise t est ing t akes place
under cont rolled condit ions t hat include low t emperat ures (20C) and low er
humidit y.
Reference Values
Normal
Negat ive w hen t he pat ient does not exhibit signif icant sympt oms, arrhyt hmias, or
ot her ECG abnormalit ies at 85% of maximum heart rat e predict ed f or age and
gender
Procedure
There are many diff erent t ypes of st ress t est s. Most include t he f ollow ing st eps:
1. Place recording elect rodes on t he pat ient 's chest (see descript ion of ECG)
and at t ach t o a monit or. Place a blood pressure recording device
appropriat ely.
2. Be aw are t hat as t he pat ient w alks on a mot or-driven t readmill, or pedals an
ergomet er if w alking is not possible, comput erized ECG and heart monit oring
devices record perf ormance. The pat ient w alks at progressively great er
speeds and higher levels of elevat ion t o increase bot h heart rat e and
w orkload.
3. Record t he init ial or rest ing ECG , heart rat e, and blood pressure. Ask t he
pat ient t o report any sympt oms such as chest pain or short ness of breat h
experienced during t he t est . Normal persons are sympt om f ree at
submaximal eff ort s; how ever, at peak or maximal eff ort s, sympt oms
expect ed in normal persons include exhaust ion, f at igue, and somet imes
nausea or dizziness.
4. Have t he pat ient undergo st ress t est ing in st ages. Each st age consist s of a
predet ermined t readmill speed (in miles or kilomet ers per hour) and a
t readmill grade elevat ion (in percent age grade or degrees).
5. Monit or t he ECG , heart rat e, and blood pressure cont inually f or
abnormalit ies and any unusual sympt oms such as int olerable dyspnea, chest
pain, or severe cramping (claudicat ion) in t he legs.
6. Record vit al signs, t oget her w it h ot her abnormalit ies and complaint s, at 1- t o
3- minut e int ervals f or 6 t o 8 minut es post t est as t he pat ient rest s. The t est
is t erminat ed if ECG abnormalit ies, f at igue, w eakness, abnormal blood
pressure changes, or ot her int olerable sympt oms occur during t he t est .
7. Remember t hat common crit eria f or t erminat ing a t est include t he f ollow ing:
a. Achieving maximum possible perf ormance
b. Emerging signs or sympt oms t hat indicat e an exist ing disease process
c. Recording a predet ermined endpoint , such as 85% of age-relat ed
maximal heart rat e, arbit rary w orkload (one t hat raises heart rat e t o 150
beat s/ minut e), or diagnost ic ECG change
8. Be aw are t hat t ot al examinat ion t ime is about 30 minut es; how ever, ask t he
pat ient t o plan t o be in t he laborat ory f or 1 t o 1. 5 hours.
Abnormal responses t o exercise t est ing include t he f ollow ing:
1. Alt erat ions in blood pressure, such as:
a. Failure of syst olic pressure t o rise
b. Progressive f all in syst olic pressure

c. Elevat ion of diast olic blood pressure
2. Alt erat ions in heart rat e, such as:
a. Tachycardia above t hat w hich is predet ermined
b. Brachycardia
3. Changes in ECG , such as:
a. Depression or elevat ion of ST segment s caused by ischemia
b. Dysrhyt hmias, vent ricular t achycardia, mult if ocal premat ure vent ricular
cont ract ions, at rial t achycardia, second- or t hird-degree at riovent ricular
block
c. Pacemaker f ailure t o perf orm w it hin set rat e limit s
4. Vent ricular or supravent ricular ect opics are considered abnormal responses
not necessarily ischemic in origin.
5. I schemic ST-segment depression > 0. 2 mm or elevat ion > 1. 0 mm is t he
most common abnormalit y. Men aged 40 t o 59 years w ho develop ST
depression during exercise t hat is not present at rest have f ive t imes t he risk
f or overt coronary heart disease compared w it h men w it hout t his ST
depression.
6. Unusual sympt oms such as:
a. Anginal pain
b. Severe breat hlessness
c. Faint ness, dizziness, light headedness, conf usion
d. Claudicat ion, leg pain
7. Unusual signs such as:
a. Cyanosis, pallor, skin mot t ling
b. Cold sw eat s, piloerect ion
c. At axia, glassy st are
d. G allop heart sounds
e. Valvular regurgit at ion
Interfering Factors
Common causes of f alse-posit ive exercise ECG responses include t he f ollow ing:
1. Lef t vent ricular hypert rophy
2. Digit alis t oxicit y

3. ST-segment abnormalit y
4. Hypert ension
5. Valvular heart disease
6. Lef t bundle-branch block
7. Anemia
8. Hypoxia
9. Vasoregulat ory ast henia
10. Low n-G anong-Levine syndrome
11. Panic or anxiet y at t ack
12. Wolff -Parkinson-Whit e syndrome
Interventions
1. Explain t he t est purpose and procedure. No f ood, coff ee, or cigaret t es are
allow ed f or 2 hours bef ore t est ing. Wat er may be t aken.
2. Ensure t hat a legal consent f orm is signed by t he pat ient or pat ient 's
designee.
3. Ask t he pat ient t o w ear f lat w alking shoes or t ennis shoes (no slippers). Men
should w ear gym short s or light , loose-f it t ing t rousers. Women should w ear a
bra, a short -sleeved blouse t hat but t ons in f ront , and slacks, short s, or
pajama pant s (no one-piece undergarment s, pant yhose, or slips).
4. Be aw are t hat cert ain medicat ions should be w it hheld or discont inued bef ore
t est ing. Bet a-adrenergic blocking agent s (eg, propranolol) should have
dosage reduced or be t apered gradually. The physician should w rit e orders
regarding management of t he pat ient 's drug regimen w ell bef ore t he t est .
care.

1. I nt erpret t est result s and monit or appropriat ely f or abnormal responses t o
exercise. Report signif icant event s or sympt oms w it hout delay.
2. Do not discharge t he pat ient unt il accept able levels f or vit al signs and ECG
monit oring have been met .
Clin ical Alert

St ress exercise t est ing can be risky f or pat ient s w it h recent onset of chest
pain associat ed w it h signif icant ly elevat ed blood pressures or w it h f requent
at t acks of angina. Test ing may require a 4- t o 6-w eek delay in t hese
sit uat ions.
Cardiac Catheterization and Angiography

(Angiocardiography, Coronary Arteriography) This
procedure is performed to evaluate the coronary
vessels and function of the left ventricle. This method
is chosen to study and diagnose defects of the
chambers of the heart, the heart valves, and certain
blood vessels by means of inserting arterial venous
catheters, which can carry contrast material into the
right and left sides of the heart. As these catheters are
introduced and advanced toward the heart, fluoroscopy
and high-speed x-ray pictures projected onto monitors
show actual heart function and motion. Injected
contrast medium provides a visual definition of cardiac
structures. Coronary artery patency and circulation is
filmed as well. The patient's heart rate, rhythm, and
pressures are monitored continuously.
Coronary art eriograms are usef ul f or evaluat ing abnormal st ress t est s,
diagnosing heart disease, assessing t he complicat ions of a myocardial inf arct ion,
diagnosing congenit al abnormalit ies, ident if ying cardiac st ruct ure and f unct ion,
and measuring hemodynamic pressures w it hin heart chambers and great vessels.
They are used t o measure cardiac out put using cont rast dilut ion, t hermodilut ion,
and Fick's met hod and t o obt ain cardiac blood samples f or measuring oxygen
cont ent and oxygen sat urat ion.
Cardiac cat het erizat ion combined w it h angiography is indicat ed f or pat ient s w ho
exhibit angina, chest pain, syncope, valve problems, ischemic heart disease,
cholest eremia, sympt oms w it h hist ory of f amilial heart disease, abnormal rest ing
or exercise ECG s, and recurring cardiac sympt oms af t er revascularizat ion. O t her
indicat ions include young pat ient s w it h a hist ory of coronary insuff iciency or
vent ricular aneurysm and pat ient s w ho experience coronary neurosis and need
assurance t hat t heir cardiac st at us is normal. This t est can be perf ormed during
t he acut e st age of myocardial inf arct ion, and if necessary, surgical int ervent ion
can be accomplished w it hout signif icant delay. Alt hough cardiac cat het erizat ion
poses some risk, it is highly accurat e diagnost ic resource.
Reference Values
Normal Cardiac Catheterization
Normal heart values, chamber size, and pat ent coronary art eries Normal w all and
valve mot ion
Normal cardiac out put (CO ): 48 L/ minut e Normal percent age of oxygen cont ent
(1522 vol. %) and oxygen sat urat ion (95%100% of capacit y, or 0. 951. 00)
Normal Cardiac Volumes

End-diast olic volume (EDV): 5090 mL/ (body surf ace area)m2
End-syst olic volume (ESV): 25 mL/ m2
St roke volume (SV): 45 12 mL/ m2
Eject ion f ract ion (EF): 0. 67 0. 07
Normal Hemodynamic Pressures (mm Hg)

Average
Range
A wave
110
U wave
Right atrium
Mean
08
Peak systolic
25
1530
End diastolic
17
Peak systolic
25
1530
End diastolic
312
Mean
15
919
PCW P
412
A wave
10
315
U wave
12
621
Mean
212
Peak systolic
130
100140
End diastolic
312
Right ventricle
PAP
Left atrium
Left ventricle
Complete aortic
Peak systolic
130
100140
End diastolic
70
6090
Mean
85
70105
PAP, pulmonary artery pressure; PCW P, pulmonary

capillary wedge pressure.
Procedure
1. Remember t hat t he t est is normally done in a special, darkened procedure
room.
2. To decrease anxiet y, explain t he procedure and provide inf ormat ion about
sensat ions t he pat ient may experience.
a. For right -heart cat het erizat ion, use t he medial cubit al, brachial, or
f emoral vein. Thread t he cat het er t hrough t he vena cava t o t he right
at rium, t hrough t he t ricuspid valve and right vent ricle, t o t he pulmonary
art ery. Take pressure measurement s and O2 sat urat ions f rom t hese
areas as you manipulat e t he cat het er.
b. For lef t -heart cat het erizat ion procedure, heparinize t he pat ient . Thread
t he cat het er t hrough t he f emoral or brachial art ery and on t hrough t he
aort ic valve t o t he lef t vent ricle. Again, t ake pressure readings.
I nt roduct ion of cont rast mat erial, if done, provides dat a about lef t
vent ricular cont ract ilit y, cont our size, and presence of mit ral
regurgit at ion.
c. O bserve st erile surgical condit ions. Prepare t he skin w it h an ant isept ic
solut ion scrub. I nject a local anest het ic int o t he cat het er insert ion sit e
area (eg, groin [ f emoral art ery] , ant ecubit al [ brachial art ery] ). Small
incisions may be made t o f acilit at e insert ion. O nce insert ed, gent ly
advance t he cat het ers t o t he heart and great vessels.
3. I f lef t -t o-right shunt is suspect ed, obt ain blood samples f rom t he superior
and inf erior vena cava also.
4. Have t he pat ient lie on a special x-ray t able, and monit or t he ECG
cont inuously. Use int ravenous sedat ion if necessary. During t he procedure,
t he pat ient is placed in several diff erent posit ions. The pat ient may be asked
t o exercise t o evaluat e heart changes associat ed w it h act ivit y. At rial pacing
can also be done as part of t he procedure in persons w ho cannot w alk (eg,
paraplegics) or use a t readmill. I n t hese inst ances, t here is a sequence of
event s t hat st ress t he heart f ollow ed by a rest period; t hen measurement s
are t aken. The heart is paced again, f ollow ed by anot her rest period.
5. Be aw are t hat somet imes t he pat ient can w at ch t he procedure on a t elevision
monit or if it happens t o be posit ioned properly.
6. Af t er x-ray f ilms have been t aken f rom all angles, remove t he cat het ers, and
apply manual pressure t o t he sit e f or 20 t o 30 minut es. Apply a st erile
pressure bandage f or several addit ional hours, if necessary. Some f acilit ies
no longer use pressure bandages. There are several devices on t he market
t o close t he access sit e (vascular closure devices) f ollow ing t he procedure.
These devices can be separat ed int o t w o cat egories: self -adsorbing sut ures
and hemost at is-promot ing pads or pat ches. Less pressure and less t ime may
be required f or venous sit es. G ive prot amine sulf at e t o reverse t he eff ect s of
heparinizat ion.
7. Reassure t he pat ient f requent ly.
Clin ical Alert

Lef t at rial f unct ion and measurement s are usually calculat ed f rom ot her
measurement s. I f direct measurement s are necessary, a t ranssept al approach
must be done by advancing t he cat het er t hrough t he saphenous leg vein int o
t he right at rium and t hen passing a needle t hrough t he cat het er t o punct ure
t he at rial sept um so t hat direct pressure readings may be obt ained. The
pat ient may be asked t o exercise during t he procedure t o evaluat e consist ent
changes; at rial pacing may be done during t he procedure t o increment ally
st ress and rest t he heart f or t hose pat ient s unable t o move normally (eg,
paraplegic pat ient s).
1. Abnormal result s include t he f ollow ing:
a. Alt ered hemodynamic pressures
b. I nject ed cont rast agent reveals alt ered vent ricular st ruct ure and
dynamics of occluded coronary art eries
c. Blood gas analysis conf irms cardiac, circulat ory, or pulmonary problems
2. Abnormal hemodynamic pressures indicat e t he f ollow ing condit ions:

a. Valve st enosis or insuff iciency
b. Lef t and/ or right vent ricular f ailure
c. I diopat hic hypert rophic subaort ic st enosis (I HS)
d. Rheumat ic f ever sequelae
e. Cardiomyopat hies
3. Abnormal blood gas result s indicat e t he f ollow ing condit ions:
a. Congenit al or acquired circulat ory shunt ing
b. Sept al def ect s
c. O t her cardiac and pulmonary def ect s or pat hology
4. When a cont rast agent is inject ed int o t he vent ricles, abnormalit ies of size,
f unct ion, st ruct ure, eject ion f ract ions, aneurysms, leaks, st enosis, and
alt ered cont ract ilit y can be det ect ed.
5. When cont rast is inject ed int o coronary art eries, occluded vessels and
circulat ory f unct ion can be recorded.
Clin ical Alert

1. Risk f act ors f or complicat ions f ollow ing cardiac cat het erizat ion include
>60 years of age, hypert ension, peripheral vascular disease, and
procedure done on an emergency basis or at same t ime as angioplast y.
Risk f act ors f or complicat ions may be as high as 10% w hen more t han
t hree f act ors are present .
2. Complicat ions associat ed w it h risk f act ors include myocardial inf arct ion,
cerebrovascular accident s, or deat h w it hin 24 hours of procedure;
hemorrhage requiring t ransf usion; pseudoaneurysm; f ist ula; or f emoral
t hromboses.
Interventions
1. Explain t he t est purpose (det ermine w het her art eries are obst ruct ed and
show evidence of lesions, grade t he occlusions, and assess lef t vent ricular
f unct ion), procedure, benef it s, and risks. A consent f orm must be signed
bef ore t he examinat ion. Alw ays check f or allergies, especially t o iodine and
cont rast media. Ext ensive t eaching may be necessary.
2. Have t he pat ient f ast f or 6 t o 8 hours bef ore t he procedure. G ive rout ine,
scheduled medicat ions, eg, cardiac drugs or insulin, bef ore t he procedure
unless direct ed ot herw ise. Discont inue ant icoagulant s at least 1 t o 2 days
3. G ive analgesics, sedat ives, or t ranquilizers bef ore t he procedure.
4. Ask t he pat ient t o void bef ore t he procedure.
5. The pat ient may w ear dent ures; have t he pat ient remove jew elry and ot her
accessories.
6. I nst ruct t he pat ient regarding t he need t o perf orm deep breat hing and
coughing during t he t est , and inf orm t hem t hat t hey may f eel cert ain
sensat ions.
a. Cat het er insert ion via ant ecubit al or groin sit es may produce signif icant
pressure sensat ions w hen t he sheat h, t hrough w hich t he cat het er is
insert ed and advanced, is int roduced.
b. A slight shock or f unny bone sensat ion may be f elt if t he nerve adjacent
t o t he art ery is t ouched. A t iny bump in t he neck may be f elt as t he
cat het er is insert ed int o t he heart . Normally, pain is not f elt .
c. When t he cont rast agent is inject ed int o t he cat het er, a pumping
sensat ion w it h f eelings of palpit at ions and hot f lashes may last 30 t o 60
seconds. Skin vessels vasodilat e, and blood rises t o t he skin surf ace f or
a short t ime.
d. Pat ient s may experience nausea, vomit ing, headache, and cough.
e. Angina may occur w it h exercise or w it h t he cont rast agent inject ion.
Nit roglycerin or narcot ics may be given.

1. Be aw are t hat bed rest is usually maint ained f or 6 hours af t er t he t est ,
based on t he nat ure of t he procedure, physician's prot ocols, and pat ient
st at us. The pat ient is usually not permit t ed t o raise his or her head more
t han 30 degrees during t his t ime because great er angles put st rain on t he
insert ion sit e. Conversely, movement of t he uninvolved ext remit ies should be
promot ed.
2. Check vit al signs f requent ly according t o inst it ut ion prot ocols. At t he same
t ime, check cat het er insert ion sit e f or hemat omas, sw elling, bleeding, or
bruit s. Normal or ot her mechanical pressure t o t he cat het er insert ion sit e
may be necessary if bleeding or hemat oma develops. A bruised appearance
around t he sit e is normal. Sw elling or lumps should be prompt ly report ed t o

physician. Neurovascular checks should be done along w it h assessment of
vit al signs in bilat eral ext remit ies and result s compared. Assess color,
mot ion, sensat ion, capillary ref ill t imes, t emperat ure, and pulse qualit y.
Report signif icant changes immediat ely.
3. Administ er prophylact ic ant ibiot ics as necessary.
4. Encourage f luid int ake. Unless cont raindicat ed, an int ravenous inf usion sit e
may be maint ained w hile t he pat ient is on bed rest in t he event t hat rapid
int ravenous access is needed.
5. Keep t he aff ect ed ext remit y ext ended, not elevat ed or f lexed. I mmobilize t he
legs w it h sandbags if necessary. Apply ice packs and/ or sandbags t o t he
cat het er sit e, if ordered; t his pressure can be very painf ul. Prescribed
analgesics can be administ ered f or pain of hemat omas or discomf ort .
6. Sut ures, if used, are removed per physician's inst ruct ions.
7. I nt erpret t est result s and monit or appropriat ely f or cardiac, circulat ory,
neurovascular, and pulmonary problems.
Clin ical Alert

1. This procedure is cont raindicat ed in pat ient s w it h gross cardiomegaly.
2. Complicat ions include t he f ollow ing:
a. Dysrhyt hmias
b. Allergic react ions t o cont rast agent (evidenced by urt icaria, prurit us,
conjunct ivit is, or anaphylaxis)
P.
c. Thrombophlebit is
d. I nsert ion sit e inf ect ion
e. Pneumot horax
f. Hemopericardium
g. Embolism
h. Liver lacerat ions, especially in inf ant s and children
i. Excessive bleeding at t he cat het er sit e
3. Not if y at t ending physician immediat ely if increased bleeding, hemat oma,
dramat ic f all or elevat ion in blood pressure, or decreased peripheral
circulat ion and abnormal or changed neurovascular f indings are not ed.
Rapid t reat ment may prevent more severe complicat ions.
4. The f ollow ing equipment should alw ays be available t o t reat complicat ions
of angiography:
a.
b.
c.
d.
e.
Resuscit at ion equipment

DC def ibrillat or
Ext ernal pacemaker
EEG monit or
Emergency drugs
FI G URE 16. 7 Sample of a cardiac cat het erizat ion report .
OTHER INVASIVE CARDIAC PROCEDURES

These procedures are perf ormed by a cardiologist in t he cardiac cat het erizat ion
laborat ory. Typically, t he procedure is perf ormed similar t o a cardiac
cat het erizat ion (ie, a sheat h is insert ed int o a f emoral, brachial, or radial art ery,
and a guide cat het er is t hen advanced int o t he coronary art eries).
Percutaneous Transluminal Coronary Angioplasty

(PTCA) PTCA is a nonsurgical procedure of dilating
significantly occluded arteries, thus allowing more
blood flow and subsequently an increase in oxygen
being delivered to the heart. It is primarily performed
as an alternative to the medical or surgical
management of coronary heart disease. This procedure
can be done at the same time as an initial
catheterization, electively at some time after the
catheterization, or urgently during an acute MI.
The procedure involves passing a small cat het er, t ipped w it h a balloon, t hrough
t he groin or brachial art ery t o t he narrow ed art ery. The balloon is t hen inf lat ed
several t imes against t he narrow ed area in an at t empt t o reduce t he occlusion
and enlarge t he inner lumen of t he art ery. During t he procedure, nit roglycerin is
f requent ly administ ered int o t he coronary art ery t o help dilat e t he art ery and t o
prevent coronary spasms. I nt ravenous ant icoagulat ion w it h heparin is also
maint ained t hroughout t he procedure t o prevent t hrombus f ormat ion on t he
cat het ers and at t he areas of vascular damage.
Coronary Artery Stent

A coronary art ery st ent is a coiled met al device permanent ly embedded int o t he
coronary art ery. The st ent can be balloon inf lat ed or self -expanding. A balloon
inf lat edt ype st ent is f luoroscopically guided t o t he occluded art ery and
subsequent ly embedded int o t he art ery upon inf lat ion of t he balloon. Self expanding st ent s are covered by a ret aining sheat h, w hich is removed at t he sit e
of occlusion. Pat ient s are maint ained on ant iplat elet agent s f or 46 w eeks af t er
t he procedure.
Directional Artherectomy
Direct ional art herect omy is a t echnique in w hich a port ion of t he blockage is
mechanically shaved off and removed f rom inside t he art ery. This procedure uses
a balloon-t ipped cat het er w it h a special cut t ing blade on one side. As t he
cat het er is placed against t he st enot ic lesion, t he balloon is inf lat ed at a low
pressure on t he opposit e side of t he art ery t o st abilize t he cat het er. The blade is
t hen passed t hrough t he plaque (w orks best on noncalcif ied lesions).
Rotational Artherectomy
Rot at ional art herect omy (Rot ablat or, rot at ional ablat ion) is used w hen t he
blockages are long and hard. This syst em uses a high-speed, rot at ing, diamondst udded burr. When t he burr is spun at a high speed (140, 000200, 000 rpm), t he
plaque is pulverized, and t he debris is t hen released int o t he bloodst ream as
micropart icles. This procedure is part icularly eff ect ive on heavily calcif ied lesions
(Chart 16. 2).
Ch art 16.2 Grading of Coronary Occlusions

1.
2.
3.
4.
5.
6.
7.
Normal, no decrease in lumen diamet er

25%: decrease in t he lumen diamet er of up t o 25%
50%: decrease in t he lumen diamet er of 26%50%
99%: hair-w idt h lumen w it h > 90% narrow ing
100%: t ot al occlusion
Footn ote
Source: The American Heart Associat ion Ad Hoc Commit t ee f or G rading of
Coronary Art ery Disease.
Electrophysiology (EP) Studies; His Bundle Procedure

Electrophysiology studies are accomplished through an
invasive test for diagnosis and treatment of ventricular
and supraventricular arrhythmias. This is similar to
cardiac catheterization,
the difference being that EP studies measure cardiac
electrical conduction system activity through solid
electrode catheters instead of the open-lumen
catheters used to measure circulatory system
pressures. Chest electrode catheters are almost alw ays
inserted into veins because of the greater risk they

pose in the arterial system (spasms, occlusion). Using
fluoroscopy as a visual guide, the catheters are
advanced into the right atrium and right ventricle. An xray monitor tracks the catheter location, and a
physiologic monitor show s ECG rhythms as w ell as
intracardiac catheter electrograms.
An EP st udy is highly usef ul f or diagnosing diseases of t he cardiac conduct ion
syst em and provides indicat ions f or opt imal t reat ment . I n addit ion t o measuring
baseline values, t he elect rode cat het ers are used t o pace t he heart in an
at t empt t o induce t he same arrhyt hmia causing t he problem. When t he pat ient is
t aking ant iarrhyt hmic drugs, t he EP st udy can det ermine how w ell t he medicat ion
is w orking by how easily t he arrhyt hmia can be induced. This is in cont rast t o t he
t rial-and-error met hod, in w hich t here is no w ay t o know t hat a part icular drug is
ineff ect ive unt il t hat drug has f ailed t o resolve t he problem, f requent ly over a
signif icant period of t ime.
EP is indicat ed t o diff erent iat e disorders of impulse f ormat ion (supravent ricular
versus vent ricular rhyt hms). EP st udies also provide diagnost ic insight int o t he
et iology and mechanism of conduct ion disorders. EP st udies are of t en part of t he
w orkup f or syncope, sick sinus syndrome, or t achyarrhyt hmias. Finally, EP
st udies are indicat ed f or t est ing t he eff ect iveness of ant iarrhyt hmic drugs. Each
ant iarrhyt hmic drug has cert ain eff ect s t hat must be ant icipat ed during t he
loading phase (eg, hypot ension w it h quinidine and procainamide, abdominal
cramping w it h quinidine, venous pain w it h phenyt oin). A st at e of happy
drunkenness may also occur. I nt ravenous saline is normally used t o support
blood pressure in t he event hypot ension occurs.
Reference Values
Normal
Normal EP/ His bundle procedure
Normal conduct ion int ervals, ref ract ory periods, and recovery t imes Cont rolled,
induced arrhyt hmias
Procedure
1. Darken t he room.
2. To decrease anxiet y, keep t he pat ient inf ormed of w hat is being done as t he
procedure evolves.
3. Posit ion t he pat ient on an x-ray t able and at t ach t he ECG leads t o specif ic
locat ions.
4. Maint ain st erile, asept ic surgical condit ions. Usually one or t w o sit es are
chosen and prepared f or cat het er insert ion (right and/ or lef t ant ecubit al
area, right and/ or lef t groin). The sit es chosen depend on w here in t he heart
t he cat het ers have t o be placed and t he pat ency and size of t he pat ient 's
veins. I nject t he insert ion sit e w it h local anest het ic bef ore cat het er insert ion.
5. As t he cat het ers are advanced t ow ard t he desired locat ion, record baseline
inf ormat ion. Somet imes cardiac pacing may be necessary; f or example,
measuring sinus node recovery t imes requires pacing at rium unt il t he sinus is
f at igued and t hen measuring t he t ime t he sinus t akes t o recover.
6. Af t er baseline values have been det ermined, use pacing t o induce
arrhyt hmias. I f a sust ained arrhyt hmia is induced, make an at t empt t o
t erminat e t he arrhyt hmia t hrough pacing. Should t he pat ient lose
consciousness, use an ext ernal cardiovert er-def ibrillat or t o t erminat e t he
arrhyt hmia.
7. Hold a cont inuous, quiet conversat ion t o assess t he pat ient 's level of
consciousness.
8. Af t er t he procedure, remove t he cat het ers, and apply a st erile pressure
bandage t o t he cat het er insert ion sit e. Manual pressure on t he sit e may be
necessary if bleeding occurs.
1. Abnormal EP result s w ill reveal t he f ollow ing condit ions:
a. Conduct ion int ervals longer or short er t han normal
b. Ref ract ory periods longer t han normal
c. Prolonged recovery t imes
d. I nduced dysrhyt hmia in a normal subject
2. Abnormal result s indicat e t he f ollow ing condit ions:
a. Long at rial His (AH) bundle int ervals indicat e disease in t he
at riovent ricular (AV) node if sympat het ic and vagal inf luences on t he AV
node have been eliminat ed.
b. Long vent ricular His (VH) bundle int ervals indicat e disease in t he HisPurkinje syst em.
c. Prolonged sinus node recovery t imes indicat e sinus node dysf unct ion
such as sick sinus syndrome.
d. Prolonged sinoat rial conduct ion t imes can indicat e sinus exit block.
e. A w ide or split His bundle def lect ion indicat es a His bundle lesion.
f. I nduct ion of a sust ained vent ricular and supravent ricular t achycardia
conf irms t he diagnosis of recurrent vent ricular t achycardia (Chart 16. 3).
Interventions
1. Explain t he t est purpose, procedure, benef it s, and risks. Describing possible
physical sensat ions t hat may be f elt helps t o reduce pat ient anxiet y. These
sensat ions may include t he f ollow ing:
a. The sensat ion of a bug craw ling in t he arm and neck as t he cat het er is
advanced
b. Palpit at ions or racing heart during pacing
c. Light headedness or dizziness (t hese must be report ed w hen f elt )
2. O bt ain a signed consent f orm bef ore t he procedure.
3. Draw blood samples f or pot assium levels, and ot her drug levels if t he
eff ect iveness of a drug is t o be det ermined.
4. Perf orm a st andard 12-lead ECG bef ore t est ing.
5. Ensure t hat not hing is consumed f or at least 3 hours bef ore t est ing.
6. Be aw are t hat analgesics, sedat ives, or t ranquilizers are usually w it hheld
7. Ask t he pat ient t o void bef ore t he procedure is init iat ed.
8. Allow t he pat ient t o w ear dent ures.
Ch art 16.3 Features of Interventional or Therapeutic EP Studies

1. Endocardial cat het er ablat ion
2. Placement of implant able cardiovert er-def ibrillat ors f or management of VT
or VP
3. Radiof requency (RF) t ranscat het er ablat ion has become t he t reat ment of
choice t o oblit erat e pat hw ays w it hin t he AV node and accessory pat hw ays
causing palpit at ions.
4. I nt racardiac t ranscat het er ablat ion is used t o dest roy accessory bypass
t racks, reent rant pat hw ays, or pat hw ays w it hin t he AV node. A special
cat het er is used t o produce an injury t o t he t arget sit e(s) using RF energy.
Footn ote
Source: Van Riper S, Van Riper J: Cardiac Diagnost ic Test s. Philadelphia, WB
Saunders, 1997, p. 320.

1. Have t he pat ient remain on f lat bed rest f or 4 t o 8 hours post procedure and
do not allow f lexion or bending of t he ext remit y used f or t he cat het er
insert ion because t his may lead t o bleeding or vascular occlusion. A pillow
may be placed under t he head.
2. Check vit al signs, neurovascular st at us of ext remit y used, and insert ion sit e
f or sw elling, bleeding, hemat oma, or bruit every 15 minut es f or 4 hours, 30
minut es f or 2 hours, and every hour f or 2 hours post procedure, or according
t o inst it ut ional prot ocols. Neurovascular checks include assessing f or pulses,
color, mot ion, sensat ion, t emperat ure, and capillary ref ill t imes.
3. Keep t he aff ect ed ext remit y ext ended, not elevat ed or f lexed, t o decrease
discomf ort and risk f or bleeding. Prescribed analgesics can be administ ered.
4. Encourage range-of -mot ion exercise of uninvolved limbs.
5. I f an elect rode cat het er is lef t in place f or sequent ial st udies, ensure t hat it
is sut ured in place and covered w it h st erile dressings. Care f or t he sit e using
st erile, asept ic t echnique.
6. I nt erpret t est result s and monit or ECG and ot her paramet ers appropriat ely.
St ress t he import ance of compliance w it h prescribed t herapies including
drugs.
care.
Clin ical Alert

1. Relat ive cont raindicat ions t o EP: alt hough an acut e myocardial inf arct ion
may limit det ailed and prolonged EP procedures, brief but clinically usef ul
procedures can be perf ormed in t his sit uat ion.
2. Complicat ions can include t he f ollow ing condit ions:
a. Rapid, dramat ic hemorrhage at t he cat het er insert ion sit e (apply
manual pressure t o t he sit e and not if y t he physician immediat ely)
b. Thrombosis at t he punct ure sit e; t hromboembolism
c. Phlebit is
d. Hemopericardium
e. At rial f ibrillat ion (usually t ransient )
f. Vent ricular f ibrillat ion or vent ricular ect opy
3. Not if y t he at t ending physician of bleeding, hypot ension, alt ered
neurovascular st at us, decrease in dist al perf usion, or lif e-t hreat ening
arrhyt hmias. Be aw are of drug st udies perf ormed and monit or f or eff ect s
of t hat drug. Have cardiopulmonary resuscit at ion equipment and drugs
readily available f or emergency use.
Transesophageal Echocardiography (TEE)

This t est permit s opt imal ult rasonic visualizat ion of t he heart w hen t radit ional
t ranst horacic (noninvasive) echocardiography f ails or proves inconclusive. A
miniat urized high-f requency ult rasound t ransducer is mount ed on an endoscope
and coupled w it h an ult rasound inst rument t o
display and record ult rasound images f rom t he heart . Endoscope cont rols allow
remot e manipulat ion of t he t ransducer t ip. Various images of heart anat omy can
be displayed by rot at ing t he t ip of t he inst rument and by varying t he dept h of
insert ion int o t he esophagus. I ndicat ions f or TEE include t he f ollow ing:
1. To assess f unct ion of prost het ic valves, diagnose endocardit is, evaluat e
valvular regurgit at ion and congenit al abnormalit ies, and examine t he aort a f or
dissect ing aneurysms
2. To monit or lef t vent ricular w all mot ion int raoperat ively
3. To measure eject ion f ract ion in select ed pat ient s
4. Sit uat ions in w hich a t ranst horacic echocardiogram has not been sat isf act ory
(eg, obesit y, chest w all t rauma, chronic obst ruct ive pulmonary disease)
5. When result s of t radit ional t ranst horacic echocardiography do not agree or
correlat e w it h ot her clinical f indings
Reference Values
Normal
Normal posit ion, size, and f unct ion of heart valves and heart chambers
Procedure

2. Apply a t opical anest het ic t o t he pharynx. I nsert a bit e block int o t he mout h
t o reduce t he risk f or damage t o t he t eet h and ot her oral st ruct ures as w ell
as t he endoscope it self (see Chapt er 12).
3. Have t he pat ient assume a lef t lat eral decubit us posit ion bef ore t he
lubricat ed endoscopic inst rument is insert ed t o a dept h of 30 t o 50 cm. The
pat ient may be asked t o sw allow so t hat t he scope advances more easily.
4. Remember t hat manipulat ion of t he ult rasound t ransducer allow s a number of
image planes t o be visualized.
Abnormal TEE f indings may reveal t he f ollow ing condit ions:
1. Heart valve diseases
2. Pericardial eff usion
4. Endocardit is
5. I nt racardiac t umors or t hrombi
6. Lef t vent ricular dysf unct ion
Interventions
2. Ensure t hat t he pat ient f ast s f rom f ood and f luids at least 8 hours bef ore t he
procedure t o reduce t he risk f or aspirat ion. Premedicat ions such as
analgesics or sedat ives may be ordered. Prescribed oral medicat ions may be
t aken w it h small sips of w at er (see Appendix C f or sedat ion and analgesia
precaut ions).

1. I nt erpret t est result s. Monit or vit al signs and level of consciousness (if
sedat ed). Ensure pat ent airw ay at all t imes.

2. Posit ion pat ient on his or her side if sedat ed t o prevent risk f or aspirat ion.
3. Evaluat e ret urn of sw allow, cough, and gag ref lexes bef ore int roducing f ood
or f luids orally.
Clin ical Alert

Sw allow ing ref lexes may be diminished f or several hours because of t opical
anest het ic eff ect s. I ngest ing f ood or f luids may result in aspirat ion if t hese
ref lexes are not int act . O bt ain signed, w it nessed, inf ormed consent .
OTHER ORGANS AND BODY FUNCTIONS

Magnetic Resonance Imaging (MRI); Magnetic
Resonance Angiography (MRA); Magnetic Resonance
Spectroscopy (MRS) Magnetic resonance (MR) is a
diagnostic modality that employs a superconducting
magnet and radiofrequency (RF) signals to cause
hydrogen nuclei to emit their own signal; computers
use these signals to construct detailed, sectional
images of the body. Unlike computed tomography (CT),
no ionizing radiation is used. Additionally, the ability of
magnetic resonance to discern anatomy is most
closely linked to the molecular nature of tissue. For
example, MR spectroscopy provides information about
the chemical composition of tissue and is commonly
used to evaluate brain function. Special techniques
primarily based on the magnetic reactions of hydrogen
nuclei can influence the MR signal to enhance certain
types of tissue (eg, fat is accentuated in T1 -weighted
images, cerebrospinal fluid and other pure fluids are
highlighted in T2 -weighted images). Computer
reconstruction techniques allow images to be produced
in any plane as well as in the three-dimensional views.
During t he procedure, t he pat ient lies on specially designed couch, w hich is
moved int o a gant ry. Closed syst ems, t ypically of higher magnet ic st rengt h, are
t he most commonly used magnet s and can range f rom 0. 5 t o 3. 0 Tesla
(int ernat ional unit of magnet ic f lux densit y). O pen magnet s have a more
spacious gant ry and are of t en used w hen claust rophobia is a problem or f or a
pediat ric scanning. O lder open magnet s employed low -f ield magnet s (3. 2
Tesla). Recent ly, high-f ield open magnet s (0. 71. 0 Tesla) have become
available. G enerally speaking, a higher Tesla st rengt h magnet is associat ed w it h
improved image qualit y. For cert ain procedures, surf ace coils are placed over
t he body area t o be imaged. During t he t est , loud, rhyt hmic knocking sounds are
produced; less noise is associat ed w it h t he open-design scanner. To relieve
pat ient anxiet y and t he pot ent ial f or claust rophobia, some laborat ories provide
music f or relaxat ion. Tw o-w ay communicat ion syst ems and pulse oximet ers are
commonly used t o monit or pat ient responses t o t he procedure. Magnet ic

resonance applicat ions are cont inually evolving and improving. I n general, t he
most common MR applicat ions include t he f ollow ing:
1. MR of the brai n provides exquisit e visualizat ion of t he sof t t issue st ruct ures
of t he brain. Some laborat ories perf orm neurof unct ional imaging, w hich maps
t he brain's response t o t he st imuli. Alt hough bony anat omy is seen using
MRI , CT is t he t est of choice t o evaluat e bone lesions and f ract ures.
2. MR of the spi ne provides excellent view s of t he spinal cord and subarachnoid
space w it hout int rat hecal cont rast inject ion.
3. MR of the muscul oskel etal system accurat ely demonst rat es f at , muscles,
t endons, ligament s, nerves, blood vessels, and bone marrow. I f t he anat omic
region of int erest is a small area, a
surf ace coil, w hich produces t he RF signal, is placed direct ly on t he skin
overlying t he part t o be examined. Dynamic st udies of t he joint in mot ion can
be perf ormed on open scanners.
4. MR of the heart (cardiac MRI ) allow s visualizat ion of t he st ruct ures of t he
heart , including valves and coronary vessels. I mage acquisit ion is
synchronized t o t he ECG a process know n as gat ingt o help eliminat e
mot ion art if act s. Funct ional st udies can evaluat e cardiac w all mot ion in
response t o exercise.
5. MR of the abdomen and pel vi s visualized sof t t issue organs, part icularly t he
liver, pancreas, spleen, adrenals, kidneys, blood vessels, and reproduct ive
organs. This is t he pref erred met hod f or st aging ut erine, cervical, and vulvar
carcinoma as w ell as prost at e cancer.
6. MR of the breast is a promising new t echnique capable of producing
exquisit ely det ailed analysis of complex breast lesions.
7. MR angi ography provides bot h anat omic and hemodynamic inf ormat ion in
t w o-dimensional and t hree-dimensional represent at ions (likened t o
noninvasive angiography). MR angiography is becoming more common and is
used t o evaluat e know n vascular lesions and is f inding great er ut ilit y in
evaluat ing st roke.
Magnet ic resonance spect roscopy uses a convent ional MR scanner t o det ect
chemicals in all body t issues t o evaluat e t umors, muscle disease, or ischemic
heart disease; t o diff erent iat e causes of coma; t o rule out Alzheimer's disease;
t o monit or cancer t reat ment ; t o diff erent iat e t he diagnosis of mult iple sclerosis,
human immunodef iciency virus (HI V) inf ect ion, and adrenoleukodyst rophy; t o
prepare f or t emporal lobe epilepsy surgery; and t o assess t he ext ent of st roke
and head injury.
I nt ravenous MR cont rast agent s, all primarily cont aining w at er-soluble gadolinium
complex (most commonly gadolinium-50-DTPA or DO TA) or ot her met als such as
manganese (Mn-DPDP) and iron (Mion, USP10) are of t en used in evaluat ing t he
cent ral nervous syst em. These agent s have been approved as saf e f or pat ient s,
including t hose < 2 years of age, and are available in oral, int ravenous (most
common) and inhalat ion f ormulat ions. G adolinium present s w it h very low t oxicit y
and f ew er side eff ect s t han t radit ional x-ray cont rast agent s because of it s rapid
renal clearance. O t her agent s used include gadodiamide (nonionic) and
gadopent et at e, w hich are used f or body scanning. MR cont rast agent s have
low er t oxicit y and f ew er side eff ect s t han x-ray cont rast agent s. How ever,
because t hese MR cont rast agent s are primarily excret ed via t he kidneys, renal
f ailure is a cont raindicat ion f or use. O t her pot ent ial cont raindicat ions include
pregnancy, allergies or ast hma, anemia, hypot ension, epilepsy, and sickle cell
disease.
Clin ical Alert

1. Adverse eff ect s, alt hough rare, of G d-DO TA include vomit ing, sensat ions
of local w armt h or coldness, headache, dizziness, urt icaria, parest hesias,
unusual mout h sensat ions, and respirat ory problems.
2. MR cont rast agent s allow f or bet t er basic cont rast and t issue signals;
most abnormal t issues show regions of increased T1 and T2 (relaxat ion
t ime, RF signals) regardless of t he nat ure of t umors, edema, hemorrhage,
inf lammat ion, and necrosis.
Reference Values
Normal
Sof t t issue st ruct ures: normal brain, spinal cord, subarachnoid spaces, f at ,
muscles, t endons, ligament s, nerves, blood vessels, marrow of limbs and joint s,
heart , abdomen, and pelvis Blood vessels: normal size, anat omy, and
hemodynamics
Procedure
1. Have t he pat ient lie supine on a movable examinat ion couch af t er a t horough
medical hist ory is obt ained.
2. Be aw are t hat sedat ion may be necessary if t he pat ient is claust rophobic or
rest less. Earplugs w it h music are anot her opt ion. A t w o-w ay communicat ion
syst em bet w een t he pat ient and t he operat or allow s cont inual monit oring and
vocal f eedback and somew hat reduces t he pat ient 's sense of isolat ion. Many
MR laborat ories rout inely use a pulse oximet er t o monit or t he pat ient 's
art erial oxygenat ion during t he st udy.
3. For examining many superf icial st ruct ures (eg, knee, neck, shoulder, breast ),
apply a surf ace coil over t he skin. O bt ain improved images of t he prost at e or
reproduct ive organs by using a t ransrect al coil.
4. O nce t he pat ient is posit ioned and inst ruct ed t o remain st ill, move t he couch
int o t he scanner.
5. I n some inst ances, inject a noniodinat ed cont rast int o a vein f or bet t er
anat omic visualizat ion. For abdominal or pelvic scans, administ er glucagon t o
reduce bow el perist alsis.
6. Be aw are t hat examinat ion t ime varies and averages bet w een 30 and 90
minut es.
NOTE
The closed-gant ry design is narrow and may upset some individuals. Reassure
pat ient s t hat t here is suff icient air t o breat he and t hat t hey w ill be monit ored
and given voice cont act during t he ent ire procedure.
Clin ical Alert

Usually, no special diet ary rest rict ions or preparat ions are necessary bef ore
MRI , unless conscious sedat ion is t o be used. How ever, numerous saf et y
f act ors must be considered.
1. Absolut e cont raindicat ions t o MRI include t he f ollow ing condit ions:
a. I mplant ed devices, including pacemakers, aut omat ic cardiac
def ibrillat ors, cochlear implant s, cert ain prost het ic devices (consult
w it h MR laborat ory f or specif ic inf ormat ion), implant ed drug inf usion
pumps, neurost imulat ors, bone grow t h st imulat ors, cardiovert ers,
cert ain int raut erine cont racept ive devices, and met al art if icial heart
valves. Most new surgical implant s are MRI compat ible; how ever,
most labs w ill not scan a pat ient w it h compat ible implant s unt il
approximat ely 2 w eeks af t er placement . The exact brand, st yle, and
serial number of t he device are needed in order f or t he MRI
depart ment t o verif y compat ibilit y.
b. I nt ernal met allic object s such as bullet s or shrapnel and cert ain
surgical clips, pins, plat es, screw s, met al sut ures, or w ire mesh
2. MRI is generally not advised f or pregnant pat ient s (increase in amniot ic
f luid t emperat ure may be harmf ul) or individuals w it h epilepsy. All pat ient s
having an MRI need t o remove hearing aids, dent ures, jew elry, hair pins,
w igs, hairpieces, and ot her accessories.
3. Pat ient s unable t o remain st ill and t hose w ho are claust rophobic may
require int ravenous conscious sedat ion bef ore MRI .
4. Cert ain t ypes of eye makeup and permanent eye liners t hat cont ain
met allic f ragment s somet imes cause discomf ort during MRI . Assess f or
t hese cosmet ic enhancement s.
5. A t horough pat ient hist ory is mandat ory bef ore any MR st udy. Commonly,
radiology services perf orm convent ional x-ray imaging t o conf irm or rule
out t he presence of met allic f ragment s bef ore MR imaging. This is
part icularly import ant f or met al or f oundry w orkers w ho may have t iny
met allic f ragment s in t heir eyes.
P.
6. Common met allic equipment (eg, scissors, oxygen t anks, elect ronic
devices) can become let hal project iles w hen exposed t o t he st rong
magnet ic f ields. Theref ore, a t horough screening of all pat ient s, visit ors,
and st aff bef ore ent ering t he scan room is mandat ory.
7. Local burns f rom ECG leads, ot her w ires, and surf ace coils have been
report ed. I t is imperat ive t hat t he pat ient describe any burning sensat ion
t o t he t echnologist during t he procedure.
Advantages of Open M RI
1. May not need t o sedat e t he claust rophobic pat ient
2. Suit able f or t he ext remely obese pat ient
3. Enhances pat ient comf ort because of t he low magnet ic f ield, anot her
person may st ay w it h t he pat ient (especially usef ul w it h children or conf used
pat ient s)
4. Kinemat ic st udies of joint s (eg, shoulders) are possible
5. I mproved accessibilit y t o t he pat ient allow s open MRI t o be used as a guide
f or int ervent ional and select surgical procedures (eg, biopsies)
6. The open head coil f eat ures a unique mirror t hat allow s t he pat ient t o see
out side t he magnet during t he procedure.
7. Less noise
Clin ical Alert

Some open MR imaging syst ems use only a f ract ion of t he t radit ional highf ield magnet s (eg, 0. 20. 3 Tesla compared w it h 1. 01. 5 Tesla). This result s in
a slimmer prof ile and much less int imidat ing appearance f or t he magnet .
Alt hough ext remely appealing in cert ain inst ances, t he open-design magnet is
current ly not t he best choice f or all MR imaging, and caref ul considerat ion t o
magnet ic f ield st rengt h should be given. Cert ain t ypes of st udies can only be
perf ormed w it h a high-f ield magnet . Some scans perf ormed on an open-design
low -f ield magnet must be repeat ed.
Interfering Factors
1. Respirat ory mot ion causes severe art if act s w it h abdominal and t horacic
imaging.
2. Morbidly obese persons may not f it int o t he gant ry opening or surf ace coil
conf igurat ions.
1. MRI and MRS of t he brain demonst rat e t he f ollow ing condit ions:
a. Whit e mat t er disease (eg, mult iple sclerosis)
b. I nf ect ious disorders aff ect ing t he brain (eg, t oxoplasmosis in acquired
immunodef iciency syndrome [ AI DS] , vasculit is, t uberculosis)
c. Neoplasms (primary and met ast at ic brain t umors, pit uit ary adenomas)
d. I schemias, cerebrovascular accident
e. Aneurysms, hemorrhage
f. Hydrocephalus
g. Vascular abnormalit ies (aneurysm, angiomas)
h. Congenit al CNS def ect s (Chiari malf ormat ion, Dandy-Walker syndrome)
2. MRI and MRS of t he spine demonst rat e t he f ollow ing condit ions:
a. Disk herniat ion or degenerat ion
b. Neoplasm (primary and met ast ases)
c. I nf lammat ory disease
d. Demyelinat ing disease
e. Congenit al abnormalit ies (eg, t et hered cord, spinal dysraphism)
3. MRI of t he heart demonst rat es t he f ollow ing condit ions:
a. Abnormal chamber size or myocardial t hickness
b. Cardiac t umors
c. Congenit al heart disorders
d. Pericardit is
e. G raf t pat ency
f. Thrombic disorders
g. Aort ic dissect ion or aneurysm
h. Cardiac ischemia
i. Anomalous pulmonary venous connect ion
4. MRI and MRS of t he limbs, joint s, and sof t t issue demonst rat e t he f ollow ing
condit ions:
a. Neoplasms of sof t t issue and bone
b. Ligament or t endon damage
c. O st eonecrosis, occult f ract ure

d. Bone marrow disorders
e. Muscle f at igue
f. Changes in blood f low
1. At herosclerosis
2. Aneurysm
3. Thrombus
4. Embolism
5. Bypass graf t s
6. Endocardit is
7. Shunt placement
5. MRI of t he abdomen and pelvis demonst rat es t he f ollow ing condit ions:
a. Neoplasms (especially usef ul in st aging t umors)
b. Ret roperit oneal st ruct ures
c. St at us of renal t ransplant s
6. MRI angiography demonst rat es t he f ollow ing condit ions:
a. Aneurysms
b. St enosis or occlusions
c. G raf t pat ency
d. Vascular malf ormat ions
FI G URE 16. 8 O pen MRI . (Court esy: G eneral Elect ric Medical Syst ems,
Waukesha, WI , USA)
FI G URE 16. 9 Closed MRI . (Court esy: G eneral Elect ric Medical Syst ems,
Waukesha, WI , USA. )
Interventions
1. Explain t he t est purpose, procedure, benef it s, and risks. Saf et y concerns f or
t he pat ient and st aff during MRI procedures are based on int eract ion of
st rong magnet ic f ields w it h body
t issues and met allic object s. These pot ent ial hazards are mainly due t o
project iles (met allic object s can be displaced, giving rise t o pot ent ially
dangerous project iles); t orquing of met allic object s (implant ed surgical clips
and ot her met allic st ruct ures or implant s can be t orqued or t w ist ed w it hin t he
body w hen exposed t o st rong magnet ic f ields); local heat ing (exposure t o RF
pulses can cause heat ing of t issues or met allic object s w it hin t he pat ient 's
body; f or t his reason, pregnant w omen are not rout inely scanned because an
increase in t he t emperat ure of t he amniot ic f luid or f et us may be harmf ul);
int erf erence w it h elect romechanical implant s (elect ronic device implant s are
at risk f or damage f rom bot h magnet ic f ields and t he RF pulses;
consequent ly, pat ient s w it h cardiac pacemakers, implant ed drug inf usion
pumps, cochlear implant s and similar devices should not be exposed t o MR
procedures); and allergic react ions t o MR cont rast agent s.
2. Assess f or cont raindicat ions t o t est ing. O bt ain a relevant hist ory regarding
any implant ed devices such as heart valves, surgical and aneurysm clips,
plat es, int ernal ort hopedic screw s and rods, and pacemakers, among ot her
object s.
3. Ensure t hat t he f ollow ing mat erials are removed bef ore t he procedure:
removable dent al bridges and oral appliances, credit cards, keys, hair clips,
shoes, belt s, jew elry, clot hing w it h met al f ast eners, w igs, hairpieces, and
removable prost hesis.
4. Remember t hat claust rophobic f eelings can be avoided if t he pat ient keeps
his or her eyes closed during t he t est . Recommend t hat t he pat ient not eat a
large meal w it hin 1 hour of t est ing t o reduce physiologic demands and
possible emesis w hile in t he scanner.
5. Encourage t he pat ient t o relax and inst ruct him or her t o remain as
mot ionless as possible during t est ing. Reassure t he pat ient t hat t his is a
painless procedure.
6. Ask pat ient s having blood f low t est ing t o abst ain f rom alcohol, nicot ine,
caff eine, and prescript ion drugs f or iron. The pat ient should f ast f or 2 hours
bef ore t est ing t o avoid unexpect ed blood vessel vasoconst rict ions or dilat ion.
No smoking is permit t ed bef ore t he t est . Promot e rest in t he supine posit ion
f or 10 minut es bef ore t he t est .
7. Be aw are t hat f ast ing or drinking only clear liquids may be necessary f or
several hours bef ore an abdominal pelvic MR.
Clin ical Alert

I n t he event of respirat ory/ cardiac arrest , t he pat ient must be removed f rom
t he scanning room bef ore resuscit at ion. Most general hospit al equipment (eg,
oxygen t anks, int ravenous pumps, monit ors) are not permit t ed in t he MR suit e.

1. I nt erpret t est result s. Counsel and monit or appropriat ely f or side eff ect s of
t he MR cont rast agent . Common side eff ect s include coldness at t he inject ion
sit e, dizziness, and headache. Treat ment is usually not needed unless
sympt oms are bot hersome or prolonged. Rare side eff ect s include
convulsions, irregular or rapid heart rat e, it ching and w at ery eyes, skin rash
or hives, f acial sw elling, t hickening of t ongue, f at igue or w eakness,
w heezing, chest t ight ness, and diff icult y breat hing. Alert t he physician if any
of t hese occur and init iat e t reat ment as indicat ed.
2. Assess t he cont rast dye inject ion sit e f or signs of inf lammat ion, bruising,
irrit at ion, or inf ect ion.
Special Pediatric Considerations for M R Testing

Pediatric cautions related to M R testing include the
follow ing considerations:
1. Age, abilit y t o underst and and cooperat e, physical condit ion, and reasons f or
t est ing
2. MRI body imaging: most of t he adult guidelines apply. Sedat ives,
t ranquilizers, or modif ied rest raint s may be necessary if t he child is
uncooperat ive or f earf ul.
3. MRI f or blood f low st udies in ext remit ies: simple rest raint s may be used t o
rest rict mot ion of arms or legs. No t ranquilizers or sedat ives may be used
because blood f low w ill be aff ect ed.
4. Also see Caut ions, pages 10601061, 1064.
SLEEP STUDIES
Excessive dayt ime sleepiness (hypersomnolence) is a classic sympt om of
inadequat e noct urnal sleep, w hich manif est s it self pat hologically in various w ays.
Typically, much of t he dayt ime sleepiness in t oday's societ y is a result of
irregular sleep pat t erns and t imes (eg, shif t w orkers), lack of adequat e sleep,
poor nut rit ion, and cert ain medicat ions. Sleep disorders are grouped int o f our
major cat egories:
1. Dyssomnias
2. Parasomnias
3. Medical-psychiat ric
4. O t hers
The dyssomnias are sleep disorders associat ed w it h t oo lit t le or t oo much sleep
as a result of problems init iat ing or maint aining sleep st at es or exhibit ing
excessive sleepiness st at es. Examples include sleep apnea (an int rinsic sleep
disorder), periodic limb movement disorder, narcolepsy, and rest less-leg
syndrome. Parasomnias include arousal disorders, sleep-w ake t ransit ion
disorders, night mares, sleep paralysis, and ot her rapid eye movement (REM)
disorders. Dement ia, Parkinson's disease, anxiet y, and mood and panic
disorders are t he most common f orms or medical-psychiat ric sleep disorders.
The ot hers cat egory includes short and long sleepers, pregnancyassociat ed sleep disorder, and sleep choking syndrome. These disorders are
diagnosed using polysomnography met hodology (eg, EEG , EMG , EO G ).
A short sleeper, also ref erred t o as a healt hy hyposomniac, sleeps
subst ant ially less in a 24-hour period t han is expect ed (sleep durat ion of < 5
hours in a 24-hour period bef ore age 60 years). A longer sleeper, also ref erred
t o as a healt hy hypersomniac, consist ent ly sleeps more in a 24-hour period
t han is expect ed (sleep durat ion of > 10 hours in a 24-hour period). People w it h
sleep choking syndrome aw aken suddenly w it h a f eeling of short ness of breat h
and a choking sensat ion. The et iology of t his disorder is unknow n, but it is more
prevalent in early t o middle adult hood in persons w it h obsessive-compulsive
anxiet y disorders.
The solut ion t o t he problem relat es t o reversing pat hologic sleep pat t erns t o
more normal st at us by means of various int ervent ions.
Use of Tests
Sleep st udies, or polysomnography (PSG ), can be divided int o t w o t ypes: f ull
PSG , or 16-channel recording, and screening PSG , or 4-channel recording. Full
PSG can be used t o diagnose any of t he previously described sleep disorders,
w hereas t he 4-channel limit ed PSG is reserved f or sleep disorders involving

breat hing (eg, sleep apnea).
Sleep Studies*
Term
EEG Definition
Sleep
onset
Transition from wakefulness to sleepfulness;

usually takes at least 10 minutes (ie, nREM
stage I)
Stage
I
nREM
Occurs at sleep onset, consists of low-voltage

EEG with mainly theta and alpha activity; 4%
5% of sleep
Stage
II
nREM
Follows stage I; low-voltage EEG with sleep

spindles and K complexes; 45%55% of sleep
Stage
III
nREM
Consists of 20%50% high-amplitude delta

waves, referred to as delta or slow wave sleep;
4%6% of sleep
Stage
IV
nREM
Consists of >50% of high-amplitude delta

waves and is also called slow wave sleep;
12%15% of sleep
Stage
Low-voltage, mixed frequency, nonalpha

activity with rapid eye movements, called
REM
paradoxical sleep; 20%25% of sleep
Sleep
offset
Transition from sleepfulness to wakefulness,

alpha and beta activity, also called awakening
*Sleep staging is done in 30-second epochs.
Classification of Tests
The f ull PSG includes t he f ollow ing t est s:
1. Elect roencephalogram (EEG ): at least 2 channels are recorded t o det ermine
sleep onset , sleep st ages, and sleep off set .
2. Elect ro-oculogram (EO G ): document s bot h slow rolling and rapid eye
movement s seen at sleep onset and in REM sleep, respect ively.
3. Elect romyogram (EMG ): t he chin EMG is used as a crit erion f or REM sleep;
t he leg EMG is used t o evaluat e periodic leg movement s or leg jerks.
4. Elect rocardiogram (ECG ): monit ors heart rat e and rhyt hm.
5. Chest impedance: monit ors respirat ory eff ort by use of
cardiopneumot achographs, st rain gauges, or piezoelect ric cryst al belt s.
6. Airf low monit ors: t hermist ors or t hermocouples are used t o monit or
oral/ nasal airf low.
7. Capnography end-t idal CO2 (ETCO 2 ): cont inuous monit oring of carbon
dioxide.
8. Pulse oximet ry (SpO2 ): cont inuous monit oring of art erial oxygen sat urat ion by
noninvasive means.
9. Snoring sensor: microphone placed just below t he jaw and lat eral t o t he
t rachea.
10. pH met er: pH probe placed in t he low er t hird of t he esophagus t ransnasally
t o monit or episodes of gast ric ref lux
11. Audio/ video recordings: document rest less sleep, sleep w alking, sleep
t alking, and night t errors, among ot her condit ions
The 4-channel limit ed PSG includes t he f ollow ing t est s:
1. Elect rocardiogram (ECG )

2. Chest impedance
3. Airf low monit oring
4. Pulse oximet ry
Polysomnography (PSG) The PSG determines

underlying sleep disorder pathology, provides
qualitative and quantitative measurements associated
w ith the disorder, and provides information upon w hich
to base the proper course of treatment. PSG is
indicated for persons complaining of daytime
sleepiness, fatigue, inability to stay on task, falling
asleep at inappropriate times, insomnia, nocturnal
aw akenings, w aking w ith gasping or choking feelings,
w itnessed sleep-related apneas, abnormal snoring
patterns, and any other unexplained symptoms
associated w ith disruption of normal sleeping patterns
that have persisted for 6 to 12 months.
Reference Values
Normal
Elect roencephalogram (EEG ): normal sleep onset t ime, sleep st ages, and sleep
off set (going f rom sleepf ulness t o w akef ulness [ ie, aw akening] )
Airf low monit ors: evidence of sust ained airf low t hroughout t he night Elect rooculogram (EO G ): normal slow, rolling movement s at sleep onset ; rapid eye
movement during REM sleep Capnography end-t idal CO2 (ETCO 2 ): normocapnic
(3545 mm Hg during t he aw ake st at e, increasing a couple of mm Hg during
sleep) Elect romyogram (EMG ): absence of periodic leg movement s or jerks
Pulse oximet ry (SpO2 ): >90%
Snoring sensor: absence of abnormal pat t erns of snoring Elect rocardiogram
(EEG ): absence of rhyt hmic dist urbances, bradycardias, or t achycardias
Audio/ video recordings: absence of rest less sleep, sleep w alking, sleep t alking,
and night t errors, among ot her condit ions Chest impedance: evidence of
sust ained respirat ory eff ort t hroughout night Respirat ory dist urbance index
(RDI ): adult s <5 apneas/ hypopneas per hour (af t er age 60, <10
apneas/ hypopneas per hour) O xygen desat urat ion index (O DI ): adult s <5 t imes
per hour (SpO2 < 90%)
Procedure
1. I nst ruct t he pat ient t o keep a sleep log f or 1 t o 2 w eeks bef ore t he
polysomnogram (PSG ).
2. Remind pat ient t hat on t he day of t he st udy, caff einat ed beverages, alcohol,
and sedat ives are not permit t ed.
3. Be aw are t hat ext ra t ime is needed t o set up and at t ach equipment t o t he
pat ient . Typically, t he PSG is recorded during t he pat ient 's normal sleep
t ime; how ever, part ial or ext ended periods of sleep deprivat ion may be
necessary if seizure act ivit y is suspect ed.
4. Be aw are t hat t he sleep t echnologist records t he pat ient 's hist ory and
f act ors such as age, height , w eight , current medicat ions, visual problems,
and hist ory of seizures, head injuries, headaches, or st rokes. The sleep log
is review ed, and a bedt ime quest ionnaire is complet ed. The pat ient w ears
normal bedt ime at t ire.
5. Use t he f ollow ing list t o ident if y t he monit oring equipment used:
a. Tw o set s of scalp elect rodes t o monit or sleep st ages (EEG )
b. O ne elect rode t o t he out er cant hus of each eye (EO G )
c. O ne elect rode t o t he chin (subment al)
d. Elect rodes t o t he legs (ant erior t ibialis; EMG )
e. ECG leads f or heart rhyt hms and rat es
f. I mpedance monit or (respirat ory eff ort )
g. O ral/ nasal t hermist or bet w een nose and upper lip (air f low )
h. Pulse oximet er (SpO2 ; O2 sensor)
6. Af t er applicat ion, int erf ace all elect rode leads w it h a jack box, w hich
cont ains t he preamplif iers and impedance met er. From t he jack box, signals
are sent t hrough addit ional amplif iers and f ilt ers and f inally t o a mult ichannel
recorder or polygraph. The polygraph can provide a hard copy recording of
all channels and signals t hat can be comput er processed and displayed on a
monit or. Elect rode connect ions are subsequent ly t est ed f or int egrit y and
adjust ment s made bef ore t he pat ient ret ires.
7. Be aw are t hat during t he recording, bot h audio and inf rared camera video
recordings are made.
8. Provide a bedside commode because t he leads are relat ively short .

9. When t he t est is complet ed and equipment removed f rom t he pat ient , ask t he
pat ient t o complet e anot her quest ionnaire; score relat ed t o t he pat ient 's
sleep experience during t he t est .
NOTE
I f seizures are a f act or, up t o 16 addit ional scalp elect rodes are applied
according t o t he I nt ernat ional 10-20 Syst em of Elect rode Placement . The
I nt ernat ional 10-20 Syst em of Elect rode Placement is t he convent ional syst em
(est ablished in 1958) used t o ident if y and place scalp surf ace elect rodes f or
t he recording of brain elect rical pot ent ials. The 10-20 Syst em nomenclat ure is
used because most of t he elect rodes are placed eit her 10% or 20% bet w een
specif ic skull landmarks (eg, t he nasion or inion) or in relat ion t o t he
circumf erence of t he head.
Clin ical Alert A h ome sleep stu dy is an altern ative for patien ts
w h o h ave trou ble fallin g asleep in a laboratory. Sen sors are
applied in th e clin ic, an d th e patien t is sh ow n h ow to attach
th e mobile mon itorin g u n it.
Interfering Factors
1. Caff einat ed beverages and alcohol can delay sleep onset or exacerbat e
some t ypes of sleep disorders.
2. Sedat ives (hypnot ics) short en sleep onset and reduce noct urnal aw akenings,
w hich may skew t he result s of t he PSG .
3. Changes in daily rout ine on t he day of t he sleep st udy may cause f alseposit ive or f alse-negat ive result s.
4. During t he PSG , environment al noise, light s, and t emperat ure may have an
adverse eff ect on t he pat ient 's abilit y t o f all asleep.
1. Abnormal EEG recordings indicat e problems w it h eit her sleep archit ect ure
(eg, sleep onset , st ages, off set ) or seizure disorders.
2. Abnormal leg EMG is consist ent w it h movement disorders (eg, rest less-leg
syndrome, noct urnal myoclonus, leg jerks).
3. A respirat ory sleep index (RDI ) > 5 indicat es sleep-disordered breat hing.
O bst ruct ive sleep apnea (O SA) is charact erized by absence of airf low f or >
10 seconds despit e cont inued respirat ory eff ort (eg, t horacic breat hing or
snoring accompanied by periods of apnea). Cent ral sleep apnea (CSA) is
charact erized by absence of bot h airf low and respirat ory eff ort ; airf low
ceases because respirat ory eff ort is absent . Mixed sleep apnea (MSA)
generally begins as a cent ral apnea and becomes obst ruct ive apnea.
Sleep apnea has been linked w it h cardiac arrest , st rokes, pulmonary
hypert ension, brain st em lesions, and head t rauma.
4. An oxygen desat urat ion index (O DI ) > 5 is associat ed w it h oxygen
desat urat ion, w hich generally occurs w it h an apneic event but can also occur
w it h hypovent ilat ion.
Interventions
1. Explain t est purpose and procedure. These t est s are done w hen signs and
sympt oms have persist ed f or at least 6 t o 12 mont hs. Caut ion t he pat ient not
t o change his or her daily rout ine t he day bef ore t he t est .
2. Reassure t he pat ient t hat lead w ires, monit ors, and sensors w ill not int erf ere
w it h changes of posit ion during sleep.
3. Record t he pat ient 's age, height , w eight , and gender. A brief hist ory and
bef ore- and af t er-bedt ime quest ionnaires are t aken.
4. Have t he pat ient prepare f or sleep at t he normal t ime according t o rout ine
and discont inue any medicat ions used t o help w it h sleep.

1. Have pat ient resume usual act ivit ies and rout ines.
2. I nt erpret t est out comes and monit or appropriat ely. I f t est result s indicat e
O SA, explain possible need f or f urt her t reat ment .
Sleepiness Tests; M ultiple Sleep Latency Test (M SLT);

M aintenance of Wakefulness Test (M WT) The multiple
sleep latency test (M SLT) is used as an objective
measure of excessive daytime sleepiness and
determines its severity. Typically, the M SLT is
administered the morning follow ing sleep study. An
alternative to this test is the maintenance of

w akefulness test (M WT), w hich measures the ability of
an individual to stay aw ake rather than to fall asleep.
Both the M SLT and M WT are used to diagnose
narcolepsy and to evaluate the effectiveness of
pharmacologic interventions in the treatment of
daytime hypersomnolence. Indications for these tests
include falling asleep at inappropriate times, daytime
hypersomnolence, suspected narcolepsy, and
evaluation of drug effectiveness in treating various
sleep disorders.
The MSLT is an object ive measure of a pat ient 's sleepiness and is done t o
evaluat e t he severit y of dayt ime sleepiness, t o diagnose narcolepsy or f alling
asleep at inappropriat e t imes, and t o evaluat e eff ect iveness of drug t herapy f or
dayt ime hypersomnolence. The MSLT is administ ered af t er a sleep st udy t o rule
out any sleep-relat ed pat hology t hat might aff ect t he result s and t o assess t he
qualit y of sleep. An alt ernat ive t o t he MSLT is t he MWT, w hich measures t he
abilit y of a person t o st ay aw ake rat her t han t o f all asleep.
The MSLT includes t he f ollow ing t est s:
1. EEG : at least 2 channels are recorded t o det ermine sleep onset , sleep
st ages, and sleep off set .
2. EO G : t o document bot h slow and rapid eye movement s present at sleep
onset and during REM sleep, respect ively
3. EMG : t he chin EMG is used as a crit erion f or REM sleep.
4. ECG : t o monit or heart rat e and rhyt hm
The MWT includes t he f ollow ing t est s:
1. Elect romyogram (EMG ): t he chin EMG is used as a crit erion f or REM sleep.
2. Elect rocardiogram (ECG ): t o monit or heart rat e and rhyt hm
FI G URE 16. 10 Pat ient report noct urnal polysomnogram (st at ist ical port ion).
(Court esy: Cent er f or Sleep Disorder Medicine, Froedt ert Hospit al,
Milw aukee, WI , USA)
Reference Values
Normal
MSLT: average sleep lat ency is 10 t o 20 minut es MWT:
Average sleep lat ency on t he 40-minut e t est is 35 minut es Average sleep lat ency
on t he 20-minut e t est is 18 minut es
Procedure
1. Remember t hat t ypically, t he MSLT or MWT is administ ered t he morning

f ollow ing a sleep st udy. Follow ing t he sleep st udy, have t he pat ient dress,
eat (avoiding caff eine), and report back t o t he sleep laborat ory.
2. Reapply t he elect rodes if necessary.
FI G URE 16. 11 Pat ient report noct urnal polysomnogram (int erpret at ion
port ion). (Court esy: Cent er f or Sleep Disorder Medicine, Froedt ert
Hospit al, Milw aukee, WI , USA)
3. Be aw are t hat t he f irst nap (f or t he MSLT) or f irst session (f or t he MWT) w ill

begin 1. 5 t o 2 hours af t er morning aw akening, w it h a minimum of f our
addit ional naps or sessions at 2-hour int ervals t hroughout t he day.
4. Terminat e t he nap or session af t er 20 minut es f or t he MSLT, or af t er 20 t o
40 minut es f or t he MWT. Wit h t he MSLT t est , if t he pat ient f alls asleep,
cont inue t he recording f or 15 minut es af t er sleep onset .
5. I nst ruct t he pat ient t o allow himself or herself t o f all asleep or not t o resist
t he urge t o f all asleep f or t he MSLT, w hereas f or t he MWT, inst ruct t he
pat ient t o resist t he urge t o sleep or t o at t empt t o remain aw ake.
6. Bet w een t he naps or sessions, ensure t hat t he pat ient remains aw ake and
encourage moving around.
7. Follow ing t he t est ing, disconnect all equipment and discharge t he pat ient .
8. Have t he t echnologist score t he MSLT or MWT in conjunct ion w it h t he PSG
t est result s.
NOTE
The t erm nap indicat es a short int ent ional or unint ent ional episode of
subject ive sleep t aken during habit ual w akef ulness, w hereas t he t erm f alling
asleep or sleep onset is def ined object ively by elect roencephalographic
recordings (EEG ) (ie, st age 1 of nREM sleep).
Interfering Factors
Caff einat ed beverages can delay sleep, w hereas sedat ives (hypnot ics) short en
sleep onset . Addit ionally, sleep deprivat ion may result in a f alse-posit ive MSLT
result . During naps, environment al noise, light s, and t emperat ure can have an
adverse eff ect on t he pat ient 's abilit y t o f all asleep.
1. An average sleep onset of 6 t o 9 minut es in t he MSLT is considered a gray
area diagnost ically because t hese t est s are done in a laborat ory set t ing and
not in t he pat ient 's home environment . Reevaluat ion may be necessary if t he
pat ient complains and sympt oms persist .
2. An average sleep onset < 5 minut es and t w o or more REM periods in t he f ive
t o six naps during t he MSLT is diagnost ic f or narcolepsy. This indicat es a
dist urbance of t he normal sleep archit ect ure pat t ern, alt hough t he REM
periods are not unlike noct urnal REM periods. These REM episodes,
how ever, occur premat urely in t he cycle and are t ermed sleep-onset REMs
(SO REMs).
Interventions
1. Explain MSLT or MWT purpose and procedure. Remind t he pat ient not t o
change daily rout ines t he day of t est ing.
2. Reassure t he pat ient t hat lead w ires, monit ors, and sensors w ill not int erf ere
w it h sleep.
3. Record t he pat ient 's age, height , w eight , and gender.
4. Remind pat ient t hat no alcohol or caff einat ed beverages should be consumed
t he day of t he t est .
5. Administ er st andard sleep quest ionnaires or scales (eg, Epw ort h Scale,
St anf ord Scale) and evaluat e (see Appendix H f or examples).
care.

1. Explain t est out come and possible need f or f ollow -up t est ing.
Nasal Continuous Positive Airw ay Pressure (nCPAP)

Titration Follow ing the diagnosis of OSA, this test is
done before treatment is begun. The nCPAP machine
supplies air under pressure, acting as a pneumatic
splint that keeps the upper airw ay open during sleep.
The pressure required depends on the severity of the
OSA and can vary; therefore, the patient is typically
required to return to the sleep laboratory on a second
night to repeat the sleep study (PSG) w hile w earing an
nCPAP mask. Positive airw ay pressures are increased
until the apneas break. This procedure is referred to
as nCPAP titration. Under some circumstances (eg,
severe sleep apnea), titration can be done on the same
night as the PSG. In that case, it is termed a splitnight study. The nCPAP machine provides continuous
positive pressure during both inspiration and
expiration. Conversely, bilevel positive airw ay pressure
(nBiPAP) uses tw o separate pressures: one during
inspiration and a low er pressure during expiration. In
cases in w hich nCPAP is not w ell tolerated, nBiPAP may
be a better alternative. An nCPAP unit may be used in
the home and preset to the test pressures that
ameliorated the apneas.
Reference Values
Normal
Elect roencephalogram (EEG ): normal t ime t o sleep onset , sleep st ages, and
sleep off set Chest impedance: evidence of cont inuous respirat ory eff ort
t hroughout t he night Elect ro-oculogram (EO G ): normal slow, rolling movement s
at sleep onset and rapid eye movement during REM sleep Airf low monit ors:
evidence of cont inuous airf low t hroughout night Elect romyogram (EMG ):
subment al chin placement used as a crit erion f or REM sleep Capnography endt idal CO2 (ETCO 2 ): normocapnic (3545 mmHg during w akef ulness, w hich may
increase a couple of mmHg during sleep) Elect rocardiogram (ECG ): Absence of
rhyt hmic dist urbances or bradycardias/ t achycardias Pulse oximet ry (SpO2 ):
>90%
Respirat ory dist urbance index (RDI ): <5 apneas/ hypopneas per hour O xygen
desat urat ion index (O DI ): <5 t imes per hour (SpO2 <90%)
Procedure
1. O n t he day of t he t it rat ion, inst ruct t he pat ient t o avoid caff einat ed
beverages, alcohol, and sedat ives, and t o keep a sleep log.
2. Allow suff icient t ime bef ore t est ing t o at t ach t he pat ient t o t he monit oring
devices and ot her equipment , including t he nCPAP machine. A brief
orient at ion t o nCPAP should t ake place bef ore t he act ual day of t it rat ion t o
relieve t he pat ient 's anxiet y.
3. Remember t hat t he sleep t echnologist t akes a brief pat ient hist ory. The sleep
log is review ed, and a bedt ime quest ionnaire is complet ed (see Appendix H).
The pat ient t hen prepares f or sleep.
4. Have t he t echnologist apply t he elect rodes, monit ors, sensors, and
microphone, and int erf ace t hese w it h t he ot her elect ronic devices (see
Polysomnography [ PSG ], page 1067).
5. Fit t he pat ient w it h an nCPAP mask and ensure t hat it can be easily removed
in case of discomf ort , short ness of breat h, or claust rophobia.
6. Provide a bedside commode because t he leads are relat ively short .
7. Adjust CPAP pressures t hroughout t he sleep period, beginning w it h 3 t o 5 cm
H2 O and increasing in 2. 5-cm H2 O increment s unt il t he apneas break. Time
increment s can vary f rom 15 minut es t o 2 hours per pressure set t ing.
Decisions are based on prot ocols being used, severit y of sleep apnea, and
pat ient t olerance f or t est ing. I f nBiPAP is being perf ormed, inspirat ory and
expirat ory pressures are adjust ed separat ely, keeping t he inspirat ory
pressure at least 2 t o 4 cm H2 O above t he expirat ory pressure.
8. Af t er t he t est , remove t he equipment and have t he pat ient complet e anot her
quest ionnaire, w hich t he sleep t echnologist evaluat es and scores.
Interfering Factors
1. Caff einat ed beverages and alcohol can delay sleep onset or exacerbat e
O SA, w hich may int erf ere w it h det ermining opt imal pressure set t ings.
2. Changes in t he pat ient 's daily rout ine on t he day of t it rat ion can alt er result s.
FI G URE 16. 12 Pat ient report split night noct urnal polysomnogram
(st at ist ical port ion). (Court esy: Cent er f or Sleep Disorder Medicine,
Froedt ert Hospit al, Milw aukee, WI , USA)
FI G URE 16. 13 Pat ient report split night noct urnal polysomnogram
(int erpret at ion port ion). (Court esy: Cent er f or Sleep Disorder Medicine,
Froedt ert Hospit al, Milw aukee, WI , USA)
3. Pat ient s w it h a deviat ed nasal sept um or chronic sinusit is may have problems
t olerat ing t he nCPAP. The use of nCPAP is cont raindicat ed in persons w it h
severe bullous emphysema or chronic perf orat ed t ympanic membrane.
4. Skin irrit at ions f rom t ight -f it t ing masks (especially on t he bridge of t he nose),
nasal congest ion, and headaches are occasional complaint s w it h t he use of
nCPAP.
5. The benef it of nCPAP t o pat ient s w it h cent ral sleep apnea has not been w ell
document ed.
1. An RDI > 5 indicat es O SA, w hich is charact erized by t he absence of airf low
f or > 10 seconds in t he presence of cont inued respirat ory eff ort . nCPAP
used in t reat ing O SA has been show n t o be clinically benef icial.
2. Follow ing even short -t erm nCPAP use, t here is document ed evidence of rapid
sympt omat ic improvement , w it h rest orat ion of noct urnal sleep and
subsequent improvement in lessening of dayt ime sleepiness and improving
qualit y of lif e.
Interventions
1. Explain t est purpose and nCPAP t it rat ion procedure.
2. Reassure pat ient s t hat t he mask can easily be removed if anxiet y or
claust rophobia develops.
3. Record t he pat ient 's age, height , w eight , and gender. A brief hist ory is t aken,
and bef ore- and af t er-bedt ime quest ionnaires are f illed out .
4. Have t he pat ient prepare f or sleep at t he normal t ime in t he usual manner.

1. Explain t est out come and possible need f or f ollow -up t est ing and t reat ment .
Depending on t he t est out come, an nCPAP unit may be ordered f or home
use.
Gastric Analysis (Tube Gastric Analysis); Gastric Fluids

This test examines stomach contents for abnormal
substances and also measures gastric acidity. It aids in
diagnosing ulcers, obstructions, pernicious anemia, or
carcinoma of the stomach. It can determine the cause
of gastrointestinal bleeding as w ell as the effectiveness
of medical or surgical therapies. Examinations of
gastric w ashings (eg, tuberculosis studies) can identify
mycobacterial infection w hen previous sputum tests
have been negative.
Reference Values
Normal
Fluid: clear or opalescent ; no f ood, blood, drugs, or bile present in sample.
pH: 1. 53. 5
Cult ure: negat ive f or mycobact erial organisms Fast ing specimen t ot al acidit y: <2
mEq or <2 mmol/ L
Basal acid out put (BAO ) w it hout st imulat ion: 05 mmol/ hour or 05 mmol/ hour
Maximal acid out put (MAO ) or normal secret ory abilit y w hen using a gast ric
st imulant such as hist amine or bet azole hydrochloride int ramuscularly or
pent agast rin subcut aneously: 1020 mEq or 1020 mmol/ hour
BAO -t o-MAO rat io: 1: 2. 5 t o 1: 5
Procedure
1. Collect f ast ing gast ric analysis specimens during endoscopy (see Chapt er
12) or t hrough a nasogast ric (NG ) t ube insert ed f or t he t est . Follow NG t ube
inst it ut ional prot ocols.
2. Aspirat e init ial gast ric acid t hrough t he NG t ube w it h a syringe, t est f or pH,
and discard. I f no acid is present , reposit ion t he NG t ube and obt ain anot her
specimen.
3. Remember t hat specimens are normally collect ed via cont inuous int ermit t ent
low suct ion over 1 t o 2 hours at 15-minut e int ervals, depending on t he t ype
of gast ric st imulant given. Each specimen is placed in a separat e specimen
cup and labeled BAO or MAO , along w it h pat ient 's name, dat e, and t ime
collect ed.
4. Remove t he NG t ube af t er all specimens are collect ed.
5. Document t he dat e and t ime; t ype of procedure; t ype and size of t ubes used;
number of specimens collect ed; appearance, consist ency, and measured
volumes of gast ric f luid obt ained; t he pat ient 's response t o t est ing;
complicat ions; int ervent ions; and ot her pert inent inf ormat ion.
1. Decreased l evel s of gast ric acid (hyposecret ion and hypochlorhydria) occur
a. Pernicious anemia
b. G ast ric malignancy
c. At rophic gast rit is
d. Adrenal insuff iciency
e. Vit iligo
g. Thyroid t oxicosis
h. Chronic renal f ailure
i. Post vagot omy
2. Increased l evel s of gast ric acid (hypersecret ion and hyperchlorhydria) occur
a. Pept ic or duodenal ulcer
b. Zollinger-Ellison syndrome
c. Hyperplasia and hyperf unct ion of ant ral gast ric cells
d. Post small int est ine resect ion
Interfering Factors
1. Lubricant s or barium f rom previous t est s present in sample aff ect s t he
result .
2. Medicat ions such as ant acids or hist amine blockers, f oods, and smoking
alt er gast ric secret ions.
3. G ast ric secret ions are alt ered in pat ient s w it h diabet es w ho use insulin or in
t hose w ho have had surgical vagot omy.
4. Elderly pat ient s have low er levels of gast ric hydrochloric acid.
Interventions
1. Assess f or cont raindicat ions t o t he procedure, including carcinoid syndrome,
congest ive heart f ailure, recent myocardial inf arct ion, or hypert ension. The
use of hist amine may exacerbat e t hese condit ions.
2. Explain t est purpose and procedure. I nf orm pat ient t hat t here may be some
discomf ort and possibly a gagging sensat ion w hen t he nasogast ric t ube is
insert ed and t hat a gast ric st imulant may be inject ed. Devise a met hod of
communicat ion f or t he pat ient bef ore insert ion of NG t ube (eg, raise index
f inger t o indicat e w ait bef ore proceeding). Explain t hat pant ing, mout h
breat hing, and sw allow ing f acilit at e t ube insert ion.
3. Record baseline vit al signs. Remove dent ures bef ore t est .
4. Have t he pat ient f ast f rom f ood, f luids, smoking, and gum chew ing f or at
least 8 t o 12 hours bef ore t est ing.
5. Rest rict or w it hhold ant icholinergic agent s, cholinergic agent s, adrenergic
blockers, ant acids, st eroids, alcohol, and caff eine f or at least 24 hours
bef ore t est ing. Check w it h t he clinician w ell bef ore t he procedure.
Clin ical Alert

1. I f hist amine is inject ed, t he pat ient may experience f lushing, dizziness,
headache, f aint ness, and numbness of t he ext remit ies and abdomen during
or immediat ely af t er t est ing. These sympt oms must be report ed
immediat ely. Have epinephrine easily available.
2. Specimens f or acid-f ast bacillus (AFB) and t uberculosis (TB) cult ures must
be w arm and should be t aken t o t he laborat ory immediat ely. Laborat ory
personnel should be alert ed.

1. Monit or vit al signs. O bserve f or possible drug side eff ect s, gast roint est inal
bleeding, or respirat ory dist ress (gast roint est inal bleeding may signal
perf orat ion).
2. Provide nasal and oral care af t er t ube removal. Allow pat ient t o rest . Provide
f ood or f luids as t olerat ed and ordered. I f a local anest het ic w as used on t he
t hroat , assess f or ret urn of gag and sw allow ref lexes bef ore allow ing pat ient
t o drink or eat (usually 2 hours post administ rat ion. )
3. I nt erpret t est out comes. Counsel pat ient regarding possible lif est yle
alt erat ions such as smoking cessat ion, rest rict ed alcohol int ake, diet ary
changes, st ress reduct ion, medicat ion, medical t reat ment , or surgical
int ervent ion.
DNA Typing or Fingerprinting

Deoxyribonucleic acid (DNA) is a complex, high-molecular-w eight prot ein
composed of deoxyribose, phosphoric acid, and f our bases (adenine, guanine,
t hymine, cyt osine). These six subst ances are arranged in t w o long chains t hat
t w ist around each ot her t o f orm a double helix. The complement ary component s
on each of t hese t w o chains link t oget her bet w een t he chains. The nucleic acid
component is present in t he cell nuclei chromosomes and f orms t he chemical
f oundat ion f or heredit y. I t carries t he genet ic mat erial f or every living organism
except RNA viruses. DNA provides t he act ual code f or individual genet ic
charact erist ics t hrough a specif ic sequence, or blueprint , t hat is unique t o t hat
person alone.
DNA t est ing is used t o est ablish ident it y (ie, milit ary and disast er casualt ies), t o
det ermine parent age (ie, inf ant abduct ions), and during immigrat ion disput es and
criminal invest igat ions (ie, murder, sexual abuse, rape) t hrough a process t ermed
restri cti on f ragment l ength pol ymorphi sm (RFLP). This process allow s evaluat ion
of diff erent DNA t issue samples f rom several sources t o det ermine mat ching
pat t erns, similar t o comparing bar codes. Polymerase chain react ions (PCR)
t echniques have become w idely popular and have advant ages over previous
t echniques. Less DNA is required, and t yping can of t en be done w it h part ially
degraded DNA.
Reference Values
Normal
Specif ic and unique t o each person
Each person has a unique DNA prof ile.
Procedure
1. Remember t hat DNA can be ext ract ed f rom dried w hole blood or any t issue
t hat cont ains nucleat ed cells (eg, skin, saliva, hair shaf t s, urine, semen. )
More cellulary dense t issues produce more DNA. Bone and t eet h are t he
most st able sources f or post mort em DNA.
2. Collect venous blood samples in a yellow -t opped (ACI ) t ube or lavendert opped (EDTA) t ube. For t issue samples, 0. 11. 0 gram of t issue is obt ained
and placed in a plast ic f reezing bag. Freeze t issue samples, and keep f rozen
unt il shipped in dry ice. Do not f reeze blood samples.
3. Process DNA samples unt il DNA f ragment s can be visually represent ed on xray f ilm. These f ilms are called autoradi ographs or autorads. At t his point ,
t he f ragment s somew hat resemble bar codes.
4. Compare t he aut orads f or mat ching or nonmat ching charact erist ics among
several samples. I f a mat ch bet w een t w o or more diff erent aut orads is
f ound, t here exist s a high probabilit y t hat t he diff erent samples come f rom
t he same source person.
Clin ical Alert

1. The DNA samples are collect ed and st ored using great care w it h prist ine
equipment t o prevent cont aminat ion and preserve specimen t hat may have
crucial legal implicat ions.
2. Samples of DNA can be st ored f or indef init e periods.
1. I dent it y is conf irmed w hen t here are mat ching pat t erns in cert ain areas of
t he aut orads. Adhere t o caut ion w hen collect ing and st oring DNA specimens
t o prevent cont aminat ion and t o preserve t he specimens, w hich may have
crucial legal implicat ion.
2. I n parent age st udies, even t hough each person has a unique DNA prof ile,
mat ching charact erist ics in cert ain areas of aut orads t hat come f rom t w o
diff erent individuals can indicat e a parent child relat ionship.
3. I n criminal cases, mat ching DNA charact erist ics associat ed w it h t issue
samples ret rieved f rom bot h vict im and suspect may est ablish t he suspect 's
presence at t he crime scene. A nonmat ch def init ively disproves t hat t he

diff erent samples came f rom t he same person.
Interfering Factors
1. I nsuff icient amount of DNA
2. DNA t issue sample det eriorat ion/ degradat ion
3. Lack of mat erial dat abase t o conduct eff ect ive sample comparison
Interventions
1. Explain t he DNA t est purpose and procedure w it h t he concerned individual
and f amily members, being mindf ul of privacy and conf ident ialit y.
2. Be aw are t hat t here must be no t ransf usion 90 days bef ore t est ing.
Clin ical Alert

1. Communicat e result s in conf idence.
2. DNA specimen collect ion ident if icat ion, packaging, and st orage are
ext remely import ant . I n f orensic st udies, t he issue of chain of cust ody
arises.

1. Counsel appropriat e persons about t he meaning of t est result s.
POSTM ORTEM TESTS

I t is t he basic civil right of deceased human beings t o have compet ent medical
invest igat ions of t heir deat hs. This is part icularly t rue in our 21st cent ury
environment of social ills, drug use, crime, violence, biot errorism, and genet ic
relat ionships t o disease and mort alit y among all sociocult ural and polit ical
classes. Any deat h has pot ent ial civil, legal, criminal, or economic implicat ions
f or t he deceased, t he f amily and signif icant ot hers, and societ y globally.
As w it h est ablishing a medical diagnosis f or a living person, t he medical model is
similarly execut ed in developing a post mort em diagnosis. A hist ory is t aken,
consist ing of medical hist ory, risk f act ors, and deat h int erpret at ion; a physical
examinat ion is perf ormed (ie, aut opsy); and laborat ory t est s are int erpret ed
(t issue, organ, post mort em blood, and ot her body f luids such as vit reous f luids,
urine, bile, CSF, or gast ric cont ent s).
Death Investigation
All deat hs, w het her f rom a nat ural sequence of event s, during medical t reat ment ,
in unexplained circumst ances, or criminally relat ed, need t o be invest igat ed
regarding cause and manner of deat h so t hat t he legal deat h cert if icat e may be
accurat ely complet ed, signed, and recorded. Deat hs can be def ined as nat ural or
medical-legal: Natural death is t he cessat ion of cardiorespirat ory f unct ion due t o
a medical disease process (eg, met ast at ic cancer, cerebrovascular accident ) or
nat ural progression of lif e event s (ie, old age).
Medi cal -l egal death result s f rom some unnat ural (unexpect ed, unusual, or
suspicious) event such as homicide, suicide, or accident ; t his sit uat ion is
specif ically governed by legal st at ut es and requires t hat a coroner, medical
examiner, and law enf orcement off icials be involved.
Death Interpretation
The process of post mort em examinat ion and int erpret at ion f ollow s a cert ain
def ined prot ocol. First , t he hist ory port ion of t he invest igat ion is obt ained. I n
nat ural deat h w it hout aut opsy, t he medical hist ory, diagnost ic t est s bef ore deat h,
clinical record, and know ledge about lif est yle can provide reasonably suff icient
inf ormat ion t o arrive at conclusions regarding cause and manner of deat h. O nly
aut opsy, how ever, can def init ively conf irm t hese suspicions and init ial
conclusions. Medical-legal deat h invest igat ion f irst f ocuses on t he deat h scene.
I nt erview s lay t he groundw ork f or t he invest igat ion. Evaluat ion of t he sit e of
deat h and ot her physical evidence involves a det ailed examinat ion of blood
st ains, disrupt ed environment , posit ion of body, and
signs of st ruggle or injury manif est ed by f luids leaking f rom body orif ices, eyes,
ears, nose, or mout h. Color changes and rigidit y can be benef icial in est ablishing
t ime f rames f or event s. I nt erview s of know n w it nesses are a part of t he

invest igat ion.
Clin ical Alert

Post mort em examinat ion f alls under t he domain of t he physician pat hologist . I n
criminal cases, f orensic pat hologist s w ho have specialized know ledge, skills,
and st at e-of -t he-art invest igat ive t echniques at t heir disposal should perf orm
t he aut opsy.
The second part of t he deat h int erpret at ion process involves t he aut opsy it self .
The aut opsy consist s of a det ailed comprehensive physical examinat ion of bot h
ext ernal and int ernal body f eat ures of t issues, organs, and f luids.
Clin ical Alert

I n t he case of a medical-legal aut opsy, samples of organs and specimen
sect ions (slides) should be ret ained f or 3 t o 5 years pending out comes of
lit igat ion and legal syst em appeals. Phot ographs should accompany report s
and should be archived.
Time of Death
Alt hough t ime of deat h is usually not a major issue, det erminat ion of t ime of
deat h is import ant in bot h nat ural deat hs (f or insurance and ot her deat h benef it s)
and unnat ural deat hs, eit her w it nessed or w hen body part s have been nat urally
or int ent ionally alt ered so t hat an individual's dist inguishing f eat ures are alt ered.
Time of deat h est imat e is based on presence of t he f ollow ing:
1. Ri gor morti s. St iff ening of body as pH changes and lack of adenosine
t riphosphat e in muscles occur; rigidit y appears anyw here f rom inst ant ly t o 6
12 hours af t er deat h.
2. Li vor morti s. Red-purple color caused by set t ling of blood in dependent body
part s due t o gravit y; onset immediat e, somet imes beginning bef ore deat h
(maximum in 812 hours).
3. Al gor morti s. Cooling of body; body t emperat ure is subject t o int erpret at ion,
based on cocaine use, presence of inf ect ion or f ever bef ore deat h, deat h
scene, heat absorpt ion, amount and t ype of clot hing, size of body, act ivit y
just bef ore deat h, and decomposit ion.
4. Decomposi ti on. Processes occur as a result of chemical breakdow n of cells
and organs due t o int racellular enzymes and put ref act ion due t o bact erial
act ion.
5. G astri c emptyi ng. Food in st omach; digest ion and st omach empt ying varies
in bot h lif e and deat h.
6. Chemi cal changes. Pot assium in vit reous f luid of t he eye; as t he t ime since
deat h becomes great er, t he concent rat ion of pot assium increases.
7. Insect acti vi ty. Flies and ot her insect s are associat ed w it h decomposed
bodies; any at t empt t o f ix t ime of deat h using insect evidence should be done
only w it h t he aid of an ent omologist .
Clin ical Alert

1. Time of deat h is expressed as an est imat e of t he t ime range during w hich
deat h could have occurred and varies according t o cooling of body, color
change, decomposit ion of st omach cont ent s, clinical changes, and insect
act ivit y.
2. There is no single accurat e marker of t ime of deat h.
When t he t ime int erval bet w een act ual deat h and t he init ial deat h invest igat ion is
mont hs or years, body changes may be quit e variable and can include
saponif icat ion of subcut aneous t issue (changes due t o prolonged exposure t o
moist ure t aking several mont hs); mummif icat ion
(drying process due t o lack of moist ure; occurs quickly in hot , dry climat e,
exposure t o air, dying of t hirst ); and skelet onizat ion (t akes mont hs t o years).
Examinat ion of bones may yield general know ledge of deceased (eg, est imat e of
age, st at ure, race, gender).
Physical evidence such as mail delivery, t elephone calls answ ered and
unansw ered, last cont act t imes can help t he deat h invest igat or est imat e t ime of
deat h.
Clin ical Alert

1. I f t he HI V st at us of decedent is not direct ly relat ed t o t he cause of deat h
or an exposure t o anot her, t he decedent 's HI V st at us need not be
recorded or report ed.
2. Some examiners may be reluct ant t o include HI V-posit ive inf ormat ion in
public record aut opsy report s out of compassion f or t he decedent 's f amily.
How ever, cert ain st at es require t hat every aut opsy done t hrough t he
medical examiner's off ice include an HI V t est . As w it h ot her issues of
conf ident ialit y, t he applicable law s must be obeyed; how ever, t he
pat hologist must make every eff ort t o prot ect t he pat ient 's and f amily's
right t o privacy t o t he degree t hat t he law w ill allow. Considerat ion of
exposure of t he decedent 's blood/ saliva/ body f luids t o ot her healt h care
w orkers, including EMTs, must be given.
Clin ical Alert

Cancer is report ed w hen t he cancer is f irst discovered or conf irmed upon
aut opsy.
The t hird st ep in deat h int erpret at ion includes collect ion of blood, bile, urine, and
ocular f luids (if available) f or analysis. Blood t oxicology st udies must be
perf ormed at a st at e-cert if ied laborat ory. Blood samples are t he only lif e/ deat h
det erminant s; urine samples provide inf ormat ion about levels of subst ances
excret ed, but t hey do not provide blood level values of t hese same subst ances.
Typical blood t oxicology screens include t he f ollow ing t est s:
1. Alcohol screens det ermine levels of various alcohols.
2. Acid-neut ral screens det ect barbit urat es and salicylat es.
3. Basic screens det ect t ranquilizers, synt het ic narcot ics, local anest het ics,
ant ihist amines, ant idepressant s, and alkaloids.
4. Higher volat ile screens use gas chromat ography t o det ect subst ances such
as t oluene, benzene, t richloroet hane, and t richloroet hylene.
5. Cannabis screens det ect t he presence of cannabis (marijuana).
All of t hese screens serve a purpose in cases t hat involve accident s and w orkrelat ed deat hs; t hey also serve t o rule out f oul play in ot herw ise nat ural deat hs.
Af t er t he lif e event s and scene invest igat ion, t he aut opsy, and t he laborat ory
t est s are complet ed, dat a f rom all sources are int egrat ed, scrut inized, and
analyzed. Findings and conclusions are t hen document ed and cert if ied on t he
deat h cert if icat e, w hich t hen becomes a mat t er of public record. Findings may
t hen be shared w it h t he decedent 's immediat e f amily, signif icant ot her, or legal
aut horit ies, or may become part of a court deposit ion process.
Autopsy
An aut opsy is an invest igat ion of t he cause and manner of deat h by direct
examinat ion of t he body. Cause of death is t he disease or injury t hat , t hrough it s
physiologic eff ect s, result s in t he
act ual deat h of t he individual. Manner of death is t he t ype of event t hat led t o
deat h and is cat egorized as nat ural, homicidal, suicidal, accident al, pending, or
undet ermined. I nt erpret at ion of physical f indings result s in set t ing f ort h an
opinion regarding t he probable cause of deat h. Bef ore aut opsy, as much
pert inent inf ormat ion as possible is gat hered about t he deceased. Available
medical records are review ed t horoughly. I n cases of medical-legal deat h
invest igat ion, not only t he medical and social background but also t he t erminal
event s and circumst ances of deat h, including t he environment , presence of drugs
and alcohol, and exact condit ion and posit ion of t he body, are t horoughly
invest igat ed (scene invest igat ion of physical evidence and personal cont act s).
Reference Values
Normal
Ext ernal and int ernal f indings: w it hin normal limit s or demonst rat e signif icant
pat hology relat ed t o cause of deat h G ross and microscopic f indings: w it hin
normal limit s or abnormalit ies relat ed t o cause of deat h No drugs, alcohol, or
ot her met abolit es present in laborat ory or t oxicology screens
Procedure
1. O bserve st andard precaut ions t hroughout . I dent if y t he body and t ag (usually
on t he great t oe) w it h t he decedent 's name (if available), gender, age, and a
number. The body is t hen w eighed and measured.
2. Phot ograph t he head and chest and mark w it h an ident if icat ion number. This
st ep occurs in nonhospit al, nonclinical inst it ut ion deat hs (eg, deat hs at home,
w ork, school, indust ry, roadw ay, w henever f oul play is suspect ed, and
w henever a 911 call result s in law enf orcement off icers at t he deat h scene).
I dent if icat ion marking of bodies is part icularly import ant in mass casualt y
disast ers such as plane crashes and building disast ers.
3. Describe and record inf ormat ion about clot hing and valuables. When t he
body is f ound by someone ot her t han a f amily member (eg, at w ork, highw ay
or airplane accident s), t hese it ems are removed, invent oried, and given t o
f amily or law enf orcement agency.
4. Take f ingerprint s only in criminal cases or in unident if ied vict ims.
5. Cleanse t he body. I n t rauma cases or unusual deat h f indings, t he f ace is
phot ographed again if blood, dirt , and ot her mat erials w ere present init ially.
6. Perf orm an ext ernal examinat ion on t he ent ire body. Record t he locat ion and
descript ion of all ident if ying marks, scars, t at t oos, incisions, injuries,
def ormit ies, and ot her signif icant f indings on a body diagram.
7. When f oul play is suspect ed, phot ograph all injuries f rom at least t w o view s:
one show ing t he locat ion of t he injury on t he body and t he ot her providing a
close-up view of t he injury. Take and record measurement s of w ounds.
8. Be aw are t hat in some inst ances, x-ray f ilms may be necessary t o verif y
gross anat omic def ormit ies, injuries (cervical spine and skull f ract ure), or
pat hologies t hat may provide clues regarding t he cause of deat h.
Radiography t racks t he t raject ory of bullet s and ot her project iles t hrough t he
ent ire body or just t hrough a specif ic area and may also be perf ormed on
exhumed organs or decomposed bodies. I n some inst ances, bodies may be
complet ely unrecognizable (eg, put ref ied beyond recognit ion). X-ray st udies
can det ermine age and can est ablish a vict im's ident it y by comparing bone
and dent al det ail t o previous x-ray f ilms and dent al x-rays of t he vict im.
9. Ensure t hat t he aut opsy proceeds in an orderly manner, observing st andard
precaut ions.
10. Document descript ions of color and dist inguishing f eat ures of t he hair and
eyes and appearance of t he nose, ears, mout h, t eet h, f ace, head, neck,
genit alia, t orso, and ext remit ies in det ail.
Examine t he f ront , side, and back of t he body t horoughly. I njuries, w ounds,
bruises, cont usions, and lacerat ions are described, mapped, measured, and
det ailed. I nclude descript ions of size, dept h, locat ion, and presence of
f oreign object s or mat erials at or near t he injured areas, as w ell as f luids
draining f rom body orif ices and w ounds, in t he report .
11. Be aw are t hat int ernal examinat ion includes a complet e head and pelvic
dissect ion w it h removal of all organs f rom t he skull, neck, abdomen, and
pelvis. Specif ic organs are subject ed t o gross examinat ion t hat includes
measurement of size and act ual w eight . O nce t his is done, t ake organ
sect ions and prepare f or microscopic slides t o be examined lat er. Save t he
slides f or evidence. Virt ually any part of t he body can be microscopically
examined. The brain and t he neck organs are alw ays removed and examined.
As part of t his examinat ion, t he dura mat t er is removed t o permit
visualizat ion of t he skull and calvarium t o det ermine injury or nat ural
pat hology.
12. Wit hdraw blood and f luid specimens by syringe f rom t he heart , aort a, eyes
(vit reous f luid), gallbladder (bile), and bladder (urine). Ref rigerat e t hese unt il
examined; t hey can be saved f or an indef init e period. I n t he inst ance of
t rauma, blood samples can be ret rieved f rom t he pulmonary t runk or t he
chest . I f clot s are present and syringe sampling cannot be done, pericardial
t apping is an alt ernat ive met hod of procuring a blood sample.
13. Be aw are t hat somet imes it is necessary t o collect specimens f or cult ure.
Most int ernal organs of previously uninf ect ed persons remain st erile f or
about 20 hours af t er deat h.
14. Ret urn t he organs t o t he body af t er examinat ion is complet ed. O rgans and
t issues may be donat ed f or t ransplant procedures.
15. Follow ing complet ion of aut opsy and possibly organ/ t issue procurement ,
release t he body immediat ely t o t he f uneral home f or burial or cremat ion per
f amily w ishes. I f t here are legal quest ions, t he body may be st ored in a
f rozen st at e f or some t ime (eg, mont hs).
Clin ical Alert

Evidence, w hich may include clot hing, a t oot hbrush, eyeglasses, and ot her
personal (physical evidence) it ems, should be t ransport ed t o t he proper
designat ed laborat ory as quickly as possible, and ref rigerat ed or f rozen if
delayed longer t han a w eek. Examples of unusual evidence mat erial t hat has
yielded successf ul DNA prof iles include:
From hands: aut omobile armrest , baseball cap brim, bot t le cap, chocolat e bar
(t he handled end), dime, doorbell, elect rical cord, ignit ion sw it ch, keys, pen,
seat belt buckle, shoelaces, gun (t rigger, st ock, handgrips), knif e handle,
hammer, w rench, screw driver, ice pick, and saw s
From mouth and nose: bit e mark, chicken w ing, envelope, glass rim, lipst ick,
f ood it em, ski coat collar, t elephone receiver, w elding goggles From eyes:
cont act lens f ragment s in vacuum cleaner, t ears on a t issue, eyeglasses From
the body i n general : burned remains, hair comb, aut omobile head rest , razor,
shirt , underarms, socks, urine in snow Appendix L describes met hods f or
collect ing f or evident iary specimens. DNA ext ract ed f rom t he vict im or relat ed
evidence is compared w it h samples t aken f rom a suspect . The odds of a
mat ch are t hen det ermined by looking at nine diff erent chromosome pairs and
examining microscopic sequences of DNA. The odds of t w o people sharing t he
exact sequence on one chromosome pair is det ermined; t hen it is mult iplied by
t he odds of t w o people sharing t he exact sequence on t w o pairs, t hree pairs,
and so on t o nine pairs. The odds reach aw esome proport ions because t hose
nine sect ions of DNA are highly variable among individuals. Scient ist s can be
more cert ain w hen t hey are eliminat ing suspect s. I f analyst s f ind a variat ion
on any of t hose nine DNA locat ions, t hey can say w it h accuracy t hat t he t w o
samples could not have come f rom t he same person.
Protocols for Retrieving Postmortem Cultures

1. Follow st andard precaut ions. See Appendix A.
2. Use st erile inst rument s and gloves w hen obt aining specimens f or cult ure.
3. Cleanse t he area w it h a povidone-iodine 5-minut e scrub f ollow ed by a 70%
alcohol 5-minut e scrub.
4. For sample collect ion, eit her aspirat e body f luid samples and t ransf er t hem
t o a st erile t ube or sw ab t he area w it h st erile sw abs.
a. O bt ain blood cult ure specimens f rom t he right vent ricle of t he heart .
b. Collect perit oneal f luid immediat ely af t er ent ering t he perit oneal cavit y.
c. Collect bladder urine direct ly f rom t he bladder w it h a syringe and needle.
d. Sample pericardial or pleural cavit y f luid on a sw ab or w it h a syringe and
needle.
5. Sear t he ext ernal surf ace of an abscess t o dryness w it h a red hot spat ula;
collect pus via syringe and needle (if possible) or use a sw ab.
Clin ical Alert

1. I f an ext ernal examinat ion or ot her noninvasive st udies are done in lieu of
an aut opsy, collect blood f rom t he subclavian vessel and vit reous humor
f rom t he eyes.
2. Do not use plast ic envelopes f or st oring biologic samples such as t issue
and hair or f oreign object s such as bullet s. Plast ic capt ures moist ure and
promot es bact erial/ f ungal grow t h. I nst ead, place object s in clean paper
envelopes or brow n paper evidence bags. I nvent ory and label each it em
properly; st ore appropriat ely.
Special Procedures
1. G unshot w ound procedure
a. Remember t hat t here is a mandat ory x-ray of all gunshot w ounds,
including ent rance and exit ; locat e bullet and f ragment s.
b. Phot ograph ent ry and exit ; cleanse w ound; repeat phot ograph.
c. O bt ain samples of gunpow der residue on hands (close-range only
w ounds).
2. Blunt f orce injury procedure
a. X-ray aff ect ed areas. X-ray hands and f orearms f or def ense w ounds.
b. Phot ograph t he w ounds in original condit ion (af t er cleansing). Use rape
kit if rape is suspect ed (bot h male and f emale) or w hen t he nat ure of t he
injury suggest s uncont rolled rage (hammer, axe, st ab w ounds) or ot her
blunt f orce (beat ings, clubbings).
3. Sharp w ound procedure
a. X-ray w ound sit es. Phot ograph w ounds in original condit ion (af t er
cleaning), af t er approximat ing w ound margins.
b. Check f or def ense w ounds on hands and arms. Trace w ounds on clear
plast ic sheet (opt ional). Save and phot ograph severed cart ilage.
4. Drug overdose procedure
a. Phot ograph evidence suggest ing drug abuse, such as inject ion sit es on
body; presence of drug paraphernalia or drugs, and drug residue on lips,

f ace, t eet h, oral cavit y, t ongue, nose, or hands.
b. Assess mout h area and body f or bit e marks and f all injuries (suggest s
seizure act ivit y associat ed w it h drug ingest ion). Check lymph nodes,
spleen, liver (abnormal in int ravenous drug abuser).
5. Special bat t ery procedure. I f sexual assault is suspect ed, perf orm t he
f ollow ing in order:
a. Wit h body supine (f ace up), obt ain scalp and pubic hair, oral samples,
semen f rom inner t highs.
b. Wit h body prone (f ace dow n), obt ain anal specimen f irst , t hen vaginal
specimen.
c. Collect f ingernail evidence.
d. Collect 25 pubic hairs f rom ent ire vulvar area.
e. Collect 25 head hairs f rom aff ect ed area.
f. O bt ain oral, anal, cervical, and ot her specimens suspect ed of cont aining
semen.
6. Child abuse/ sudden inf ant deat h syndrome (SI DS) procedure
a. X-ray and phot ograph ent ire body.
b. Perf orm ext ernal examinat ion of conjunct ival pet echiae, f ingert ip bruises,
t orso and shoulders (f ront / back), f renulum, and back; post erior t highs
and but t ocks may be incised f rom buckles or ot her sharp object s.
c. Perf orm int ernal examinat ion f or hemat omas (due t o direct injury); if
present and no evidence of head t rauma, remove eyes and examine
ret ina (show s charact erist ic signs in presence of sudden inf ant deat h
syndrome).
d. Document recent or healed f ract ures and est imat ed t ime of injury.
e. Re-examine and re-phot ograph t he f ollow ing day t o delineat e bruises not
previously evident .
NOTE
Copper- and aluminum-jacket bullet s remain in t he body. Aluminum jacket s are
diff icult t o visualize on x-ray f ilms, especially w hen lodged in bone.
Clin ical Alert

1. O bserve st andard precaut ions during t hese procedures. Risk f or disease
t ransmission, hepat it is, TB, and HI V exposure is high.
2. Sket ch, measure, and mark w ounds on diagram in bot h inches and
cent imet ers (U. S. resident s relat e t o inches more accurat ely). Project ile
(bullet ) caliber is est imat ed as small, medium, or large.
3. Procure t oxicologic specimens if indicat ed. Specimens f or t oxicologic
analysis include t he f ollow ing:
a. All ocular f luid f rom bot h eyes
b. Bloodsodium f luoride preservat ive (50 mL)
c. Bloodsodium f luoride preservat ive (ret ainer t ube) (10 mL)
d. Liver (3 g)
e. Bile (10 mL)
f. Urine (50 mL)
g. St omach and small bow el cont ent s
4. St ore specimens and f ragment s in paper envelopes or bags; never use
plast ic, w hich allow s bact eria, mold, and f ungus t o grow.
5. Rout e specimens and report s t o appropriat e depart ment or individual.
6. Maint ain chain-of -evidence cust ody in suspect ed criminal cases.
Metabolic Autopsy
The report ed f requency of sudden inf ant deat h syndrome (SI DS) is
approximat ely 1 in 1000 live birt hs (25% of all report ed deat hs in t he f irst year
of lif e in indust rialized nat ions). A specif ic
medical diagnost ic cause of deat h in such cases does not result even f ollow ing a
complet e and t horough aut opsy.
G row ing research init iat ed in t he mid-1980s suggest s t hat met abolic
derangement is implicat ed in SI DS deat hs. A clinical pict ure of a child w it h
let hargy, vomit ing and/ or f ast ing, and previous sibling deat h, coupled w it h
post mort em det erminat ion of diff use f at t y changes in t he liver as det ermined
f rom t andem mass spect romet ry analysis of blood and bile specimens, is
implicat ed in such cases of sudden unexpect ed childhood deat h. This genet ic
error in met abolism is hypot hesized t o be relat ed t o medium-chain acyl-CoA

dehydrogenase def iciency and disorders of mit ochondrial f at t y acid bet aoxidat ion.
The required sophist icat ed laborat ory analyses are limit ed t o highly specialized
laborat ories in major diagnost ic cent ers. How ever, rout ine blood and bile
specimens collect ed at aut opsy as dried spot s on f ilt er paper along w it h f rozen
sect ions of liver and skin biopsy specimens can be submit t ed t o such a ref erence
laborat ory f or t he required mass spect romet ry analysis.
Ben efits of Metabolic Au topsy

1. A medically plausible cause of deat h w hen an inf ant dies unexpect edly
2. Family opport unit y t o prevent morbidit y and mort alit y in siblings
3. O pport unit y f or genet ic counseling and prenat al diagnosis
4. Rule out child abuse or neglect
Causes of deat h are cat egorized as nat ural and unnat ural.
1. Nat ural causes
a. Cardiovascular
1. Myocardial inf arct ion
2. Vent ricular t achycardias
3. Fibrillat ion (cardiac arrhyt hmias)
4. Hypert ensive cardiovascular disease
5. Cardiomyopat hies
6. St renuous act ivit y during ext remes of heat or cold w eat her
7. Drug use
8. Anorexia nervosa
b. Brain
1. Cerebrovascular accident
2. Poorly cont rolled epilepsy or seizure disorders complicat ed by
cardiac arrest relat ed t o O2 deprivat ion
3. Brain hemorrhage
4. Primary brain t umors
5. Aneurysms
6. Head t rauma
c. Respirat ory
1. Epiglot t is
2. Pulmonary t hrombosis/ embolus
3. St at us ast hmat icus
4. Aspirat ion of f ood/ gast ric cont ent s/ blood
5. Cavernous t uberculosis
6. Premat ure birt h
7. Fulminat ing pneumonia
8. Chest t rauma
d. G ast roint est inal
1. G I bleed
2. Trauma
3. Perit onit is
4. Massive splenic enlargement or rupt ure
5. I ngest ed caust ic subst ances
6. Liver or pancreat ic diseases
7. Diabet es mellit us in t he presence of diabet ic coma (diagnosed by
elevat ed glucose in vit reous of eye)
e. O t her
1. Tubal pregnancy rupt ure leading t o massive hemorrhage
2. HI V inf ect ion
3. Chronic illness in bedridden persons w it h sept ic decubit us ulcers
4. Malnut rit ion
5. Dehydrat ion
6. Environment al causes (eg, Legionnaire's disease, hant avirus)
7. Communicable disease exposure such as inf luenza and meningit is
2. Unnat ural causes
a. Trauma
1. Body w ounds
2. Cut s
3. Lacerat ions
4. Traumat ic amput at ions
5. Self -inf lict ed and self -def ense w ounds
6. Asphyxia
7. Mot or vehicle/ cycle accident s
8. Airplane crashes
b. O t her
1. Sudden inf ant deat h syndrome (SI DS), w hich is t he unexpect ed deat h
of an apparent ly healt hy inf ant . Post mort em examinat ion may not
reveal t he cause of deat h. Neonati ci de ref ers t o t he deliberat e killing
of an inf ant w it hin 24 hours of birt h; i nf anti ci de is murder of a child.
2. Fire or smoke inhalat ion
3. Drow ning
4. Elect rocut ion
5. Hypert hermia (heat )
6. Hypot hermia (cold)
7. Embolism
8. Homicide may be associat ed w it h rape, criminal abort ion, drug
overdose, drug abuse, and drug-relat ed or alcohol-relat ed deat hs.
Interventions
1. Family preparat ion f or aut opsy
a. Explain rat ionale f or post deat h procedures. Concern and respect f or t he
deceased and signif icant ot hers can reduce anxiet y and object ions t o or
misint erpret at ions of af t er-deat h t est ing. O bt ain a signed, w it nessed
consent f orm f or aut opsy. (Consent is not required f or coroner/ medical
examiner invest igat ive aut opsies. )
b. Consider cult ural habit s and pract ices. Human responses and pract ices
surrounding t he deat h of a loved one vary among societ ies, religions,
cult ures, and races. I n t his light ,
post mort em examinat ion may be off ensive t o some groups. Use elders,
clergy, and social w orkers t o assist in explanat ions.
c. Assure t he f amily t hat not hing w ill be done w it hout t heir permission
except w here required by law.

d. I f f ear of mut ilat ion and delay in release of body f or burial are concerns,
provide clear and concise inf ormat ion t o help w it h decision making. I n t he
case of religious dilemmas, f acilit at e counsel and communicat ion
bet w een clergy and ot her appropriat e individuals or agencies.
e. Conf lict can occur w hen st at ut ory aut horit y is at odds w it h f amily w ishes.
Explanat ions and empat hic dialogue are essent ial.
2. Family af t ercare af t er aut opsy
a. I nt erpret post mort em t est result s and counsel f amilies appropriat ely
about organs procured f or donat ion (as appropriat e).
b. I ndicat e need f or f ollow -up if genet ic or f amilial pat hologic f indings are
discovered (eg, young adult w it h acut e myocardial inf arct ion,
cardiomyopat hy, SI DS, heredit ary diseases).
c. Aut opsies are f requent ly mandat ory procedures, especially in sudden,
suspicious, or unexplained deat hs.
d. I nvest igat ion of accident - and w ork-relat ed deat hs serve t he f ollow ing
f unct ions:
1. Serve as qualit y-cont rol indicat ors t o conf irm predeat h diagnoses and
t o assess eff ect iveness of drug t herapy, diagnost ic procedures,
surgical t echniques, gene t herapy, and ot her diagnost ic and
t reat ment modalit ies
2. I dent if y, t rack, and monit or disease prevalence, incidence, t rends, or
associat ion w it h cert ain lif est yle, environment al, or occupat ional or
saf et y inf luences (O ccupat ional Saf et y and Healt h Administ rat ion
[ O SHA] )
3. I nf ormat ion gat hered f rom aut opsy f indings provides a f ramew ork f or
developing bet t er and more sophist icat ed t reat ment s f or disease and
illness cont rol or eradicat ion.
3. Consent f rom f amily is required unless aut opsy is ordered by t he coroner or
medical examiner.
4. Should f amily members be undecided regarding aut opsy, t hey w ish t o
consider it in t he f ollow ing circumst ances:
a. When no f irm medical diagnosis has been est ablished
b. I f t here are quest ions about an unexpect ed or myst erious deat h due t o
apparent nat ural causes
c. I f t here are heredit ary, genet ic, or cont agious diseases
d. When t he cause of deat h could aff ect insurance set t lement s and ot her
legal mat t ers
e. When deat h occurs in t he presence of unexpect ed medical or obst et ric

complicat ions
f. During t he use of experiment al drug t herapies
g. I f deat h is a result of cert ain dent al, invasive, surgical, or diagnost ic
procedures
h. When t he deat h does not come under t he jurisdict ion of t he medical
examiner, hospit al deat h w it h inconclusive medical diagnosis bef ore
deat h, Alzheimer's deat h, brain st udies
Organs for Donation

O rgans and t issues donat ed by t he deceased or t he deceased's f amily f or
t ransplant are procured bef ore, during, or immediat ely f ollow ing aut opsy. A
special consent f orm must be signed by a responsible adult and w it nessed by a
prof essional. Lif e-saving organs (eg, kidneys, lungs, heart , pancreas, liver,
int est ines) are harvest ed bef ore aut opsy w hile t he deceased is st ill on lif e
support f ollow ing declarat ion of brain deat h. O t her t issues and organs are
harvest ed simult aneously w it h aut opsy procedures or af t er aut opsy: eyes,
bones, connect ive t issues, joint s, ligament s, t endons, cart ilage, heart valves,
and veins. A request f or organ donat ion can be made in a hospit al
or t o a medical examiner (in most st at es). The request and donat ion report are
document ed in t he deceased person's medical record or coroner/ medical
examiner's report .
Indications for Organ Donor Testing Before

Transplantation
1. Det ermine exposure t o inf ect ious disease (eg, viral hepat it is B and C,
possibly TT virus in t he f ut ure, HI V-1, HI V-2, human T-cell lymphot rophic
virus [ HTLV-I and -I I ] , cyt omegalovirus [ CMV] , syphilis, ot her sexually
t ransmit t ed diseases) t o exclude t he organ.
2. Mat ch donor and recipient .
3. Est ablish blood t ype compat ibilit y, ABO and Rh, f or all t ransplant donors and
recipient s.
4. Test post mort em specimens f or hepat it is B and HI V.
5. Cadaver donor blood specimens are usually obt ained bef ore deat h, except in
post -mort em specimens f or corneal t ransplant at ion, w hich may not be
procured unt il days af t er deat h.
Incidence and Frequency of Blood Group and Rh

Type
Blood Group and

Rh Type
Incidence
Frequency of
Occurrence (%)
O positive
1 of 3
37.4
O negative
1 of 15
6.6
A positive
1 of 3
35.7
A negative
1 of 16
6.3
B positive
1 of 12
8.5
B negative
1 of 67
1.5
AB positive
1 of 29
3.4
AB negative
1 of 167
0.6
Procedure
2. O bt ain common blood and urine samples f or init ial t est ing and evaluat ion of
t he pot ent ial organ donor.
1. Vict ims of poisoning may be organ donors, especially in cases det ermined by
brain deat h st at us.
2. Examples of t oxins f ound in organs t o be t ransplant ed are included in Table
16. 1.
Table 16.1 Toxins Found in Transplanted Organs
Toxin
Organs Transplanted
Acetaminophen
Heart, cornea, kidney
Carbon
monoxide
Heart, liver, kidney, pancreas
Barbiturate
Liver, heart, kidney
Ethanol
Kidney
Cocaine
Liver, kidney
Cyanide
Cornea, skin, bone, heart, liver,

kidney, pancreas
Methaqualone
Liver
Benzodiazepines
Kidney, heart, liver
Tricyclic
antidepressants
Kidney
Methanol
Kidney
Insulin
Kidney, heart, pancreas (islet

cells)
3. G uidelines published f or opt imal t ime t o t ransplant at ion f rom a poisoned

organ donor f or cert ain select ed t oxins are included in Table 16. 2.
Table 16.2 Organ Transplantation Guidelines From

a Poisoned Organ Donor
Toxin
Optim al Tim e for Transplant
Ethylene glycol,
methanol,
ethanol (ETOH)
Acidosis corrected and

plasma/serum ethylene glycol
<1.5 mg/L (<24 mol/L)
Blood methanol <1.5 g/mL (<47
mol/L)
Plasma/serum ethanol <20
mg/dL (<4.34 mmol/L)
Cyanide
Shock corrected and serum

cyanide level <0.2 mg/mL (<4.6
mol/L)
Interventions
Pretest Preparation
1. Discuss pot ent ial t issue and organ donat ion w it h grieving f amily members.
2. Explain t he rat ionale f or aut opsy, t est ing, procurement , and mort ician
procedures af t er deat h and f or donat ion of t issue or organ. Concern,
sensit ivit y, and respect f or t he deceased and signif icant ot hers can reduce
anxiet y and object ions t o or misint erpret at ion of af t er-deat h t est ing. O rgan
donat ion may be off ensive t o some people.
3. O bt ain a signed, w it nessed consent f orm f or t he aut opsy and organ/ t issue
donat ion.
4. Det ermine suit abilit y f or eye, organ, and t issue donat ion. Crit eria include
communicable diseases (HI V, hepat it is, inf ect ion, age).
5. Be sensit ive. Allow f amily members t o have as much t ime as needed t o be
present w it h t heir loved one.
6. O bt ain a signed, inf ormed consent f orm f or organ/ t issue donat ion. (Consent
not required f or coroner/ medical examiner invest igat ion aut opsies. )
In tratest Care
1. Prepare t he body f or t issue donat ion af t er consent has been given by
applying saline drops t o t he eyes, elevat ing t he head, paper-t aping t he eyes
closed, placing eye pads over t he brow, and placing t he body in a
ref rigerat ed morgue w hen possible.
2. Type human leukocyt e ant igen (HLA) on lymphocyt es and det ermine
compat ibilit y bef ore kidney and pancreas t ransplant at ion. A st rong react ion
in compat ibilit y t est ing predict s rapid t ransplant reject ion and is a
cont raindicat ion.
Posttest Aftercare for Organ Don ation

Counsel f amily about organ and t issue procured f or donor t ransplant at ion.
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Wilkins
> B ac k of B ook > Appendic es > Appendix A - S tandar d/Univer s al P r ec autions
Appendix A Standard/Universal Precautions

The t erm standard precauti ons ref ers t o a syst em designed t o reduce t he risk of
t ransmission of microorganisms f rom bot h recognized and unrecognized sources
of inf ect ions. St andard precaut ions direct saf e pract ice and are designed t o
prot ect healt h care w orkers, pat ient s, and ot hers f rom exposure t o blood-borne
pat hogens or ot her pot ent ially inf ect ious mat erials f rom any body f luid or unf i xed
human t issue f rom any person, l i vi ng or dead.
Revised guidelines are based upon new inf ormat ion about inf ect ious disease
pat t erns and modes of t ransmission. The guidelines, designed t o be more user
f riendly, cont ain t w o t iers of precaut ions. Tier one, Standard Precauti ons, is
designed t o cont rol nosocomial inf ect ions and reduce t he risk of t ransmission of
bot h know n and suspect ed inf ect ions. Tier two, used in addit ion t o st andard
precaut ions, includes airborne, droplet , and cont act precaut ions t o prevent t he
spread of know n or suspect ed t ransmissible and virulent pat hogens.
SAFE PRACTICE
When handling specimens and perf orming or assist ing w it h diagnost ic
procedures, it is import ant f or all healt h care w orkers t o prot ect and al ways t ake
care of t hemselves f i rst. Presume t hat all pat ient s have hepat it is B, human
immunodef iciency virus (HI V), hepat it is C, or ot her pot ent ial pat hogens, and
pract ice st andard precaut ions consist ent ly. Use special care w hen collect ing,
handling, packaging, t ransport ing, st oring, and receiving specimens. I nit ial
observat ions and specimen handling are t o be perf ormed under a laminar f low
hood, and prot ect ive clot hing, w hich includes, but is not limit ed t o, gloves,
gow ns, f ace masks or shields, and eye prot ect ion. These same precaut ions
prevail in t he perf ormance of invasive diagnost ic procedures. Follow Chapt er 1
guidelines f or saf e, eff ect ive, inf ormed pretest, i ntratest, and posttest care .
COM M ON CATEGORIES OF BODY SUBSTANCES,

SECRETIONS, AND FLUIDS
1. Blood and blood product s
2. Urine
3. Vaginal secret ions
4. Saliva
5. Pericardial f luid
6. Perit oneal f luid
7. Pleural f luid
8. Cerebrospinal f luid
9. G ast ric f luid
10. Respirat ory secret ions
11. Semen
12. Synovial f luid
13. Vomit us
14. Wound or ulcer drainage
15. Ascit es
16. Amniot ic f luid
17. Sw eat
NOTE
St andard precaut ions should also be used w hen handling amput at ed limbs and
during removal of body part s (surgery, aut opsy, or donat ion).
STANDARD PRECAUTION GUIDELINES AND PRACTICES

FOR SPECIFIC SITUATIONS
Personal Protection Equipment
1. Take appropriat e barrier precaut ions w hen exposure of skin and mucous
membranes t o blood, blood droplet s, or ot her body f luids is ant icipat ed.
2. Use prot ect ive equipment devices t o prot ect eyes, f ace, head, ext remit ies,
air passages, and clot hing. This equipment must alw ays be used during
invasive procedures. Ensure proper f it .
Gloves
1. Wear gloves w hen collect ing and handling specimens; t ouching blood, urine,
ot her body f luids, mucous membranes, or nonint act skin; or perf orming
vascular access procedures or ot her invasive procedures.
2. Wear gloves w hen handling it ems or surf aces soiled w it h blood, urine, or
body f luids.
3. Mandat e w earing of gloves w hen t he healt h care w orker's skin is cut ,
abraded, or chapped during examinat ion of a pat ient 's oropharynx,
gast roint est inal or genit ourinary t ract , nonint act or abraded skin, or act ive
bleeding w ounds; and w hen cleaning specimen cont ainers or engaged in
decont aminat ing procedures.
4. Possi bl e excepti ons to use of gl oves:
a. When gloves impede palpat ion of veins f or venipunct ure (eg, neonat es,
morbidly obese pat ient s)
b. I n a lif e-t hreat ening sit uat ion w here delay could be f at al (w ash hands and
w ear gloves as soon as possible)
5. Disposable gloves must be changed:
a. When moving bet w een pat ient s
b. When moving f rom a cont aminat ed t o a cleaner sit e on a pat ient or on an
environment al surf ace
c. When gloves are t orn or punct ured or t heir barrier f unct ion is
compromised (do so as soon as f easible)
Clin ical Alert Gloves, barrier gow n s, apron s, an d masks are

w orn on ly at th e site of u se. T h ey are disposed of appropriately
at th e site of u se.
Gow ns, M asks, and Eye Protection

1. Wearing of gow ns, aprons, and/ or f luid impervious lab coat s t o cover all
exposed skin is necessary w henever t here is a pot ent ial f or splashing ont o
clot hing.
2. G ow ns or aprons may not be hung and reused.
3. Wear masks correct ly sit uat ed over nose and chin and t ied at t he crow n of
t he head and t he nape of t he neck. Do not hang t he mask around t he neck.
Change t he mask w hen it becomes moist .
4. Wear mask, f ace shields, and goggles (or prescript ion glasses w it h side
shields) w hen cont aminat ion of eye, nose, or mout h f rom f luid is most likely
t o occur.
5. Shoe covers should be w orn in areas w here cont aminat ion might occur (eg,
operat ing room obst et rics or emergency depart ment ). These are disposed of
at t he sit e of care.
6. Provide masks, ambu-bags, or ot her vent ilat ion devices as part of
emergency resuscit at ion equipment kept in st rat egic locat ions.
Disposal of Medical Wastes

1. Pour f luids low and slow t o prevent splash, spray, or aerosol eff ect .
2. Take precaut ions t o prevent injuries caused by needles, lancet s, scalpels,
and ot her sharp inst rument s and devices during and af t er procedures and
w hen disposing of used needles. Do not recap needles under normal
circumst ances.
3. Dispose of all disposable sharp inst rument s in specially designed, punct ureresist ant cont ainers. Do not recap, bend, break by hand, or remove needles
f rom disposable syringes (Figure A. 1). Use f orceps or cut int ravenous t ubing
if necessary. Use care w hen t ransf erring sharps t o anot her person. Use
f orceps or put t he sharp in a recept acle.
FI G URE A . 1 Needle saf et y device. (1) At t ach any brand of needle. (2)
Remove cap and draw pat ient . (3) Press sheat h on f lat surf ace. (4) Snap
closed and dispose. (Source: Market Lab I nc. , Kent w ood, Michigan, USA)
4. Place and t ransport specimens in leakproof recept acles w it h solid, t ight f it t ing covers. Cap port s of cont ainers. Bef ore t ransport , specimens must be
placed in a t ight ly sealed bag marked w it h a biohazard t ag. Biohazard
symbols w arn of biologic hazards and must be displayed in t he presence of
t hese hazardous biologic agent s or locat ions.
5. Place soiled linens and similar it ems in leakproof bags bef ore t ransport .
Placement of Warning Tags and Signs

1. Properly place w arning t ags t o prevent accident al injury or illness t o
clinicians w ho are exposed t o equipment or procedures t hat are hazardous,
unexpect ed, or unusual.
2. Require w arning t ags t o cont ain a si gnal word or symbol, such as
Biohazard or Biochemical Mat erial, along w it h t he major message, such
as Blood Banking Specimen I nside. All specimens are placed in biohazard
bags.
General Environmental Cautions

1. Use approved ant imicrobial soaps bet w een care of individual pat ient s.
2. Wash hands immediat ely af t er removing gloves.
3. Wash hands and ot her skin surf aces immediat ely and t horoughly if
cont aminat ed w it h blood or ot her body f luids.
4. Consider saliva w hen blood is visible t o be pot ent ially inf ect ious, even t hough
it has not been implicat ed in HI V t ransmission.
5. Transmission of acquired immunodef iciency syndrome (AI DS) is possible
f rom st ool specimens, especially if t here is a possibilit y of blood exist ing in
t he st ool.
6. Healt h care w orkers w it h open skin lesions or skin condit ions should not
engage in direct care unt il t he condit ion clears up or does not present a risk
t o t he pat ient .
7. Development of an HI V inf ect ion during pregnancy may put t he f et us at risk
f or inf ect ion.
In Case of Exposure to Human Immunodeficiency Virus

or Hepatitis B Virus
1. I dent if y, obt ain consent , and t est source of exposure immediat ely f or
evidence of HI V, HBV, and HCV. I f t he pat ient ref uses consent , a
nonconsent ing f orm must be signed (see Appendix H). I f nonconsent ing
t est ing is done on t he source, t he exposed st aff member must also have
t est ing.
2. Advise t he HI V-negat ive w orker t o seek medical evaluat ion of any acut e
f ebrile illness t hat occurs w it hin 12 w eeks af t er exposure t o HI V and be
ret est ed at 6 w eeks, 12 w eeks, and 6 mont hs af t er exposure.
3. Vaccine is available at no cost t o healt h care w orkers t o prevent hepat it is B
inf ect ion. There is no vaccine f or HI V or hepat it is C.
Handwashing Protocols Unless the situation is a true

emergency, hands must always be washed:
1. Bef ore and af t er care act ivit ies t hat involve direct cont act
2. Bef ore surgical or obst et ric procedures
3. Bef ore and af t er endoscopy
4. Bef ore and af t er invasive procedures
5. Bef ore direct cont act w it h an immunocompromised pat ient
6. Af t er cont act w it h body f luids or t issues or w it h soiled equipment , supplies,
or surf aces
7. Af t er direct cont act w it h pat ient s in isolat ion unit s
Protocols for First Responders Examples of protocols

for suspected serious infectious disease w ith signs and
symptoms classified as high risk (eg, skin rash or skin
involvement and high fever); high fever prodrome, as in
possible smallpox (classic lesions); yellow fever
(jaundice); and plague (buboes) are stated as follow s:
w hen any of these other serious infectious diseases
cannot be ruled out and there is uncertain diagnosis or
no diagnosis, the patient is classified as high risk.
Institute airborne and contact precautions, report
immediately, and notify appropriate health department.
If rash is present, obtain a dermatology consult and
collect specimens by specially trained personnel.
Testing is done at the Centers for Disease Control and
Prevention (CDC).
Some of t hese diseases may be result of possible biot errorism (see Chapt er 7)
and can only be diagnosed by t he f ebrile st age and classic signs. A diagnosis of
smallpox (a serious disease t hat kills 30% of inf ect ed people) is based upon
t est s f or variola virus and recognit ion of t he f ebrile st age, classic smallpox
lesions, and lesions in same st age of development .
Clin ical Alert

1. All f irst responders and response t eams need t o be vaccinat ed bef ore
exposure t o smallpox, w it hin 3 days t o a w eek af t er exposure.
2. Anyone direct ly exposed and t hose at risk f or exposure should be
vaccinat ed.
For addit ional inf ormat ion, go t o t he CDC w ebsit e (w w w. cdc. gov/ smallpox).
Bibliography Centers for Disease Control: Public Health

Services Guidelines for the M anagement of Healthcare
Worker Exposures to HIV and Recommendations for
Post-exposure Prophylaxis. M orbidity and M ortality
Weekly Report 47 (No. RR-7), M ay 15, 1998
G arner JS and t he Hospit al I nf ect ion Cont rol and Pract ice's Advisory
Commit t ee and t he Cent er f or Disease Cont rol and Pract ice: G uidelines f or
I solat ion Precaut ions in Hospit als. American Journal of I nf ect ion Cont rol.
24(1): 2444, February 1996
Code of Federal Regulat ions. O ccupat ional Exposure t o Bloodborne
Pat hogens. Eff ect ive dat e: November 27, 2001.

Wilkins
> B ac k of B ook > Appendic es > Appendix B - Latex and R ubber Aller gy P r ec autions
Appendix B
Latex and Rubber Allergy Precautions
The rise in incidence of lat ex allergy may be at t ribut ed not only t o increased use
of lat ex product s in pat ient care (especially since st andard/ universal precaut ions
w ere mandat ed), but also t o t he manner in w hich raw lat ex w as collect ed and
aged. Allergic react ions are caused by lat ex prot eins ret ained in t he f inished
product s, w hich can show great variat ions in lat ex allergen levels. The great est
environment al hazard exposure is produced by lat ex gloves and t he pow der f rom
t hese gloves t hat becomes airborne.
The U. S. Food and Drug Administ rat ion now requires t hat all medical devices
cont aining nat ural rubber lat ex t hat may direct ly or indirect ly cont act t he pat ient
display t he f ollow ing st at ement : THI S PRO DUCT CO NTAI NS NATURAL RUBBER
LATEX.
As allergy t o lat ex product s becomes more prevalent , bot h in t he healt h care
set t ing and in t he general environment , it becomes necessary f or agencies t o
inst it ut e specif ic guidelines and prot ocols t o maximize lat ex-saf e environment s
f or pat ient s and f or healt h care personnel.
Persons at great est risk f or lat ex or rubber allergy include:
1. Healt h care w orkers (an est imat ed 17% are aff ect ed) compared t o 1% t o 3%
of t he general populat ion
2. Persons w it h spina bif ida, spinal cord injury, myelodysplasia, or urogenit al
anomalies (up t o 73% are aff ect ed)
3. I ndividuals w it h a personal or f amily hist ory of allergies (including hay f ever,
bee st ings, ast hma, pet dander, and f ood or drug allergies)
4. Persons w it h a hist ory of mult iple surgeries
5. Persons w it h occupat ional exposure (eg, rubber indust ry w orkers; 10% of
t hose handling or manuf act uring rubber are aff ect ed)
6. Persons w it h at opic dermat it is or eczema
7. Persons w it h int raoperat ive anaphylaxis (f or unknow n reason)
I ncreased or cont inued exposure increases sensit ivit y t o lat ex allergens and
w orsens allergic react ions. Pat ient s and healt h care w orkers can become
sensit ized t o lat ex t hrough repeat ed skin or mucous membrane cont act or by
inhaling aerosolized glove allergens.
Persons w it h lat ex allergies are more likely t o react t o cert ain f oods t hat cont ain
cross-react ive prot eins, especially bananas, avocados, chest nut s, almonds, kiw i
f ruit , raw pot at o, t omat o, peach, plum, cherry, melons, celery, apple, pear, and
papaya. Lat ex allergy of t en begins w it h a rash on t he hands (f rom gloves).
Besides lat ex allergies, ot her glove-associat ed react ions may occur.
LATEX ALLERGY PRECAUTIONS TO PROTECT THE

PATIENT
St rat egies and prot ocols include t he f ollow ing:
1. I dent if y allergic pat ient s (t hose w it h a hist ory of problems relat ed t o
cat het ers, t ubes, drains, household it ems, condoms, lat ex gloves, balloons,
t oys, and so on); allergy t est ing (see Chapt er 8) may be desirable.
Communicat e and document dat a appropriat ely.
Reaction
Signs and
Sym ptom s
Causes
Irritant contact
dermatitis
(nonallergic
irritation)
Dry, crusty, hard

bumps, sores,
and horizontal
cracks on skin
may manifest as
itchy dermatitis
on the back of
the hands under
the gloves.
Handwashing,
insufficient
rinsing,
scrubs,
antiseptics,
glove
occlusion,
glove powder
Red, raised,
palpable area
with bumps,
sores, and
horizontal
Delayed-type
hypersensitivity;
allergic contact
dermatitis;
chemical allergy
Immediate-type
hypersensitivity;
latex allergy;
cracks may
extend up the
forearm. Occurs
after a
sensitization
period. Appears
several hours
after glove
contact and may
persist for many
days.
W heal-and-flare
response or
itchy redness on
the skin under
the glove.
Occurs within
minutes; fades
away rapidly
after removal of
the glove. In
chronic form
may mimic
irritant and
allergic contact
dermatitis.
Symptoms can
include facial
swelling;
generalized
rashes; nasal,
sinus, and eye
Exposure to
chemicals
used in latex
manufacturing,
mostly
thiurams
Exposure to
proteins in
latex on glove
surface and/or
bound to
powder and
suspended in
protein allergy
symptoms;
asthma; and
respiratory
distress. In rare
cases,
anaphylactic
shock may
occur and is
life-threatening.
Generalized
hives,
bronchospasm,
hypotension,
extreme facial
edema and
laryngeal
edema, and
tachycardia may
occur.
the air, settled

on objects, or
transferred by
touch
American Nurses Association latex allergy work

place information series, W ashington, DC, 1996.
2. Sensit ive persons should carry aut oinject able epinephrine (Epi-Pen), nonlat ex
gloves, and emergency medical inst ruct ions; should w ear a medical alert
bracelet ; should avoid al l f orms of lat ex; and should alert clinicians, f amily,
f riends, and employers of t he diagnosis and need t o avoid lat ex.
3. Never w ear pow dered lat ex gloves w hen caring f or a sensit ized pat ient .
4. Avoid cont act of lat ex w it h t issue (eg, w ounds, mucous membranes, vaginal
skin). Practi ce proper handwashi ng.
5. Use lat ex-f ree product s. Examples include:
a. G loves
b. Endot racheal t ubes
c. Suct ion and w ound drainage t ubes and reservoir syst ems
d. Cat het ers
e. Blood pressure cuff s
f. St et hoscopes
g. Temperat ure probe covers, t ape, dressings, Ace w raps
h. Monit oring equipment and supplies (leads, pulse oximet er probes, and
cables)
6. Remove rubber st oppers f rom vials bef ore w it hdraw ing or reconst it ut ing
cont ent s. Rinse syringes w it h st erile w at er or saline bef ore use.
7. Remove lat ex port s f rom int ravenous t ubing and replace w it h st opcocks or
nonlat ex plugs. Tape port s shut if no ot her alt ernat ive is available. Replace
port s on int ravenous t herapy bags w it h nonlat ex port s.
8. Keep resuscit at ion equipment and emergency supplies and medicat ions
readily accessible at all t imes in t he event t hat anaphylaxis occurs. (Cauti on:
Some resusci tati on suppl i es and equi pment may contai n l atex.)
9. I nst ruct t he pat ient about lat ex-cont aining supplies, bot h medical and
nonmedical, t hat could pose problems (see list s).
10. The Spina Bif ida Associat ion of America publishes updat ed list s of lat excont aining product s t w ice a year. Their address is: Spina Bif ida Associat ion
of America, 4590 MacArt hur Boulevard NW, Suit e 250, Washingt on, DC
2007-4226 (t elephone 800-621-3141).
Medical Supply Item s T hat

Frequently Contain Latex
Hom e and Com m unity

Item s T hat Frequently
Contain Latex
Appliance Cords
Anesthesia equipment/ET
tubes, airways
Appliques (clothing);
Spandex Art supplies
(paint, glue, rubber
bands, erasers, ink)
Balloons/toys/water toys
Bandages/tapes
and equipment Balls

(tennis, Koosh)
Bed protectors
Blood pressure tubing/cuffs
Bulb syringes
Catheters (many and varied
types) Dressings/elastic
wraps G-tubes/drains
IV access (Y-sites,
tourniquets, adapters, etc.)
OR masks, hats, shoe
covers Oxygen
masks/cannula/resuscitation
devices Suction equipment
Reflex hammers, syringes
Carpet backing/rubber
floors/cushions
Condoms/diaphragms
Crutch accessories
(tips/grips) Dental
braces, chewing gum
Diapers/incontinence
products Elastic in
socks, underwear, etc.
Feeding
nipples/pacifiers
Handles on
garden/sporting
equipment Kitchen
gloves
Tires, hoses
Note: These lists are not all-inclusive. If latex content

is unknown, checking with the manufacturer or supplier
before use is strongly advised.
NOTE
Assembling and maint aining a cart w it h lat ex-f ree supplies and equipment may
be desirable t o f acilit at e saf e pat ient care.
NOTE
I f lat ex-f ree blood pressure cuff s and st et hoscopes are not available, shield
t he pat ient 's arm w it h st ockinet t e and apply t he cuff over it . Small-diamet er
(f inger-sized) st ockinet t e can be used t o cover st et hoscope t ubing, leads, and
so on.
Clin ical Alert Symptoms of an aph ylaxis in clu de a dan gerou s

drop in blood pressu re, dyspn ea, flu sh ed facial appearan ce,
sw ellin g (of th roat, ton gu e, an d n ose), a feelin g of impen din g
doom, an d loss of con sciou sn ess.
STRATEGIES AND PRECAUTIONS TO REDUCE THE

RISK OF LATEX ALLERGIES FOR HEALTH CARE
PERSONNEL
Lat ex sensit ivit y is a healt h hazard f or healt h care w orkers. I t is one problem
w it h many causes. Consequent ly, w orkplace pract ices t o reduce t he incidence of
exposure are absolut ely necessary t o maint ain a saf e environment f or clinicians.
Early ident if icat ion and t reat ment of lat ex allergy are import ant . Allergist s w ho
specialize in t reat ing lat ex allergy may recommend pat ch t est ing w it h glove
chemical sensit izers and lat ex allergy t est ing by serum or skin prick t est s. Blood
t est s are not as sensit ive or as accurat e as t he skin t est s.
Clin ical Alert Cu rren tly, n o commercially prepared latex skin

test extract is available, an d office-prepared skin test extract
from gloves can vary in latex protein con ten t.
Ways t o reduce t he risk of lat ex allergies f or healt h care w orkers include t he
f ollow ing:
1. Use lat ex-f ree gloves (pow der-f ree gloves low in prot ein and chemical
allergens) w henever possible and keep exposure t o lat ex at a minimum.
2. Wear gloves t hat are appropriat e f or t he t ask; remove gloves at least hourly
t o air and dry hands.
3. Wash, rinse, and dry hands t horoughly af t er removal of gloves or bet w een
glove changes.
4. Use a pH-balanced soap and avoid cut aneous cont act w it h damaging
chemicals.
5. Apply nonsensit izing product s (out side of t he w orkplace) t o rest ore t he skin's
lipid barrier.
6. Wear synt het ic gloves or cot t on liners w it h lat ex w ork gloves f or w et w ork, if
possible.
7. Seek early medical diagnosis t o prevent f urt her allergy complicat ions.
8. Advocat e f or and promot e purchase of lat ex-f ree product s t hat are of
comparable f unct ion and qualit y.
9. O bserve all lat ex allergy precaut ions t hat apply t o pat ient s. Nat ural lat ex is
f ound in many consumer product s, such as condoms, balloons, t ires, rubber
t oys, nipples, and pacif iers.
Clin ical Alert Simply u sin g pow der-free gloves w ill n ot solve
th e problem.
Clin ical Alert Protocols for man agemen t of an allergic reaction :
1. Airw ay maint enance
2. Administ rat ion of oxygen
P.
3.
4.
5.
6.
7.
Volume expansion (int ravenous lact at ed Ringer's or normal saline solut ion)
Epinephrine I V
St eroids (orally or I V)
Diphenhydramine (orally or I V)
Aminophylline I V
M ANDATES AND STRATEGIES FOR EM PLOYEES

REGARDING LATEX OR RUBBER ALLERGY
1. I nclude lat ex allergy inf ormat ion as part of new -employee orient at ion and
conduct in-service educat ion t raining on t his subject .
2. O ccupat ional Saf et y and Healt h Administ rat ion Right To Know law s require
employers t o inf orm employees of pot ent ially dangerous subst ances in t he
w orkplace on an annual basis.
3. Make available current lat ex allergy inf ormat ion in new slet t ers; lat ex allergy
should be on t he agenda of risk management commit t ees.
4. Make alt ernat ive product s available.
5. Est ablish prot ocols and procedures relat ed t o lat ex allergy t o ensure a saf e
pract ice environment .
6. Prot ect lat ex-allergic w orkers f rom being required t o w ork in lat excont aminat ed areas.
NOTE
I n March 1999, t he U. S. House of Represent at ives conduct ed a hearing t o
examine lat ex allergy recommendat ions of O SHA, CDC, and t he FDA (Food
and Drug Administ rat ion).

Wilkins
> B ac k of B ook > Appendic es > Appendix C - S edation and Analges ia P r ec autions
Appendix C
Sedation and Analgesia Precautions

I ncreasing numbers of pat ient s are receiving short -t erm moderat e sedat ion and
analgesia (of t en ref erred t o as consci ous sedati on) f or invasive diagnost ic
procedures. Even t hough t he anest hesiologist or at t ending physician assumes
responsibilit y f or int ravenous moderat e sedat ion, ot her clinicians may administ er
t he drugs and monit or t he pat ient 's response t o t hese drugs. Advant ages of
moderat e sedat ion and analgesia include short , rapid recovery, early ambulat ion,
pat ient pref erence f or light sleep and amnesia, pat ient cooperat ion during t he
procedure, prot ect ive ref lexes remain int act , vit al signs remain st able, and t here
are inf requent complicat ions.
The American Societ y of Anest hesiologist s Task Force f or Sedat ion and
Analgesia by Non-Anest hesiologist s (2002) recommends t he t erm moderat e
sedat ion and analgesia as t he more accurat e descript ion of t he goal of
administ ering t hese drugs. The def init ion of moderat e sedat ion and analgesia is
as f ollow s: a drug-induced depression of consciousness during w hich pat ient s
respond purposef ully t o verbal commands, eit her alone or accompanied by light
t act ile st imulat ion. No int ervent ions are required t o maint ain a pat ent airw ay, and
spont aneous vent ilat ion is adequat e. Cardiovascular f unct ion is usually
maint ained. There are t w o goals of moderat e sedat ion and analgesia: (1) t o
allow t he pat ient t o undergo unpleasant procedures by diminishing his or her
discomf ort , pain, and anxiet y (w hile maint aining adequat e cardiorespirat ory
f act ors and response t o verbal commands and st imulat ion); and (2) immobilize
t he pat ient t o expedit e complex procedures t hat require t hat t he pat ient not
move, especially in children and uncooperat ive adult s. Because it is not alw ays
possible t o predict how a specif ic pat ient w ill respond t o sedat ive and analgesic
medicat ions, pract it ioners int ending t o produce a given level of sedat ion should
be able t o rescue pat ient s w hose level of sedat ion becomes deeper t han init ially
int ended.
INTERVENTIONS FOR ADULT PATIENTS RECEIVING

M ODERATE SEDATION AND ANALGESIA
Preadministration Patient Preparation

1. Explain t he purpose of moderat e sedat ion/ analgesia bef ore administ ering t he
medicat ions. I t is most commonly used f or t hese diagnost ic procedures:
biopsies, bronchoscopy, ERCP, colonoscopy, gast roscopy, angiogram,
cardiac cat het erizat ion, EP st udies, and cyst oscopy. Medicat ions may by
administ ered int ravenously or by mout h.
2. Assess t he pat ient 's healt h st at us, hist ory of chronic or acut e condit ions,
drug allergies, current medicat ions and pot ent ial drug int eract ions, previous
diagnost ic t est result s, level of underst anding, orient at ion, ment al st at us,
and abilit y t o cooperat e w it h t he procedure. Screen and ident if y pat ient s w ho
are at high risk f or development of complicat ions: t he very young, t he very
old, and t hose w it h heart , lung, liver, kidney, or CNS disease, marked
obesit y, sleep apnea, pregnancy, or drug or alcohol abuse. Pat ient s
present ing f or moderat e sedat ion/ analgesia should undergo a f ocused
physical examinat ion including vit al signs, auscult at ion of t he heart , lungs,
and evaluat ion of t he airw ay.
3. Explain t he process and procedure and w hat t he pat ient may experience
(f eel sleepy, relaxed, no anxiet y). Use a calm, caring manner. Cont roversy
exist s about f ast ing t ime f rames; but t here is an agreement t hat
preprocedure f ast ing decreases risks during moderat e sedat ion. Check your
agency policy. For adult s, no f ood or liquid (f or 2 t o 6 hours) t o allow f or
gast ric empt ying. For inf ant s under 6 mont hs, f ast 4 t o 6 hours (t his includes
milk, f ormula, and breast milk); clear liquids, 2 hours.
4. Bef ore beginning t he procedure, est ablish an int ravenous line and keep it
open w it h t he ordered int ravenous solut ion. Monit or pat ency of t he line.
5. Monit or pulmonary vent ilat ion (exhaled carbon dioxide) and apply pulse
oximet er sensor (oxygenat ion) especially if t he pat ient is unable t o be
observed during moderat e sedat ion. Monit or elect rocardiogram, pulse
oximet ry, and pat ient response t o verbal commands according t o est ablished
guidelines bef ore administ ering moderat e sedat ion. Pat ient 's vit al signs
should be document ed (pre-, int ra-, and post -procedure).
6. Provide a saf e and caring environment . A designat ed individual, ot her t han
t he pract it ioner perf orming t he procedure, should be present t o monit or t he
pat ient t hroughout t he procedure. I n ant icipat ion of emergency sit uat ions,
have resuscit at ion equipment and supplies of appropriat e size readily
available (oxygen t herapy, I V f luid, reversal agent s, and vasopressors).
7. Follow Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest care.
Intratest Patient Care

1. Cont inuously assess pain or discomf ort and sedat ion levels at f requent
est ablished int ervals.
2. Administ er sedat ion and analgesics as ordered, of t en in increment al doses.
I n pediat rics, oral Versed, ket amine, or chloral hydrat e may be administ ered
in chocolat e syrup.
3. Recognize physiologic eff ect s of agent s used f or moderat e sedat ion. These
medicat ions include t he f ollow ing, among ot hers:
a. Meperidine hydrochloride (Demerol)
b. Diazepam hydrochloride (Valium)
c. Midazolam hydrochloride (Versed)
d. Lorazepam (At ivan)
e. Droperidol (I napsine) (Check w it h your pharmacy or inst it ut ional policy
regarding use of t his drug. )
f. Fent anyl cit rat e (Sublimaze)
g. Morphine sulf at e
4. Monit or t he int ravenous sit e f or inf ilt rat ion and t he general eff ect s of t he
medicat ion as w ell as local analgesia sit e. Local anest hesia and sedat ion
may cause adverse react ions.
5. Assess level of consciousnessresponses of pat ient s t o commands during
t he procedure serves as a guide t o t heir level of consciousness. I f ref lex
w it hdraw al f rom painf ul st imulat ion is t he only response, t he pat ient is likely
t o be deeply sedat ed, approaching t he st at e of general anest hesia.
6. Monit or pulmonary vent ilat ion by auscult at ion of breat h and observat ion of
spont aneous respirat ion. Aut omat ed apnea monit oring (det ect ion of exhaled
CO 2 ) may be used, but is not a subst it ut e f or monit oring vent ilat ory f unct ion.
7. Be aw are t hat det ect ing changes in heart rat e and blood pressure f or
hemodynamics reduces risk of CV collapse and hypoedema.
8. Use oximet ry t o det ect hypoxemia and decrease adverse out comes such as
cardiac arrest and deat h.
9. Ant icipat e and monit or f or pot ent ial complicat ions. Arrhyt hmias should be
prompt ly report ed and t reat ed if necessary. Many of t hese medicat ions are
respirat ory depressant s, mandat ing f requent respirat ory assessment s. I f
oxygen sat urat ion drops below accept able
levels (90%), sedat ion may need t o be held or reversed. Have int ravenous
reversal agent s such as naloxone (Narcan) and f lumazenil (Romazicon)
readily available. Supplement al oxygen t herapy may be necessary unt il
oxygen sat urat ion levels, vit al signs, neurologic response, and cardiac
rhyt hms are at accept able levels.
10. Respond t o emergencies rapidly and appropriat ely during administ rat ion of ,
or recovery f rom, moderat e sedat ion and analgesia.
11. Document caref ully and complet ely all observat ions, including medicat ions
and dosages. Record unexpect ed out comes and f ollow -up care.
12. Follow Chapt er 1 guidelines regarding saf e, eff ect ive, inf ormed i ntratest
care.
Postadministration Patient Aftercare

1. Monit or vit al signs, elect rocardiogram, pulse oximet ry, vent ilat ion, neurologic
signs, level of consciousness, and pat ient response t o verbal commands
according t o est ablished guidelines.
2. Monit or t he pat ient af t er t he procedure unt il t he pat ient is st able and
react ive t o preprocedure levels.
3. Provide bot h verbal and w rit t en post t est inst ruct ions. Moderat e sedat ion may
not complet ely w ear off f or several hours. Pat ient s should not:
a. Drive or operat e pow er machinery or t ools f or at least 24 hours.
b. Consume alcoholic beverages or make legal decisions f or 24 hours.
c. Smokeif t he pat ient is a smoker, emphasize t he risks of smoking in t he
post sedat ion st at e (ie, f alling asleep).
d. Take t ranquilizers, pain medicat ions, or ot her medicat ions t hat may
int eract w it h drugs used f or sedat ion w it hout f irst cont act ing t he
physician.
4. Provide inst ruct ions f or post t est care and t he need f or cont act ing t he
physician if any unexpect ed out comes should occur.
5. Evaluat e t he pat ient f or readiness f or discharge. Pat ient s should be alert and
orient ed, or if alt ered ment al st at us w as init ially present , should have
ret urned t o baseline. Vit al signs should be st able and w it hin accept able
limit s. Provide a saf e t ransport or discharge in t he presence of a responsible
adult .
6. Allow suff icient t ime (up t o 2 hours) t o elapse f ollow ing t he last
administ rat ion of reversal agent s t o ensure t hat pat ient s do not become resedat ed af t er reversal eff ect s have w orn off .
Clin ical Alert

Record vent ilat ory/ oxygen st at us and hemodynamics before t he procedure
begins, af t er administ rat ion of sedat ive and analgesia, upon complet ion of
procedure, during init ial recovery, and at t ime of discharge.
The primary drugs used f or moderat e sedat ion and analgesia are
benzodiazepams and opiat es, w hich are CNS depressant s. O piat es are also
used f or sedat ion, as are some t ranquilizers (droperidol [ I napsine] ); f or pain
relief , f ent anyl (Sublimaze), morphine, and meperidine are used. (See Chart
C. 1). Combinat ions of drugs may be more eff ect ive t han single agent s in some
inst ances. Agent s must t hen be appropriat ely reduced, and t here is a great er
need t o monit or respirat ory f unct ion. I nt ravenous sedat ive and analgesic drugs
are t o be given in small increment al doses. When drug is administ ered orally,
rect ally, int ranasally, int ramuscularly, or subcut aneously, allow t ime f or drug
absorpt ion bef ore giving anot her dose.
Ch art C.1 Examples of Sedatives and Analgesic Drugs Used

Diazepam (Valiu m)
CNS depressant , amnesic, lacks analgesia. Durat ion: 28 h.
Dosage guidelines: 25 mg t o maximum of 10 mg. No more t han 5 mg/ min.
G ive addit ional doses in 2. 5 mg increment s. Wait 3 min bef ore redosing.
O nset : 510 min; I V, 1530 min. Reduce dose by 1/ 3 w hen an opiat e is being
used concomit ant ly.
Precautions: I ncreased eff ect s if t aking CNS depressant s, alcohol,
cimet idine, or disulf iram. Avoid in pat ient s w it h renal disease.
Midazolam (Versed)
CNS depressant ; t hree t o f our t imes as pot ent as diazepam. Provides
sedat ion, amnesia, and decreases anxiet y. Lacks analgesia. Durat ion: 6090
min.
IV dosage guidelines: I nit ial dose: 0. 10. 2 mg/ kg. 0. 51. 0 mg given slow ly
over at least 23 min; not t o exceed 4 mg. Wait at least 2 minut es bef ore
redosing. G ive in small increment s af t er init ial dose. O nset : 12 min (I V), 10
20 min (I M), 1015 min (int ranasally), 1030 min (orally), and 1030 min
(rect ally). Decrease dose if given w it h narcot ics (by 25%30% in healt hy
adult , by 55%60% in elderly or debilit at ed). Durat ion: 3060 min (I V), 12 h
(I M), 4560 min (int ranasally), and 6090 min (orally or rect ally).
Precautions: Wat ch f or respirat ory depression, especially in children.
Cont raindicat ed in pat ient s w it h narrow -angle glaucoma.
Lorazepam (Ativan )
CNS depressant ; lacks analgesia. Durat ion: 46 h.
Dosage guidelines: 0. 52 mg I V, given slow ly; maximum 4 mg. O nset : 510
min. Decrease dose in elderly.

Precautions: I ncreased eff ect s w it h MAO I s, barbit urat es, narcot ics,
hypnot ics, t ricyclic ant idepressant s, alcohol; decreased eff ect s w it h oral
ant icoagulant s and heparin. Use w it h great caut ion in children. O w ing t o
ant icholinergic act ions, use w it h caut ion in pat ient s w it h ast hma, narrow -angle
glaucoma, prost at ic hypert rophy, or bladder neck out let obst ruct ion.
Meperidin e (Demerol) Opiate n arcotic an algesic sedative; 6080

mg meperidin e = 10 mg morph in e. Du ration : 24 h .
IV dosage guidelines: 10 mg I V. G ive increment s slow ly; 2550 mg I V over 2
min; repeat at 5-min int ervals; 1015 mg maximum; 150 mg over t ot al period
of procedure. Decrease dose in elderly or debilit at ed; use caut ion w it h renal
disease.
Precautions: Cont raindicat ed if pat ient has had a MAO I in last 14 days; may
precipit at e severe and irreversible react ion and deat h; decrease dose if given
w it h ot her narcot ic, barbit urat e, t ranquilizer, t ricyclic ant idepressant , or
sedat ive. Use w it h caut ion in pat ient s w it h supravent ricular t achycardia; may
cause increased vent ricular response.
Droperidol (In apsin e) Major tran qu ilizer; n o an algesic

properties. Produ ces cogn itive dissociation a sen se of
detach men t; an tiemetic. Du ration : Varies over several h ou rs.
IV dosage guidelines: 0. 6251. 25 mg; decrease dose in elderly. O nset : 310
min. Peak act ion: 30 min.
P.
Precautions: Pot ent iat es narcot ics and ot her CNS depressant s. Produces
mild alpha-adrenergic block.
Fen tan yl (Su blimaze) Opiate n arcotic an algesic sedative; mu ch

more pow erfu l th an morph in e. Du ration 3060 min .
IV dosage guidelines: 1. 02. 0 mcg/ kg. 2550 mg I V at 5-min. int ervals,
t it rat ing t ime t o pat ient response. May also be given by t ransdermal pat ch, or
as a lollipop f or children. O nset of sedat ion: 12 min; onset of analgesia:
may not be not ed f or several minut es. Maximum dosage: 500 mg/ 5 h.
Precautions: Pot ent iat es narcot ics and ot her CNS and respirat ory
depressant s. Produces mild adrenergic block. Reversal w it h Narcan: Rapid I V
administ rat ion may cause chest w all rigidit y; t reat w it h chemical paralyt ics,
int ubat ion, and vent ilat ory support .
Morph in e
O piat e narcot ic analgesic. Durat ion: 13 h.
IV dosage guidelines: 215 mg I V over a 5-min period; maximum of 20 mg
over t ot al procedure t ime.
Precautions: Causes analgesia and respirat ory depression; check respirat ory
st at us.
Ketamin e (Ketalar)
A PCP derivat ive used in pediat rics: analgesic, sedat ive, and amnest ic.
Durat ion: 1030 min (I V), 6090 min (I M).
Dosage guidelines: Rapid onset w it h bot h I V and I M (1 min I V and 56 min
I M); longer if given orally or rect ally.
Precautions: Causes copious saliva product ion and airw ay secret ions (t reat ed
w it h at ropine or Robinul). Does not cause respirat ory depression. Associat ed
w it h night mares (rare in children) and not w it h oral or rect al rout es.
Clin ical Alert

Ket amine is know n as a club drug t hat is used unknow ingly by t he vict im,
w ho is lat er sexually assault ed.
Su fen tan il (Su fen ta) An algesic more poten t th an fen tan yl; u sed
in pediatrics. Du ration : 12 h .
Dosage guidelines: O nset : 515 min, int ranasally; may be administ ered w it h
Versed.
Precautions: Reversal w it h Narcan. Precaut ions same as f or f ent anyl
(Sublimaze).
Bibliography
An Updat ed Report by t he American Societ y of Anest hesiologist s Task Force
f or Sedat ion and Analgesia by Non-Anest hesiologist s. Pract ice guidelines f or
sedat ion and analgesia by non-anest hesiologist s. Anest hesiology, 96: 1004
1017, 2002
Conscious Sedat ion. Crit ical Care Nursing Clinics of Nort h America 9(3):
Sept ember 1997
DeBoer S, Felt y C: Help Make Boo Boos Bet t er w it h Conscious Sedat ion.
Nursing Spect rum: Vol. 13, No. 21, 48, 2000

Wilkins
> B ac k of B ook > Appendic es > Appendix D - C onver s ions Fr om C onventional to S ys tm e Inter national
( S I) Units
Appendix D
Conversions From Conventional to Systme
International (SI) Units
Normal or ref erence values f or laborat ory result s are report ed in convent ional
unit s, SI unit s, or bot h. The SI syst em uses seven dimensionally independent
unit s of measurement t o provide logical and consist ent measurement s. For
example, SI concent rat ions are w rit t en as amount per volume (moles or
millimoles per lit er) rat her t han as mass per volume (grams, milligrams, or
millequivalent s per decilit er, 100 millilit ers, or lit er). Universal values may diff er
bet w een syst ems or may be t he same. For example, chloride is t he same in bot h
syst ems: 95105 mEq/ L (convent ional unit s) and 95105 mmol/ L (SI unit s).
Clinical laborat ory dat a may be report ed in eit her convent ional unit s or SI unit s,
or bot h. Examples of conversion of dat a f rom t he t w o syst ems are included
(Table D. 1). To convert SI unit s t o convent ional U. S. unit s, di vi de by t he f act or;
t o convert convent ional U. S. unit s t o SI unit s, mul ti pl y by t he f act or.
Table D.1 Examples of Conversions to Systme
System
Present
Reference
Intervals
Present
Unit
Alanine
aminotransferase
(ALT)
Serum
540
U/L
Albumin
Serum
3.95.0
g/dL
Com ponent
Con
F
Alkaline
phosphatase
Serum
35110
U/L
0.
Aspartate
aminotransferase
(AST)
Serum
540
U/L
0.
Bilirubin
Serum
Direct
00.2
mg/dL
Total
0.11.2
mg/dL
Calcium
Serum
8.610.3
mg/dL
Carbon dioxide,
total
Serum
2230
mEq/L
Chloride
Serum
98108
mEq/L
Cholesterol
Serum
Age <29 yr
<200
mg/dL
0.
3039 yr
<225
mg/dL
0.
4049 yr
<245
mg/dL
0.
>50 yr
<265
mg/dL
0.
Complete blood
count
Blood
Hematocrit
Men
4252
W omen
3747
Men
4.66.2
10 6
/mm 3
W omen
4.25.4
10 6
/mm 3
W hite cell count
4.511.0
10 3
/mm 3
Platelet count
150300
10 3
/mm 3
8 AM
525
/dL
8 PM
313
g/dL
2090
g/24 hr
Red cell count
Cortisol
Blood
Serum
Cortisol
Urine
Creatine kinase
Serum
High CK group
(black men)
50250
U/L
Intermediate CK
group (nonblack
men, black
women)
35345
U/L
Low CK group
(nonblack
women)
25145
U/L
Creatinine
kinase
isoenzyme, MB
fraction
Serum
>5
Creatinine
Serum
0.41.3
mg/dL
Men
0.71.3
mg/dL
W omen
0.41.1
mg/dL
0.52.0
ng/mL
80100
microns 3
Digoxin,
therapeutic
Serum
Erythrocyte
indices
Blood
Mean
corpuscular
volume (MCV)
Mean
corpuscular
hemoglobin
(MCH)
2731
pg
Mean
corpuscular
hemoglobin
concentration
(MCHC)
3236
29438
ng/mL
9219
ng/mL
2.520.0
ng/mL
12 or <
mIU/mL
2.010.0
mIU/mL
W omen,
follicular
3.29.0
mIU/mL
W omen,
midcycle
3.29.0
mIU/mL
Ferritin
Serum
Men
W omen
Folate
Serum
Folliclestimulating
hormone (FSH)
Serum
Children
Men
W omen, luteal
2.06.2
mIU/mL
PO 2
8095
mm Hg
PCO 2
3743
mm Hg
Gases, arterial
Blood
Glucose
Serum
62110
mg/dL
0.
Iron
Serum
50160
g/dL
Iron-binding
capacity
Serum
230410
g/dL
1555
120300
U/L
4.915.0
mIU/mL
W omen,
follicular
5.025
mIU/mL
W omen, luteal
3.113
mIU/mL
TIBC
Saturation
Lactic
dehydrogenase
Serum
Luteinizing
hormone
Serum
Men
Magnesium
Serum
1.21.9
mEq/L
Osmolality
Serum
278300
mOsm/kg
Osmolality
Urine
None
defined
mOsm/kg
Phenobarbital,
therapeutic
Serum
1540
g/mL
Phenytoin,
therapeutic
Serum
1020
g/mL
Phosphate
(phosphorus,
inorganic)
Serum
2.34.1
mg/dL
Potassium
Serum
3.75.1
mEq/L
g/mL
Protein, total
Serum
6.58.3
g/dL
Sodium
Serum
134142
mEq/L
Theophylline,
therapeutic
Serum
520
g/mL
Thyroidstimulating
hormone (TSH)
Serum
05
IU/mL
Thyroxine
Serum
4.513.2
g/dL
T 3 -uptake ratio
Serum
0.881.19
Triiodothyronine
(T 3 )
Serum
70235
ng/mL
0.
Triglycerides
Serum
50200
mg/dL
0.
Urate (uric acid)
Serum
Men
2.98.5
mg/dL
W omen
2.26.5
mg/dL
Urea nitrogen
Serum
625
mg/dL
Vitamin B12
Serum
2501000
pg/mL
(Blair, E. R. et al. [ed.]: Damon Clinical Laboratories Handb

1989.)
Exampl e:
To convert a digoxin level of 0. 6 nmol/ L (SI unit s), divide by t he f act or 1. 281 t o
obt ain convent ional unit s of 0. 5 ng/ dL.
To convert a Ca+ + value of 8. 6 mg/ dL (convent ional unit s), multiply by t he f act or
0. 2495 t o obt ain t he SI unit s of 2. 15 mmol/ L.

Wilkins
> B ac k of B ook > Appendic es > Appendix E - Guidelines for S pec im en Tr ans por t and S tor age
Appendix E
Guidelines for Specimen Transport and Storage
Rout ines f or collect ion and handling of specimens and report ing of specif ic
pat ient inf ormat ion vary depending on agency prot ocols, t he clinical set t ing, and
specialt y laborat ory requirement s. The primary object ives in t he t ransport of
diagnost ic specimens are t o maint ain t he sample as near t o it s original st at e as
possible w it h minimum det eriorat ion and t o minimize hazards t o specimen
handlers. Specimens should be collect ed and t ransport ed as quickly as possible
(a 2-hour t ime limit is recommended). For urine t ransport , a small amount of
boric acid may be used; a holding or t ransport medium can be used f or most
ot her specimen t ypes. Follow caref ully t he inst ruct ions f or handling and t ransport
of specimens provided on t he kit or by t he manuf act urer, or by t he laborat ory
t hat has provided t hese collect ion kit s.
1. When t he pat ient delivers t he specimen direct ly, provide a biohazard bag and
include clearly w rit t en direct ions about t he specif ic handling precaut ions,
st orage condit ions, and specif ic direct ions f or locat ing t he physical f acilit y.
2. Specimens may be mailed or t ransport ed t o specialt y laborat ories locat ed in
ot her cit ies or dist ant areas. To avoid delays in specimen analysis, it is
import ant t o f ollow specif ic inst ruct ions f or collect ion, packaging, labeling,
and t ransport ing of specimens. Some specimens must be received in t he
laborat ory w it hin an exact t ime f rame, under specif ied st orage condit ions.
Regulat ory agencies (eg, t he Depart ment of Transport at ion [ DO T] , or t he
I nt ernat ional Air Transport Associat ion [ I ATA] ) require t raining t o ensure t hat
samples are properly packaged. The DO T requires t raining every 3 years,
w hereas I ATA requires every 2 years.
a. When packaging a specimen f or shipping t o a specialt y laborat ory, place
t he specimen in a securely closed, w at ert ight cont ainer (such as a t est
t ube, vial, or ot her primary cont ainer), t hen enclose t he ent ire primary
cont ainer in a second, durable, w at ert ight cont ainer (secondary
cont ainer). Each set of primary and secondary cont ainers should t hen be
enclosed in a st urdy, st rong out er shipping cont ainer (Fig. E. 1).
FI G URE E. 1 Proper t echnique f or packaging of biologically

hazardous mat erials. (CDC Laborat ory Manual, DHEW publicat ion
No. [ CDC] 74-8272, At lant a, Cent ers f or Disease Cont rol, 1974. )
b. Follow appropriat e labeling f or et iologic agent s and biomedical mat erials

(Fig. E. 2 and Fig. E. 3). I f t he package becomes damaged or leaks, t he
carrier is required, by f ederal regulat ions, t o isolat e t he package and
not if y t he Biohazards Cont rol O ff ice, Cent ers f or Disease Cont rol and
Prevent ion, in At lant a, G eorgia. The carrier must also not if y t he sender
t hat (improper) packaging not meet ing regulat ory requirement s can
cause a signif icant delay in specimen analysis, report ing of result s, and
medical diagnosis and t reat ment of t he pat ient 's problem. Examples of
specialt y laborat ory requirement s f or t ransport ing, packaging, and
mailing of specif ic specimens are show n in t he t able.
FI G URE E. 2 Et iologic agent s logo and not ice t o carrier t hat must
be aff ixed t o t he out side of any package cont aining pot ent ially
hazardous and inf ect ious biologic mat erials. Ref er t o packaging
inst ruct ions in t he event addi-t ional paperw ork is required t o
accompany t he package.
FI G URE E. 3 I nf ect ious subst ance label.
P. 1120
P. 1
Specimen
Cautions (also include Packaging and

Mailing Instructions)
Observe contamination control in
sample collectionfor example, most
blood tubes are contaminated with
trace metals, and all plastic syringes
with black rubber seals contain
Blood for
trace metals
Blood for
photosensitive
analysis
aluminum, varying amounts of zinc,

and all heavy metals (lead, mercury,
cadmium, nickel, chromium, and
others). The trace metal sample
should be collected firstonce the
needle has punctured the rubber
stopper, it is contaminated and should
not be used for trace metal collection.
Use alcohol swabs to cleanse sets;
avoid iodine-containing disinfectants,
use only stainless steel phlebotomy
needles. Blood for serum testing of
trace elements should be collected in
a royal-blue top (sodium heparin
anticoagulant) trace element blood
collection tube. After collecting and
centrifuging, place in a 5-mL, metalfree, screw-capped polypropylene vial;
transfer 5 mL using sterile
polypropylene pipette. Cap vial tightly,
attach specimen label, and send to lab
cool or frozen. All specimens stored
>48 hours should be frozen and sent
on dry ice. (Keep specimen cool with
frozen coolant AprilOctober,
refrigerated coolant November
March.)
Avoid exposure to any type of light
(artificial or sunlight) for any length of
time. These specimens need aluminum
foil wrap or brown plastic vial.
Specimens for vitamin A, vitamin B6 ,
-carotene, porphyrins, vitamin D, and

bilirubin are examples of substances
that need to be protected from light.
Routine
urinalysis,
random,
midstream
Preferred transport container is a

yellow plastic screw-top tube that
contains a tablet that preserves any
formed element (crystals, casts, or
cells) and prevents alteration of
chemical constituents caused by
bacterial overgrowth. Pour urine into
tube, cap tube securely, and invert to
dissolve the tablet.
Urine culture
Use a culture and sensitivity (C&S)

transport kit containing a sterile
plastic tube and transfer device for
collection. This tube contains a
special urine maintenance formula that
prevents rapid multiplication of the
bacteria in the urine. Pour the urine
specimen into the tube and seal
properly.
Urine for
calcium,
magnesium,
and oxalate
Use acid-washed plastic containers for

collection and transport of specimen.
If urine pH is >4, the results may be
inaccurate. Do not collect urine in
metal-based containers such as metal
bed pans or urinals.
Use a special 1000-mL container, such
as Nalgene, for total sample collection
Stool
and a 100-mL white polypropylene

container for a portion of a large
sample (aliquot) for feces collection.
Each container should have a similar
label affixed before it is given to the
patient. W hen the container is given
to the patient, provide the following
instructions: test to be done,
specimen requirements, diet
requirements, collection and storage
of specimen; two 1000-mL Nalgene
containers provided for timed
collection and one-100 mL container
for a random collection specimen;
information on how to obtain additional
containers if necessary, and do not fill
any
P.11
container more than full (indicated
line on label). At the time that the
patient returns the container to the
clinic, the health care worker fills in
the label with the correct information.
If Other is checked, enter duration
on line on label. If more than one
container is sent, be sure to indicate
total number sent on the line.
For a homogenized (blended)
specimen, the required mailed
specimen is a 80-mL portion of
homogenized feces. Homogenize and
weigh according to laboratory
Stool,
homogenized
Infectious
substance
protocol. Pour the homogenate into

the container as soon as possible (to
avoid settling). On the request form,
indicate specimen total weight and
amount of water added. Include length
of period of collection on request form,
also. Send the homogenized specimen
at the preferred transport temperature
listed in agency specimen
requirements protocol. This test is
usually performed at a special
reference laboratory.
A biohazard (Etiologic Agent) label
must be affixed (or preprinted on bags)
to all patient specimens for transport.
Body fluids have been recognized by
the Centers for Disease Control and
Prevention as being directly linked to
the transmission of HIV (AIDS) and
hepatitis B virus (HBV). Standard
precautions apply to these fluids and
include special handling requirements
of blood, semen, blood products,
vaginal secretions, cerebrospinal fluid,
synovial fluid, pleural fluid, peritoneal
fluid, pericardial fluid, amniotic fluid,
and concentrated HIV and HBV. Also,
a Biohazard label must be affixed to
all microbiology specimens, including
anaerobic and aerobic bacteria,
mycobacteria, fungi, and yeast. The
specimen must be sent on an agar
slant tube in a special transport

container (a pure culture, actively
growing); do not send on culture
plates. The outer shipping container of
all etiologic agents transported via
interstate traffic must be labeled as
illustrated in Figure E.2.
Specimens
requiring
exceptional
handling
Clearly and accurately label each

specimen with patient's full name, sex,
birth date, unique identification
number, time and date of specimen
collection, name of practitioner
ordering specimen, and signature of
person collecting specimens. The test
order form and sample should be
checked for a match and transported
in a single package.
Frozen
If a delay of >4 days before specimen

examination is expected, freezing of
the specimen is preferred. Place the
specimen in a plastic vial (not glass);
the container should not be more than
full, to allow for expansion when
frozen. Store in freezer or on dry ice
until specimen is picked up by carrier
or transported to the laboratory. Label
vial with patient's name, date, type of
specimen (eg, EDTA plasma, serum,
urine).
Urine, respiratory exudates, and stool
Refrigerated
(iced or
cooled)
or feces (transport medium is not

used) must all be refrigerated before
transport. Specimen that must be kept
at room temperature (ambient) before
inoculation of media include spinal
fluids and other body fluids, specimen
for Neisseria gonorrhoeae isolation,
and blood and wound cultures. Place
specimen in the refrigerator for
storage before pickup by courier.
W hen packaging, place the specimen
container in the zip-lock portion of bag
and the required coolant in the outer
pouch. If dry ice or a refrigerant is
used, it must be placed outside the
secondary container and the outer
shipping container; the shockabsorbant material should be placed
so that the secondary container does
not become loose inside the outer
shipping container as the dry ice
evaporates.
Aspiration with a needle and syringe,

rather than a swab, is the preferred
method of collection of a specimen for
recovery of anaerobic bacteria; once
collected, the specimen must be
protected from ambient oxygen and
kept from drying until it can be
processed in the laboratory. Transport
container for anaerobic specimen
includes:
1. Syringe and needle for aspiration

valid only if specimen can be
transported without delay. Remove
needle cap before transporting.
(Organism will survive in the
aspirated material.)
2. Port-a-cult (tube or vial)tubes are
used primarily for insertion of swab
specimens; vials are used for
inoculation of liquid specimen.
Anaerobic
3. Anaerobic culturetteplastic tube

or jacket is fitted with a swab and
contains either transport or prereduced medium. The culturette
system also includes a vial or
chamber separated by a membrane
that contains chemicals that
generate CO2 catalysts and
desiccants to get rid of any residual
O 2 that may get into the system.
The ampule must be crushed to
activate this system.
4. Bio-bag or plastic pouch system
transparent plastic bag that
contains a CO2 -generating system,
palladium catalyst cups, and an
anaerobic indicator. Bag is sealed
after inoculated plates have been
inserted and the CO2 -generating
system is activated. The advantage
of this system is that the plates can
be directly observed for early

growth of colonies.
Clin ical Alert T h e Code of Federal Regu lation s govern in g th e

sh ipmen t of etiologic agen ts (S72.2 Transportation of
Diagnostic Specimens, Biological Products, and Other Materials;
Minimum Packaging Requirements) reads as follow s: No person
may kn ow in gly tran sport or cau se to be tran sported in
in terstate traffic, directly or in directly, an y material, in clu din g,
bu t n ot limited to, diagn ostic specimen s an d biological
produ cts w h ich su ch person s reason able believe may con tain
an etiologic agen t u n less su ch material is packaged to
w ith stan d leakage of con ten ts, sh ocks, pressu re ch an ges, an d
oth er con dition s in ciden t to ordin ary h an dlin g in
tran sportation .

Wilkins
> B ac k of B ook > Appendic es > Appendix F - Vitam ins in Hum an Nutr ition
Appendix F
Vitamins in Human Nutrition
Vitamin Testing
Bot h f at -soluble and w at er-soluble vit amins play a
variet y of physiologic roles in t he body. Vit amin concent rat ions in
blood, urine, and cert ain body t issues can be measured and ref lect t he
nut rit ional st at us of t he pat ient .
Vit amins have varying modes of act ion. For inst ance,
vit amin E is an ant ioxidant , vit amin C is an enzyme cof act or, and
vit amin A is an ant i-inf ect ion agent .
Sources of f at-sol ubl e vit amins include ingest ed (diet ary) subst ances and
biologic or
int est inal microorganisms. Fat -soluble vit amins include vit amin A
(know n as ret inol or carot ene), vit amin D (calcif erol), vit amin E
(t ocopherol), and vit amin K (consist ing of phylloquinones or K1 , menaquinones or
K 2 , and menadiones or K3 ).
The sources of water-sol ubl e vit amins are diet ary (ingest ed) subst ances and
int est inal
microorganisms. Wat er-soluble vit amins include ascorbic acid (vit amin
C) and t he B-complex vit amins, such as biot in, cobalamin (vit amin B12 ), f olat e
(f olic acid), niacin (vit amin B3 ), pyridoxine (vit amin B6 ), ribof lavin (vit amin B2 ),
t hiamine (vit amin B1 ), and pant ot henic acid.
These t est s are measurement s of nut rit ional st at us. Low
levels indicat e recent inadequat e oral int ake, poor nut rit ional st at us,
and/ or malabsorpt ion problems. They may not ref lect t issue st ores. High
levels indicat e excessive int ake, int oxicat ion, or absorpt ion problems.
Reference Values
Diet ary Ref erence I nt akes (DRI s), t he most recent
approach adopt ed by t he Food and Nut rit ion Board, I nst it ut e of
Medicine, and Nat ional Academy of Sciences, provide est imat es of
vit amin int ake. The DRI s look beyond def iciency disease and include t he
role of nut rient s and f ood component s in long-t erm healt h. The DRI s
consist of f our ref erence int akes: Recommended Daily Allow ances (RDAs),
Tolerable Upper I nt ake Levels (ULs), Est imat ed Average Requirement s
(EARs), and Adequat e I nt ake (AI ). When an RDA cannot be set , an AI is
given as a normal value; bot h are t o be used as goals f or t he pat ient .
Levels are given f or each individual vit amin. The RDAs are t he amount s
of ingest ed vit amins needed by a healt hy person t o meet daily met abolic
needs, allow f or biologic variat ion, maint ain normal blood serum
values, prevent deplet ion of body st ores, and preserve normal body
f unct ions.
Procedure
1. Examine blood, urine, and hair or nail samples f or vit amin levels. The t ypes
of specimens needed are list ed in t he t able.
2. Test f or vit amins by bot h direct and indirect met hods.
I ncreased and decreased levels and crit ical ranges are show n in t he t able.
Interfering Factors
Fact ors t hat aff ect vit amin levels include age, season
of t he year, diarrhea or vomit ing, cert ain drugs, various diseases, and
long-t erm hyperaliment at ion.
Interventions
1. Assess overall nut rit ional st at us and

address pot ent ial def iciencies. O f t ent imes, one def iciency is
accompanied by several nut rient def iciencies.
2. Evaluat e signs and sympt oms of disrupt ed vit amin-relat ed met abolic
react ions t hat indicat e t he need f or t est ing.
3. Be aw are t hat cost of t est ing (high) and
t ime f rames f or obt aining t est result s (slow ) are issues. Samples f or
vit amin t est s are usually sent t o specialt y laborat ories, w hich
increases cost and t urnaround t ime dramat ically.
4. Explain t he purpose of t he t est bef ore collect ing blood, urine, hair, or nail
specimens.
5. I nf orm t he pat ient t hat vit amins are
micronut rient s t hat can be det ect ed in t he blood and urine as an
indicat ion of overt nut rit ional def iciency st at es, t oxic levels, or
subclinical hypovit aminosis. The pot ent ial f or t oxicit y f rom excessive
int ake exist s.
6. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest and i ntratest
care.
7. I nt rat est careCollect required specimens.

1. Verif y and report ref erence ranges (RR)
and crit ical ranges (CR). Take appropriat e act ion w hen values are t oo
high or t oo low. Treat nut rient def iciencies and t oxicit ies immediat ely.
2. I n collaborat ion w it h ot her clinicians

(eg, pharmacist , diet ician), counsel t he pat ient about abnormal
result s, f ollow -up t est s, diet ary changes, and t reat ment . Wat er-soluble
vit amins are needed on a daily basis. Ref erence ranges vary and are
met hod dependent . Check w it h your laborat ory.
Substance Tested
(Specim en Needed),
Reference Range (RR),
and Critical Toxic
Range (CR) and RDIs
When Available
FAT-SOLUBLE VITAMINS
Patient Preparation,
Substance
Function, and
Indications for Test
Increase
Vitamin A
Retinol (serum)
RR: 3601200 g/L or
0.701.75 mol/L
CR: <10 g/dL or <0.35
mol/L indicates severe
deficiency,
>1002000 g/dL or
>3.4969.8 mol/L
indicates
hypervitaminosis A
Carotene (serum)
RR: 50300 g/dL or
1.57.4 mol/L
CR: >250 g/dL or
>4.65 mol/L indicates
carotenemia
RR: Retinyl esters <10
g/L when selected
Relative dose response
(%)
RR: >20; CR: >50
deficiency
Children show an agerelated rise in serum
retinol, and values lower
before puberty.
Levels in adults
increase slightly with
age.
Premenopausal women
have slightly lower
Fasting. No alcohol
24 h before blood
draw
Prevents night
blindness and other
eye problems and
skin disorders (acne)
Enhances immunity,
protects against
pollution and cancer
formation
Needed for
maintenance repair
of epithelial tissues
Aids fat storage
Protects against
colds, infections
Acts as antioxidant
(protects cells
against cancer and
other diseases)
Evaluate night
blindness, malabsorption disorders,
chronic nephritis,
acute protein
deficiency, Bitot's
Activatio
and/or c
Alopecia
Amenorr
Arthralgi
Birth def
Caroteno
Cheilosi
Chronic
Cortical
Excessiv
supplem
Hepatos
Hyperch
Hyperlip
Peeling
Permane
disabiliti
Pregnan
Prematu
closure
Pseudot
Spontan
Nyctalop
blindnes
Oral con
(caroten
Pancrea
Protein-e
(marasm
values than men. After

menopause, values are
similar.
RDI: Men: 1000
g/retinol equivalent
(RE)/d
W omen: 800 g/retinol
equivalent (RE)/d
infections, chronic
intake of >10 mg
retinol equivalent
(RE)
Perifollic
hyperker
disease)
Sprue
Xerophth
Xerosis
and corn
Fasting
Synthesized by skin
exposure to the
sunshine
Required for
absorption of calcium
and phosphorous by
the intestinal tract
Necessary for normal
development of
bones in children
Protects against
muscle weakness,
involved in regulation
of heartbeat
Important in
treatment of
osteoporosis and
hypocalcemia
Gastroin
(anorexia
vomiting
Infants:
hypercal
to thrive
retardati
aorta
Metasta
calcifica
Renal co
spots, intestinal
parasites, acute
Vitamin D
1, 25dihydroxycholecalciferol,
calciferol (serum)
RR: 60 ng/mL or 150
nmol/L
Toxic: >150 ng/mL or
>375 nmol/L
Deficient: <10 ng/mL or
<25 nmol/L
CR: Serum calcium
levels of 1216 mg/dL or
3.04.0 mmol/L (vitamin
D toxicity)
RDI: Adults:
Cholecalciferol 10 g/d
or 400 U of vitamin D
Evaluate rickets,
osteomalacia, fat
malabsorption;
disorders of
Supplem
W illiams
parathyroid, liver or
kidney; prolonged
supplement intake of
2,000 IU/d
Vitamin E
Serum alpha tocopherol,

TE (most active)
RR (serum): Adults:
0.51.8 mg/dL or 1242
mol/L
Fasting. No alcohol
24 hours before draw
Antioxidant
Important in
prevention of cancer
and cardiovascular
diseases
Promotes normal
blood clotting,
healing
Reduces wound
scarring
Improves circulation
necessary for tissue
repair; maintains
Low-birth
(sepsis,
enteroco
Vitamin
NOTE: Concentration of
vitamin E in newborns is
less than half that of
adults
RDI: Men: 10 mg
Alpha tocopherol
equivalent (-TE)
W omen: 8 mg/-TE
healthy nerves and

muscles while
strengthening
capillary walls
Prevents cell damage
by inhibiting the
oxidation of lipids
and formation of free
radicals
(antioxidants)
Aids utilization of
vitamin A
Retards aging and
may prevent age
spots
Evaluate prematurebirth-weight infants,
abetalipoproteinemia,
malabsorption
Vitamin K
Fasting
Needed for the
production of
prothrombin (blood
clotting)
Increase
tendency
Impaired
formatio
Reduced
formatio
carotene
levels)
Phylloquinone (K1 )
plants; menaquinone (K2
series) bacterial;
menadione (K2 )
synthetic
RR: 1.31.9 ng/mL,
PIVKA 11 test (proteins
induced in vitamin K
absence). This test is
superior. Plasma
prothrombin concentration
10.512.5 seconds
RDI: Men: 80 g/d
W omen: 6065 g/d
Essential for bone

formation and repair
Necessary for
synthesis of
osteocalcin (the
protein in bone
tissue on
which calcium
crystalizes)
Therefore, prevents
osteoporosis
Plays role in
converting glucose
into glycogen for
storage in liver
Antibiotics interfere
with absorption of
vitamin K
Evaluate renal
insufficiency and
chronic antibiotic
treatment
WAT ER-SOLUBLE VITAMINS
Glucose
dehydro
Increase
administ
preparat
Low-birth
(increas
Anemia
Hyperbil
Kernicte
encepha
Loss of s
Postkern
Ascorbic Acid (Vitamin

C)
RR: 0114 mol/L
plasma; 02.0 mg/dL
plasma, 114301
nmol/10 3 cells (mixed
leukocytes), 2053
g/10 3 cells (mixed
leukocytes)
CR: <11 mol/L plasma
ascorbate, <0.2 mg/dl
plasma ascorbate, <57
nmol/10 3 cells (mixed
leukocytes), <10 mg/103
cells (mixed leukocytes)
W omen consistently
show higher vitamin C
levels in tissues and
fluids than men.
Plasma values are the
best indicator of recent
dietary intake.
Leukocyte vitamin C
levels are indicative of
cellular stores and body
pool.
NOTE: Salivary vitamin
C levels are not
Antioxidant needed
for tissue growth and
repair, adrenal gland
function, and healthy
gums
Aids in production of
antistress hormones
and interferon;
needed for
metabolism of folic
acid, tyrosine, and
phenylalanine
Increases absorption
of iron; reduces
cholesterol levels
and high blood
pressure
Essential in
neurotransmitter
synthesis and
metabolism
Essential in the
formation of
collagen; promotes
wound healing;
protects against
infection
Enhances immunity
Decreas
effect of
warfarin
Diarrhea
Overabs
Supplem
of tests
occult bl
Nausea
Some pa
of kidney
increase
stones w
vitamin C
consistent; urinary
vitamin C levels are not
useful.
RDI: Adults: 60 mg/d
Evaluate scurvy,
poor diet, and
nephrolithiasis.
Biotin
(plasma)
RR: 0.822.87 nmol/L
CR: <1.02 nmol/L
deficiency
(whole blood or serum)
RR: 200500 pg/mL or
0.822.05 nmol/L
Prenatal diagnosis of
multiple carboxylase
Biotin is produced by
the gut flora.
Aids in cell growth,
fatty acid production,
metabolism of fats,
carbohydrates, and
proteins, and
utilization of other
complex vitamins
Promotes healthy
deficiency (MCD) by
direct
analysis of amniotic
fluid for methylcitric acid
or 3-hydroxyisovaleric
acid.
RDI: 30 g/d
sweat glands, nerve

tissue, and bone
marrow
Needed for healthy
hair and skin
Assess for ingestion
of raw eggs,
inflammatory bowel
disease, alcoholism,
sulfonamide therapy,
depression.
Cobalamin (Vitamin B12 )
Overnight fast. Avoid
(serum)
RR: >200835 pg/mL or
148616 pmol/L
CR: <100 pg/mL or <74
pmol/L deficiency
RDI: Adults 2.4 g/d
heparin, ascorbic
acid, fluoride, and
alcohol before
testing.
Aids folic acid in
formation of iron;
prevents anemia
Required for proper
digestion, absorption
of food, synthesis of
protein and
metabolism of fats
and carbohydrates.
Prevents nerve
damage, maintains
fertility, production of
acetylcholine
(neurotransmitter
that assists memory
and learning)
Found mostly in
animal sources, so
strict vegetarians
may need
supplements
Regional enteritis
Evaluate strict
vegetarian diet
spanning 2030 y,
alcoholism, after
gastrectomy, and
parasitic infections.
Improved
in elderl
supplem
Toxicity
not been
Folate (Folic Acid)
(pteroylglutamate,
pteroylglutamic acid, 5methyltetrahydrofolate)
Red blood cell folate
(best indicator of status)
RR: 150800 ng/mL or
34018,120 nmol/L
whole blood, corrected
to packed cell volume of
45%
Tissue folate depletion
(serum dietary
Fasting
Needed for energy
production and
formation of red
blood cells
Strengthens
immunity by aiding
white blood cell
functioning
fluctuations): <160
ng/mL or <360 nmol/L
RR: 321 ng/mL or 6.7
47.5 nmol/L
CR: <1.5 ng/mL or <3.4
nmol/L deficiency
Negative folate balance:
<3 ng/mL or <7 nmol/L,
RDI: Adults: 400 g/d
Other methods
(infrequently used):
Deoxyuridine
suppression test (DU or
dUST), a functional
indicator of
folate status; in vitro
laboratory test that
defines presence of
megaloblastosis and
identifies which nutrient
deficiency is
responsible
(folate or vitamin B12 )
Formiminoglutamic acid
(FIGLU)after histidine
loading
Urine24 hours after
initial dose
RR: <35 mg/d or <201
mol/d
Folate deficiency: <35
Important for healthy

cell division and
replication (DNA and
RNA synthesis)
Protein metabolism
Prevention of folic
acid anemia
In pregnancy,
regulates embryonic
and fetal nerve cell
formation, prevents
premature birth
W orks best when
combined with
vitamins B12 and C
Cooking destroys
folic acid
Evaluate
megaloblastic
anemia, cancer,
inflammatory bowel
disease,
alcoholism, drug
treatment with
phenytoin,
cholestyramine,
sulfasalazine, oral
contraceptives
Detect folate
deficiency
Folacin i
serum a
Loss of s
Acute re
Active liv
Red bloo
Supplem
g/4 mg
mg/d or <201 mol/d
Riboflavin (Vitamin B2 )
(serum or plasma)
RR: 424 g/dL or 106
638 nmol/L
urinemuch more
sensitive to nutritional
status
RR: >80 g/d or >213
nmol/dL erythrocyte;
1050 g/dL or 266
1330 nmol/L
Creatinine indicates
deficiency <27 g/g
Fasting
Necessary for red
blood cell formation,
antibody production,
cell respiration, and
growth
Alleviates eye fatigue
and important in
treatment and
prevention of
cataracts
Aids metabolism of
fat, carbohydrates,
and protein
W ith Vitamin A,
maintains and
improves mucous
membranes in
digestive tract
Helps absorption of
creatinine (urine) or <8

mol/mol creatinine
Erythrocyte glutathione
reductase assay,
expressed in activity
coefficients (AC). Test
cannot be used in
persons with
glucose-6-phosphate
deficiency
RR: 1050 g/dL or
2661330 nmol/L
RDI: Men: 1.3 mg/d
W omen: 1.1 mg/d
iron and B6
Pure, uncomplicated
riboflavin deficiency
is rareif seen, it is
usually accompanied
by multiple nutrient
deficiencies.
Needed for
metabolism of amino
acid tryptophan,
which is converted to
niacin in the body
Easily destroyed by
light, anti-biotics,
and alcohol
Increased need for
B 2 with use of oral
contraceptives or
strenuous exercise
Assess poor dietary
intake, as in
congenital heart
disease and some
cancers.
Niacin (Vitamin B3 )
24-h urine collection
Essential for proper
circulation and
healthy skin
Aids functioning of
nervous system and
None
metabolism of
carbohydrates,
Nicotinic acid,
niacinamide (urinary Nmethylnicatinamide,
NMN) 24-h urine
RR: 2.46.4 mg/d or
17.546.7 mol/d
CR: <0.8 mg/d or <5.8
mol/d deficiency
RDI: Men: 16 mg/d
W omen: 14 mg/d
fats, and protein in

the production of
hydrochloric acid for
digestion
Involved in normal
secretion of bile and
stomach fluids and
synthesis of sex
hormones
Lowers cholesterol
Helpful for
schizophrenia and
other mental
diseases
Evaluate
antituberculosis drug
therapy (isoniazid),
malabsorptive
disorders, and
alcoholism
Pyridoxine (Vitamin B6 )
Fasting or urine
collection
Needed for
production of
hydrochloric acid and
absorption of fats
Abnorma
Hypocho
Use as h
Atrial fib
Cystoid
Epigastr
Glucose
Gout
Hypergly
Hypoten
Pruritus
Smooth,
Upper bo
and
RR (direct)
Plasma vitamin B6 ; 524
ng/mL or 2097 nmol/L
Plasma pyridoxal 5
phosphate >7 ng/mL or
>30 nmol/L
Plasma total vitamin B6
> 10 ng/mL or >40
nmol/L
Urinary 4-pyridoxic acid
(4rPA) <3.0 mol/d
(useful short-term index)
Urinary total vitamin B6
antagonists B6 >0.5
mol/day (isoniazid,
penicillamine,
cycloserine)
RR (indirect):
Erythrocyte alanine
transaminase index
(EALT/EGPT) >1.25
(EALT is a
better indicator than
EAST; standardized
approach needed to
compare
tests).
protein, sodium and

potassium balance,
and red blood cell
formation
Required by nervous
system for normal
brain function
Tryptophan
metabolism
Niacin formation
Gluconeogenesis
Synthesis of nucleic
acids, RNA and DNA;
activates many
enzymes and aids in
absorption of vitamin
B 12
Cancer immunity,
prevents
arteriosclerosis
Mild diuretic
reduces
premenstrual
syndrome
Diuretics and
cortisone drugs block
absorption of B6 .
Antidepressants,
estrogen therapy,
and oral
contraceptives
Infants:
symptom
distress
Peripher
progress
lower lim
Photose
Neurotox
increase need for B6 .

Evaluate groups at
risk, including
newborn infants with
low B6 , some
cancers, excess
alcohol.
Thiamine (Vitamin B1 )
RR: 0.20.4 g/dL or

5.9118 nmol/L (serum
or plasma)
Fasting
Enhances circulation
and blood formation,
carbohydrate
metabolism, and
production of
hydrochloric acid
Optimizes cognitive
activity and brain
function
2.57.5 g/dL or 74222

nmol/L (whole blood)
Late changes: <50 g/d
or <148 nmol/d urine
with elevated blood
pyruvate
Red blood cell
transketolase
measurement (most
reliable method)
Enzyme assaysusing
thiamine pyrophosphate
(TPP): 79178 nmol/L
RR (stimulation): 0%
25%; deficiency, >20%
RDI: Men: 1.3 mg/d
W omen: 1.1 mg/d
Has a positive effect

on energy, growth,
normal appetite, and
learning capacity
Needed for muscle
tone of intestines,
stomach, and heart
Acts as antioxidant,
protecting body from
degenerative effects
of aging, alcohol
consumption, and
smoking
Evaluate alcoholism,
impaired absorption,
excess intravenous
glucose
infusion, in diets
primarily of refined,
unenhanced grain
products
Parenter
High-car
increase
Thiamin
in adults
protein d

T itle: M anual of Laboratory & D i agnosti c Tests, 7th Edi ti on Copyri ght
2004 Li ppi ncott Wi l l i ams & Wi l ki ns
> B ac k of B ook > Appendic es > Appendix G - Miner als in Hum an Nutr ition
Appendix G
Minerals in Human Nutrition
M ineral Testing
Minerals are micronut rient s needed in relat ively small
amount s. Unlike vit amins, t he source f or minerals comes f rom nonliving,
nat urally occurring element s, such as mineral salt s in t he soil t hat
become a part of t he chemical const it uent s of f ood or minerals t hat are
dissolved in ocean w at er and ingest ed in seaf ood. Mineral
concent rat ions in blood, urine, and cert ain body t issues can be
measured and ref lect t he nut rit ional st at us of t he pat ient .
Minerals are eit her macronut rient s (major) or
micronut rient s (t race or ult rat race). I f t he body requires a
signif icant amount of t he mineral (> 100 mg/ d) and an RDA has been
est ablished, it is a macronut rient ; if t he body requires less (a f ew
milligrams per day) and an RDA or Est imat ed Saf e and Adequat e Daily
Diet ary I nt ake (ESADDI ) has been est ablished, it is a micronut rient
t race mineral; if t he body requires <1 mg/ d and no RDA or ESADDI has
been est ablished, it is a micronut rient ult rat race mineral.
Macronutri ents (major mi neral s) include calcium, chloride, magnesium,
phosphorous, pot assium, sodium,
and sulf ur. Macronut rient s are not list ed in t his t able; t hey are
explained in Chapt er 6.
Trace mi neral s include t he micronut rient s chromium, cobalt , copper, f luorine,
iodine, iron, manganese, molybdenum, selenium, and zinc.
Ul tratrace mi neral s include t he micronut rient s arsenic, boron, bromine, cadmium,
lead, lit hium, nickel, silicon, t in, and vanadium.
Minerals f ound in t he body w it hout an assigned met abolic
role include aluminum, ant imony, beryllium, bismut h, cyanide (an anion
t hat f orms a salt w it h minerals), gold, mercury, silver, lead,

t hallium, and many ot hers.
These measurement s of minerals are used t o assess
environment al or occupat ional exposure and t oxicit y, monit or
eff ect iveness of t reat ment , and evaluat e mineral st at us along w it h
ot her laborat ory levels t o verif y def iciencies.
References Values
Diet ary Ref erence I nt akes (DRI s), t he most recent
approach adopt ed by t he Food and Nut rit ion Board, I nst it ut e of
Medicine, and Nat ional Academy of Sciences, provide est imat es of
mineral int ake. The DRI s look beyond def iciency disease and include t he
role of nut rient s and f ood component s in long-t erm healt h and
prevent ion of chronic disease (ie, calcium balance and calcium
ret ent ion). The DRI s consist of f our 4 ref erence int akes: Recommended
Daily Allow ances (RDAs), Tolerable Upper I nt ake Levels (ULs), Est imat ed
Average Requirement s (EARs), and Adequat e I nt ake (AI ). The RDAs and EAR
levels have been est ablished f or some minerals, including t hose w it h
and w it hout an assigned role in t he human body.
Procedure
1. Examine blood, urine, hair, or nail samples f or mineral levels by indirect and
direct met hods.
2. Types of specimens required are list ed in t he t able.
I ncreased and decreased levels and crit ical t oxic ranges are f ound in t he t able.
Interfering Factors
Fact ors t hat aff ect mineral levels include: G enet ic makeup
1. Age or st age of lif e cycle
2. Environment al f act ors
3. Drugs
4. I nt est inal malabsorpt ion
5. St ress
6. St renuous physical act ivit y
7. Smoking
8. Alcohol consumpt ion
9. Diet ary int ake
Interventions

1. Evaluat e overall nut rit ional st at us, diet ary int ake, and supplement usage t o
det ermine overconsumpt ion.
2. Evaluat e signs and sympt oms of

occupat ional and environment al t oxicit y and mineral def iciencies t hat
indicat e t he need f or t est ing.
3. Explain t he purpose of t he t est bef ore collect ing blood, urine, hair, or nail
specimens.
4. I nf orm t he pat ient t hat minerals are
nut rient s t hat can be det ect ed in t he blood and urine as an indicat ion
of t oxicit y or exposure and nut rit ional st at us. The amount s needed are
det ermined by w hat is necessary f or opt imal f unct ion and healt h and t o
prevent disease.
5. See Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed pretest and i ntratest
care.

1. Verif y and report ref erence ranges (RR)
and crit ical t oxic ranges (CR). Take appropriat e act ion w hen values are
t oo high or t oo low.
2. Counsel t he pat ient appropriat ely about

abnormal result s, f ollow -up t est ing, occupat ional and lif est yle
changes, t reat ment , and diet . Ref erence ranges vary and are met hod
dependent . Check w it h your laborat ory. Not if y employer, w orkplace, and
physician about exposure result s.
3. Follow Chapt er 1 guidelines f or saf e, eff ect ive, inf ormed postest care .
Substance
Tested
(Specim en
Needed),
Reference
Range (RR),
Critical
Toxic Range
Clinical Im
Patient
Preparation,
Substance
Function, and
Indications for
Increased
(CR), and
RDIs if
Available
Test
Aluminum (Al)
Aluminum
absorption with
citrate-containing
drugs (effervescent
or analgesics)
Use of aluminumcontaining
astringents,
hydroxide gels,
aluminumcontaining
phosphate binders
Excessive
occupational
exposure
(serum)
RR: 20550
g/L or
Collect urine in
acid-washed
polypropylene
container.
No metabolic role
Toxicity:
Aluminosis (lung
disease)
Aluminum-induced
encephalopathy
Hypophosphatemia
Dialysis dementia
Iron-resistant
microcytic anemia
0.7420.4
mol/L
dialysis
patients
(urine)
RR: 530
g/L or
0.191.11
mol/L
Metal used in
other forms as an
astringent
(Burrow's
solution) and
as an antacid
Assess for
occupational
exposure,
toxicity from
antacids; monitor
dialysis patients.
Aluminum-related
osteomalacia
In renal failure,
when aluminum
containing antacids
are used; long-term
intermittent dialysis
NOTE: Aluminum is
a neurotoxin. The
primary symptom is
motor
dysfunction leading
to dysarthria,
myoclonus, or
epilepsy. Aluminum
toxicity is not
related to
Alzheimer's
disease. Aluminum
can be found
in laboratory
solutions used with
tissue samples and
in laboratory
dust. New testing
methods are being
adopted to rule out
contamination.
Antimony (Sb)
(24-h urine)
RR: <10 g/L
or
<82.1 nmol/L
CR: >1 mg/L
or
>8.2 mol/L
(plasma)
RR: 0.03
0.07 g/dL or
2.55.7
nmol/L
No metabolic role
Compounds used
in alloys,
medicines,
poisons
Assess for
occupational
exposure
and toxicity.
Excessive
occupational
exposure (ore from
mining, bronze
ceramics)
Ingested
compounds (drugs
used in parasitic
infections)
Toxicity: Acid
metallic taste,
burning
gastrointestinal
pain (as
in arsenic
poisoning), throat
constriction,
dysphagia,
pulmonary edema,
liver and renal
failure
Lethal dose: 550
mg/kg body weight
Arsenic (As)
(hair or
nails)
<1.0 g/g of
hair or
nails
(serum)
5 g/mL or
0.07 mol/L
Normal
concentration,
100500 g/L
or
1.336.65
mol/L
Toxic
concentration,
5000 g per
specimen
(chronic
poisoning)
505000 g/L
or
0.6766.5
mol/L
(acute
poisoning)
100020,000
g/L or
13.3266
mol/L
(whole blood)
223 g/L or
0.030.31
mol/L
Dermatoses
(hyperpigmentation,
hyperkeratosis,
desquamation, and
hair loss);
hematopoietic for
hair and nails
Ultratrace
mineral; no
function
Found in
pesticides and
paints
Used as a
homicidal poison
High selectivity
Assess for
occupational
exposure,
exposure from
pesticides and
herbicides,
intentional
poisoning.
Depression
Liver damage
characterized by
jaundice
Peripheral
neuropathy
Accidental or
intentional
poisoning
Excessive
occupational
exposure (ceramics,
agriculture)
Toxicity: Metallic
taste and odor of
garlic on breath,
burning
pain in
gastrointestinal
tract, shock
syndrome, bloody
diarrhea,
pulmonary edema,
liver failure
Lethal dose: 550
mg/kg body weight
(24-h urine)
550 g/day
or
0.070.67
mol/L
Beryllium (Be)
Acute beryllium
disease (a chemical
pneumonitis)
Excessive
occupational
exposure (metal
extraction, refinery,
rocket
(24-h urine)
RR: negative,
none detected
CR: >20 g/L
or
>2.22 mol/L
No metabolic role;
a metallic
element.
Assess for
occupational
exposure
and toxicity.
base, nuclear plant,

extensive coal
burning); secondary
polycythemia
Historical
beryllium mining,
electronics,
chemical plants,
manufacture of
fluorescent lights
(inhalation,
introduction into or
under skin and/or
conjunctiva):
berylliosis or
granulomatosis
NOTE: Almost
impossible to
distinguish from
sarcoidosis
Bismuth used as
treatment for
syphilis in a
growing child when
mother has been
treated during
pregnancy
Collect urine in
metal free
container.
Bismuth (Bi)
(24-h urine)
RR: 0.34.6
g/L or
1.422.0
No metabolic role.
W orkers exposed
in cosmetics,
disinfectants,
pigments, and
Treatment of peptic
ulcer with bismuthcontaining drug
(zolimidine,
colloidal bismuth
subcitrate)
Bismuth
subcarbonate,
subgallate, and
subnitrate
compounds (used
as
antiseptics,
astringents,
sedatives, and to
nmol/L
(plasma)
0.13.5 g/L
or
0.516.7
nmol/L
solder industries
Used in some
drugs; poisoning
as a consequence
of therapy for
syphilis
Assess for
occupational
exposure, toxicity,
and medication
levels.
treat diarrhea and

inflamed
skin)
Toxicity: Ulcerative
stomatitis,
anorexia,
headache, rash,
renal
tubular damage,
bluish line at gum
margin,
albuminuria;
resembles lead
poisoning, without
the blood changes
and paralysis;
rheumatic-like pain
Boron (Bo)
Ultratrace
mineral; a
Increase in total
plasma calcium
concentrations and
urinary excretions
of calcium and
(blood, 4-mL
serum)
total RR: <2
mg/L or
33 mol/L
CR: >20 mg/L
or
>330 mol/L
nonmetallic
element, found as
a compound such
as boric acid or
borox
Assess for
exposure and
toxicity, ingestion
of boric acid, and
un-expected
absorption of
boric acid from
diapers or
infant pacifier
dipped in borax
preparation and
honey.
magnesium
Toxicity:
Riboflavinuria;
lethargy;
gastrointestinal
symptoms; bright,
red rash; shock.
Infants: reports of
scanty hair; patchy,
dry, erythema;
anemia; seizure
disorders
Lethal dose
(adults): boric acid
or borate salts, 50
500 mg/kg body
weight
Bromine (Br), Bromide

Ultratrace
mineral; a central
(serum)
RR: 20120
mg/dL or
nervous system
depressant.
Bromine is a
liquid, nonmetallic
element
obtained from
Bromide acne
Neurologic
disturbances
Increased spinal
2.515.0
mmol/L
(plasma)
RR: 1000
2000 mg/L or
12.525.0
mmol/L
natural brines
from wells and
sea water;
compounds used
fluid pressure
in medicine and
photography
Lethal dose: 500

5000 mg/kg body
weight
Toxicity: Bromism or
brominism
Assess for
occupational
exposure to
bromide in
medicine or
photography.
Cadmium (Cd)
(blood)
RR: 05
ng/mL or
044 nmol/L
(urine
preferred)
05.0 g/24h
or
044 nmol/d
Ultratrace
mineral, a metallic
element in zinc
ores
Used in
electroplating and
in atomic reactors
Its salts are
poisonous.
In tissue, in
prostatic and renal
cancer
In urine, in
hypertension,
industrial exposure
(electroplating
atomic reactors,
zinc ores, cadmium
solder)
In blood, poisoning
from foods
prepared in
cadmium-lined
vessels, inhalation
of cadmium dust
and
Toxic: 100
3000 g/L or
0.926.7
mol/L
Assess for
occupational
exposure,
environmental
poisoning.
fumes, softened
drinking water,
goods grown in soil
heavily fertilized
with
superphosphate
Toxicity: Severe
gastroenteritis, mild
liver damage, acute
renal failure;
pulmonary edema;
cough; duck-like
gait; brown urine
Lethal dose:
Several hundred
mg/kg body weight
Chromium (Cr)
(whole blood)
RR: 0.728.0
g/L or
13.4538
nmol/L
Required for
normal glucose
metabolism;
affects cholesterol
synthesis
Assess for
Excessive industrial
exposure
(24-h urine)
0.12.0 g/d
or
1.938.4
nmol/d
occupational
exposure, poor
diet, elderly at
risk. Severe
trauma and stress
increase need.
(carcinogenic)
Renal damage
Cobalt (Co)
(part of the
vitamin B12
molecule)
(serum)
RR: 0.11
0.45 g/L or
1.97.6
nmol/L
Essential element
in vitamin B12
stimulates
production of red
blood cells
Assess for
occupational
exposure and
monitor dialysis.
Cardiomyopathy
after
industrial exposure,
during maintenance
dialysis, and after
drinking
beer contaminated
with cobalt during
processing
Copper (Cu)
(serum, 3 mL)
RR (total):
85150 g/dL
or
13.323.6
mol/L
(24-h urine)
RR: 335
Required for
hemoglobin
synthesis,
essential
component of
several enzyme
T-cell proliferation
Hepatic glutathione
W ilson's disease
(hepatolenticular
degeneration)
Ingestion of
solutions of copper
salts
Contaminated water
g/d or
0.0470.55
mol/d
(plasma)
RR: 90150
g/dL or
14.123.6
mol/L
Ceruloplasmin
is an
indirect test
for copper
RR: 2153
mg/dL,
210530 mg/L
(neonate: 5
18 mg/dL,
50180 mg/L)
systems; present
in
the liver and
excreted by the
kidneys and in
bile
Assess for
excessive antacid
intake, nephronic
malabsorptive
disorder,
hemodialysis, and
consumption of
water high in
copper by infants.
or dialysis fluids
Native-American
childhood cirrhosis
Female rheumatoid
arthritis
Oral contraceptive
use
Inflammatory
conditions
Cancer at injection
sites or muscles
Toxicity: Hepatic or
renal failure
Lethal dose: 50
500 mg/kg body
weight
Cyanide (Cn Radical)
(blood, 5 mL)
RR: <0.02
mg/L or
<0.61 mol/L
Nonsmokers:
toxic: >0.1
mg/L or
>3.84 mol/L
No metabolic role
The most common
and most deadly
poisonstops
cellular
respiration by
inhibiting the
actions of
cytochrome
oxidase, carbonic
anhydrase, and
Industrial exposure
(pesticides,
metallurgy)
Inhalation of
hydrocyanic acid
and fumes from
burning nitrogencontaining products
other enzyme
systems.
Ingestion of salts
and
laetrile (derived
from broken seeds
of apricots,
peaches, jetberry
Toxicity comes
from inhalation or
ingestiona
hazard to
firefighters.
Assess for
industrial
exposure,
inhalation, or
accidental
poisoning from
ingestion.
bush, toyon, bitter

almonds, and some
apple seeds)
Toxicity: Lethal
dose is <5 mg/kg
body weight (small
child),
fatal dose = 525
seeds. Death within
5 min of
ingestion/inhalation.
Adverse effects are
dizziness,
weakness, mental
and motor
impairment,
and sudden death.
Fluorine (F)
(plasma)
RR: 0.010.2
g/mL or
0.510.5
mol/L
(urine)
RR: 0.023.2
g/mL or
1.05168.3
mol/L
RDI: Men 4
mg/d
W omen 3
mg/d
Gaseous chemical
found in soil in
combination with
calcium.
Used as a
compound
(fluoride) in
toothpaste
Assess for excess
ingestion;
evaluate dental
caries or mottling.
Fluorosis (excess
fluorine use; >4
million ppm in
water; treatment of
osteoporosis,
multiple myeloma,
or Paget's disease)
Osteosclerosis
Exostoses of spine
and genuvalgum
Excess ingestion
from swallowing
fluoridated
toothpaste
Toxicity: Peculiar
taste with salivation
and thirst
(salty-soapy),
hemorrhagic
gastroenteritis;
hypoglycemia;
central
nervous system
depression; renal
failure
Lethal dose: 50
500 mg/kg body
weight; 510 g
sodium fluoride
Gold (Au)
Rheumatoid
arthritis if gold
sodium thiomalate
or gold thioglucose
(aurothioglucose) is
given parenterally;
oral gold compound
(colloidal gold
in
cerebrospinal
fluid)
RR: minute
amount
(serum)
RR: <10
g/dL or
<0.5 mol/L
(therapeutic
range)
100200
g/dL or
5.110.2
mol/L
Collect in metalfree container.

No metabolic role;
a metallic element
Salts used in
early rheumatoid
arthritis and in
nondisseminated
lupus
erythematosus
Detectable in
serum 10 mo after
cessation of
treatment
Assess for toxicity
in treatment of
rheumatoid
arthritis.
Toxicity: At least
35% of patients
undergoing
chrysotherapy
develop some
degree of toxicity.
Pruritus, dermatitis,
stomatitis,
albuminuria with or
without nephrotic
syndrome,
agranulo-cytosis,
thrombocytopenic
purpura, and
aplastic anemia
Adverse reactions:
Enterocolitis,
intrahepatic
cholestasis, skin
hyperpigmentation,
peripheral
neuropathy, and
pulmonary
infiltrates
Iodine (I)
(plasma)
RR: 24
g/dL, 60
ng/mL
Deficiency:
IDD (iodine
deficiency
disorders)
(daily urine)
Mild IDD, RR:
50100 g/d
(median
urine, 3.5
g/dL)
Moderate
IDD, RR: 25
Nonmetallic
element belonging
to the halogen
group
Aids in the
development and
function of the
thyroid gland,
formation of
Prolonged
excessive intake of
iodine leading to
iodide-goiter and
myxedema
(common with preexisting
Hashimoto's
thyroiditis)
Excessive
consumption of
seaweed, kelp
supplements;
caffeine
High dietary intake
of known goitrogens
(rutabagas, turnips,
cabbages)
Hypothyroidism in
autoimmune thyroid
diseases, inhibition
of thioamide drugs
49 g/d
(median
urine, 23.4
g/dL)
Severe IDD,
RR: <25 g/d
(median
urine, 01.9
g/dL)
RDI: adults
150 g/d
thyroxine, and
prevention of
goiter
Assess for goiter.
Dysgeusia
Acne-like skin
lesions
Toxicity: Mucous
membranes stained
brown; burning pain
in mouth and
esophagus,
laryngeal edema,
shock, nephritis,
circulatory collapse
Lethal dose: 550
mg/kg body weight
Iron (Fe)
(serum, 5 mL,
diurnal;
morning
specimen
shows higher
values)
RR: 35140
g/d toxic:
>300 g/dL
Iron RR
values:
Males: 65
175 g/dL or
11.631.3
mol/L
Females: 50
170 g/dL or
9.030.4
mol/L
Newborn:
100250
g/dL or
17.944.8
mol/L
Child: 50120
g/dL or
9.021.5
mol/L
Total iron
Diets high in heme

iron or high in
promoters of
nonheme iron
absorption
Excessive iron
absorption
hereditary
hemochromatosis
(African or
Essential to
hemoglobin
formation,
transportation of
oxygen, and
cellular
respiration
Plays a role in the
nutrition of
epithelial tissues
and the
development of
red blood cells
Assess for
ingestion of iron
pills or
vitamin and
mineral pills
Bantu siderosis);
prolonged
therapeutic
administration of
iron to
subjects not iron
deficient; chronic
alcoholism or liver
disease,
pancreatic
insufficiency
potential; shunt
hemochroma-tosis;
severe
anemia with
ineffective
erythropoiesis and
increased
hemolysis;
binding
capacity
(TIBC)
RR: 250100
g/dL
Transferrin
RR values:
Adult: 250
425 mg/dL or
44.876.1
mol/L
Newborn (04
days):
130275
mg/dL or
1.302.75 g/L
Child: 203
360 mg/dl or
2.033.60 g/L
RDI: Adults:
1015 mg/d
(toxicity).
Populations at
risk for
deficiency are
infants and
children 0.54.0
y, early
adolescents, and
women who are
pregnant.
diabetes in 80% of
patients
Transfusional
hemosiderosis thalassemia major,
some chronic
sideroblastic
anemias,
hypoplastic or other
refractory anemias
Other: cancers
(primary hepatic
carcinoma, acute
leukemia, early
breast cancer);
demyelinating
disease;
Alzheimer's
disease; increased
risk of congestive
heart disease,
listeriosis
Also see Chapter 6
Lead (Pb)
Collect specimen
in lead-free
(blood,
preferred
specimen
2 mL, collect
with
oxalatefluoride
mixture)
container and
avoid airborne
contaminants. For
blood, use
specifically
manufactured
tubes for blood
lead collection.
Ultratrace
Children:
irreversible
cognitive deficits,
acute
encephalopathy
Adults: progressive,
irreversible renal
disease; toxic
psychosis from
inhalation of
tetraethyl or
tetraethylead
Children and adults,
hypochromic
microcytic anemia
Lead sources:
Ingested or inhaled
leaded paint
(renovation
dust), contaminated
soil; contaminated
RR: <25
g/dL or
<1.21 mol/L
in children
and in most
adults without
occupational
exposure
CR: 100
g/dL or
4.8 mol/L in
adults
(24-h urine)
RR: <80 g/L
or
<0.39 mol/L
(hair)
RR: <5 g/g
CR: >2 g/g
mineral; a metallic
elementits
compounds are
poisonous, and
any level of lead
in blood is
abnormal.
Lead oxides are
used in paint
pigment; lead
additives in
gasoline provide
air pollutants.
Earthenware
made of clay rich
in lead salts, lead
in some
insecticides
Assess for
environmental or
occupational
contaminants and
toxic exposure.
water (lead pipes,

lead solder
on copper pipes,
softened water);
retention of a lead
object in the
stomach or joint
(shot, curtain
weight, fishing
weight, bauble),
contaminated acidic
foods and
beverages (storage
in lead-glazed
ceramics, leaded
crystal, galvanized
or nonstainless
steel pots);
inhalation (burning
lead-painted wood
or battery casings
in home
fireplaces or
stoves); leaded gas
fumes; occupational
exposure
Lethal dose: 30
g/kg body weight
Lithium (Li)
(serum)
RR: 0.50.9
mg/dL or
0.71.3
mmol/L
(24-h urine)
0.8 mg/24h or
115 mol/d
Ultratrace
mineral; a metallic
element
Lithium carbonate
is used as drug to
treat manic phase
of manicdepressive
illness.
Decreased dietary
sodium intake
lowers the
excretion rate of
lithium.
Assess
psychotherapeutic
drug monitoring.
Therapy for bipolar

disorder
Diabetes insipidus
Renal failure,
weight gain
Diminished taste
perception
High hard water
levels
Manganese (Mn)
(serum)
RR: 1.62.6
mg/dL or
Essential for lipid

and carbohydrate
Chronic inhalation
of airborne
manganese (mines,
steel mills,
chemical industries)
Manganic
madness,
permanent crippling
neurologic disorder
of the
0.661.07
mmol/L
CR: >100
ng/mL
(24-h urine)
RR: 6.010.0
mEq/d or
3.05.0
mmol/d
CR: Urine:
>10 g per
specimen
metabolism, bone
and tissue
formation, and
reproductive
processes
Assess for
occupational
exposure and
evaluate certain
diseases.
extrapyramidal
system (similar to
lesions in
Parkinson's
disease)
Increased urine
levels in acute
hepatitis,
myocardial
infarction and
rheumatoid arthritis
Low tissue values
in children with
maple syrup
disease and
phenylketonuria
Mercury (Hg)
Mercury poisoning;
Use acid-washed,
leakproof
container, keep
specimen on ice.
No metabolic role.
Mercury is the
only metal that is
liquid at ordinary
occupational
activities (smelters,
miners, gilders,
hatters, and
factory workers),
hobbies (painting,
ceramics, target
shooting), home
(24-h urine)
RR: <20 g/L
or
<0.10 mmol/L
W hole blood
dark-blue
topped
container,
refrigerate
RR: 0.659.0
g/L or
3.0294.4
mmol/L
Toxic:
>150 g/L or
>0.75 mmol/L
Lethal:
>800 g/L or
>4.0 mmol/L
temperatures.
Primarily
absorbed by
inhalation, but
can also be
absorbed through
the skin and
gastrointestinal
tract. It is then
distributed to the
central nervous
system and
kidneys and
excreted in
the urine.
Evaluate for
mercury toxicity,
neurologic
findings related
to inorganic or
organic
mercurials,
inhalation of
mercury vapors.
Assess for
occupational
exposure, toxicity,
and poisoning
from
contaminated fish.
renovation, auto
repair
Most common
nonindustrial
mercury poisoning
is the consumption
of methyl mercury
contaminated fish.
Blood is
recommended
specimen for
organic mercury,
and urine is
recommended
specimen for
inorganic mercury
measurement.
Iodine-containing
drugs may cause
false low levels.
Organic mercury
poisoning is more
serious because it
develops quickly.
Inhalation of
mercury vapors may
lead to
pneumonitis, cough,
fever, and other
pulmonary
symptoms.
Acute and chronic
mercury poisoning
affects kidneys,
central nervous
system, and
gastrointestinal
tract.
Molybdenum (Mo)
(serum)
RR: 0.13.0
g/L or
1.031.3
nmol/L
A trace element,
associated with
the inborn error of
molybdenum
metabolism
Assess for
genetic and
dietary
molybdenum
deficiency.
Massive ingestion
of tungsten (W )
Occupational and
high dietary intake
(elevated uric acid
blood
concentration, gout)
Sulfur amino acid
toxicity
Growth depression
and anemia similar
to copper deficiency
Nickel (Ni)
(serum or
plasma)
RR: 0.141.0
g/L or
2.417.0
nmol/L
(urine)
RR: 0.110
g/d or
Ultratrace
mineral; metallic
element
Nickel carbonyl is
an industrial
chemical used in
plating metals
toxic when
inhaled, causes
pulmonary edema.
Consistent in
alcoholic liver
disease
Nickel dermatitis
Inhalation of nickel
carbonyl (promotes
lung cancer)
2170 nmol/L
Assess for
occupational
exposure.
Selenium (Se)
(component of
the enzyme
glutathione
peroxidase,
isolated from
human
red blood
cells)
(serum)
RR: 46143
g/L or
0.581.82
mol/L
RDI: Men 50
70 g/d
A chemical
element
resembling sulfur,
found in soil
Has a role in the
metabolism of
enzymes
As a sulfide, used
in treating
dandruff and tinea
versicolor (ie,
Selsun Blue)
Determine cause
for loss of
pigmentation of
hair and skin.
Silicon (Si)silicic acid (H2 SiO 3 )
Endemic selenosis
Nail and hair loss
Increased dietary
intake owing to high
soil concentrations
(North
Dakota, USA;
Venezuela),
excessive intake
from health store
tablets
(skin lesions,
polyneuritis)
Hair and nail loss,
changes in nail
beds, inhibition of
protein synthesis
(plasma)
RR: 0.13
0.15 mg/L or
4.635.43
mol/L
(24-h urine)
RR: 6.015.0
mg/24 h or
214534
mol/d
Ultratrace
mineral;
nonmetallic
element in soil.
Occurs in traces
in skeletal
structures (bones
and teeth)
Necessary for the
formation of
collagen, bones,
and connective
tissue; healthy
nails, skin and
hair; and
calcium
absorption in
early stages of
bone formation
Needed to
maintain flexible
arteries and major
role in
cardiovascular
disease
Important in
prevention of
Alzheimer's
disease and
osteoporosis;
inhibits aging
process in tissues
Long-term antacid
therapy
(magnesium
trisilicate)
Siliceous renal
calculi
Evaluate renal
stone etiology.
Silver (Ag)
(serum)
RR: 0.21
0.15 ng/dL,
19.47 13.90
nmol/L
(24-h urine)
<1 g/d or
<9.3 nmol/d

No metabolic role.
Salts used as
antiseptic and
bacteriostatic
agents
In normal
individuals, silver
slowly
accumulates in
body tissue with
age but causes
no apparent harm.
Assess for
occupational
exposureor
toxicity from
medicinal uses of
silver.
Chemical
conjunctivitis from
silver nitrate
Gastroenteritis
(dose by mouth)
grayish
discoloration of
mucous membranes
Argyria (bluish gray
skin dis-coloration)
from nose/eye
drops over time or
industrial exposure
Silvadene topically
for burns
Silver picrate
(antiseptic)
Lethal dose: 3.535
g total dose
Thallium (Tl)
No metabolic role
Formerly used in
ant, rat, and roach
poisons
(blood)
RR: <0.5
g/dL or
<24.5 nmol/L
CR: 10800
g/dL or
0.539.1
mol/L
(urine)
RR: <2 g/L
or
<9.8 nmol/L
CR: 1.020.0
mg/L or
4.997.8
mol/L
Used in
medications,
cosmetics, and
pesticides
Poisoning occurs
from ingestion or
from absorption
through intact
skin and mucous
membranes;
accumulates in
liver, kidneys,
bone, and muscle
tissue.
Assess for toxicity
from either
accidental
ingestion or
exposure.
Toxicity:
Thallotoxicosis
(ingestion of
pesticides);
vomiting, hair loss,
delirium, coma,
ataxia, pulmonary
edema, paralysis,
death
Poisoning results in
blindness, facial
paralysis,
paresthesias,
peripheral
neuropathy, liver
and renal damage.
Lethal dose: 550
mg
Tin (Sn)
(serum)
RR: 2450
g/L or
202421

Ultratrace
mineral. Used in
manufacturing of
alloys, plating,
food containers
Diet high in canned

fruits/juices
Zinc balance
negatively affected
at 50-mg intake,
industrial exposure
to organic tin
compounds and
dust.
Tin salts used in
calico printing
nmol/L
Assess for
industrial
exposure.
Organic compounds
found in polyvinyl
plastics, chlorinated
rubber paints,
fungicides,
insecticides, and
anthelmintics
Vanadium (V)
Occupational
inhalation (fuel
(serum)
RR: 0.01
0.23 g/L or
0.204.51
nmol/L
(hair)
RR: 0.10
0.16 g/g
dry wt. or
1.963.14
nmol/g
dry wt.
(urine)
RR: <0.24
g/L or
<4.7 nmol/L

Ultratrace mineral
Used in the steel
industry and to a
lesser degree in
photography and
in
the manufacturing
of insecticides,
dyes, inks,
paints, and
varnish
Assess for
occupational
exposure.
combustion for
electricity),
hemorrhagic
endotheliotoxic with
leukocytotactic and
hematotoxic
components
Toxicity: Industrial
processes (sore
eyes and bronchi),
dermatitis,
depletion of
ascorbic acid,
gastrointestinal
distress;
cardiac palpitation,
kidney damage,
central nervous
system
disturbances; green
tongue and
disturbances of
mental function
Zinc (Zn)
Fasting morning
specimen
Plays a role in
protein synthesis;
critical for growth
and sexual
maturation
Important in
wound healing
and sensory
perception
(particularly taste
and smell)
Important in
Zinc therapy for

W ilson's disease
Ingestion of food or
beverage
contaminated by
storage in a
galvanized
container
Long-term ingestion
of excessive zinc
supplements >150
mg/d (secondary
copper deficiency)
(serum)
RR: 70120
g/dL or
10.718.4
mol/L
(24-h urine)
RR: 150
1200 g/d or
2.318.4
mol/d
activating certain
serum enzymes
and in insulin and
porphyrin
metabolism
Assess population
that may have
increased needs
for intake
alcoholism,
chronic illness,
stress, trauma,
surgery, malabsorption,
lactovegetarians,
children
consuming
vegetarian diets,
decubitus
Low serum highdensity lipoprotein

Gastric erosion
Depressed immune
system
Lethargy in dialysis
patients
Hyperzincuria
increasing with the
severity of diabetes
Inhalation of zinc
oxide fumes
causing neurologic
damage (metal
fume
fever, brassfounders' ague, zinc
shakes), metallic
taste, bloody
diarrhea
ulcers, anorexics.

Wilkins
> B ac k of B ook > Appendic es > Appendix H - E xam ples of For m s
Appendix H
Examples of Forms
The healt h care prof ession assist s pat ient s t o properly use and complet e
required f orms as part of t heir pret est , int rat est , and post t est care. These f orms
are part of t he document at ion and recording process and, in some cases, may
become part of t he permanent healt h care record. Accurat ely document ing healt h
care diagnost ic procedures may be necessary f or reimbursement , legal, or
compliance issues. For example, an inf ormed consent f orm signif ies a f reely
given agreement on t he part of t he pat ient t o undergo cert ain diagnost ic,
surgical, or t reat ment procedures. Bef ore signing any f orm, t he pat ient ,
guardian, or w it ness should caref ully read t he ent ire f orm and ask quest ions if
not t horoughly underst ood. I f t he pat ient cannot read and sign a given f orm,
document at ion of a qualif ied individual (eg, parent or guardian) w ho is signing
t he f orm should be recorded. Anyt hing t hat occurs out of t he ordinary w hen
preparing, administ ering, explaining or signing a f orm should also be
document ed.
Forms included in t his appendix are used f or HI V t est ing, drug screening, sleep
logs and quest ionnaires, evident iary specimen collect ion, sexual assault
examinat ion, int erview ing/ videot aping a pat ient , and molecular genet ic t est ing.
These are not all-inclusive but provide examples of commonly used f orms.
FI G URE H. 1 St at e of Maryland Healt h Depart ment f orm f or HI V t est ing.
FI G URE H. 2 Consent f orm f or w it nessed urine drug t est ing in communit y,

occupat ional, or clinic set t ing.
FI G URE H. 3 Sleep log.
FI G URE H. 4 Epw ort h Sleepiness Scale. Tot al score <6 normal, scores >10
are associat ed w it h mild sleep apnea, scores >16 are associat ed w it h
idiopat hic hypersomnia, narcolepsy, and moderat e sleep apnea. Ref erence:
Johns MW: A new met hod f or measuring dayt ime sleepiness. The Epw ort h
sleepiness scale. Sleep 14(6): 540 5 55, 1991.
FI G URE H. 5 Sleep disorders quest ionnaire.
FI G URE H. 6 Female evidence collect ion. Ref erence: O lshaker JS, Jackson
MC, Smock WS: Forensic Emergency Medicine, Philadelphia, Lippincot t
Williams & Wilkins, 2001.
FI G URE H. 7 Male evidence collect ion. Ref erence: O lshaker JS, Jackson MC,
Smock WS: Forensic Emergency Medicine, Philadelphia, Lippincot t Williams
& Wilkins, 2001.
FI G URE H. 8 Male suspect sexual assault evident ial examinat ion. Ref erence:
O lshaker JS, Jackson MC, Smock WS: Forensic Emergency Medicine,
Philadelphia, Lippincot t Williams & Wilkins, 2001.
FI G URE H. 9 Hist ory checklist : Vict ims and perpet rat ors of sexual assault .
Ref erence: O lshaker JS, Jackson MC, Smock WS: Forensic Emergency
Medicine, Philadelphia, Lippincot t Williams & Wilkins, 2001.
FI G URE H. 10 Consent f orm f or int erview ing, videot aping, and/ or

phot ographing a pat ient . Ref erence: O lshaker JS, Jackson MC, Smock WS:
Forensic Emergency Medicine, Philadelphia, Lippincot t Williams & Wilkins,
2001 (modif ied).
FI G URE H. 11 Example of a consent f orm used by neighborhood nurses in

public healt h off ices prior t o t est ing client s f or STDs.
FI G URE H. 12 Example of a consent f orm used f or sickle cell anemia t est ing
program.
FI G URE H. 13 Non-consent ing or deceased pat ient aut horizat ion f orm f or HI V
t est ing, St at e of Wisconsin, USA.
FI G URE H. 14 Consent f or molecular genet ic t est ing. Source: CompG ene,

Comprehensive G enet ics Services, S. C. , Milw aukee, WI , USA.

Wilkins
> B ac k of B ook > Appendic es > Appendix I - P anic or C r itic al Values
Appendix I
Panic or Critical Values

I t is recognized t hat crit ical laborat ory values (eg, low or high crit ical [pani c]
value) indicat e t he need f or prompt clinical int ervent ion. The healt h care
prof essional review s records f or any sudden change in values t hat may also
signal alarm (eg, new diagnoses of leukemia, sickle cell anemia, aplast ic crisis).
Crit ical (panic) laborat ory values represent serious medical condit ions t hat may
be lif e t hreat ening unless
immediat e act ions are t aken. Not if icat ion and collaborat ion w it h t he clinician and
ot her members of t he healt h care t eam must t ake place w hen crit ical values are
ident if ied so t hat prompt t reat ment can begin (eg, a blood glucose level <70 or
>300 mg/ dL [ <4 or >17
mmol/ L] , an increased bleeding t ime [ >15 minut es] , a hemoglobin <7. 0 or >20. 0
g/ dL [ <70 or >200 g/ L] , a brow n t o black-gray urine upon st anding w it h an
increasing pH, or an elevat ed digoxin 2. 0
mg/ mL [ >2. 6 mmol/ L] ). (See Table I . 1).
Table I.1
Test
Low Critical
Value
SI Units
High Cr
Value
Lead/capillary
blood
09 g/dL
(RR) not
critical value
0<0.43
mol/L
>45 g/d
BLOOD BANK
Antibody
identification
Positive
Cord blood
workup
Positive
Coombs
BLOOD HEMATOLOGY AND COAGULAT ION ST UDIES

Absolute
neutrophil count
500
10 3 /mm 3
(thou)
500,000/mm 3
None
Hematocrit
<20%
<0.20
>60%
Hematocrit
(neonate)
<33 vol %
<14.7 mmol/L
>70 vol
Hemoglobin
<7.0 g/dL
<70 g/L
>20.0 g/
Hemoglobin
(neonate)
<9.5 g/dL
<95 g/L
>22 g/dL
W hite blood cell

(W BC count)
<2
10 3 /mm 3
<2000/mm 3
>30 10
Platelets, adult
<40
10 3 /mm 3
<40,000/mm 3
>10,000
10 3 /mm
Platelet,
sedation
<20,000/mm 3
<20,000/mm 3
>1,000,0
Activated partial
thromboplastin
time (APTT)
None
Fibrinogen
<100 mg/dL
>78 sec
<2.9 mol/L
>700 mg
Prothrombin
time (PT)
None
INR: >3
730 sec
control
Bleeding Time
None
>15 min
NOT E
exceptions:
Hematocrit
high critical
value
>60 doe
apply to
newborn
Hemoglobin
high critical
value
>20 doe
apply to
newborn
The presence of blast cells and sickle cells is to be reporte

CHEMIST RY
Bilirubin, adult
None
None
>15 mg/
Bilirubin,
neonate
None
None
>13 mg/
BUN
2 mg/dL
0.71 mmol/L
>80 mg/
Calcium
<6 mg/dL
<1.5 mmol/L
>13 mg/
Carbon dioxide
(CO 2 )
<10 mEq/L
<10 mmol/L
>40 mEq
Creatinine
0.4 mg/dL
35 mol/L
2.8 mg/d
Glucose, adult
<70 mg/dL
<3.9 mmol/L
>300 mg
Glucose,
neonate
<30 mg/dL
<1.7 mmol/L
>325 mg
Magnesium
<1.0 mg/dL
<0.4 mmol/L
None
Osmolality
250
mOsm/kg
250 mmol/kg
325 mO
Phosphorus
1.2 mg/dL
0.4 mmol/L
9 mg/dL
Potassium,
adult
<2.8 mEq/L
<2.8 mmol/L
>6.7 mE
Potassium,
neonate
<2.8 mEq/L
<2.8 mmol/L
>7.0 mE
Sodium
<120 mEq/L
<120 mmol/L
>160 mE
Calcium
<8 mg/dL
<2 mmol/L
>11 mg/
Glucose
<70 mg/dL
<3.9 mmol/L
>300 mg
Hematocrit
<20%
<0.20
None
HEMODIALYSIS
Hemoglobin
<6.0 g/dL
<60 g/L
None
Phosphorus
<2.0 mg/dL
0.71 mmol/L
None
Potassium
<2.8 mEq/L
<2.8 mmol/L
>6.5 mE
CO (carbon
monoxide)
None
None
>10%
HCO 3
bicarbonate
<10 mEq/L
<10 mmol/L
>40 mm
mEq/L
Methemoglobin
None
None
>10%
O 2 content
<9.0 vol %
<4.0 mmol/L
None
O 2 saturation
<75%
<0.75
None
pCO 2
<20 mm Hg
<2.7 kPa
>77 mm
pH
<7.20
<7.20
>7.60
pO 2
<40 mm Hg
<5.3 kPa
None
Potassium
<2.5 mEq/L
<2.5 mmol/L
>6.5 mE
Sodium
<120 mEq/L
<120 mmol/L
>160 mE
BLOOD GASES
Arterial
Venous
HCO 3
<10 mEq/L
<10 mmol/L
>40 mEq
Saturation
<40%
<0.40
>85%
pCO 2
<20 mm Hg
<2.7 kPa
>60 mm
pH
<7.20
<7.20
>7.60
pCO 2
<20 mm Hg
<2.7 kPa
>60 mm
pH
<7.20
<7.20
>7.60
pO 2
<25 mm Hg
<3.3 kPa
None
Total T3
<50 ng/dL
<0.8 nmol/L
>300 ng
Total T4
<2.0 g/dL
<25.7 nmol/L
>15.0 g
Capillary
MICROBIOLOGY (QUALITAT IVE RESULT S) AND SEROLO

Blood
culture/smear
growth
None
Positive
of patho
CSF
culture/smear
Gram's stain
None
Positive
Bacterial
antigens
None
Antigen
detected
Blood cross
match
None
Incompa
Blood parasites
malaria
None
Present
Stool
culture/smear
None
Enteric
pathoge
present.
Positive
Salmone
Shigella
Campylo
Clostridium
difficile toxin
(Inpatients and
residents of
long-term care
facilities)
None
Positive
Cryptosporidium
antigen
None
Positive
Culture, Group
B Strep, genital
(delivery and
nursery)
None
Positive
Culture/Smear,
acid-fast bacilli
None
Positive
Culture/Smear,
Legionella
E. coli K1
antigen
None
Positive
Enteric
pathogens
None
Positive
Giardia antigen
None
Positive
Haemophilus
antigen
None
Positive
Legionella
antigen
None
Positive
Meningococcal
antigen
None
Positive
Methicillinresistant
None
Positive
Staphylococcus
aureus
None
Positive
Ova and
parasites
None
Positive
None
Positive
Pneumococcal
antigen
Pneumocystis
carinii DFA
None
Positive
Strep Group B
antigen
(delivery and
nursery)
None
Positive
Strep Group B
antigen (spinal
fluid)
None
Positive
Vancomycinresistant
Enterococcus
Positive
SPECIFIC ORGANISMSBLOOD
Tuberculosis
stain
None
Positive
fast or c
Hepatitis
None
Positive
Syphilis
None
Positive
AIDS
None
Positive
Malaria smear
None
Positive
SPINAL FLUID (CSF)
CSFtotal
protein
CSFglucose
Lownone
High: >4
mg/dL
Low <80% of
blood level
CSFW BC
Lownone
High: inc
over 20
segmen
neutroph
CSFblasts or
malignant cells
Lownone
High: >1
Urine, micro
None
Patholog
crystals
cysteine
leucine,
presen
Urine RBC
casts, casts
micro
None
Presenc
RBC
Urine glucose,
macro
None
Strongly
positive
mg/dL
Urine ketone,
macro
None
Strongly
positive
URINALYSIS
NOT E: T here are variance in unpublished liststhis is

NOT E
EXCEPT IONS:
Urine
glucose in
preop patient
>250 mg
Urine
glucose in
patient <2
years
Positive
Urine
ketones in
patient <2
years

T itle: M anual of Laboratory & D i agnosti c Tests, 7th Edi ti on
Copyright 2004 Lippincot t Williams & Wilkins
> B ac k of B ook > Appendic es
> Appendix J - Eff ect s of t he Most Commonly Used Drugs on Frequent ly

O rdered Laborat ory Test s (Blood, Whole Plasma, Serum, St ool, and
Urine)
Appendix J
Effects of the Most Commonly Used Drugs on
Frequently Ordered Laboratory Tests (Blood,
Whole Plasma, Serum, Stool, and Urine)
DRUGS AND LABORATORY TEST OUTCOM ES

Many prescript ion medicat ions, over-t he-count er
medicat ions, vit amins, minerals, and herbal preparat ions can inf luence
t he result s of laborat ory t est s. Mechanisms of drug eff ect s are eit her
pharmacologic (eg, f urosemide usually increases t he excret ion of
pot assium, result ing in a low serum pot assium level) or analyt ic (eg,
w hen a drug in a pat ient 's body f luid or t issue int erf eres w it h a
chemical st ep in a laborat ory t est , result ing in an erroneous t est
result ). The drug classes t hat cause t he majorit y of analyt ical
int erf erences include ant ibiot ics, ant ihypert ensives, ant iconvulsant s,
hormones, and ant idepressant s.
Accurat e and complet e medicat ion hist ories, including
prescript ion medicat ions, over-t he-count er medicat ions, vit amins,
minerals, and herbal preparat ions, are essent ial t o int erpret
laborat ory t est result s t hat f all out of t he normal range.
The f ollow ing t able (Table J. 1) is by no means
exhaust ive, and w henever laborat ory result s are suspect ed of being
spurious, f urt her research is necessary. There are many ref erences
available, including drug monographs in Ameri can Hospi tal Formul ary Servi ce
(AFHS), Drug Inf ormati on (published by t he American Societ y of Healt h Syst em
Pharmacist s), drug package insert s, and t he Physi ci an's Desk Ref erence (PDR),
w hich cont ains off icial product inf ormat ion. Services t hat
maint ain t his inf ormat ion include t he I ow a Drug I nf ormat ion Service
(I DI S) and DRUG DEX.
Discoloration of Feces Caused by Drugs
1. Blackacet azolamide,
aluminum hydroxide, aminophylline, 5-aminosalicylic acid, amphet amine,
amphot ericin B, ant acids, ant icoagulant s, aspirin, bet amet hasone,
bismut h, charcoal, chloramphenicol, chlorpropamide, clindamycin,
cort icost eroids, cort isone, cyclo-phosphamide, cyt arabine, digit alis,
et hacrynic acid, f errous salt s, f loxuridine, f luorides, f luorouracil,
halot hane, heparin, hydralazine, hydrocort isone, ibuprof en,
indomet hacin, iodine, levart erenol, levodopa, manganese, melphalan,
met hylprednisolone, met hot rexat e, met hylene blue, paraldehyde,
phenacet in, phenolpht halein, phosphorous, pot assium salt s,
prednisolone, procarbazine, reserpine, salicylat es, sulf onamides,
t et racycline, t heophylline, t hiot epa, t riamcinolone, w arf arin
2. G raycolchicine
3. G reenindomet hacin, iron, medroxyprogest erone
4. Dark browndexamet hasone
5. Bluechloramphenicol, met hylene blue
6. Pinkant icoagulant s, aspirin, salicylat es,
7. Redant icoagulant s, aspirin, phenolpht halein, salicylat es, t et racycline
8. O rangephenazopyridine, rif ampin
9. Tarryw arf arin, ergot preparat ions, ibuprof en, salicylat es
10. White/ specklingaluminum hydroxide, indocyanine green
11. Yellowsenna
Discoloration of Urine Caused by Drugs

1. Blackcascara, co-t rimoxazole, f errous salt s, levodopa, met hocarbamol,
met hyldopa, napht halene, quinine, sulf onamides
2. Darkcascara, levodopa, met ronixazole, primaquine, quinine, senna

3. Browncascara,
chloroquine, levodopa, met hocarbamol, met hyldopa, met ronidazole,
nit rof urant oin, primaquine, quinine, rif ampin, senna, sulf onamides
4. Blueindigo blue, met hylene blue, mit oxant rone, nit rof urant oin, t riamt erene
5. Blue/ greenamit ript yline, Doan's pills, indigo blue, indomet hacin,
magnesium salicylat e, met hylene blue, propof ol
6. O rangechlorzoxazone, dihydroergot amine, heparin, phenazopyridine,
rif ampin, sulf asalazine, w arf arin
7. Pinkant hraquinone dyes, aspirin, cascara, def eroxamine, met hyldopa,
phenyt oin, salicylat es, senna
8. Purplephenolpht halein
9. Redcascara,
chlorpromazine, daunorubicin, def eroxamine, dihydroergot amine,
dimet hylsulf oxide, doxorubicin, heparin, ibuprof en, met hyldopa,
phenazopyridine, phenolpht halein, phenot hiazines, phenyt oin, rif ampin,
senna
10. Red-purplechlorzoxazone, ibuprof en, senna
Table J.1 Effects of the Most Commonly Used Drugs

on Frequently Ordered Laboratory Tests
Test
Increased Can Lead to a

False-Positive Value
Decreased Can Lead to a
False-Negative Value
Acid Phosphatase
(Serum )
Increased by: p-aminosalicylic

acid
Decreased by: clofibrate,
mirtazapine, pemoline
Increased by: acebutolol,
acetaminophen,
acetohexamide, acyclovir,
albendazole,
aldesleukin, allopurinol,
alprazolam, aminoglutethimide,
aminosalicylic
acid, amiodarone, amitriptyline,
amoxapine, amphotericin B,
ampicillin,
amrinone, anabolic steroids,
anastrazole, anticonvulsants,
antifungal
agents, ardeparin, arsenic
trioxide, asparaginase, aspirin,
atorvastatin, atovaquone,
auranofin, aurothioglucose,
azathioprine,
azithromycin, aztreonam,
barbiturates, barium, BCG
vaccine, benazepril,
bepridil, betaxolol,
bicalutamide, bismuth
subsalicylate, bisoprolol,
bitolterol, bromocriptine,
bupropion, busulfan, calcitriol,
candesartan, capecitabine,
carbenicillin, carmustine,
cephalosporin
antibiotics, cerivastatin,
cetirizine, chenodiol, chloral
hydrate,
chlorambucil, chloramphenicol,
chlordiazepoxide,
chlorothiazide,
chlorpheniramine,
chlorpromazine,
chlorpropamide,
chlortetracycline,
chlorthalidone, chlorzoxazone,
cholestyramine, choline
magnesium
trisalicylate, cidofovir,
cimetidine, cinoxacin,
ciprofloxacin,
cisplatin, cladribine,
clarithromycin, clindamycin,
clofazimine,
clofibrate, clomiphene,
clomipramine, clonidine,
clopidogrel,
clorazepate, cloxacillin,
clozapine, colestipol,
conjugated estrogens,
cortisone, cyclobenzaprine,
cyclophosphamide,
cyproheptadine,
cytarabine, dactinomycin,
dalte-parin, danazol,
dantrolene, dapsone,
demeclocycline, desipramine,
diazepam, diclofenac,
didanosine,
dienestrol, dienestrol,
diethylstilbestrol, diflunisal,
diltiazem,
disopyramide, disulfiram,
docetaxel, doxorubicin,
doxycycline,
dronabinol, enalapril, enoxacin,
enoxaparin, erythromycin,
esterified
estrogens, estropipate,
ethacrynic acid, ethambutol,
ethchlorvynol,
ether, etodolac, etoposide,
etretinate, famotidine,
felbamate,
fenofibrate, fenoprofen,
flecainide, fluconazole,
flucytosine,
fluorouracil, fluoxymesterone,
fluphenazine, flurazepam,
flutamide,
fluvastatin, fluvoxamine,
foscarnet, fosphenytoin,
furazolidone,
furosemide, ganciclovir,
gemcitabine, gemfibrozil,
gentamicin,
glimepiride, glycopyrrolate,
gold, goserelin, granisetron,
griseofulvin, guanethidine,
haloperidol, hepatitis A
vaccine, hepatitis
B vaccine, hydralazine,
hydrochlorothiazide,
hydroflumethiazide,
ibuprofen, idarubicin,
ifosfamide, imipenem/cilastin,
imipramine,
indinavir, indomethacin,
interferon, interleukin, iron,
isoniazid,
isosorbide dinitrate,
isotretinoin, isradipine,
itraconazole,
kanamycin, ketamine,
ketoconazole, ketoprofen,
ketorolac, labetalol,
lamotrigine, lansoprazole,
leflunomide, levamisole,
levodopa,
Alanine
Am inotransferase
levomethadyl acetate,
levothyroxine, lincomycin,
lisinopril, LMW
heparins, lomefloxacin,
loracarbef, loratadine,
lovastatin, loxapine,
MAO inhibitors, maprotiline,
mechlorethamine,
meclofenamate,
medroxyprogesterone,
mefenamic acid, mefloquine,
melphalan, meperidine,
meprobamate, mercaptopurine,
meropenem, mesalamine,
metaxalone,
methenamine, methimazole,
methotrexate, methoxsalen,
methyldopa,
methylphenidate,
methyltestosterone,
metoclopramide, metolazone,
metoprolol, mexiletine,
minocycline, mirtazapine,
mitomycin,
mitoxantrone, moexipril,
molindone, montelukast,
moricizine, morphine,
moxalactam, muromonab-CD3,
mycophenolate, nabumetone,
nafarelin,
nafcillin, nalidixic acid,
naltrexone, nandrolone,
naproxen,
nefazodone, nelfinavir,
netilmicin, nevirapine, niacin,
niacinamide,
nicardipine, nifedipine,
nilutamide, nisoldipine,
nitrofurantoin,
nizatidine, norethandrolone,
norfloxacin, nortriptyline,
octreotide,
ofloxacin, oleandomycin,
olsalazine, omeprazole,
ondansetron, oral
contraceptives, oxacillin,
oxaprozin, oxazepam,
oxymetholone,
palivizumab, papaverine,
pargyline, paroxetine,
pegasparagase,
pemoline, penicillamine,
pentoxifylline, perphenazine,
phenazopyridine,
phenelzine, phenobarbital,
phenothiazines, phenytoin,
phosphorus,
pindolol, pioglitazone,
piperacillin, piroxicam,
polythiazide,
pralidoxime, pravastatin,
prazosin, probenecid,
procainamide,
prochlorperazine, propafenone,
propoxyphene, propranolol,
propylthiouracil, protriptyline,
pyrazinamide, pyrimethamine,
quazepam,
quinapril, quinethazone,
quinidine, ramipril, ranitidine,
rifampin,
riluzole, risperidone, ritonavir,
rosiglitazone, saquinivir,
sargramostim semustine,
sibutramine, sildenafil,
simvastatin,
sparfloxacin, spectinomycin,
stanozolol, stavudine,
streptokinase,
streptomycin, streptozocin,
sulfadiazine, sulfamethoxazole,
sulfanilamide, sulfasalazine,
sulfisoxazole, sulfonylureas,
sulindac,
sumatriptan, tacrine,
tacrolimus, terbinafine,
terbutaline,
tetracycline, thiabendazole,
thiazides, thiethylperazine,
thiocyanate,
thioguanine, thiopental,
thioridazine, thiothixene,
thiouracil,
ticarcillin, ticlopidine, timolol,
tinzaparin, tobramycin,
tocainide,
tolazamide, tolazoline,
tolbutamide, tolcapone,
tolmetin, trandolapril,
tranylcypromine, trastuzumab,
tretinoin, trichlormethiazide,
trifluoperazine, trimethoprim,
trimetrexate, trimipramine,
trioxsalen,
triptorelin, troglitazone,
troleando-mycin, trovafloxacin,
uracil
mustard, ursodiol, valproic
acid, valsartan, venlafaxine,
verapamil,
vidarabine, warfarin,
zalcitabine, zidovudine,
zileuton, zolmitriptan,
zolpidem
Alanine
Am inotransferase
(Serum )
Decreased by: aspirin,

carvedilol, cyclosporine,
interferon, ketoprofen,
phenothiazines, simvastatin,
toremifene, ursodiol
Increased by: amikacin,
basiliximab, calcitriol,
carbamazepine, carvedilol,
cisplatin,
diazoxide, doxorubicin,
gentamicin, lansoprazole,
lithium, mesalamine,
Album in (Urine)
naproxen, nifedipine,
norfloxacin,
ofloxacin, oral contraceptives,
radiographic agents,
sevoflurane,
triazolam, venlafaxine,
verapamil, zalcitabine
Decreased by: atenolol,
captopril, cilostazol,
dipyridamole, enalapril,
fosinopril, furosemide,
ibuprofen, indapamide,
perindopril, quinapril, ramipril
Aldolase (Serum )
Increased by: corticotropin,

diclofenac, itraconazole,
lovastatin, niacin, quinidine (IM
injection), simvastatin,
thiabendazole, vasopressin
Decreased by: probucol
Increased by: amiloride,
ammonium chloride,
chlorthalidone, corticotropin,
Aldosterone
(Plasm a)
dobutamine, fenoldopam,
fosinopril, furosemide,
hydralazine,
indomethacin, laxatives,
metoclopramide,
nifedipine, opiates, pravastatin,
spironolactone, triamterene,
verapamil
candesartan, captopril,
carvedilol, cilazapril, clonidine,
cyclosporine, dexamethasone,
enalapril, ergoloid mesylates,
etomidate,
finasteride, fosinopril,
furosemide, indomethacin,
ketoconazole,
lisinopril, LMW heparins,
losartan, nicardipine,
nifedipine,
nisoldipine, nonsteroidal antiinflammatory drugs,
perindopril,
ramipril, ranitidine, verapamil

acetaminophen,
acetohexamide, acyclovir,
albendazole,
alprazolam, altretamine,
aluminum hydroxide,
amantadine,
aminoglutethimide,
aminoglycosides,
aminosalicylic acid,
amiodarone, amitriptyline,
amrinone,
anabolic steroids, anastrazole,
anticonvulsants, antifungal
agents,
arsenicals, asparaginase,
aspirin, atovaquone, auranofin,
azathioprine,
baclofen, barbiturates, BCG
vaccine,
subsalicylate, bleomycin,
bromocriptine,
budesonide, bupropion,
busulfan, candesartan,
capecitabine,
capreomycin, captopril,
carbamazepine, carbenicillin,
carmustine,
carvedilol, cephalosporin
cetirizine,
chenodiol, chloramphenicol,
chlordiazepoxide, chloroform,
chlorothiazide, chloroform,
chlorothiazide, chlorpromazine,
chlorpropamide,
chlorzoxazone, cidofovir,
ciprofloxacin, clindamycin,
clofibrate, clonidine, clozapine,
colchicine, colestipol,
cyclobenzaprine,
cyclophosphamide,
cycloserine, cyclosporine,
cyproheptadine,
danazol, dantrolene, dapsone,
demeclocycline,
desipramine, diazepam,
diazoxide, diclofenac,
didanosine, diltiazem,
disopyramide, disulfiram,
doxycycline,
enalapril, erythromycin,
estrogens, estropipate,
ethacrynic acid,
ethambutol, ether,
ethionamide, etoposide,
etretinate, factor IX
complex, famotidine, felodipine,
fenoprofen, flecainide,
fluconazole,
flucytosine, fluorouracil,
fluoxymesterone, fluphenazine,
flurazepam,
flutamide, fluvastatin,
foscarnet, fosphenytoin,
ganciclovir,
gem-citabine, gemfibrozil,
gentamicin, glimepiride,
glyburide,
glycopyrrolate, gold,
granulocyte colony-stimulating
factor,
griseofulvin, haloperidol,
hepatitis A vaccine, hepatitis B

vaccine,
human growth hormone,
hydralazine,
hydroflumethiazide, ibuprofen,
idarubicin, ifosfamide,
imipenem/cilastin, imipramine,
indomethacin,
interferon, interleukin,
irinotecan, isoniazid,
isradipine,
Alkaline
Phosphatase
(Serum )
itraconazole, kanamycin,
ketamine, ketoconazole,
ketoprofen, ketorolac,
labetalol, lamotrigine,
lansoprazole, leflunomide,
levodopa,
lisinopril, lithium, lomefloxacin,
loracarbef, loratadine,
lovastatin, MAO inhibitors,
mechlorethamine,
meclofenamate,
melphalan, meprobamate,
mercaptopurine, meropenem,
mesalamine, metaxalone,
methimazole,
methyldopa,
methyltestosterone,
metoprolol, minocycline,
mirtaza-pine,
misoprostol, mitoxantrone,
moexipril, molindone,
morphine, moxalactam,
nafarelin, naladixic acid,
nandrolone,
naproxen, nelfinavir, netilmicin,
niacin, niacinamide,
nicardipine,
nifedipine, nilutamide,
nitrofurantoin, nizatidine,
norethindrone,
octreotide, ofloxacin,
oleandomycin,
osalazine, omeprazole, oral
contraceptives, oral
hypoglycemics,
oxacillin, oxaprozin, oxazepam,

oxymetholone, papaverine,
pargyline,
paroxetine, pegasparagase,
penicillamine, perphenazine,
phenazopyridine,
phenobarbital, phenothiazines,
phenytoin, phosphorus,
pindolol, piperacillin,
piroxicam, plicamycin,
polythiazide,
procainamide,
prochlorperazine,
progesterone, promazine,
promethazine,
propafenone, propoxyphene,
quazepam, quinapril,
quinethazone,
quinidine, ramipril, ranitidine,
rifampin, riluzole, risperidone,
sargramostim, sildenafil,
spectinomycin, stanozolol,
streptokinase,
sulindac, tacrolimus,
terbinafine,
thiazides, thiethylperazine,
thioguanine,
thiopental, thioridazine,
thiothixene, thiouracil,
ticarcillin,
ticlopidine, timolol, tocainide,
tolbutamide,
tolcapone, tolmetin,
toremifene, tramadol,
trastuzumab, tretinoin,
triazolam, trichlormethiazide,
trioxsalen, troglitazone,
troleandomycin,
trovafloxacin, uracil mustard,
ursodiol, valproic acid,
venlafaxine,
verapamil, vidarabine, vitamin
D, warfarin, zalcitabine,
zidovudine,
zolmitriptan, zolpidem
Decreased by: acyclovir,
alendronate, aluminum
antacids, antithyroid therapy,
arsenicals, azathioprine,
calcitonin, calcitriol, carvedilol,
chemotherapy, clofibrate,
colchicine, cyclosporine,
danazol, estrogens,
etidronate, norethindrone, oral
contraceptives, pamidronate,
penicillamine, prednisolone,
prednisone, tamoxifen,
trifluoperazine,
ursodiol, vitamin D
Increased by: acetaminophen,

amikacin, amino-caproic acid,
amphetamine, ampicillin,
aspirin, bismuth subsalicylate,
brompheniramine, carbenicillin,
cefaclor, cefadroxil, cephalexin,
cephradine, cisplatin,
cloxacillin,
colistin, corticotropin,
cytarabine, doxorubicin,
ephedrine,
Am ino acids
(total/fractions)
(Urine)
erythromycin, gentamicin,
hydrocortisone, ifosfamide,
isomil, insulin,
kanamycin, levarterenol,
levodopa, mafenide,
methamphetamine,
methyldopa, neomycin,
nystatin, penicillamine,
parathyroid extract,
phenobarbital, phenylephrine,
phenylpropanolamine,
primidone, ProSobee,
pseudoephedrine, streptozocin,
tetracycline, triamcinolone,
triprolidine, tromethamine
Decreased by: insulin

Increased by: acetazolamide,
asparaginase, chlorothiazide,
chlorthalidone, ethacrynic
Am m onia (Plasm a)
acid, felbamate, furosemide,

hydroflumethiazide, ion
exchange resins,
isoniazid, pegasparagase,
tetracycline, thiazides, valproic
acid
Decreased by: cefotaxime,
diphenhydramine, kanamycin,
lactobacillus acidophilus,
levodopa, MAO inhibitors,
neomycin, tetracycline,
tromethamine
asparaginase, aspirin,
atovaquone, azathioprine,
azithromycin,
benzthiazide, bethanechol,
calcitriol, cerivastatin, chloride
salts,
chlorothiazide, chlorthali-done,
cholinergics, cidofovir,
cimetidine,
cisplatin, clozapine, codeine,
corticosteroids,
cyclosporin A, cyclothiazide,
cyproheptadine, cytarabine,
demeclocycline, desimpramine,
dexamethasone, diazoxide,
didanosine,
donepezil, doxorubicin,
enalapril, estropipate,
ethacrynic acid,
felbamate, fentanyl,
fludrocortisone, fluvastatin,
foscarnet,
furosemide, glucocorticoids,
hetastarch, human growth
hormone,
Am ylase (Serum )
hydrochlorothiazide, hydroflumethiazide, ibuprofen,

indinavir,
indomethacin, isoniazid,
lamivudine, lisinopril,
meperidine,
mercaptopurine, mesalamine,
methacholine,
methyclothiazide,
methylprednisolone,
metolazone, metronidazole,
minocycline,
mirtazapine, morphine,
nabumetone, naproxen,
narcotics, nelfinavir,
niacin, nitrofurantoin,
norfloxacin, octreotide, opium
alkaloids, oral
contraceptives,
pegasparagase, penicillamine,
piroxicam, polythiazide,
potassium iodide, prazosin,
prednisolone, prednisone,
quinapril,
radiographic agents,
simvastatin, sulfamethoxazole,
sulindac,
tamoxifen, tetracycline,
thiazides, trastuzumab,
tretinoin,
triamcinolone,
trichlormethiazide, valproic
acid, zalcitabine,
zidovudine, zolmitriptan
Decreased by: anabolic
steroids, cefotaxime,
lamivudine, proplythiouracil,
somatostatin, zidovudine
Increased by: nicardipine,
triiodothyronine
Decreased by: benazepril,
captopril, cilazapril, enalapril,
Angiotensin
Converting Enzym e
(Serum )
fosinopril, imidapril, lisinopril,

magnesium sulfate,
methylprednisolone,
nicardipine, perindopril,
propranolol, quinapril, ramipril,
trandolapril
Antidiuretic
Horm one (Plasm a)
Increased by: chlorthalidone,

cisplatin, ether, furosemide,
hydrochlorothiazide, lithium
methyclothiazide, polythiazide
Decreased by:
chlorpromazine, clonidine,
guanfacine
amitriptyline, anticonvulsants,
bisoprolol, captopril,
chlorpromazine, ethosuximide,
fluvastatin, gemfibrozil,
hydralazine,
Antinuclear
Antibody Test (ANA)
(Serum )
interferon alfa-2a, isoniazid,

labetalol, methyldopa,
mexiletine,
nitrofurantoin, oral
contraceptives, penicillamine,
phenytoin,
piroxicam, procainamide,
propafenone, propyl-thiouracil,
quinidine,
sulfasalazine, tocainide,
valproic acid
acetaminophen,
acetohexamide, acetylcysteine,
acyclovir,
albendazole, aldesleukin,
allopurinol, alprazolam,
amantadine,
aminocaproic acid, aminoglutethimide, aminosalicylic
acid, amiodarone,
amitriptyline, amoxapine,
amoxicillin, amphotericin,
ampicillin,
amrinone, anabolic steroids,

antifungals,
ardeparin, arsenicals, ascorbic
acid, asparaginase, aspirin,
atorvastatin, atovaquone,
azathioprine,
baclofen, barbiturates, barium,
BCG vaccine,
benazepril, bepridil, betaxolol,
bethanechol, bicalutamide,
bisoprolol,
bleomycin, bupropion,
busulfan, calcitriol,
candesartan, canola oil,
carmustine,
carvedilol, cephalosporin
cetirizine,
chenodiol, chloral hydrate,
chlorambucil, chloramphenicol,
chlorothiazide,
chlorpheniramine,
chlorpromazine,
chlorpropamide,
chlortetracycline,
chlorthalidone,
chlorzoxazone, cholestyramine,
choline magnesium
trisalicylate,
cholinergics, cidofovir,
ciprofloxacin,
cisplatin, cladribine,
clarithromycin, clinda-mycin,
clofazimine,
clofibrate clomiphene,
clomipramine, clonidine,
clopidogrel,
clor-azepate, clotrimazole,
cloxacillin, clozapine, codeine,
colchicine, colestipol,
cortisone,
cyclobenzaprine,
cyclophosphamide,
cyclothiazide, cyproheptadine,
dactinomycin, dalteparin,
danazol,
desmopressin,
diazepam, diazoxide,
diclofenac, dicloxacillin,
didanosine, dienestrol,
diltiazem, disopyramide,
disulfiram,
doxycycline, dronabinol,
enalapril, enoxacin,
enoxaparin, epirubicin,
erythromycin, estazolam,
esterified estrogens,
estramustine, estropipate,
ethacrynic acid, ethambutol,
ethchlorvynol,
ether, ethionamide,
ethosuximide, ethyl chloride,
etodolac, etoposide,
etretinate, factor IX,
famotidine, felba-mate,
fenofibrate, fenoprofen,
flucytosine, fluoxymesterone,
fluphenazine,
flurazepam, flutamide,
foscarnet,
fosphenytoin, furazolidone,
gemcitabine,
gemfibrozil, gentamicin,
glimepiride, glyburide,
goserelin, granisetron,
griseofulvin, guanethidine,
haloperidol,
halothane, hepatitis A vaccine,
hepatitis B vaccine,
hydralazine,
idarubicin,
ifosfamide, imipenem/cilastin,
imipramine, indinavir,
indomethacin,
interferon, interleukin,
irinotecan, iron, isoniazid, isoproterenol,
isotretinoin, isra-dipine,
itraconazole,
Aspartate
Am inotransam inase
or Aspartate
Am inotransferase
(AST ) (Serum )
kanamycin, ketamine,
lamivudine, lamotrigine,
lansoprazole, leflunomide,
lepirudin,
levamisole, levodopa,
lincomycin, lisinopril, LMW
heparins,
lomefloxacin, loracarbef,
losartan, lovastatin, loxapine,
MAO
inhibitors, maprotiline,
mechlorethamine,
melphalan, meperidine,
meprobamate,
mesalamine, mesoridazine,
metaxolone,
methacholine, methenamine,
methimazole, methotrexate,
methoxsalen,
methyldopa, methylphenidate,
methyltestosterone,
metoclopramide,
metolazone, metoprolol,
metyrosine, mexiletine,
minocycline,
mirtazapine, mitomycin,
molindone,
montelukast, moricizine,
morphine, moxalactam,
muromonab-CD3,
nafarelin, nafcillin, nalidixic
acid,
naltrexone, nandrolone,
naproxen, narcotics,
nefazodone, nelfinavir,
netilmicin, nevirapine, niacin,
niacinamide, nicardipine,
nicotinic
acid, nifedipine, nilutamide,
nisoldipine, nitrofurantoin,
nizatidine,
oleandomycin,
omeprazole, ondansetron,
opium alkaloids, oral
contraceptives,
oxacillin, oxaprozin, oxazepam,
oxymetholone, papaverine,
pargyline,
penicillin,
pentoxifylline, perphenazine,
phenazopyridine, phenelzine,
phenytoin, phosphorus,
pindolol,
pioglitazone, piperacillin,
piroxicam, plicamycin,
polythiazide,
pralidoxime, pravastatin,
procainamide,
prochlorperazine,
promethazine, propafenone,
propoxyphene, propranolol,
pyrazinamide, quazepam,
quinidine, quinolones,
ramipril, ranitidine, rifampin,
riluzole, risperidone, ritonavir,
rosiglitazone, salicylate,
saquinavir, sibutramine,
sildenafil,
simvastatin, sirolimus,
sparfloxacin, stanozolol,
stavudine,
streptokinase, streptomycin,
streptozocin, sulfadiazine,
sulfamethoxazole,
sulfisoxazole,
sulfonylureas, sulindac,
sumatriptan, tacrine,
tacrolimus, tamoxifen,
terbinafine, terbutaline,
thiazides,
thiethyl-perazine, thioguanine,
thiothixene,
tocainide,
tolbutamide, tolcapone,
tolmetin, topotecan,
toremifene, tramadol,
tranylcypromine, trastu-zumab,
tretinoin,
trioxsalen, triptorelin,
troglitazone,
troleandomycin, trovafloxacin,
uracil mustard, ursodiol,
valproic acid,
valsartan, vasopressin,
venlafaxine, verapamil,
vidarabine,
vinorelbine, warfarin,
Decreased by: allopurinol,

ascorbic acid, clomipramine,
cyclosporine, ibuprofen,
ketoprofen, metronidazole,
naltrexone, penicillamine,
pindolol,
prednisone, progesterone,
rifampin, simvastatin,
toremifene,
trifluoperazine, ursodiol
Apolipoprotein A
(Serum )
Increased by: carbamazepine,

furosemide, gem-fibrozil,
nisoldipine, oral
contraceptives, phenobarbital,
phenytoin, prednisolone
Decreased by: lovastatin
Increased by: amiodarone,
atenolol, chlorthalidone,
cyclosporine,
estrogen/progestin therapy,
etretinate, furosemide,
Apolipoprotein B
(Serum )
gem-fibrozil, isotretinoin,
levonorgestrel, methyclothiazide,
metoprolol, oral
contraceptives, phenobarbital,
radioactive iodine,
simvastatin, stanozolol
Decreased by: atorvastatin,

bisoprolol, captopril,
cholestyramine, colestipol,
doxazosin, fenofibrate,
gemfibrozil,
indomethacin, interferon alfa2a, interferon beta-1b,
ketoconazole,
levothyroxine, lisinopril, LMW
heparins, losartan, lovastatin,
neomycin, niacin, nicotinic
acid, nifedipine, phenytoin,
pravastatin,
prazosin, prednisolone,
probucol, psyllium, raloxifene,
simvastatin,
tacrolimus
Increased by: atenolol,

captopril, carteolol,
Atrial Natriuretic
Peptide (Plasm a)
cyclosporine, dipyridamole,
doxorubicin,
morphine, nifedipine, oral
contraceptives, vasopressin,
verapamil
Decreased by: benazepril,
chlorthalidone, clonidine,
erythropoietin, methimazole,
prazosin, ramipril
Basophils
Increased by: desipramine,

paroxetine, tretinoin, triazolam,
venlafaxine
Decreased by: procainamide,
thiopental
acetaminophen, acetazolamide, acetohexamide,
acetophenazine, acyclovir,
allopurinol,
alprazolam, amiloride,
aminoglutethimide,
amoxapine, amphotericin,
amrinone, amyl nitrate,
anabolic steroids,
antifungal agents,
antimalarials, antipyretics,
ascorbic acid,
atorvastatin, auranofin,
azathioprine,
azithromycin, barbiturates,
BCG vaccine, benazepril,
benzthiazide,
subsalicylate, bleomycin,
bupropion, busulfan,
candesartan, captopril,
carbamazepine, carmustine,
carvedilol,
cefazolin, cefdinir,
cefoperazone, cefoxitin,
cefpodoxime, ceftazidime,
ceftibuten, ceftizoxime,
ceftriaxone, cefuroxime,
cephalothin,
cerivastatin, cetirizine,
chenodiol, chloral hydrate,
chlorambucil,
chloramphenicol, chlordane,
chloroquine,
chlorpropamide,
chlortetracycline,
chlorzoxazone, cidofovir,
cimetidine, cladribine,
clindamycin,
clofazimine, clofibrate,
clonidine, clopidogrel,
clozapine, colchicine,
Coumadin, cyclobenzaprine,
cyclophosphamide,
dactinomycin,
desipramine, dextrothyroxine,
diazepam,
diclofenac, dicloxacillin,
didanosine, dienestrol,
diethylstilbestrol,
diflunisal, diltiazem,
dimercaprol, diphenhydramine,
disopyramide,
disulfiram, docetaxel, doxepin,

doxorubicin, doxycycline,
enalapril,
enoxaparin, erythromycin,
estramustine, estropipate,
ethacrynic acid,
ethambutol, ether,
ethionamide, ethosuximide,
etoposide, etretinate,
factor IX, famotidine,
fenoprofen, fluconazole,
flucytosine,
fluorouracil, fluoxymesterone,
fluphenazine, flurazepam,
flutamide,
fosphenytoin, furosemide,
ganciclovir,
glyburide,
halothane, hepatitis A
vaccine, hepatitis B vaccine,
hydralazine,
idarubicin, imipramine,
indinavir,
indomethacin, interferon,
interleukin, iron, isonazid,
isotretinoin,
isradipine, itraconazole,
kanamycin, ketoconazole,
ketoprofen,
Bilirubin (Serum )
lansoprazole,
levamisole, levodopa,
lincomycin, lisinopril,
lomefloxacin, losartan,
lovastatin, loxapine, Lugol's
iodine, MAO inhibitors,
mefenamic acid, melphalan,
meprobamate,
mesalamine, mesoridazine,
metaxalone,
methacholine, methimazole,
methsuximide,
methyclothiazide, methyldopa,
methylene blue,
methyltestosterone,
minocycline, mirtazepine,
mitoxantrone,
molindone, moricizine,
morphine, mox-alactam,
nambumetone, nalidixic
acid, naproxen, netilmicin,
nevirapine, niacin,
niacinamide,
nicardipine, nitrofurantoin,
nitrofurazone, nizatidine,
norethandrolone,
norethindrone, nortriptyline,
novobiocin, octreotide,
ofloxacin, oleandomycin,
omeprazole, oral
contraceptives, oxacillin,
oxazepam, oxymetholone,
papaverine, pargyline,
paroxetine,
pegasparagase, pemoline,
penicillamine, penicillin,
pentoxifylline,
perphenazine,
phenytoin, phosphorus, piperacillin,
piroxicam, polythiazide,
prazosin, primaquine,
probenecid,
procainamide, procarbazine,
prochlorperazine,
propoxyphene, propylthiouracil,
pyrazinamide, quazepam,
quinidine, quinine,
quinupristin, radiographic
agents, ramipril, ranitidine,
rifampin,
salicylate, saqui-navir,
sargramostim, sorbitan,
stanozolol, stavudine,
streptomycin, sulfacetamide,
sulfadiazine, sulfadoxine,
sulfamethizole,
sulfamethoxazole,
sulfinpyrazone,
sulindac, tacrine, tacrolimus,
tamoxifen,
terbinafine, tetracycline,
thiabendazole, thiazides,
thiethylperazine,
thioguanine, thiopental,
thioridazine, thiothixene,
thiouracil,
tobramycin, tocainide,
tolazamide,
tolazoline, tolbutamide,
tolcapone, tolmetin, topotecan,
toremifene,
tramadol, trandolapril,
tranylcypromine, trastuzumab,
tretinoin,
triflu-operazine,
trimethobenzamide,
trimethoprim, trimetrexate,
trimipramine, trioxsalen, troleandomycin,
uracil mustard, valproic acid,

venlafaxine, verapamil,
vidarabine,
vinorelbine, vitamin K,
Decreased by: amikacin,

anticonvulsants, aspirin,
barbiturates, carbamazepine,
cyclosporine,
hydroxyurea, isotretinoin,
penicillin, pindolol, prednisone,
sulfisoxazole, theophylline,
thioridazine, ursodiol, valproic
acid
Increased by: acetohexamide,

acetophenazine, aminosalicylic
acid, chlorpromazine,
Bilirubin (Urine)
dapsone, etodolac,
fluphenazine, imipramine,
isoniazid, methyldopa,
nabumetone, norethandrolone,
perphenazine, phenothiazines,
tolmetin
Decreased by: ascorbic acid,

chlorhexidine
Increased by: acetylsalicylic
acid, aminocaproic acid,
ampicillin, aspirin, canola
oil, carbenicillin, clopidogrel,
dextran, diflunisal, diltiazem,
flubiprofen, fluoxetine,
gabapentin, hetastarch,
ketorolac, moxalactam,
Bleeding tim e
(Blood)
nafcillin, naproxen, nifedipine,

nonsteroidal anti-inflammatory
drugs,
oxaprozin, penicillin, piroxicam,
plicamycin, propafenone,
propranolol,
streptokinase, sulindac,
ticarcillin, ticlopidine, tolmetin,
valproic
acid, warfarin
Decreased by: conjugated
estrogens, desmopressin,
epoetin alfa, erythropoietin
Increased by: abciximab,

aldesleukin, alprostadil,
alteplase, ardeparin, auranofin,
aurothioglucose, basiliximab,
BCG vaccine, bicalutamide,
candesartan,
carvedilol, cefuroxime,
chlorothiazide, cidofovir,
clofibrate,
clopidogrel, danazol,
diethylstilbestrol, donepezil,
doxorubicin,
ethosuximide, etretinate,
fenoprofen, gabapentin,
ganciclovir,
gemcitabine, gold, goserelin,
ibuprofen, indinavir,
indomethacin,
Blood Cells and

Red Casts (Urine)
isotretinoin, itraconazole,
ketoprofen, ketorolac,
lansoprazole,
leuprolide, lomefloxacin,
mefenamic acid, mesalamine,
metyrosine,
mirtazapine, misoprostol,
mycophenolate, naproxen,
nisoldipine,
olsalazine, omeprazole,
oxaprozin, oxycodone,
penicillamine, piroxicam,
probenecid,
pyrimethamine, rifampin,
risperidone, sargramostim,
somatotropin,
sulfasalazine, sulfisoxazole,
sulindac, thiabendazole,
ticlopidine,
tolazoline, tolcapone, tolmetin,
trastuxumab, urokinase,
venlafaxine

captopril, finasteride,
lamotrigine
Increased by: ACE
inhibitors, acetaminophen,
acetazolamide, acyclovir,
albendazole,
aldesleukin, alkaline antacids,
allopurinol, altretamine,
amantadine,
amikacin, amiloride, amino

acids, aminocaproic acid,
amiodarone,
amphotericin B, amyl nitrite,
anabolic steroids, arsenicals,
asparaginase, aspirin, atenolol,
azathioprine, azithromycin,
bacitracin, benazepril,
benzthiazide, betaxolol,
bismuth subsalicylate,
bisoprolol, busulfan, calcitriol,
candesartan, cannabis,
capreomycin,
captopril, carbamazepine,
carvedilol, castor oil, cefaclor,
cefamandole, cefazolin,
cefixime, cefonicid,
cefoperazone, cefotaxime,
cefotetan, cefoxitin,
ceftibuten,
ceftizoxime, ceftriaxone,
cefuroxime, cephalexin,
cephalothin,
cetirizine, chemotherapy,
chloroform, chlorothiazide,
chlorpheniramine,
chlortetracycline,
chlorthalidone, cimetidine,
cinoxacin,
ciprofloxacin, cisplatin,
clarithromycin, clindamycin,
clonidine,
clorazepate, co-trimoxazole,
codeine, colistin, cyclosporin,
demeclocycline,
dexamethasone, dextran,
diazepam, diazoxide,
diclofenac, disopyramide,
diuretics, doxorubicin,
doxycycline,
enalapril, epoetin alfa,
eprosartan, ergot preparations,
ethacrynic
acid, ethambutol, ether,
ethosuximide, etidronate,
etretinate,
fenoprofen, flucytosine,
fludarabine, foscarnet,
furosemide,
gabapentin, ganciclovir,
gemcitabine, gentamicin, gold,
griseofulvin,
guanethidine, hydralazine,
hydroflumethiazide,
Blood Urea
Nitrogen (BUN)
hydroxyurea, ibuprofen,
imipramine, immune
globulin, indomethacin,
interleukin, irbesartan, iron,
isosorbide,
kanamycin, ketoprofen,
ketorolac, labetalol, leuprolide,
levodopa,
levorphanol, lisinopril,
lomefloxacin, loracarbef,
losartan,
meclofenamate, mefenamic
acid, melphalan, meropenem,
mesalamine,
methicillin, methotrexate,
methsuximide,
methysergide, metolazone,
metoprolol, micardis,
minocycline,
misoprostol, mitomycin,
molindone, moxalactam,
nabumetone, nalidixic acid,
naproxen, neomycin,
netilmicin, nifedipine,
nilutamide, nisoldipine,
nitrofurantoin, norfloxacin,
ofloxacin,
olsalazine, oxacillin, oxaprozin,
oxytetracycline, pamidronate,
pargyline, paromomycin,
penicillamine,
penicillin, pentamidine,
pentostatin, phenazopyridine,
phosphorus,
piper-acillin, piroxicam,
plicamycin, probenecid,
propafenone,
propranolol, propylthiouracil,
quazepam, quinapril,
quinethazone,
quinine, radiographic agents,
ramipril, rifampin, risperidone,
sargramostim, semustine,
silver, spectinomycin,
spironolactone,
streptokinasae,
sulfamethoxazole,
sulindac, suprofen, tacrolimus,
tetracycline, thallium,
thiazides,
tolmetin,
trandolapril, tretinoin,
triamterene, trimethoprim,
trimetrexate,
trovafloxacin, vancomycin,
vasopressin, venlafaxine,
vitamin D,
zalcitabine, zolpidem
ascorbic acid, capreomycin,
cefotaxime, chloramphenicol,
levodopa, phenothiazines,
streptomycin
C3 Com plem ent

(Serum )
Increased by: cimetidine,

cyclophosphamide, oral
contraceptives
Decreased by: danazol,

hydralazine, methyldopa,
phenytoin
C4 Com plem ent
(Serum )
Increased by:
cyclophosphamide, danazol,
oral contraceptives
Decreased by: dextran,
methyldopa, penicillamine
C-Peptide (Plasm a)
Increased by: betamethasone,

deferoxamine, glimepiride,
glyburide, indapamide,
isoproterenol, oral
contraceptives, prednisone,
terbutaline
calcitonin, miglitol
Calcitonin (Plasm a)
Increased by:
pentagastrin
Decreased by: estrogens,
octreotide, phenytoin
Increased by: aldesleukin,
alkaline antacids, aluminum,
anabolic steroids, antacids,
basiliximab, calcitriol, calcium
gluconate, captopril,
cefotaxime,
chlorothiazide, chlorpropamide,
chlorthalidone, dienestrol,
diethylstilbestrol,
dihydrotachysterol,
doxorubicin, estramustine,
estropipate, etretinate,
fluoxymesterone, hydralazine,
hydrochlorothiazide, iron,
leuprolide, lithium, magnesium,
Calcium (Serum )
methyclothiazide,
methyltestosterone,
metolazone, mycophenolate,
nandrolone, nisoldipine, oral
contraceptives, oxymetholone,
parathyroid
hormone, paroxetine,
pentostatin, phenobarbital,
polystyrene sulfonate,
polythiazide, progesterone,
propranolol, riluzole, sirolimus,
spironolactone, tamoxifen,
theophylline, thiazides,
toremifene,
trastuzumab, tretinoin,
trichlormethizide, vitamin D,
zalcitabine
Decreased by: acetazolamide,
aldesleukin, alendronate,
amifostine, amlodipine,
amphotericin B,
anticonvulsants, arsenic
trioxide, asparaginase,
aspirin, basiliximab,
bisphosphonates, calcitonin,
carbamazepine,
chloroquine, chlorothiazide,
cidofovir, cisplatin,
corticosteroids,
cortisone, diuretics,
doxorubicin, erythropoietin,
estrogen/progestin
therapy, estropipate,
etidronate, etretinate,
felbamate, foscarnet,
furosemide, gallium,
gentamicin, glucocorticoids,
insulin, interferon, iron dextran,
isoniazid, ketoconazole,
laxatives,
magnesium salts, methicillin,
mycophenolate, oral
contraceptives,
pamidronate, paroxetine,
pentamidine, phenobarbital,
phenytoin,
plicamycin, polystyrene
sulfonate, prednisone,
probucol, raloxifene,
sargramostim, streptozocin,
tacrolimus, tamoxifen,
tetracycline,
theophylline, tobramycin,
trimetrexate, zalcitabine,
zoledronic acid

aluminum hydroxide, amiloride,
ammonium chloride,
ascorbic acid, asparaginase,
bumetanide, calcitonin,
chlorothiazide,
cholestyramine,
corticosteroids, corticotropin,
dexamethasone,
diltiazem, dimercaprol,
diuretics, ergocalciferol,
ethacrynic acid,
Calcium (Urine)
fenoldopam, furosemide,
glucocorticoids, interferon,
mannitol,
methylclothiazide, metolazone,
nandrolone, parathyroid
extract,
plicamycin, prednisolone,
spironolactone, torsemide,
triamcinolone,
triamterene, viomycin, vitamin
D, vitamin K
Decreased by: alendronate,

bicarbonate, bisphosphonates,
calcitonin, chloroquine,
chlorothiazide, etidronate,
gallium nitrate, hormone
replacement
therapy, hydrochlorothiazide,
ketoconazole, lithium,
mestranol,
methyclothiazide, neomycin,
octreotide, oral contraceptives,
pamidronate, parathyroid
extract, phenytoin,
polythiazide, quinapril,
spironolactone, thiazides,
trichlomethiazide, vitamin K
acetylcysteine, ammonium
chloride, aspirin, cannabis,
cefotaxime, chloride salts,
chlorothiazide,
cholestyramine,
corticosteroids, cyclosporine,
diazoxide, etretinate,
Chloride (Serum )
guanethidine,
hydrocortisone, iodide, ion
exchange
resins, lithium,
methyltestosterone,
neostigmine, triamterene

amiloride, ascorbic acid,
bicarbonate, bumetanide,
cefotaxime, chlorpropamide,
chlorthalidone, corticosteroids,
corticotropin, cortisone,
diuretics, etretinate,
furosemide,
hydrocortisone,
hydroflumethiazide, laxatives,
mannitol, methyclothiazide,
metalazone, polythiazide,
prednisone,
silver, thiazides, triamterene,
trimethoprim
acetophenazine,
aminoglutethimide,
amiodarone,
amphotericin B, anabolic
steroids, amprenavir,
anastrozole,
antibiotics, antihypertensives,
ascorbic acid, asparaginase,
aspirin,
atenolol, azathioprine,
basiliximab, bicalutamide,
beclomethasone,
betaxolol, beta blockers,
calcitriol, carbamazepine,
carvedilol,
chenodiol, chlorothiazide,
chlorpromazine,
chlorpropamide,
chlorthalidone, clofibrate,
clonidine, clopidogrel,
conjugated
estrogens, corticosteroids,
cortisone, cyclophosphamide,
cyclosporine,
diclofenac, disulfram, enalapril,
ether,
etretinate, fluoxymesterone,
fluvoxamine, glyburide, gold,
hydrochlorothiazide, ibuprofen,
imipramine, indapamide,
isotretinoin,
Cholesterol (Serum )
lansoprazole, levarterenol,
lisinopril, lithium,
mapazine, meprobamate,
methimazole, methyclothiazide,
methyltestosterone,
miconazole, mirtazepine,
mycophenolate, nafarelin,
nandrolone, naproxen,
nefazodone, norethandrolone,
norfloxacin,
Norplant, ofloxacin, oral
contraceptives, oxymetholone,
paroxetine,
penicillamine, pergolide,
phenytoin,
pindolol, polythiazide,
pravastatin, prednisolone,
prochlorperazine,
promazine, propranolol,
radioactive iodine, riluzole,
rosiglitazone,
sargramostin, sirolimus,
sotalol, spironolactone,
sulfadiazine,
tamoxifen, theophylline,
thiouracil,
ticlopidine, tolcapone,
tretinoin, troglitazone,
venlafaxine, vitamin
D, zolpidem
Decreased by: acarbose,
acebutolol, albuterol,
aluminum hydroxide,
amikacin, amiloride,
amiodarone, amlodipine,
ampicillin, ascorbic acid,
atorvastatin, azathioprine,
bisoprolol, captopril, carvedilol,
chlorambucil, chloroform,
chlorpropamide, chlorthalidone,
cholestyramine, clazapril,
clofibrate, clomiphene,
clonidine, coenzyme
Q10, colchicine,
colestipol,
conjugated
estrogens, diltiazem,
doxazocin, enalapril,
erythromycin, esterified
estrogens, estrogen
therapy, fenofibrate,
fluoxymesterone, fluvastatin,
fosinopril,
gemfibrozil, glyburide,
factor,
guanabenz, haloperidol, HMG
CoA-reductase inhibitors,
indomethacin,
insulin, isoniazid, isotretinoin,
isradipine, kanamycin,
ketoconazole,
lansoprazole, levonorgestrel,
lisinopril,
LMW heparin, losartan, MAO
inhibitors,
metformin,
methyldopa, metoprolol,
metronidazole, nandrolone,
neomycin, niacin,
nicotinic acid, nifedipine,
Norplant, oral contraceptives,
oxandrolone,
oxymetholone, perindopril,
phenytoin, pindolol,
pravastatin, prazosin,
prednisolone, probucol,
progesterone, psyllium,
raloxifene, ramipril,
simvastatin, spironolactone,
statins, streptokinase,
tacrolimus,
tamoxifen, terazosin,
tetracycline, thiazides, thyroid,
tolbutamide,
trazodone, ursodiol, valproic
acid, verapamil
Chorionic
Gonadotropin
(Plasm a)
Decreased by: octreotide
Coagulation Tim e
(Blood)
Increased by: anticoagulants,

carbenicillin, dicumarol,
pegasparagase, plicamycin,
tetracycline, ticarcillin
Coom bs Test
Decreased by: aminophylline,

oral contraceptives
Positive result by:
aminosalicylic acid, aztreonam,
cefonicid, ceftazidime,
ceftizoxime,
cefuroxime, chlorpromazine,
chlorpropamide, ethosuximide,
hydralazine,
ibuprofen, imipenem cilastatin,

isoniazid, levodopa, mefenamic
acid,
melphalan, methyldopa,
moxalactam, penicillamine,
phenytoin,
procainamide, quinidine,
quinine, streptomycin,
sulfonylureas,
tetracycline
Increased by: anticonvulsants,

aspirin, atropine,
benzodiazepines, citalopram,
clomipramine, corticotropin,
corticotropin-releasing
hormone,
cortisone, diazoxide,
diclofenac, estrogens, ether,
ethinyl, estradiol,
Cortisol (Plasm a)
fenoprofen, furosemide,
gemfibrozil, glyburide,
hydrocortisone,
insulin, interferon, interleukin,
lithium, methadone,
methoxamine,
metoclopramide, naloxone,
octreotide, opiates, oral
contraceptives,
ranitidine, spironolactone,
tumor necrosis
factor, vasopressin
Decreased by:
aminoglutethimide,
barbiturates, beclomethasone,
budesonide, clonidine,
corticosteroids, danazol,
dexamethasone,
dextroamphetamine, diazoxide,
ephedrine, etomidate,
fluocinolone, indomethacin,
ketoconazole,
labetalol, levodopa, lithium,
magnesium sulfate,
megestrol, mesalamine,
methylprednisolone,
midazolam, morphine,
nifedipine, nitrous oxide,
norethindrone, oxazepam,
phenobarbital,
phenytoin, pravastatin,
prednisolone, ranitidine,
rifampin,
sumatriptan, triamcinolone,
trimipramine
Increased by: ACE
inhibitors, acebutolol,
acetohexamide,
acetaminophen, acyclovir,
alkaline antacids, alprazolam,
alprostadil,
altretamine, amikacin,
amiloride, amiodarone,
amphotericin B, ascorbic
aztreonam,
barbiturates, benazepril,
betazolol, bicalutamide,
bisoprolol,
candesartan, capreomycin,
carvedilol,
caspofungin, cefaclor,
cefamandole, cefazolin,
cefixime, cefoperazone,
cefotaxime, cefotetan,
cefoxitin, cefpodoxime,
ceftibuten, ceftizoxime,
ceftriaxone, cefuroxime,
cephalexin, cephaloridine,
cephalothin,
cephradine, cetirizine,
chlorothiazide, chlorpropamide,
chlorthalidone,
cidofovir, cimetidine, cinoxacin,
ciprofloxacin, cisplatin,
clarithromycin, clofibrate,
clonidine, clorazepate, cotrimoxazole,
colistimethate, colistin,
cyclosporine, danazol,
demeclocycline,
dextran, diclofenac,
disopyramide, diuretics,
enalapril, enflurane, epoetin
alfa, eprosartan, ethambutol,
etidronate,
etretinate, fenoprofen,
flucytosine, fludarabine,
foscarnet,
furosemide, gabapentin,
gentamicin, glycerin,
griseofulvin, hydralazine,
Creatinine (Serum )
idarubicin, imipramine, immune

globulin, indomethacin,
interleukin
alfa-2, irbesartan, isotretinoin,
kanamycin, ketoprofen,
ketorolac,
labetalol, lamotrigine,
lansoprazole, leuprolide,
levodopa, lidocaine,
lisinopril, lithium, loracarbef,
losartan, lovastatin, mannitol,
meclofenamate, mefenamic
acid, meropenem, mesalamine,
methicillin,
methotrexate, methyldopa,
methylprednisolone,
mitomycin, mitoxantrone,
moexipril, moxalactam,
mycophenolate,
nalidixic acid, naproxen,
neomycin, netilmicin,
nifedipine, nilutamide,
nisoldipine, nitrofurantoin,
drugs,
norfloxacin, ofloxacin,
olsalazine, oxacillin, oxaprozin,
pamidronate,
paromomycin, pegasparagase,
pentamidine,
pentostatin, phenazopyridine,
phosphorus, piperacillin,
piroxicam,
plicamycin, prednisone,
propafenone, quazepam,
quinapril, radiographic
agents, ramipril, ranitidine,
risperidone, salsalate,
sargramostim,
sevoflurane, streptokinase,
streptomycin, streptozocin,
sulfamethoxazole,
sulindac, suprofen,
tacrolimus, tetracycline,
thiazides, ticarcillin,
ticlopidine, timolol,
tobramycin, tramadol,
trandolapril, tretinoin,
triamterene, triazolam,
trimethoprim, trimetrexate,
trovafloxacin, ursodiol,
valsartan,
vancomycin, vasopressin,
venlafaxine, vitamin D

ascorbic acid, cannabis,
captopril, dobutamine,
ibuprofen, interferon
alfa-2a, lisinopril, methyldopa,
nicardipine, prednisone,
terazosin,
triazolam, tromethamine,
valproic acid, zidovudine
Increased by: aminocaproic

acid, amphotericin B, ampicillin
(IM injection),
analgesics (IM injection),
atorvastatin, azithromycin,
candesartan,
carbenicillin, carteolol,
cefotaxime, ceftizoxime,
cerivastatin,
chlordane, chlorpromazine,
chlorthalidone, cholestyramine,
clindamycin,
clofibrate, clonidine, clozapine,
danazol, dantrolene,
diclofenac,
didanosine, digoxin, diltiazem,
diuretics (IM injection),
donepezil,
ethchlorvynol, etidocaine,
etretinate, fenofibrate, 5fluorouracil,
fluvastatin, foscarnet,
ganciclovir, gemfibrozil,
haloperidol, insulin,
Creatinine Kinase
(CPK) (Serum )
interleukin, isotretinoin,
itraconazole, labetalol,
lamivudine,
levamisole, lidocaine, lithium,

meperidine,
morphine (IM injection),
narcotics (IM injections),
nelfinavir, niacin,
nifedipine, olanzapine, oral
contraceptives, paroxetine,
penicillamine,
penicillin, phenelzine,
pindolol,
pioglitazone, pramipexole,
pravastatin, probucol,
promethazine,
propranolol, quinidine,
risperidone, ritonavir,
simvastatin, sirolimus,
streptokinase, succinylcholine,
tolcapone, trimethoprim,
troglitazone,
tubocurarine, vasopressin,
zalcitabine, zidovudine
Decreased by: acetylsalicylic

acid, amikacin, ascorbic acid,
dantrolene, phenothiazines,
pindolol, prednisone,
sulfamethoxazole
Increased by: ascorbic
acid, cefoxitin, cephalothin,
corticosteroids,
fluoxymesterone,
Creatinine (Urine)
nandrolone, nitrofurantoin,
nitrofurazone,
oxymetholone, prednisone

steroids, captopril, ketoprofen,
nandrolone, prednisone,
quinapril, thiazides
amoxapine,
amoxicillin, amphotericin B,
ampicillin, auranofin,
aztreonam,
benazepril, capreomycin,
carbenicillin,
carisoprodol, caspofungin,
cefamandole, cefdinir,
cefonicid,
cefoperazone, cefotaxime,
cefpodoxime,
ceftazidime, ceftizoxime,
ceftriaxone, cephalexin,
cephalothin,
chloramphenicol,
chloropromazine, cinoxacin,
ciprofloxacin,
clindamycin, clofibrate,
clonazepam, cloxacillin,
cyclobenzaprine,
defixime, demeclocycline,
desipramine,
diazoxide, diclofenac,
donepezil, doxepin,
enalapril, ethosuximide,
felbamate, flucytosine,
fluorouracil,
fluphenazine, furazolidone,
famciclovir, gemfibrozil,
gentamicin,
Eosinophils (Blood)
factor, haloperidol, hepatitis A
vaccine, ibuprofen,
imipenem/cilastin, interleukin,
isoniazid,
ketorolac, lamotrigine,
lansoprazole, levodopa,
loracarbef,
maprotiline, mefenamic acid,
mephenytoin, methsuximide,
methysergide,
minocycline, moxalactam,
nafarelin, nafcillin, naproxen,
netilmicin,
nitrofurantoin, nizatidine,
drugs,
paroxetine, penicillamine,
pentazocine,
pergolide, perphenazine,
procarbazine,
propafenone, quinolones,
ramipril, ranitidine, rifampin,
spironolactone, streptomycin,
sulfamethoxazole,
sulfasalazine,
tetracycline, thioridazine,
thiothixene, ticarcillin,
ticlopidine,
tobramycin, topiramate,
triazolam, trifluoperazine,
trimipramine,
trovafloxacin, valproic acid,
venlafaxine, zalcitabine,
zolmitripan
Decreased by: amitriptyline,

aspirin, captopril, clozapine,
corticotropin,
desipramine, ethosuximide,
indomethacin, niacin,
niacinamide,
nortriptyline, olsalazine,
procainamide, rifampin,
sulfamethoxazole,
triazolam
Increased by: alglucerase,

antithyroid therapy,
Erythrocytes
(Blood)
basiliximab, corticotropin,
danazol,
dexfenfluramine, erythropoietin,
etretinate, glucocorticoids,
mycophenolate, pilocarpine
Decreased by:
acetaminophen,
acetazolamide, acetohexamide,
acetophenazine, acyclovir,
allopurinol, aminoglutethimide,
amitriptyline, amphetamine,
amphotericin B, ampicillin,
amyl nitrate, antimalarials,
antineoplastics, aspirin,
auranofin, azathioprine,
barbiturates,
benazepril, benzocaine,
bupropion, busulfan,
capecitabine, captopril,
carvedilol,
ceftazidime, ceftizoxime,
cephaloridine, cephalothin,
chloramphenicol,
chlordiazepoxide, chloroquine,
chlorothiazide,
chlorpheniramine,
chlorpromazine,
chlortetracycline,
clomipramine, clonazepam,
colchicine, corticosteroids,
cyclophosphamide,
cycloserine, cyclosporin A,
dapsone, demeclocycline,
desipramine, digitalis,
dimercaprol,
diphenhydramine, donepezil,
doxapram, doxorubicin,
eflornithine,
ethosuximide, etidronate,
etoposide, etretinate,
fenoprofen,
fluorouracil, fluphenazine,
fluvastatin,
furazolidone, furosemide,
haloperidol,
hydralazine,
hydroflumethiazide,
hydroxychloroquine,
idarubicin, indomethacin,
iodoquinol, isoniazid,
isotretinoin, levodopa, Lipomul,
local
anesthetics, MAO inhibitors,
mechlorethamine,
meclofenamate, melphalan,
mephobarbital, meprobamate,
mercaptopurine, mesoridazine,
methazolamide, methicillin,
methimazole, methotrexate,
methsuximide,
methylene blue, mitomycin,
mitoxantrone,
nalidixic acid, naproxen,
neomycin, nitrofurantoin,
nitrofurazone,
norfloxacin, omeprazole, oral
contraceptives, orphenadrine,
oxacillin,
penicillin, pentamidine,
pentoxifylline,
phenazopyridine,
phenytoin,
phytonadione, piperazine,
piroxicam, primaquine,
primidone, probenecid,
procainamide, procarbazine,
propylthiouracil,
pyrimethamine, quinidine,
radioactive compounds,
ramipril, rifampin,
streptomycin, sulfadiazine,
sulfamethoxazole,
sulfinpyrazone,
sulfisoxazole, tetracycline,
thiazides, thioridazine,
thiotepa,
thiothixene, ticlopidine,
tocainide, tolazamide, tolmetin,
trastuzumab,
trazodone, triamterene,
trichlormethiazide,
trifluoperazine,
trimethoprim, tripelennamine,
uracil mustard, vinblastine,
zidovudine

aspirin, carbamazepine,
cephalothin, cephapirin,
clozapine, cyclosporine A,
dexamethasone, etretinate,
fluvastatin,
Erythrocyte
Sedim entation Rate
(Blood)
hydralazine, indomethacin,
isotretinoin, lomefloxacin,
methysergide,
misoprostol, ofloxacin, oral
contraceptives, procainamide,
propafenone,
quinidine, sulfamethoxazole,
zolpidem

cyclophosphamide,
dexamethasone, gold,
hydroxychloroquine,
leflunomide, methotrexate,
minocycline,
drugs, penicillamine,
prednisolone,
prednisone, quinine,
sulfasalazine, tamoxifen,
trimethoprim
Erythropoietin
(Serum )
Increased by: anabolic

steroids, daunorubicin,
erythropoietin,
fluoxymesterone, hydroxyurea,
theophylline, zidovudine
amphotericin B, cisplatin,
enalapril, furosemide,
theophylline
Ethanol (Serum )
Increased by: aspirin, chloral

hydrate, cimetidine,
metoclopramide, ranitidine
atropine, phenobarbital,
propantheline
Euglobulin Clot
Lysis tim e (Blood)
Increased by: cyclosporine A
Decreased by: asparaginase,

clofibrate, dextran, gemfibrozil,
streptokinase
Increased by: aminophylline,
amphetamine, chlorpromazine,
clonidine, desipramine,
diazoxide, enoxaparin, growth
hormone-releasing hormone,
human growth
Fatty Acids (Free)

(Serum )
hormone, isoproterenol,
levarterenol, levodopa,
mescaline, molindone,
oral contraceptives, prazosin,
reserpine, ritodrine,
terbutaline,
theophylline,
trichlormethiazide, valproic
acid

acebutolol, amino acids,
clofibrate,
glyburide, insulin,
isoproterenol, levothyroxine,
metformin,
metoprolol, neomycin, niacin,
prazosin,
simvastatin, sotalol,
streptozocin
Ferritin (Blood)
Increased by: ferrous sulfate,

iron preps, oral contraceptives,
theophylline
Decreased by: antithyroid
therapy, ascorbic acid,
deferoxamine, methimazole
Increased by: aspirin,
bicalutamide, chemotherapy,
estropipate, fluvastatin,
gemfibrozil,
Fibrinogen
(Plasm a)
lovastatin, norethandrolone,
oral contraceptives,
oxandrolone,
oxymetholone, pyrazinamide,
simvastatin
steroids, anistreplase,
asparaginase, atenolol,
cefamandole,
clofibrate, danazol, dextran,
estrogens,
factor VIIa, fenofibrate, 5fluorouracil, gemfibrozil, iron,
kanamycin,
lamotrigine, lovastatin,
medroxyprogesterone, oral
contraceptives,
pegasparagase, pentoxifylline,
phosphorus, pravastatin,
prednisone,
raloxifene, reteplase,
simvastatin, streptokinase,
sulfisoxazole,
ticlopidine, valproic acid
Decreased by: aminosalicylic
acid, ampicillin, antacids,
anticonvulsants, aspirin,
barbiturates, chloramphenicol,
cholestyramine, cycloserine,
diethylstilbestrol, erythromycin,
estropipate, iron, isoniazid,
Folic acid (Serum )
levodopa, lincomycin,
metformin, methotrexate,
contraceptives, penicillin,
pentamidine, phenobarbital,
phenytoin,
primidone, pyrimethamine,
rifampin, sulfasalazine,
sulfisoxazole,
tetracycline, triamterene,
trimethoprim
Increased by: bicalutamide,

bromocriptine, cimetidine,
clomiphene, danazol,
erythropoietin, finasteride,
follicle-stimulating hormone,
Follicle Stim ulating
Horm one (FSH)
(Plasm a)
gonadotropin-releasing
hormone, growth hormonereleasing hormone,
hydrocortisone, ketoconazole,
leuprolide, levodopa,
metformin,
naloxone, nilutamide,
phenytoin, pravastatin,
tamoxifen
steroids, anticonvulsants,
carbamazepine, conjugated
estrogens,
hormone, danazol,
diethylstilbestrol,
finasteride, goserelin,
leuprolide,
megestrol, octreotide, oral
contraceptives,
phenothiazines, pimozide,
pravastatin, prednisone,
stanozolol,
tamoxifen, toremifene, valproic
acid
Free T hyroxine
Index (Serum )

carbamazepine, furosemide,
levothyroxine, oral
contraceptives, orphenadrine,
phenobarbital, propranolol
Decreased by: amiodarone,

aspirin, clomiphene, cotrimoxazole, corticosteroids,
ferrous sulfate, iodide,
isotretinoin, lovastatin,
methimazole,
phenobarbital, phenytoin,
primidone, radioactive iodine,
salsalate
Glucagon (Plasm a)
calcitonin, danazol,
glucocorticoids, guanabenz,
insulin, interferon alpha-2a,
nifedipine, prednisolone,
propranolol

insulin, metoprolol, octreotide,
pindolol, propranolol,
troglitazone, verapamil
Glucose
(Cerebrospinal
Fluid)
Increased by: cefotaxime,

dexamethasone
Decreased by: cefotaxime

aminosalicylic acid, ampicillin,
ascorbic acid,
azlocillin, benzthiazide,
bupropion, captopril,
carvedilol,
cefaclor, cefamandole,
cefazolin, cefdinir, cefepime,
cefiximine,
cefoperazone, cefuroxime,
cephalexin, cepha-losprorin
antibiotics,
chlorthalidone, cidofovir,
dexamethasone,
dextroamphetamine,
diazoxide, doxorubicin,
enalapril, ephedrine,
ethacrynic acid, ether,
ethionamide, etretinate,
fludrocortisone, foscarnet,
furazolidone,
Glucose (Urine)
furosemide, gabapentin,
histrelin, hydrochlorothiazide,
ifosfamide,
indomethacin, isoniazid,
lansoprazole, lisinopril, lithium,
methyclothiazide, metolazone,
mirtazapine, misoprostol,
nalidixic acid,
naproxen, niacin,
ofloxacin, penicillin,
perphenazine,
phenazopyridine,
piperacillin,
polythiazide, probenecid,
quinethazone, reserpine,
ritodrine,
sevoflurane, somatropin,
streptozocin, sulfonamides,
tacrine,
tetracycline, theophylline,
thiazides, thiothixene,
ticarcillin,
timolol, triamcinolone,
venlafaxine

ampicillin, ascorbic acid
aspirin, bisacodyl, chloral
hydrate,
cholestyramine, diazepam,
digoxin, ferrous sulfate,
flurazepam,
furosemide, hydroquinone,
insulin, levodopa,
oxytetracycline,
phenazopyridine,
phenobarbital, radiographic
agents, secobarbital,
tetracycline, vitamin
preparations
Increased by: acarbose,

atenolol, clofibrate,
fluoxymesterone, glyburide,
guanethidine,
Glucose Tolerance
(Serum )
lisinopril, MAO inhibitors,

metformin, metoprolol,
nandrolone,
norethindrone, octreotide,
pargyline, phenytoin, prazosin,
terazosin,
troglitazone
Decreased by: acebutolol,

atenolol, beclomethasone,
betamethasone, calcitonin,
cannabis, chlorothiazide,
chlorpromazine, chlorthalidone,
clofibrate,
cortisone, danazol,
dexamethasone, diazoxide,
diethylstilbestrol, estropipate,
ethacrynic acid, felodipine,
fludrocortisone, foscarnet,
furosemide, human growth
hormone,
hydroflumethiazide,
imipramine, interferon
alfa-2a, iron, levonorgestrel,
lithium, medroxyprogesterone,
mefenamic
acid, mestranol,
methandrostenolone,
methylprednisolone,
metoprolol,
naproxen, niacin, niacinamide,
nitrofurantoin, norethindrone,
perphenazine, phenytoin,
pindolol, polythiazide,
prednisolone,
prednisone, promethazine,
quinethazone, spironolactone,
streptozocin,
thiazides, triamcinolone,
triamterene, verapamil
Glycosylate
Hem oglobin (Hb
A 1c ) (Blood)
atenolol, beta-blockers,
gemfibrozil, glimepiride,
indapamide, lovastatin, niacin,
nicardipine, nicotinic acid,
propranolol
deferoxamine, diltiazem,
enalapril, glipizide, glyburide,
insulin,
lisinopril metformin,
nisoldipine, pravastatin,
ramipril, terazosin,
verapamil

amiodarone, amphotericin B,
aurothioglucose, azithromycin,
barbiturates, captopril,
carbamazepine, cefdinir,
cefonicid,
cetirizine, chloramphenicol,
chlorpromazine,
chlorpropamide, cimetidine,
cisplatin, clomipramine,
clozapine,
cyclosporin A, dactinomycin,
dantrolene, diclofenac,
disopyramide,
disulfiram, doxorubicin,
doxycycline, enalapril,
esterified estrogens,
estropipate, etoposide,
etretinate, famotidine,
fluconazole,
flucytosine, fluoxmesterone,
flutamide, fluvastatin,
fosphenytoin,
gold, griseofulvin, haloperidol,
hepatitis A vaccine,
hydrochlorothiazide, ibuprofen,
interferon alfa-n3, isoniazid,
isotretinoin, isra-dipine,
ketamine, ketoprofen,
labetalol,
lansoprazole, levothyroxine,
lisinopril, lomefloxacin,
loratadine,
Glutam yltransferase
(GT T ) (Serum )
lovastatin,
meropenem, mesalamine,
methotrexate,
moexipril, mycophenolate,
nelfinavir, nevirapine, naicin,
nicardipine, nisoldipine,
nitrofurantoin, nortriptyline,
olsalazine,
omeprazole, oral
contraceptives, papaverine,
pegasparagase,
phenazopyridine,
phenytoin, piroxicam,
prochlorperazine, propafenone,
propoxyphene,
quinapril, quinidine, rifampin,
riluzole, ritonavir, silbutramine,
stanozolol, streptokinase,
sulfamethoxazole,
sulfasalazine,
sulfisoxazole, sulindac,
terbinafine, thiabendazole,
thiethyl-perazine,
tocainide, tolmetin,
trifluoperazine,
troglitazone, trole-andomycin,
valproic acid, warfarin,
zalcitabine,
zidovudine
Decreased by: azathioprine,

clofibrate, conjugated
estrogens, methotrexate,
ursodiol
Increased by: amino
acids, anabolic steroids,
citalopram, clomipramine,
clonidine,
desipramine, dexamethasone,
diazepam, ethinyl estradiol,
growth
Growth Horm one
(Plasm a)
hormone-releasing hormone,
indomethacin, insulin,
interferon,
interleukin, methamphetamine,
metoclopramide, midazolam,
niacin, oral
contraceptives, phenytoin,
propranolol, pyridostigmine,
tumor necrosis
factor, vasopressin
Decreased by: bromocriptine,

chlorpromazine,
corticosteroids,
hydrocortisone,
methyldopa, octreotide,
prednisone, propantheline,
valproic acid

chlordiazepoxide, cisplatin,
diazepam, ephedrine,
5Hydroxyindoleactic
Acid (Urine)
flurazepam, fluorouracil,
guaifenesin, melphalan,
methocarbamol,
naproxen, phenobarbital,
phentolamine, rauwolfia,
sulfasalazine,
reserpine

chlorpromazine, corticotropin,
imipramine, interferon alfa-2a,
isoniazid, levodopa, MAO
inhibitors, methyldopa,
octreotide,
phenothiazines, promazine,
streptozocin
Com plem ent CH 50
(Serum )
Increased by: chlorpropamide,

cyclophosphamide
Decreased by: hydralazine
Increased by: acarbose,
ACE inhibitors, albuterol,
atorvastatin, beclomethasone,
captopril,
cerivastatin, chenodiol,
cholestyramine,
cimetidine, clofibrate,
coenzyme Q10, colestipol, corn
oil, diltiazem,
doxazocin, estrogen therapy,
efavirenz,
fenofibrate, fluvastatin,
furosemide, gemfibrozil,
glyburide,
High-Density
goserelin, hydroxychloroquine,
Lipoprotein (HDL)
Cholesterol (Serum )
indapamide, insulin, isradipine,

ketoconazole, lovastatin,
metformin, methimazole,
minoxidil, nafarelin, niacin,
nicardipine, nicotinic acid,
nifedipine,
nisoldipine, norplant, oral
contraceptives, perindopril,
phenobarbital,
phenytoin, pindolol,
pravastatin, prazosin,
prednisone, ramipril,
rosiglitazone, simvastatin,
terazosin, terbutaline,
theophylline,
troglitazone, verapamil
Decreased by: acebutolol,

ascorbic acid, atenolol,
azathioprine, bisoprolol,
beta-blockers, carvedilol,
chenodiol, chlorpropamide,
clofibrate,
cyclosporin A, danazol,
etretinate,
gemfibrozil,
indapamide, indomethacin,
interferon
alfa-2a, isotretinoin,
levothyroxine, linseed oil,
lisinopril,
methimazole, methyldopa,
metoprolol, nadolol,
nandrolone, neomycin,
norplant, oral contraceptives,
prednisolone,
probucol, propranolol, psyllium,
raloxifene, sotalol,
spironolactone,
stanozolol, tamoxifen,
thiazides, timolol,
trichlormethiazide,
ursodiol, verapamil

corticosteroids, cyclosporine,
danazol, hormone
replacement, interferon,
Hydroxyproline
(Urine)
levothyroxine, nafarelin,
parathyroid hormone,
somatotropin, thyroid,
tolbutamide, vitamin D
Decreased by: antineoplastic

agents, ascorbic acid, aspirin,
bisphosphonates,
budesonide, calcitonin,
corticosteroids,
etidronate, gallium nitrate,
glucocorticoids,
pamidronate, plicamycin,
propranolol
Im m unoglobulin E
Antibody (Serum )
Increased by: aztreonam,

penicillin G
Decreased by: phenytoin
adenosine, albuterol, amino
acids, aspirin,
beclomethasone, calcium
gluconate, cannabis, captopril,
chlorpropamide,
chlorthalidone, deferoxamine,
glimepiride, glipizide,
glyburide, human
growth hormone,
hydrochlorothiazide, insulin,
interferon alfa-2a,
Insulin (Plasm a)
isoproterenol, levodopa,
lisinopril,
megestrol,
methylprednisolone,
metoprolol, niacin, nicotinic
acid, norethindrone,
perindopril, prazosin,
quinine, rifampin, ritodrine,
secretin, spironolactone,
streptozocin,
terbutaline, tolazamide,
tolbutamide, trichlormethiazide,
verapamil

acetohexamide, calcitonin,
chlorpropamide, cimetidine,
clofibrate,
conjugated estrogen,
diazoxide, diltiazem, doxazocin,
enalapril,
enprostil, ethacrynic acid,
ether, furosemide,
metformin, midazolam,
morphine, niacin, nifedipine,
octreotide,
phenytoin, prazosin,
propranolol, psyllium,
tolazamide, tolbutamide,
troglitazone

acid, cefotaxime,
chemotherapeutic agents,
Iron (Blood)
chloramphenicol, cisplatin,
ferrous sulfate, iron, iron
dextran,
methicillin, methimazole,
methotrexate, multivitamin, oral

contraceptives, pyrazinamide
aspirin, cholestyramine,
deferoxamine, metformin,
oxymetholone, pergolide,
pyrazinamide,
risperidone
Increased by: acetylcysteine,

aminosalicylic acid, aspirin,
captopril, cefdinir,
cefixime, dimercaprol, ether,
etodolac, ifosfamide, isoniazid,
Ketones (Urine)
levodopa, mesna, metformin,

methyldopa, niacin,
paraldehyde,
penicillamine, phenazopyridine,
phenolphthalein,
phenothiazines,
streptozosin, valproic acid
phenazopyridine
amiodarone, amphotericin B,
anabolic steroids, aspirin,
auranofin, azithromycin,
betaxolol, captopril,
carbenicillin, cefdinir,
cefonicid, cefotaxime,
cefuroxime, chloramphenicol,
chlordane, chlorpromazine,
chlorpropamide,
ciprofloxacin, clindamycin,
clofibrate,
codeine, dapsone, diclofenac,
diltiazem, donepezil,
doxorubicin,
estramustine, etretinate,
fenoprofen, floxuridine,
fluphenazine,
fluvoxamine, foscarnet,
gentamicin, gold,
factor, hydralazine, ibuprofen,

Lactate
Dehydrogenase
(LD) (LDH) (Serum )
imipramine, interferon alfa-2a,

interleukin-2, isotretinoin,
itraconazole, levodopa,
meperidine, mesalamine,
methotrexate,
morphine, mycophenolate,
nefazodone,
nelfinavir, nifedipine,
ofloxacin,
oxacillin, oxaprozin, paroxetine,
pegfilgrastim, pemoline,
penicillamine, pindolol,
piperacillin, plicamycin,
propoxyphene,
quinidine,
quinupristin/dalfopristin,
riluzole, sibutramine,
simvastatin, streptokinase,
streptozocin,
sulfamethoxazole,
tetracycline, thiopental,
ticarcillin, tobramycin, tolmetin,
valproic
acid, vasopressin, verapamil

anticonvulsants, ascorbic acid,
cefotaxime, clofibrate,
enalapril, hydroxyurea,
metronidazole, naltrexone
Increased by: bicalutamide,
bromocriptine, clomiphene,
finasteride,
Luteinizing
Horm one (LH)
(Plasm a)
gonadotropin-releasing
hormone, goserelin, growthreleasing hormone,
hydrocortisone, ketoconazole,
leuprolide, naloxone,
nilutamide,
spironolactone, tamoxifen,
valproic acid

steroids, anticonvulstants,
carbamazepine, conjugated
estrogens,
hormone, danazol,
diethylstilbestrol, digoxin,
ethinyl estradiol, finasteride,
goserelin,
ketoconazole, leuprolide,
megestrol, metformin,
pimozide,
progesterone, stanozolol,
tamoxifen,
thioridazine, toremifene,
valproic acid
asparaginase, azathioprine,
bethanechol, calcitrol,
cerivastatin, chlorothiazide,
cholinergic agents, cidofovir,
cimetidine, clozapine, codeine,
cyclosporine,
diazoxide, didanosine,
donepezil,
doxorubicin, enalapril,
estropipate, fluvastatin,
furosemide, human
growth hormone,
hydrocortisone, ibuprofen,
indomethacin, interferon,
Lipase (Serum )
lisinopril, meperidine,
methacholine,
methylprednisolone,
metolazone, metronidazole,
minocycline,
mirtazapine, morphine,
narcotics, nitrofurantoin,
norfloxacin, octreotide, oral
contraceptives, oxaprozin,
pegasparagase,
penicillamine, pentazocine,
piroxicam, prazosin,
prednisone, quinapril,
secretin, simvastatin,
sulfamethoxazole, sulindac,
trastuzumab,
tretinoin, valproic acid,
zalcitabine, zolmitriptan
Decreased by: calcium,

hydroxyurea, mesalamine,
protamine, somatostatin
Increased by: aminosalicylic
acid, cefaclor, cefdinir,
ceftazidime, chlorambucil,
chlorpropamide,
dexamethasone, gabapentin,
granulocyte
Lym phocytes
(Blood)
levodopa,
narcotics, niacinamide,
ofloxacin, paroxetine,
pergolide,
propylthiouracil, quazepam,
spironolactone, triazolam,
valproic acid,
venlafaxine
Decreased by: alprazolam,

asparaginase,
benzodiazepines, bupropion,
cefdinir,
cefpodoxime, ceftriaxone,
chlorambucil, cyclosporine,
dexamethasone,
eprosartan, fludarabine, folic
acid, furosemide,
glucocorticoids,
hydrocortisone, ibuprofen,
irinotecan, levetiracetam,
levofloxacin,
lithium, mechlorethamine,
mirtazapine, muromonab-CD3,
nelfinavir,
niacin, ofloxacin, olsalazine,
pamidronate, pentostatin,
phenytoin,
quazepam, rabeprazole,
sirolimus, terbinafine, thiamine,
trastuzumab,
triazolam
Increased by: alkaline
antacids, amiloride,
aminoglycosides, aspirin,
calcitriol, cefotaxime,
Magnesium (Serum )
felodipine, hydroflumethiazide,
lithium, magnesium salts,
progesterone, sodium
bicarbonate, tacrolimus,
triamterene
Decreased by: albuterol,

aldesleukin, amphotericin B,
arsenic trioxide, azathioprine,
basiliximab, calcitriol, calcium
gluconate, cefotaxime,
chlorothiazide,
chlorthalidone, cisplatin,
cyclosporine, digoxin,
doxorubicin,
ethacrynic acid, foscarnet,
furosemide, gentamicin,
haloperidol,
hydroflumethiazide, insulin,
metolazone, neomycin,
pamidronate, pentamidine,
prednisolone, sirolimus,
tacrolimus, theophylline,
thiazides, tobramycin,
trastuzumab,
zalcitabine
ammonium chloride,
amphotericin B, bumetanide,
calcitonin, chlorothiazide,
cisplatin, cyclosporin A,
ethacrynic acid,
Magnesium (Urine)
hydrochlorothiazide, lithium,
magnesium
hydroxide, methyclothiazide,
thiazides, torsemide,
triamterene

amiloride, calcium gluconate,
interferon alfa-2a, oral
contraceptives, parathyroid
extract
aminosalicylic acid, amyl
nitrite, analgesics,
antimalarials, aspirin,
benzocaine, bismuth nitrate,
chloramphenicol,
chlorpheniramine, cotrimoxazole, dapsone,
dimercaprol, furazolidone,
Methem oglobin
(Blood)
isoniazid, isosorbide, local

anesthetics, methicillin,
methylene blue,
metoclopramide, nitrofurantoin,
nitrofurazone, nitroglycerin,
phenazopyridine, phenytoin,
potassium chloride,
primaquine, probenecid,
quinidine, quinine,
sulfacetamide, sulfamethizole,
sulfanilamide,
sulfisoxazole
Decreased by:
sulfamethoxazole,
sulfasalazine, trimethoprim
Increased by: alprazolam,
ampicllin, carbenicillin,
chlorpromazine, granulocyte
Monocytes (Blood)
lomefloxacin,
methsuximide, paroxetine,
penicillamine, piperacillin,
prednisone,
propylthiouracil, quazepam
Decreased by: alprazolam,
glucocorticoids (transient),
factor, triazolam
Oxalate (Urine)
Increased by: ascorbic acid,

bumetanide, ethylene glycol
calcium carbonate
Increased by: chemotherapy,
cyclosporine,
foscarnet,
Parathyroid
Horm one Assay
(Plasm a)
human growth hormone,

hydrocortisone, isoniazid,
ketoconazole, lithium,
nifedipine, octreotide,
pamidronate, phenytoin,
prednisone, tamoxifen,
valdecoxib, verapamil
Decreased by: aluminum

hydroxide, calcitriol,
cimetidine, diltiazem,
famotidine, gallium
nitrate, gentamicin, magnesium
sulfate, oral contraceptives,
parathyroid hormone, pindolol,
prednisone, thiazides, vitamin
D

aluminum hydroxide, anabolic
steroids, aspirin,
azithromycin, basiliximab,
bisoprolol, cefdinir, cefotaxime,
dipyridamole, epoetin alfa,
erythropoietin, etidronate,
etretinate,
foscarnet, furosemide, human
growth hormone,
Phosphate (Serum )
mannitol,
methicillin, methyltestosterone,
methotrexate, minocycline,
nafarelin, naproxen, nifedipine,
Phospho-Soda,
pindolol, rifampin, risedronate,
risperidone, sirolimus,
tacrolimus,
tetracycline, theophylline,
timolol, venlafaxine, vitamin D
albuterol, aldesleukin,
alendronate, alkaline antacids,
aluminum salts, amino acids,
amlodipine, anesthetic agents,
anticonvulsants, azathioprine,
calcitonin, calcitriol,
carbamazapine,
cefdinir, cisplatin, doxorubicin,
etretinate, foscarnet,
hydrochlorothiazide, insulin,
isoniazid, lithium, mannitol,
mestranol,
mycophenolate, niacin,
nicardipine, oral
contraceptives, pamidronate,
plicamycin, raloxifene,
sirolimus,
sucralfate, tacrolimus,
theophylline, venlafaxine
Plasm inogen
(Blood)

steroids, danazol,
fluoxymesterone,
norethandrolone, oral
contraceptives, oxandrolone,
oxymetholone, stanozolol
Decreased by: alteplase,
anistreplase, asparaginase,
chemotherapy, dextran,
gemfibrozil, streptokinase
Increased by: alglucerase,
amoxapine, auranofin,
cefazolin, cefdinir, cefonicid,
cefotetan, cefpodoxime,
ceftibuten, ceftriaxone,
cidofovir,
clindamycin, clozapine,
danazol, diltiazem,
dipyridamole, donepezil,
epoetin alfa, ertapenem,
erythropoietin, estropipate,
etretinate,
fludarabine, gemfibrozil,
glucocorticoids,
imipenem/cilastin, immune
Platelet (Blood)
globulin, indinivir, interferon

lansoprazole,
lithium, lomefloxacin,
megestrol, meropenem,
mesalamine,
methylprednisolone,
metoprolol, metyrosine,
miconazole, moxalactam,
netilmicin, ofloxacin, oral
penicillamine,
pergolide, propranolol,
steroids, ticlopidine,
venlafaxine,
zalcitabine, zidovudine
Decreased by: abciximab,

acetaminophen, acet-
azolamide, albendazole,
albuterol,
aldesleukin, alemtuzumab,
allopurinol, altretamine,
aminocaproic acid,
aminoglutethimide,
amoxicillin, amphotericin
B, ampicillin, amrinone,
anagrelide, anticonvulsants,
antineoplastic
agents, ardeparin, arsenic
trioxide, asparaginase, aspirin,
auranofin,
aurothioglucose, azathioprine,
azithromycin, bacampicillin,
barbiturates, basiliximab, BCG
vaccine, benazepril,
benzthiazide,
betaxolol, bicalutamide,
bleomycin, bupropion,
candesartan, capecitabine,
carbamazepine,
carbenicillin, carmustine,
carvedilol, cefaclor,
cefamandole,
cefazolin, cefditoren, cefixime,
cefonicid, cefotetan, cefoxitin,
cefpodoxime, ceftibutin,
ceftizoxime, ceftriaxone,
cefuroxime,
cetirizine, chlorambucil,
chloramphenicol,
chlordiazepoxide,
chloroquine, chlorothiazide,
chlorpheniramine,
chlorpromazine,
chlorpropamide,
chlortetracycline,
cladribine, clemastine,
clomipramine,
clonazepam, clopidogrel, cotrimoxazole, codeine,
colchicine,
cyclobenzaprine,
cyclophosphamide,
dacarbazine, dactinomycin,
dalteparin, danazol,
demeclocycline,
desipramine,
dextroamphetamine, diazoxide,
diclofenac, didanosine,
diethylpropion,
diethylstilbestrol, digitalis,
digitoxin, diltiazem,
diphenhydramine,
disopyramide, docetaxel,
donepezil, doxepin,
eflornithine, enalapril,
enoxaparen,
epirubicin, eprosartan,
erythromycin, esomeprazole,
estramustine,
etanercept, ethacrynic acid,
ethchlorvynol, ethosuximide,
etidronate,
etoposide, etretinate, factor VII
a, famotidine, fenoprofen,
fluorouracil,
fluphenazine, fluvastatin,
fluvoxamine, fomivirsen,
fondaparinux,
fosphenytoin, furosemide,
gabapentin, galantamine,
ganciclovir,
gatifloxacin, gemcitabine,
glyburide, gold,
granisetron, hepatitis B
vaccine, hydralazine,
hydroxychloroquine,
imatinib, imipenem/cilastin,
imipramine, immunoglobulin,
indinavir,
indomethacin, infliximab,
interferon alfa-2a, interleukin2,
ironotecan, isoniazid,
isotretinoin,
itraconazole, ketoprofen,
lansoprazole,
lepirudin, levamisole, levodopa,

lincomycin, lisinopril,
lomefloxacin,
lomustine, loracarbef,
maprotiline, measles virus
vaccine, mechlorethamine,
meloxicam,
melphalan, meprobamate,
mesalamine,
mesoridazine, metformin,
methazolamide, methicillin,
methimazole,
methotrexate, methsuximide,
methylphenidate,
methysergide, metoprolol,
metronidazole, metyrosine,
mexiletine, milrinone,
minocycline, mirtazepine,
misoprostol,
mitomycin, mitoxantrone,
moricizine, morphine,
moxalactam, mumps virus
vaccine, muromonab-CD3,
nalidixic acid,
naproxen, netilmicin,
nevirapine, niacin, nicardipine,
nitrofurantoin,
nitroglycerin, nizatidine,
nystatin,
ofloxacin, olsalzine,
omeprazole, orphenadrine,
oxacillin,
oxytetracycline, paclitaxel,
pamidronate, pegasparagase,
pemoline,
pentamidine, pentostatin,
pentoxifylline,
pergolide, perphenazine,
pindolol,
piroxicam, plicamycin, polio
virus vaccine, polythiazide,
potassium
iodide, pravastatin,
prednisone, primadone,
probenecid, procainamide,
procarbazine, promazine,
propranolol,
propyl-thiouracil, protriptyline,
quazepam, quinidone,
rabeprazole,
raloxifene, ramipril, reserpine,
rifampin, risperidone,
rivastigmine,
rubella virus vaccine,
saquinavir, sargramostim,
sirolimus, smallpox
vaccine, spironolactone,
stavudine, streptomycin,
streptozocin,
sulfamethoxazole,
sulfonylureas,
tamoxifen, temozolomide,
tetracycline,
thioguanine, thioridazine,
thiotepa,
thiothixene, ticarcillin,
ticlopidine, timolol, tinzaparin,
tobramycin,
tocainide, tolazamide,
tolazoline, tolbutamide,
tolcapone, tolmentin,
topotecan, toremifene,
tranylcypromine, trastuxumab,
trichlormethiazide,
trimetrexate,
trimipramine, tripelennamine,
trovafloxacin, uracil mustard,
valdecoxib, valganciclovir,
valproic acid, vancomycin,
vinblastine,
vincristine, vinorelbine,
zidovudine, zolmitriptan
acid, anticonvulsants,
barbiturates, cascara,
chlordiazepoxide,
chlorpromazine,
chlorpropamide, griseofulvin,
Porphobilinogen
(Urine)
imipenem/cilastin,
meprobamate, oral
contraceptives,
phenothiazines,
pentazocine, phenytoin,
procaine, tolbutamide
Decreased by: actinomycin,
ascorbic acid, cimetidine, oral
contraceptives
Increased by: antipyretics,
barbiturates, chloral hydrate,
chlordiazepoxide,
chlorpropamide, ciprofloxacin,
diazepam, ergot preparations,
griesofulvin, nalidixic acid,
hydantoin derivatives,
norfloxacin,
Porphyrins (Urine)
meprobamate, methyldopa,
hydroxychloroquine, ofloxacin,
oxytetracycline, pentazocine,
phenazopyridine, progestin
derivatives,
sulfamethoxazole, tetracycline,
vitamin K
Decreased by: oral
contraceptives
Increased by: ACE
inhibitors, aldesleukin,
amiloride, aminocaproic acid,
aminoglutethimide, ammonium
chloride, amphotericin B,
atenolol,
basiliximab, benazepril,
betaxolol,
bisoprolol, candesartan,
cannabis, captopril, cefdinir,
cefotaxime,
clofibrate, cyclosporine,
danazol, dexamethasone,
digoxin, doxorubicin,
enalapril, epoetin alfa,
erythropoietin, etretinate,
felodipine,
fosphenytoin, indomethacin,
isoniazid, ketoconazole,
ketorolac,
Potassium (Serum )
labetalol, lisinopril, lithium,

LMW heparin, lovastatin,
mannitol,
methicillin, methyltestosterone,
mycophenolate,
naproxen, netilmicin,
nifedipine, nonsteroidal antiinflammatory drugs,
paroxetine, penicillin,
pentamidine,
perindopril, pindolol, piroxicam,
propranolol, quinapril,
ramipril, risedronate, sirolimus,
somatotropin, spironolactone,
succinylcholine, sulindac,
tacrolimus,
timolol, trandolapril,
triamterene, trimethoprim,
valsartan,
venlafaxine, zalcitabine

albuterol, aldesleukin,
amlodipine, ammonium
chloride,
amphotericin, arsenic trioxide,
aspirin, azathioprine,
basiliximab,
benzthiazide, betamethasone,
betaxolol, bisacodyl,
bumetanide,
carbenicillin,
carvedilol, cathartics,
cephalexin, chloroquine,
chlorothiazide,
chlorthalidone, cidofovir,
cisplatin, corticosteroids,
corticotropin,
cortisone, dexamethasone,
digoxin immune fab, diuretics,
dobutamide,
donepezil, doxazocin,
doxorubicin, enalapril,
epoprostenol, ethacrynic
acid, etretinate, fluconazole,
flucytosine, fludrocortisone,
fosinopril, fosphenytoin,
furosemide,
gentamicin,
hydrochlorothiazide, imatinib,
indapamide, insulin,
itraconazole, ketoprofen,
laxatives, levodopa, lithium,
lomefloxacin,
methazolamide,
methyclothiazide,
methylprednisolone,
metoclopramide,
metolazone, milrinone,
moxalactam, mycophenolate,
neomycin, nifedipine,
nisoldipine, ondansetron,
pamidronate,
paroxetine, penicillin,
pergolide, piperacillin,
plicamycin,
polythiazide, prednisolone,
prednisone,
quinethazone, riluzole,
risperidone, ritodrine, sodium
bicarbonate,
spironolactone, streptozocin,
tacrolimus, terbutaline,
tetracycline,
theophylline, thiazides,
ticarcillin, tobramycin,
triamterene,
trichlormethiazide,
trimethoprim, venlafaxine,
vidarabine, zalcitabine
ammonium chloride,
antibiotics, aspirin,
betamethasone,
carbenicillin, cathartics,
chlorthalidone,
cortisone, dexamethasone,
diuretics,
ethacrynic acid, fenoldopam,
fludrocortisone, gentamicin,
Potassium (Urine)
hydrocortisone, indomethacin,
isosorbide,
levodopa, lithium, mafenide,
methyclothiazide, metolazone,
niacinamide,
parathyroid extract,
prednisolone, quinethazone,
streptozocin, thiazides,
torsemide, triamcinolone,
viomycin
Decreased by: amiloride,

anesthetic agents,
carbamazepine, cyclosporin A,
diazoxide,
felodipine, ketoconazole,
levarterenol, niacin, ramipril,
sulfamethoxazole, trimethoprim
Pregnanediol
(Urine)

phenazopyridine, tamoxifen
Decreased by:
diethylstilbestrol,
contraceptives,
phenothiazines, progesterone
Progesterone
(Plasm a)

ketoconazole, progesterone,
tamoxifen
Decreased by: ampicillin,
carbamazepine, danazol,
goserelin, leuprolide,
contraceptives, pentobarbital,
phenytoin,
pravastatin, valproic acid
Increased by: amitriptyline,

amoxapine, butorphanol,
carbidopa, chlorpromazine,
cimetidine, citalopram,
clomipramine, danazol,
desipramine,
diethylstilbestrol, enalapril,
fenoldopam, fluphenazine,
fluvoxamine,
furosemide, gonadotropinreleasing hormone, growth
hormone-releasing
hormone, haloperidol,
imipramine, insulin, interferon,
interleukin,
Prolactin (Serum )
labetalol, loxapine, megestrol,

mestranol, methyldopa,
metoclopramide,
molindone, morphine, nitrous
oxide, oral contraceptives,
parathyroid
hormone, perphenazine,
phenytoin, prochlorperazine,
promazine,
ranitidine, reserpine,
risperidone, thioridazine,
thiothixene,
thyrotropin-releasing hormone,
trifluoperazine, trimipramine,
tumor
necrosis factor, verapamil
Decreased by:
anticonvulsants, bromocriptine,
calcitonin, carbamazepine,
conjugated
estrogens, cyclosporine,
dexamethasone, finasteride,
levodopa,
metoclopramide, morphine,
nifedipine, octreotide,
phenytoin
Increased by: ampicillin,

aspirin, cefotaxime,
chloramphenicol, ibuprofen,
imipramine, methicillin,
methotrexate, oxytetracycline,
penicllin,
Protein
(Cerebrospinal
fluid)
perphenazine, phenothiazines,
procaine, radiographic agents,
streptomycin, sulfadiazine,
sulfanilamide, sulfisoxazole,
tetracycline,
tolbutamide, trifluoperazine,
vancomycin
Decreased by:
acetaminophen, cytarabine,
cefotaxime, dexamethasone,
ranitidine, rifampin, ropinirole,
tamoxifen, toremifene, valproic
acid
acetazolamide, aldesleukin,
aminophylline,
amphotericin B, ampicillin,
arsenicals, ascorbic
bacitracin,
benazepril, betaxolol,
bicarbonate, bismuth
subsalicylate, capreomycin,
carbamazepine, castor oil,
cefaclor, cefamandole, cefdinir,
cephaloridine, cephalothin,
chloral hydrate, chlorhexidine,
chloroform,
chlorpromazine,
chlorpheniramine,
chlorpropamide, chlorthalidone,
cidofovir, cisplatin,
codeine, colistin,
cyclosporine, dantrolene,
demeclocycline,
dihydrotachysterol, doxapram,
doxycycline, enalapril,
ergot preparations, ether,
ethosuximide, etretinate,
fenoprofen,
foscarnet, furosemide,
gabapentin, gemcitabine,
gentamicin, glyburide,
glycerin, gold, griseofulvin,
hepatitis A vaccine,
hydralazine,
Protein (Urine)
ibuprofen, ifosfamide,
indomethacin, interferon alfa2a,
iodine-containing drugs, iron,
isoniazid, isotretinoin,
kanamycin,
ketorolac, lipomul, lithium,
mefenamic acid, mercury
compounds,
mesalamine, metaxalone,
methenamine, methicillin,
mitomycin, miotane,
moxalactam, naphthalene,
naproxen, neomycin,
netilmicin, nifedipine,
drugs, norfloxacin, olsalazine,
oxacillin, oxaprozin,
paraldehyde, paramethadione,
paromomycin,
pegasparagase, penicillamine,
penicillin, phenazopyridine,
phenolphthalein, phosphorus,
plicamycin,
probenecid, promazine,
quinine, radiographic agents,
ramipril,
ranitidine, rifampin, salsalate,
silver, sodium bicarbonate,
streptokinase, streptomycin,
sulindac, suprofen, tacrolimus,
tetracycline, thallium,
theophylline, thiabendazole,
ticarcillin,
ticlopidine, tobramycin,
tolbutamide, tolmetin,
tramadol,
trifluoperazine, vancomycin
Renin (Plasm a)
Elevated by: captopril,

furosemide
Decreased by: oral
contraceptives
amiloride, amino acids,
ampicillin, anabolic steroids,
betamethasone, cannabis,
carbamazepine, cefotaxime,
chlorthalidone,
cholestyramine, clonidine,
corticosteroids, cortisone,
diazoxide,
doxorubicin, etretinate,
fludrocortisone, guanethidine,
human growth
Sodium (Serum )
hormone, hydrocortisone,
isosorbide, mannitol,
methyclothiazide,
methyldopa,
methyltestosterone, oral
contraceptives, phenelzine,
progesterone,
ramipril, sildenafil, sodium
bicarbonate, sodium sulfate,
tetracycline,
ticarcillin/clavulanate,
zalcitabine
Decreased by: aldesleukin,
amiloride, aminoglutethimide,
ammonium chloride,
amphotericin, atovaquone,
benazepril, captopril,
carbamazepine,
carvedilol, cathartics,
chlorothiazide,
chloropropamide,
chlorthalidone, cisplatin,
clozapine, cyclophosphamide,
dapsone,
desmopressin, diuretics,
doxepin, doxorubicin,
esomeprazole, ethacrynic
acid, etretinate, fluoxetine,
furosemide,
glyburide, glycerin, haloperidol,
hydroflumethiazide,
indomethacin, isosorbide
dinitrate, itraconazole,
ketorolac,
laxatives, lisinopril, lithium,
mannitol, methyclothiazide,
methylprednisolone,
metolazone, miconazole,
morphine, nicardipine,
nifedipine, nisoldipine,
drugs,
omeprazole, paroxetine,
pentostatin,
phenoxybenzamine, pimozide,
polythiazide, propafenone,
quinethazone, ramipril,
risperidone,
sertraline, sirolimus, sodium
bicarbonate, somatostatin,
spironolactone, sulfonylureas,
tacrolimus, theophylline,
thiazides,
ticlopidine, tobramycin,
trastuzumab, triamterene,
trimethoprim,
trimetrexate, trovafloxacin,
valproic acid, vasopressin,
venlafaxine,
vidarabine, vincristine,
zalcitabine
Increased by: ACE

inhibitors, acetazolamide,
amiloride, ammonium chloride,
aspirin,
atenolol, benzthaizide,
captopril, carvedilol,
chlorothiazide, chlorthalidone,
cisplatin, clofibrate,
cyclothiazide,
dexamethasone, digitalis,
doxepin, enalapril, ethacrynic
acid,
felodipine, fenoldopam,
furosemide,
Sodium (Urine)
hydrocortisone,
hydroflumethiazide, ifosfamide,
isosorbide, levodopa, lithium,
losartan, mannitol,
methyclothiazide,
metoprolol, metolazone, niacin,
niacinamide, oral
contraceptives,
paramethasone, parathyroid
extract, polythiazide,
progesterone,
quinethazone, secretin,
spironolactone, tetracycline,
thiazides,
torsemide, triamcinolone,
triamterene, triclomethiazide,
trimethoprim,
verapamil, vincristine
Decreased by: anesthetic

agents, carbamazepine,
corticosteroids, cortisone,
cyclosporine, diazoxide,
etodolac, fluoxetine, ibuprofen,
indomethacin,
insulin, ketorolac, levarterenol,
lithium, methylprednisolone,
naproxen, nifedipine,
octreotide, omeprazole,
propranolol, ramipril
Elevated by:
aminoglutethimide, clonidine,
dexamethasone, goserelin,
Som atom edin C

(Insulin-like Growth
Factor I) (Plasm a)
human growth
hormone,
prednisolone, somatropin,
tamoxifen
Decreased by: estrogens,

ethinyl estradiol, methimazole,
tamoxifen
steroids, barbiturates,
bromocriptine, Casodex,
cimetidine, clomiphene,
danazol, estrogen/progestin,
finasteride, flutamide,
goserelin,
Testosterone
(Serum )
leuprolide, levonorgestrel,
mifepristone, nafarelin,
nalmefene,
naloxone, nilutamide, oral
contraceptives, phenytoin,
pravastatin,
rifampin, tamoxifen, valproic
acid
Decreased by:
carbamazepine, cimetidine,
cyclophosphamide,
diazoxide, diethylstilbestrol,
digoxin,
estradiol valerate, fenoldopam,
finasteride, follicle-stimulating
hormone, gemfibrozil,
goserelin, interleukin,
ketoconazole, letrozole,
leuprolide, magnesium,
metformin,
methylprednisolone, nafarelin,
spironolactone, stanozolol,
tamoxifen,
tetracycline, verapamil
T hrom bin Tim e

(Blood)
Increased by: anistreplase,

asparaginase, streptokinase,
urokinase
Decreased by: dextran, LMW

heparin
T hyroglobulin
(Serum )
Increased by: amiodarone

Decreased by: neomycin,
thyroxine
atenolol, calcitonin,
carbamazepine,
chlorpromazine,
clomiphene, conjugated
estrogens, ferrous sulfate,
iodide,
T hyroid-Stim ulating
Horm one (T SH)
(Serum )
levothyroxine, lithium,
lovastatin, methimazole,
metoclopramide,
morphine, phenytoin,
potassium iodide, prazosin,
prednisone,
propranolol, radiographic
agents, rifampin, sumatritan,
tamoxifen,
thyrotropin-releasing hormone,
valproic acid

anabolic steroids, aspirin,
carbamazepine, clofibrate,
corticosteroids, danazol,
fenoldopam, growth-releasing
hormone,
hydrocortisone, interferon alfa2, levothyroxine, nifedipine,
octreotide, somatostatin,
thyroxine, troleandomycin
Increased by: carbamazepine,
clofibrate, diethylstilbestrol,
erythropoietin,
T hyroxine-Binding
Globulin (T BG)
(Serum )
estrogens, mestranol, oral

contraceptives, perphenazine,
phenothiazines, progesterone,
raloxifene, tamoxifene

steroids, asparaginase,
colestipol, corticosteroids,
corticotropin,
cortisone, danazol,
fluoxymesterone,
methyltestoterone, nandrolone,
norethandrolone,
norethindrone, oxymetholone,
phenytoin, prednisone,
propranolol, stanozolol
Increased by:
aminoglutethimide,
amiodarone, anabolic steroids,
aspirin, barbiturates,
chlorpropamide, cobalt,
corticosteroids,
Triiodothyronine
Uptake (Serum )
Coumadin, fluoxymesterone,
furosemide, levothyroxine,
methyltestosterone,
metoprolol, miotane,
nandrolone, Norplant,
orphenadrine, oxymetholone,
penicillin, phenytoin,
propranolol,
stanozolol, sulfonylureas,
tamoxifen, thyroid, tolbutamide

chlordiazepoxide, clofibrate,
diazepam, diflunisal,
estropipate, fluoxymesterone,
lithium, medroxyprogesterone,
methimazole, oral
contraceptives, perphenazine,
phenothiazines,
thiazides
amphetamine, clofibrate,
erythropoietin, estropipate,
fluorouracil, insulin,
levothyroxine, mestranol,
methadone, opiates,
Triiodothyronine
(T 3 ) (Serum )
propylthiouracil,
ranitidine, tamoxifen,
terbutaline, thyrotropinreleasing hormone,
valproic acid
anabolic steroids,
carbamazepine,
cholestyramine, cimetidine,
clomiphene, clomipramine,
cotrimoxazole, corticosteroids,
diclofenac,
furosemide, glucocorticoids,
hydrocortisone, interferon alfa2, iodide,
isotretinoin, lithium,
methimazole, metoprolol,
mitotane, naproxen,
netilmicin, oral contraceptives,
penicillamine, phenobarbital,
phenytoin, potassium iodide,
prednisone, propranolol,
propylthiouracil,
radiographic agents, salsalate,
somatostatin, stanozolol,
sulfonylureas, theophylline
aspirin, carbamazepine,
danazole, enoxaparen,
T hyroxine (T 4 ) Free
(Serum )
erythropoietin, furosemide,
levothyroxine, phenytoin,
propranolol,
propylthiouracil, radiographic
agents, tamoxifen, thyroxine,
valproic
acid
anabolic steroids,
carbamazepine, clofibrate,
corticosteroids, estrogen
therapy, isotretinoin,
levothyroxine,
lithium, mestranol, methadone,
methimazole, norethindrone,
octreotide,
ranitidine

acid, amiodarone, ardeparin,
ascorbic acid, atenolol,
bisoprolol, beta-blockers,
Casodex,
chlordane, chlorothiazide,
colchicine,
cyclosporine, danazol,
didanosine, enalapril,
estrogen/progestin
therapy, estrogens, etretinate,
fluconazole, fluvastatin,
furosemide,
glucocorticoids, glycerin,
goserelin, hydrochlorothiazide,
interferon
Triglycerides
(Serum )
itraconazole, labetalol,
levothyroxine,
metoprolol, miconazole,
mirtazapine,
nadolol, nafarelin, norfloxacin,
ofloxacin, oral contraceptives,
perindolol, pindolol,
polythiazide, prazosin,
propranolol, radioactive iodine,
simvastatin,
sotalol, spironolactone,
tamoxifen, tenofovir, thaizides,
ticlopidine,
timolol, tretinoin,
trichlormethiazide, warfarin,
zalcitabine

ACE inhibitors, acetylsalicylic
acid, amiodarone, amlodipine,
anabolic
steroids, ascorbic acid,
asparaginase, atorvastatin,
azathioprine,
bisoprolol, captopril, carvedilol,
cerivastatin, chenodiol,
clofibrate, colestipol, danazol,
dexfenfluramine, diltiazem,
doxazosin, enalapril, estrogen
therapy,
fenofibrate, flaxseed oil,
fluvastatin, gemfibrozil,
glyburide, HMG
CoA-reductase inhibitors,
hydroxychloroquine,
hydroxyurea,
ketoconazole, levodopa,
levonorgestrel,
levothyroxine, LMW heparins,
lovastatin,
metformin, methimazole,
niacin, nicardipine, nicotinic
acid,
nifedipine, nisoldipine,
norethindrone, oxandrolone,
pentoxifylline,
pindolol, pravastatin, prazosin,
prednisolone, probucol,
psyllium,
simvastatin, stanozolol,
terazosin, troglitazone,
unfractionated
heparin, verapamil
acetazolamide, aldesleukin,
amiloride, ampicillin,
anabolic steroids,
antineoplastic agents,
asparaginase, ascorbic acid,
aspirin, atenolol, azathioprine,
basiliximab, benzthiazide,
betaxolol,
bisoprolol, bumetanide,
busulfan, calcitriol,
carvedilol, chloral hydrate,
chlorambucil, chlorothiazide,
cisplatin, clopidogrel,
clozapine,
cyclosporine, cytarabine,
dantrolene, dextran, diazoxide,
diclofenac,
didanosine, diltiazem,
diuretics, donepezil, doxazocin,
doxorubicin,
epoetin alfa, ethacrynic acid,
ethambutol, etoposide,
fludarabine,
goserelin, granulocyte colonystimulating
factor, hydralazine,
hydroflumethiazide,
indomethacin, irbesartan,
isoniazid, isosorbide
Uric Acid (Serum )
dinitrate, isotretinoin,
lansoprozole, leuprolide,
levarterenol,
levodopa, lisinopril,
lomefloxacin, losartan,
mechlorethamine,
methicillin, methotrexate,
methylclothiazide, metolazone,
misoprostol, mitomycin,
mycophenolate,
nambumetone, naproxen,
nelfinavir, niacin, niacinamide,
nicotinic acid,
nisoldipine, nizatidine,
oxytetracycline, pancrelipase,
paroxetine,
pegasparagase, pentostatin,
pergolide, phenelzine,
phenothiazines,
pindolol, piroxicam,
polythiazide, prednisone,
propranolol,
propylthiouracil, pyrazinamide,
quinethazone, radioactive
agents,
ramipril, rifampin, riluzole,
salicylates,
sildenafil, spironolactone,
sulfanilamide, tacrolimus,
theophylline,
thiazides, thioguanine,
thiotepa, timolol, triamterene,
trichlormethiazide,
trimetrexate, venlafaxine,
vincristine, warfarin,
zalcitabine
Decreased by:
acetohexamide, allopurinol,
amiloride, amlodipine, ascorbic
acid,
aspirin, azathioprine, cannabis,
cannola oil, chlorothiazide,
chlorpromazine, cidofovir,
clofibrate, corticosteroids,
corticotropin,
cortisone, Coumadin,
dobutamine,
doxazocin, enalapril,
ethacrynic acid, etodolac,
fenofibrate,
griseofulvin, guaifenesin,
ibuprofen, indomethacin,
levodopa,
lisinopril, lithium, mannitol,
mechlorethamine, mefenamic
acid,
phenothiazines, prednisolone,
probenecid,
radiographic agents, salicylate,
sertraline, spironolactone,
sulfamethoxazole,
sulfinpyrazone,
ticarcillin/clavulanate,
verapamil,
vinblastine

acetaminophen, ascorbic acid,
busulfan, chlorothiazide,
clofibrate, corticotropin,
cortisone,
coumadin, diethylstilbestrol,
ethacrynic acid, ifosfamide,
lithium,
Uric Acid (Urine)
mannitol, mercaptopurine,
methotrexate, niacinamide,
nifedipine,
pancrelipase, pergolide,
phenothiazines, prednisolone,
probenecid,
salicylates (large doses),
sulfamethoxazole,
sulfinpyrazone,
thioguanine, triamterene,
verapamil
allopurinol, aspirin (low dose),
azathioprine,
bumetanide, chlorothiazide,
chlorthalidone, diazoxide,
ethacrynic acid,
ethambutol, furosemide,
levarterenol, niacin,
probenecid, pyrazinamide,
salicylates (low doses),

thiazides
Urine Specific
Gravity
Increased by: dextran,

isotretinoin, penicillin,
radiographic agents
Decreased by: lithium
Urobilinogen
(Stool)
Increased by: amyl nitrate

Decreased by: antibiotics,
aspirin, chloramphenicol,
chlordiazepoxide,
chlorpromazine, erythromycin,
methimazole, nalidixic acid,
neomycin,
oxymetholone,
prochlorperazine, promazine,
sulfamethoxazole,
sulfisoxazole, tetracycline,
thiabendazole,
thiazides, tolbutamide,
trifluoperazine

acid, chlorpromazine,
disulfiram, guaifenesin,
guanethidine, insulin,
isoproterenol, labetalol,
levarterenol,
Vanillylm andelic
Acid (VMA) (Urine)
levodopa, lithium,
methocarbamol, methyldopa,
nalidixic acid,
nifedipine, nitroglycerin,
oxytetracycline,
phenazopyridine, prazosin,
prochlorperazine, rauwolfia,
reserpine
Decreased by: clonidine,
disulfiram, fluvoxamine,
guanethidine, guanfacine,
imipramine, levodopa, MAO
inhibitors, methyldopa,
morphine, phenelzine,
phenothiazines, radiographic
agents, reserpine
Vitam in B12 (Serum )
Increased by: chloral hydrate,

omeprazole
Decreased by:
anticonvulsants, ascorbic acid,
cholestyramine,
chlorpromazine,
colchicine, metformin,
neomycin, octreotide, oral
contraceptives,
ranitidine, rifampin
BIBLIOGRAPHY
Drug Fact s and Comparisons 2003, 57t h ed. Philadelphia, Lippincot t Williams
& Wilkins, 2003

Wilkins
> B ac k of B ook > Appendic es > Appendix K - P r otoc ols for Hair, Nails , S aliva, S putum , and B r eath
S pec im en C ollec tion
Appendix K
Protocols for Hair, Nails, Saliva, Sputum, and
Breath Specimen Collection
Specimen collect ion of hair, nails, and saliva are easy t o obt ain and noninvasive.
Breat h specimen collect ion met hodologies can range f rom t he simple t o t he
complex, and sput um collect ion involves specif ic prot ocols. Sput um specimens
are generally easy t o obt ain, not ing t hat specif ic procedures are f ollow ed.
Result s f rom analysis of t hese samples aid in diagnosing several diseases and
may be used as evidence in legal sit uat ions. I t is imperat ive t hat all prot ocols
are f ollow ed precisely t o avoid int erf erence in evaluat ing t est result s.
Samples of clean hair and nails can be analyzed f or evidence of f ungal
inf ect ions, abnormal concent rat es of t oxic and nut rient minerals (selenium),
heavy met als (mercury and lead), t herapeut ic drugs, and illegal drugs. High
levels of some element s are caused by exposure t o indust rial w ast es and by
cont aminat ed drinking w at er. The limit of det ect ion of most drugs in hair is 0. 1
ng/ mL or higher.
I ndicat ions f or t est ing of hair samples f or drugs:
1. As a marker of t oxin exposure
2. To monit or parolees and probat ioners
3. To validat e drug self -report ing
4. To ident if y i n utero drug use
5. To assess pat t ern of drug use (at 1-mont h int ervals)
6. To aid in drug t reat ment programs
7. Test ing in w orkplace
8. To evaluat e parent s' drug use in child cust ody cases
9. As f orensic evidence af t er deat h
10. Compliance w it h nonpsychot ropics (eg, ant ihypert ensives or ant ibiot ics) f or
mont hs t o years
O ral f luid saliva specimens may be used t o ident if y high levels of I gG in t he

gingival crevice. This crevice secret es a f luid or t ransudat e t hat cont ains a
relat ively high concent rat ion of I gG . The procedure f or oral f luid saliva specimen
collect ion involves obt aining a gingival cervicular f luid (ie, mucosal t ransudat e)
specimen by rubbing t he oral mucosa (ie, lining of t he gum and cheek) in t he
mout h w it h a cot t on collect ion pad on a st ick.
Sput um specimens are examined t o ident if y pat hogens or condit ions relat ed t o
t he respirat ory syst em. Pert inent sympt oms may include cough w it h or w it hout
sput um product ion, f ever, chest pain, short ness of breat h, and f at igue. Sput um
specimens can also provide clues about ant ibiot ic or drug sensit ivit y, t he best
course of t reat ment , and t he eff ect iveness of t reat ment .
Exhaled breat h specimens are obt ained t o ident if y H. pyl ori inf ect ion, det ect
alcohol, and monit or hormones and ot her byproduct s of abnormal met abolism by
using special analyzers or kit s t hat may involve specif ic inst ruct ions.
REFERENCE VALUES
Normal
1. Hair and nails, negat ive f or presence of :
a. Fungus
b. Heavy met als
c. Therapeut ic and illegal drugs
d. Anabolic st eroids
2. Sput um, negat ive f or presence of :
a.
TB
b. St rept ococcus
c. St aphylococcus
d. O t her pat hogens
3. Saliva, negat ive f or presence of :
a. Alcohol
b. Tobacco
c. Therapeut ic and illegal drugs
d. Hepat it is A, B, C
e. Cancer
f. Diabet es
g. Aut oimmune diseases and inf ect ions
h. Hormone levels out side normal ranges (see each specif ic hormone in
Chapt er 6).
4. Breat h, negat ive f or presence of :
a. Urease in H. pyl ori inf ect ion
b. Alcohol and ot her drugs and t oxins
c. There is no signif icant change in breat h specimens af t er ingest ion of
subst ance such as lact ose.
PROCEDURES
1. Hair Sampling
a. Use ext reme care in obt aining hair samples. Wear gloves and f ollow
est ablished prot ocols. Hair should be shampooed and f ree of oil,
condit ioners, hair spray, and gels. Clip t he hair close t o t he scalp or
skin. Color-t reat ed hair is usually accept able; in t his inst ance, pubic hair
is pref erred.
b. O bt ain hairs f rom t he correct sit es: beard, must ache, axilla, genit al area,
and scalp. I nf orm t he pat ient not t o use any deodorant , pow der, or lot ion
af t er shampooing or bat hing unt il sampling is done. Use steri l e scissors
or inst rument s w hen cut t ing hair or nails.
c. O bt ain a 10-g specimen of hair so t hat drugs such as opiat es, cocaine,
met hadone, and amphet amines can be ext ract ed af t er w ashing and
decont aminat ion w it h subst ances such as acet one, met hylene chloride, or
met hanol.
d. Be aw are t hat hair is most of t en collect ed f rom t he back of t he head
(nape of t he neck).
e. Cut hair as close as possible t o t he scalp and st ore in a dry t ube.
f. Tie a pencil-t hick specimen of hair w it h st ring bef ore cut t ing t o a lengt h
of 6 cm (if possible).
2. Nail Sampling
a. Wear gloves and f ollow est ablished prot ocols
b. Clip nails close t o t he cut icle; t oenails are pref erred. Bef ore clipping,
t horoughly w ash and dry t oenails or f ingernails.
3. Bot h Hair and Nail Samplings
a. Transf er specimens t o t he laborat ory in a special envelope w it h a
biohazard label or a met al-f ree, screw -t op plast ic cont ainer.
b. Document t he t ype and amount of specimen, sit e of hair or nail sampling,
t est s ordered, disposit ion of specimen, hair color and if chemically
t reat ed, condit ion of nails (eg, sof t , gangrenous), appearance of f ollicle
at hair shaf t , t he t ime collect ed, and t he relevant skin condit ions (eg,
scaling, dermat it is, inf lamed, reddened).
4. Saliva Sampling
a. Wear gloves. O bt ain a special t est ing kit . The kit usually includes a
specially t reat ed cot t on pad on a nylon st ick and a vial cont aining a
nont oxic preservat ive solut ion. Saline solut ion in t he pad f acilit at es oral
f luid sample absorpt ion.
b. Follow t he est ablished procedure precisely. Place t he pad bet w een t he

low er cheek and gum, rub it back and f ort h gent ly but f irmly unt il
moist ened, and t hen leave it in place f or at least 2 minut es up t o a
maximum of 5 minut es. Avoid salivary gland injury. Af t er t he elapsed
t ime, remove t he t reat ed pad f rom t he mout h, and insert it all t he w ay t o
t he bot t om of t he specimen vial t hat cont ains special ant imicrobial
preservat ive solut ion. Hold t he vial upright t o prevent spillage. Bend t he
pad st ick handle unt il t he upper half snaps off . Discard t he broken piece,
leaving t he sampling pad inside t he vial.
c. When placing t he st opper cap on t he vial, be sure t o press t he cap
complet ely int o t he vial t o prevent leakage.
d. Aff ix a signed and dat ed t amper-evident t ape over t he cap and dow n
bot h sides of t he vial.
e. Place t he specimen cont ainer in a resealable biohazard bag and label it
properly.
f. Transport t he specimen t o t he laborat ory as soon as possible. I n t he
laborat ory, some saliva samples are quick f rozen (ie, cort isol, est riol,
est radiol, progest erone, and t est ost erone).
g. Document t he pat ient 's name, t ype of specimen, t est ordered, dat e and
t ime of collect ion, and ot her pert inent observat ions.
5. Procedures f or Sput um Sampling
a. Remember t hat sput um specimens must come f rom t he bronchi.
Post nasal secret ions or saliva are unaccept able. Expect orat ion;
ult rasonic nebulizat ion, chest physiot herapy, nasot racheal or t racheal
suct ioning, and bronchoscopy are met hods used t o obt ain sput um and
bronchial specimens. Early morning specimens are t he best .
b. I nst ruct t he pat ient t o remove dent ures, rinse t he mout h w it h w at er, and
gargle, if possible.
c. The pat ient should f irst clear t he nose and t hroat , t ake t hree or f our
deep breat hs, perf orm a series of short coughs, and t hen inhale deeply
and cough f orcef ully t o raise a sput um specimen.
d. The sput um should be expect orat ed int o a st erile cont ainer w it h t he
proper preservat ive if indicat ed. A 2- t o 3-mL sample is adequat e. Place
t he sealed cont ainer int o a leak-proof biohazard bag and t ransf er it t o
laborat ory af t er labeling properly.
e. Sput um specimens are usually not ref rigerat ed and should be t aken t o
t he laborat ory as soon as possible. I nclude t he pert inent inf ormat ion,
such as t ype of specimen, appearance, preservat ive, t est s ordered, dat e
and t ime of collect ion, and disposit ion of specimen.
f. Document t he specimen appearance and t he pat ient 's response t o t he

procedure.
6. Breat h Sampling
a. Wear gloves. Use special t est ing kit t hat is needed. Follow inst ruct ions
caref ully; t hese inst ruct ions are supplied w it h t he kit . These procedures
require special t raining f or most t ypes of t est s.
b. Some kit s are disposable, cont ain a breat h analyzer scanner, and are
designed f or one-t ime use (eg, alcohol).
c. All collect ions, bot h single and mult iple, are clinician supervised. The
pat ient inhales normally and exhales int o t he t ube-t ype mout hpiece.
d. The special kit f or lact ose def iciency t est ing cont ains a mout hpiece
at t ached t o a special bag, vacuum-sealed collect ion t ubes, and lact ose
f or oral ingest ion and dilut ion.
e. I n t he collect ion procedure f or t he lact ose breat h t est , t he exhaled
breat h is collect ed in a special bag and/ or vacuum-sealed t ubes
(baseline value) bot h bef ore and af t er drinking a solut ion of lact ose and
w at er (1, 2, and 3 hours). The pat ient must drink t he lact ose solut ion
w it hin 5 minut es of t he f irst sip, f ast ing as required f or lact ose t est s.
f. Breat h analysis has t w o phases:
1. G as phase <5cc/ mL
2. Liquid phase (condensat e)
Clin ical Alert

1. Urine samples provide inf ormat ion about short -t erm drug use; hair
provides inf ormat ion about long-t erm drug use.
2. A challenged urinalysis f rom an employee should be invest igat ed w it h hair
analysis.
Clin ical Alert For all specimen collectin g, w ear gloves an d u se

stan dard precau tion s an d precise procedu res. Docu men t type
an d amou n t of specimen s, site of h air an d n ail samplin g,
appearan ce of n ails (soft, gan gren ou s), appearan ce of saliva,
spu tu m, relevan t symptoms (eg, skin in flamed, cou gh in g,
sh ortn ess of breath ), time of collection (eg, breath alcoh ol at
10:12 a.m.).
NOTE
Some devices (eg, O mniSal) employ a diff erent collect ion met hod in w hich a
cot t on pad is placed under t he t ongue. An indicat or in t he collect ing device
changes color w hen an adequat e amount of oral f luid has been collect ed.
Clin ical Alert In some u n ion ized w orkplaces, saliva specimen s

are tested on ce a mon th or as often as tw o times a day as part
of Last Ch an ce agreemen ts, or w h en th ere is reason able
su spicion of alcoh ol abu se. If th e w orkplace saliva alcoh ol
ou tcome is 20 mg/dL (4.3 mmol/L), th e employee is sen t by taxi
for breath alcoh ol test at an emergen cy room or prepared clin ic.
INTERFERING FACTORS
Unsat isf act ory sput um samples include dry specimens (ie, saliva samples
w it hout act ual sput um) or cont aminat ed specimens.
CLINICAL IM PLICATIONS
1. Hair and Nail Sampling:
a. Abnormal f indings reveal presence of chronic heavy met al exposure and
monit ored levels present in t he body as part of a t herapeut ic regimen
b. Presence of f at t y acid et hyl est ers (FAEEs) in hair is a marker of longt erm alcohol abuse
c. Presence of hair and nail f ungal inf ect ions
d. I dent if icat ion of illegal drug use
e. Mot her and new born inf ant hair t est ed corroborat es indicat ions of
mot her's drug use during pregnancy
f. I n post mort em assays, drug use det ermined as part of hist ory in
det ermining t he cause of deat h
g. For pre-employment and ongoing evaluat ions in t he w orkplace
2. Saliva Sampling: Normal f indings include:
a. Presence of alcohol and drugs of abuse (eg, amphet amines,
barbit urat es, benzodiazepines, caff eine, cocaine, inhalant s, LSD,
marijuana, opiat es, t obacco)
b. Presence of HI V inf ect ion
c. Presence of hepat it is A, B, and C; Hel i cobacter pyl ori inf ect ion;
aut oimmune disease; cancer (eg, carcinoembryonic ant igen, prost at especif ic ant igen, CA 125 ant igen); diabet es (t ypes 1 and 2); presence of
t herapeut ic drugs and ot her drugs (ie, saliva drug concent rat es are low er
t han t hose in urine or blood plasma); hormone levels above or below
expect ed out comes f or pat ient , (eg, cort isol, t est ost erone, progest erone,
prolact in, DHEA); anabolic st eroids; ABO blood group t yping ident if ied
d. Specimen cont ains f indings or result s t hat may be usef ul f or research or
invest igat ional purposes (Table K. 1).
Table K.1 Saliva to Plasma Ratios for Common

Drugs
Saliva/Plasm a
Drug
Ratio*
Amphetamine
2.76
Antipyrine
Buprenorphine
0.050.41
Caffeine
0.61.0
Carbamazepine
0.10.3
Chlorpromazine
0.4
Clorazepate
5.78
Cocaine
Crack, 42 mg
1.517.0
Intranasal, 42 mg
0.713
IV, 25 mg
0.53.5 (average,
1.3)
Codeine
3.33.6
Cotinine
Smokers
0.81.4
Nonsmokers
Unknown
Dehydroepiandrosterone
0.001
Delta-9tetrahydrocannabinol
0.56.0
Diazepam
0.013
Diphenylhydantoin
0.10.3
Doxorubicin
2.3
Ethanol
1.031.08
Etoposide
1.0
5-Fluorouracil (5 Fu)
0.8
Haloperidol
2.2
Heroin (smoked)
Unknown
Heroin (IV)
0.11.9
Hexobarbital
0.34
Hydromorphone
0.32.3
Lithium
313
Lysergic acid diethylamide

(LSD)
1.4
Melphalan
1.2
Meperidine (Demerol)
2.6
Methaqualone
0.1
Morphine
0.40.7
Pentobarbital
0.36
Phencyclidine
2.4
Phenobarbital
0.3
Secobarbital
0.240.38
Theophylline
0.51.0
Thiocyanate
Smokers
10.6
Nonsmokers
13.4
* Saliva pH of 6.8, serum pH of 7.4

From Malamud D, Tabak L: Saliva as a
diagnostic fluid. Annals of the New York
Academy of Sciences, 694, 1993.

3. Sput um Sampling
a. Abnormal f indings indicat e t he cause of pneumonia and ot her respirat ory
disease (eg, inf luenza virus, Legi onel l a spp., mycobact erium,
t uberculosis, Mycopl asma spp., and Staphyl ococcus aureus). See
Chapt er 7 f or complet e list of causat ive organisms.
4. Breat h Sampling:
a. Abnormal result s reveal presence of alcohol, t oxins produced by
bact eria, or hydrogen (H2 ) af t er ingest ion of lact ose and elect rolyt es.
b. A f lat curve is seen in most persons w it h lact ose def iciency w ho are not
diabet ic.
Clin ical Alert If th e test pu rpose is to detect HIV, to iden tify

alcoh ol, illegal dru gs, or to establish patern ity, a ch ain of
cu stody protocol is implemen ted.
1. The pat ient must sign a consent f orm and t he t amper-evident t ape t hat
prot ect s t he int egrit y of t he specimen.
2. Provide t he pat ient 's name, dat e of birt h, and collect ion dat e on t he vial.
INTERVENTIONS
1. Hair and Nail Sampling
a. Pret est Pat ient Preparat ion
1. Assess and document signs and sympt oms of drug presence or t oxic
exposure. I nclude t he geographic locat ion, w at er supply sources and
qualit y, pest icide use, indust rial w ast e exposure, f ood cont aminant s,
and current medicat ions.
2. Explain how kerat in is laid dow n in bone, hair, and nails, and how t his
relat es t o t he t est purpose. Toenail may give more accurat e
measures of exposure t o cert ain subst ances such as selenium. I t
t akes 3 mont hs f or t he nail on t he lit t le t oe t o grow out and a year
f or t he big t oe t o grow out .
3. Explain how mycot ic organisms (eg, ringw orm) at t ack t he kerat in.
4. I f t est ing is done f or illegal or improperly used drugs, f ollow chain of
cust ody prot ocols.
5. Check t o see if dandruff shampoos have been used; t hey cont ain
selenium and can skew result s.
6. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed pretest
care.
b. Post t est Pat ient Care
1. I nf orm t he pat ient regarding ant icipat ed t imes t he t est result s report s
are expect ed.
2. I nt erpret t est result s and counsel appropriat ely regarding any f ollow up t est ings or t reat ment int ervent ion needed.
3. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed posttest
care.
2. Saliva Sampling
1. Explain t he purpose, procedure, and any int erf ering f act ors relat ed t o
oral f luid specimen collect ion. There should be no candy or gum in
t he mout h. Recent f ood int ake, smoking, use of oral hygiene, and
t reat ment w it h ant icholinergic drugs do not aff ect t est result s. Drug
excret ion in oral f luid depends on t he pH and salivary f lora.
2. Reassure t he pat ient t hat t here is no discomf ort w it h t he procedure.
Pat ient s w ho f ear dent al w ork may be apprehensive about having
anyt hing done in t he mout h.
3. Usually, dent ures or part ials do not have t o be removed. Assess f or
an allergy t o cot t on.

4. Follow st andard precaut ions, and w ear gloves (see Appendix A).
care.
1. I nf orm t he pat ient regarding ant icipat ed t imes t he t est result s report s
are expect ed.
2. I nt erpret t est result s and counsel appropriat ely regarding any f ollow up t est ings or t reat ment int ervent ion needed.
3. Af t er collect ing specimen, pat ient may resume act ivit ies (eg, gum
chew ing, eat ing candy, f oods) immediat ely. Af t er lact ose ingest ion,
diarrhea and cramps may occur.
care.
3. Sput um Sampling
1. Explain purpose and procedure of sput um specimen collect ion. An
early morning specimen produces t he best organism-concent rat ed
sput um sample of deeply locat ed pulmonary secret ions.
2. O bt ain a sput um collect ion kit and supplies.
3. I nst ruct t he pat ient about all aspect s of collect ion, including any
specif ic body posit ioning or chest physiot herapy, such as chest
clapping.
4. I nf orm t he pat ient not t o t ouch inside of t he sput um cont ainer.
care.
1. Evaluat e pat ient out comes, and counsel appropriat ely about
t reat ment and self -care f or respirat ory illness.
2. Monit or t he respirat ory st at us as necessary, and int ervene
appropriat ely w hen indicat ed.
care.
4. Breat h Sampling
a. Pret est Pat ient Care
1. Explain t est purpose and t ype of specimen collect ion. I nf orm t he

pat ient t hat during t he act of breat hing, cert ain subst ances may
occur in t he exhaled breat h, w hich are t hen ident if ied by means of a
breat h analyzer.
2. Diet ary rest rict ions may apply. Check w it h your laborat ory (eg,
f ast ing 6 t o 12 hours prior t o lact ose t est ing).
3. Act ivit y is limit ed during complex procedures. No st renuous act ivit y
prior t o t est s.
care.
1. Evaluat e pat ient out comes and counsel appropriat ely about result s,
f urt her t est ing, and possible t reat ment .
care.
Clin ical Alert

1. Ult rasonic nebulizers may be used f or sput um induct ion w hen t he cough is
not product ive. I f t his is t he case, proper cleaning and disinf ect ion of t he
nebulizer must be done.
2. Do not obt ain a suct ioned sample w it hout f irst consult ing t he physician.
3. Specimens t hat are t o be t ransport ed w it hin an inst it ut ion should be
placed in a biohazard zip-lock bag. I deally, t he requisit ion should
accompany t he specimen but not be sealed inside t he bag (t ypically t here
is a pocket on t he out side of t he bag f or t he requisit ion).
BIBLIOGRAPHY
Auw rt er V, et al: Fat t y Acid Et hyl Est ers in Hair as Markers of Alcohol
Consumpt ion. Segment al Hair Analysis of Alcoholics, Social Drinkers, and
Teet ot alers. Clinical Chemist ry 47: 12, 1142123, 2001
Malamud D, Tabak L: Saliva as a diagnost ic f luid. Annals of t he New York
Academy of Sciences, 694, 1993

Wilkins
> B ac k of B ook > Appendic es > Appendix L - P r otoc ols for E videntiar y S pec im en C ollec tion in C r im inal
or For ens ic C as es
Appendix L
Protocols for Evidentiary Specimen Collection in
Criminal or Forensic Cases
I mport ant evident iary specimens are collect ed f rom t he living and t he dead and
can include blood, t issue, hair, nails, body f luids (eg, urine, semen, saliva,
vaginal f luid, gast ric f luid), and evidence generat ed by diagnost ic procedures
such as x-ray, CT scans, angiograms, endoscopy, and elect rocardiograms. All
collect ion procedures are t o be f ollow ed precisely, w it h complet e document at ion
w it h appropriat e signat ures and t it les as required. These specimens and t est
result s of t en become evidence f or legal sit uat ions. Collaborat ion w it h ot her
prof essionals is mandat ory. Healt h prof essionals may int eract w it h assault and
abuse vict ims in set t ings ot her t han emergency rooms and ambulances (eg,
crit ical care areas, medical/ surgical depart ment s in hospit als, home
environment s and school set t ings).
PROCEDURES FOR SPECIM EN COLLECTION AND

PRESERVATION IN CRIM INAL OR FORENSIC CASES
1. O bt ain evidence f rom t he vict im or subject , including vict ims of predat ory
crimes, physical and sexual assault (bot h f emale and male), homicide, and
child, elder, and spousal abuse, vict ims of dat e rape drugs, poisons, and
t oxic drugs. Specimens may be obt ained f rom t he pat ient , f rom t he deceased
person, t he perpet rat or, t he suspect , t he accused or f alsely accused, drug
addict s, or t he public in general.
2. Collect evident iary mat erial required by law enf orcement , t he medical
examiner, part icipant s in t he scient if ic invest igat ion of deat h and criminal
injury, and needed f or public or legal proceedings.
3. Ret rieve evident iary it ems during diagnost ic and t herapeut ic procedures (eg,
head shot project ions, shot gun w adding or bullet s) t hat are of t en recovered
f rom t he vict im or suspect 's clot hing, or t he sheet s/ blanket s on w hich t he
vict im is t ransport ed. These it ems should be w rapped in gauze and placed in
an envelope or cup.
4. Collect vict im's clot hing t hat may cont ain t he vict im's or perpet rat or's blood,
body f luid and/ or t issue.
5. O bt ain t race evident iary specimens, such as t races of soot as in gunshot
w ounds, t at t ooing f rom gunpow der, punct at e abrasions in int ermediat erange gunshot w ounds, or collect debris (eg, gravel, grass, soil, t w igs,
glass) t hat place t he vict im at t he crime scene.
6. Record and have a w it nessed record (ie, by a record person) of narcot ics
f ound on t he vict im, dangerous drugs, and money (ie, have t w o people
count ).
7. Place it ems in paper bags, not plast ic.
8. Document pat ient 's condit ion, signs and sympt oms of club drugs ingest ion,
malignant hypert hermia, and/ or odor of alcohol. Club drugs are colorless,
t ast eless, and odorless. Combinat ion of t hese drugs can lead t o muscle
breakdow n, cardiovascular f ailure, and deat h. (See Table L. 1)
Table L.1 Date Rape and Common Club Drugs
Drug Nam es
(Chem ical and
Street)
FDA Drug Schedule
(I, II, III)
Route of
Adm inistration
MDMA (I)
34 methylene
dioxymethamphetamine
Ecstacy, Adam, XTC,
X, Hug Drugs, Beans,
Smoked,
snorted,
swallowed,
injected
Physical
Exam inatio
(findings, s
and sym pto
of use in un
victim s)
Tachycardia
hypertension
hyperthermia
mydriasis,
diaphoresis,
stimulant, en
genic effects
Love Drugs, Lover's,

Speed
GHB (I)
Gamma
hydroxybutyrate
Liquid ecstacy, Liquid
X, Everclear, Soap,
Easy Lay, Goops,
Georgia home boy
hallucination
Liquid shots
(capfuls), ften
mixed with
alcohol, or
juices due to
bitter taste;
pills, capsules,
injected
intramuscularly
Bradycardia
respiratory
depression,
hallucination
amnesia
Oral (odorless,
tablets
capsules),
"blotters"
(blotting paper)
Tachycardia
hypertension
hyperthermia
mydriasis,
lacrimation,
hallucination
synthesias a
tremors
Sniffed,
snorted, mixed
with alcohol or
water, injected
with heroin
Respiratory
depression,
Hypotension
Orientation,
dizziness, V
disturbances
anterograde
LSD (I)
Lysergic acid
diethylamide
Acid, L, Blotter, Trips,

Cid, Tabs, Microdots
Rohypnol (I)
Flunitrazepam
Rophies, Roofies,
Roach, Rope, Circles,
Mexican valium
Methamphetamine (II)
Methylamphetamine
Speed, Ice, Meth,

Crystal, Crank, Fire,
Glass
Ketamine (III)
Ketamine
hydrochloride
Special K, Lady Kay,

Vitamin K, Jet, K,
Keets, Super C, Cat
valium, K-hole
Smoked,
snorted,
swallowed,
injected
intravenously
Tachycardia
hypertension
hyperthermia
mydriasis,
diaphoresis,
hallucination
"floating out
body" or "ne
death" Expe
Swallowed,
snorted,
smoked,
injected intramuscularly,
combined with
other drugs (eg,
MDMA),
smoked with
marijuana and
tobacco
Tachycardia
hypertension
nystagmus,
respiratory
depression,
hallucination
cataleptic st
Clin ical Alert

1. Never leave evidence unat t ended.
2. Human bit es have an inf ect ion rat e of 15%20%.
Procedure for Sexual Assault

1. O bt ain consent using f orm in st andard sexual assault kit .
2. Wear gloves and use st andard precaut ions in conscious, cooperat ive,
nonhallucinat ory vict ims.

3. For obt aining specimens af t er sexual assault , use a Sexual Assault Evidence
Collect ion Kit , w hich cont ains t he it ems needed t o collect samples as
required by t he area crime laborat ory f or alleged sexual assault cases.
Samples can be obt ained w it h t he kit f rom males and f emales, vict ims and
suspect s. Phot ographs of assault areas are of t en t aken.
4. Provide inf ormat ion on a f orm enclosed in t he evident iary specimen kit and
have t he individual and t he examining medical prof essional sign and dat e t he
f orm.
5. Be aw are t hat one-sw ab t echniques are generally used f or moist secret ions
and t w o-sw ab t echniques are used f or dry secret ions f or t he f ollow ing t est s:
a. Clot hing samples
1. Have t he individual st and on clean pieces of examinat ion paper if he
or she is conscious and able t o st and.
2. Have t he individual remove clot hing, placing each art icle int o a new,
clean paper bag. Then f old t he examinat ion paper, placing it also int o
a clean paper bag. Dat e, seal, and init ial each bag.
b. Vaginal sw ab:
1. Using t he f our sw abs in t he kit , t horoughly sw ab t he vagina.
2. Prepare a smear using t he f our sw abs; allow t he sw abs and smear
t o air dry.
3. Place t he sw abs in a sw ab box, ret urn t he smear t o t he cardboard
slid holder, and t ape it shut . Seal and complet e t he inf ormat ion
request ed on t he envelope provided.
c. Cervical sw ab
1. Using t w o sw abs, t horoughly sw ab t he cervix and immediat ely
prepare a smear.
2. Allow t he sw abs and smear t o t horoughly air dry, ret urn t he sw abs t o
t he sw ab box, and ret urn t he smear t o t he cardboard slide holder.
Seal and complet e t he inf ormat ion request ed on t he envelope
provided.
d. Rect al sw ab
1. Using a single sw ab, moist en it w it h st erile w at er, gent ly insert int o
t he rect um (t o a dept h of about 3 cm) and rot at e.
2. Allow t he sw ab t o air dry, place it in t he envelope, and seal and label
it .
e. Penile sw ab
1. Using a single sw ab, moist en it w it h st erile w at er, and t horoughly

sw ab t he ext ernal area of t he ent ire penis.
2. Use at least t w o (2) sw abs, allow t he sw abs t o air dry, place t hem in
t he envelope, seal, and label.
f. Pubic hairs
1. Using comb provided, obt ain 20 t o 30 pubic hairs, or obt ain at least
20 t o 25 plucked pubic hairs f rom t he vict im. Pat ient s are given t he
opt ion of plucking t heir ow n hairs.
2. Be aw are t hat t hese hairs are compared w it h suspect 's hairs.
g. Blood and/ or urine samples f or DNA t est ing
1. Perf orm a venipunct ure, and collect at least 5 mL of blood in t he
lavender-st oppered (EDTA) blood t ube provided in t he kit . Label t he
t ube w it h t he individual's name and t he dat e.
2. From t his t ube, w it hdraw 1 mL of blood, and f ill each of t he f our
print ed circles on t he DNA St ain Card.
3. Allow t he card t o air dry, w rit e t he individual's name on t he card,
place it in t he envelope, seal it , and complet e t he inf ormat ion
request ed. The blood t ube should be placed in t he St yrof oam blood
t ube holder.
4. Seal t he holder w it h t he evidence t ape, supply t he inf ormat ion
request ed, and place t he unit in t he zip-lock bag provided. DNA can
be ident if ied in skin cells, dandruff , and perspirat ion st ains on
clot hing. Urine specimen collect ion can be random w it nessed or
obt ained by cat het erizat ion.
h. O t her samples
1. Be aw are t hat only cert ain commercial analyzers are approved f or
evident iary breat h t est ing (eg, breat h alcohol).
2. Remember t hat saliva samples f or evident iary use are usually not
collect ed, as ot her specimens f or DNA evidence are more import ant .
6. Bef ore int ernal specimen examinat ion, use Wood's lamp (long-w ave
ult raviolet light ) t o scan genit al area. Record f indings. Apply t oluidine blue
dye t o ext ernal perineal area w it h cot t on-t ipped applicat ors. Area is t hen
gent ly w iped dry and lubricat ing gel applied.
7. Af t er all samples have been collect ed, place all specimens (except blood
t ube) back int o t he kit . The blood t ube should be ref rigerat ed and t he kit
kept at room t emperat ure unt il picked up by t he police. I t ems t hat are w et
(eg, bloody clot hing) are f irst dried and t hen placed in t hick paper bags (not
pl asti c) and t hen labeled as a biohazard. Each specimen is t o be labeled and
packaged separat ely.

8. I n cases of rape, obt ain samples f or ident if icat ion of sexually t ransmit t ed
diseases (STDs).
a. Record and report f indings, t he t ypes of specimens saved, and report t o
proper aut horit ies. Dat e rape or acquaint ance rape f acilit at ed by means
of club drugs w ill exhibit varied signs and sympt oms (eg, memory loss,
conf usion, vert igo, slurred speech, drow siness, et c. ).
b. Assess and record evidence of t rauma. Colposcopic examinat ion is of t en
done.
c. Record use of w eapons, f orced drug use, f requency of sexual act s, and
penet rat ion of vagina or rect um by penis or object .
Clin ical Alert

1. Specimens in suspect ed rape cases are t est ed f or pregnancy, HI V,
hepat it is B, syphilis, t richomoniasis, gonorrhea, and chlamydia.
2. Specimens of new born cord blood and meconium may be examined f or
evidence of t he mot her's drug use during pregnancy. Nail clippings and nail
scrapings are also examined.
3. Check level of consciousness and record vit al signs in semiconscious,
unconscious, and nonresponding persons.
4. Tachycardia, bradycardia, hypert ension, and hypert hermia are signs of
club drug administ rat ion. Treat immediat ely.
5. Examine, measure, phot ograph, and record evidence of bit e marks, burns,
abrasions, ecchymosis, and t rauma.
6. Document presence of f ecal mat t er.
7. Document w het her t rauma is present or absent .
8. Specimen collect ion af t er deat h is explained in Chapt er 16.
Procedure for Collecting Other Evidentiary Specimens

in Violent and Trauma Cases
1. Be cert ain not t o cut t hrough bullet holes or marks f rom ot her w eapons t hat
may have been used in a violent at t ack.
2. Do not give clot hing or ot her it ems belonging t o t he vict im back t o t he
possible off ender. The possible off ender may have accompanied t he vict im.
3. Seal clot hing in paper bag, as bact eria could dest roy DNA evidence if st ored
in plast ic bags.
4. Examine evidence caref ully, such as looking f or t rauma, at spat t er pat t erns
on clot hing, in hair f ibers, presence of gunshot pow der and ident if ying
pot ent ial causes of w ounds (gunshot , st abbing). Take phot ographs and be
sure t o include ident if ying inf ormat ion (eg, vict im's name, dat e/ t ime, case
number and ot her relevant inf ormat ion) on t he phot ograph, slide mount , or
negat ive.
5. For example, in sit uat ions w here children have been exposed t o home
met hamphet amine labs, assess f or possible met hamphet amine ingest ion,
collect evidence, and prepare children f or going int o prot ect ive cust ody. To
gain children's cooperat ion, develop a posit ive rapport w it h t hem and
alleviat e t heir f ears.
1. Presence of sperm or semena negat ive f inding in suspect ed rape cases is
<10 U/ L (or <167 nkat / L) of acid phosphat ase, w hereas a level t hat is >50
U/ L (or >833 nkat / L) indicat es a posit ive result f or t he presence of semen.
Alt hough t he acid phosphat ase levels of prost at ic f luid can st ill be elevat ed in
about 10% of w omen 72 hours af t er assault , low or no appreciable levels do
not exclude recent penile penet rat ion (eg, ejaculat ion may not have
occurred).
2. DNA samples f rom blood, semen deposit s, st ains in clot hing, et c. are t aken
and compared w it h venous blood sample f rom vict im.
3. Posit ive or negat ive f indings f or pregnancy, STDs, HI V, hepat it is B, syphilis,
chlamydia, gonorrhea, and t richomoniasis
4. Diff use upt ake or no upt ake f rom t oluidine blue dye, a negat ive f inding f or
presence of microlacerat ions
5. No abnormal f indings on colposcopy of t rauma or genit al injuries
6. No posit ive f indings of dat e rape drugs, poisons, or ot her t oxic subst ances
7. Clinical implicat ions of t hese f indings can be cat egorized as some concern,
seri ous concern, and grave concern (see Table L. 2. )
Table L.2 Level of Concern and Their Indicators
Level of
Concern
Clinical Indicators
Some
Anal dilation (> 2 cm) or fissures

Perianal bruising
Friable posterior fourchette
Presence of labial friability (in girls
beyond the diaper-wearing age)
Serious
Anal scarring or tags (beyond the

midline)
Disruptions of the hymenal border
Genital injury
Posterior scars
Grave
Pregnancy
Presence of semen, sperm, or acid
phosphatase
Anogenital injury
Non-perinatally acquired STD
Adapted from Olshaker JS, Jackson MC, Smock
W S: Forensic Emergency Medicine, p. 156.

Philadelphia, Lippincott W illiams & W ilkins, 2001
Interfering Factors
1. Samples should ideally be collect ed immediat ely af t er an alleged assault ,
because 66% of w omen examined w it hin 6 hours of t he incident do not show
mot ile sperm. Consequent ly, est imat ing t he t ime of assault may be
hampered. Bat hing can w ash aw ay evidence.
2. See examples of f orm used f or vict im inf ormat ion in Appendix H.
Interventions

1. To help reduce vict im's acut e psychological t rauma, be especially sensit ive
and nonjudgment al w hen caring f or vict ims, w ho of t en are f illed w it h guilt ,
shame, and self -blame.
2. Explain t he purpose and procedure of procuring samples as t hey relat e t o
t he alleged incident . Check t o see w het her inf ormed consent must be signed
bef ore obt aining specimens. Whenever
possible, enlist t he aid of rape crisis prof essionals. Sedat ives may be given
t o childhood vict ims of sexual assault and abuse.
3. Become f amiliar w it h eff ect s of st reet drugs t hat may have been given t o
t he vict im of sexual assault .
4. Ensure t hat all f orms are complet ed accurat ely and signed by t he vict im.
(See examples of f orms used in Appendix H. )
5. Use st andard precaut ions t o collect specimens.
6. Prepare t o inst it ut e a w it nessed chain of cust ody procedure, and f ollow
t hese policies t hroughout w hen obt aining, handling, and preserving
specimens.
7. O bt ain names, addresses, and t elephone numbers of w it nesses or persons
accompanying t he vict im.
8. Use f orms (examples of t ypical f orms in Appendix H) f or f emale and male
evidence collect ion.

9. Follow guidelines in Chapt er 1 f or saf e, eff ect ive, inf ormed pretest care

1. Follow chain of cust ody (chain of evidence) w hen t urning over evident iary
specimens t o law enf orcement off icials.
2. Record all act ions regarding specimen ret rieval, including phot ographs and
expect ed and unexpect ed samples (eg, bullet s, drugs). Vict im's name,
ident if ying number, case and/ or hospit al number, and ot her relevant
inf ormat ion should be w rit t en on t he phot ograph, or slide mount or negat ive
envelope.
3. Evaluat e pat ient out comes, monit or, and counsel t he pat ient appropriat ely
about f urt her t est s (pregnancy, syphilis, HI V at 6, 12, and 24 w eeks) or
t reat ment or f ollow -up f or post -t raumat ic st ress disorder. As appropriat e:
ant ibiot ics, t et anus f or human bit es, hydrat ion, coolant s f or hypert hermia,
muscle relaxant s, placing pat ient in a quiet area, act ivat ed charcoal t o
remove drugs f rom st omach, sedat ives and ant iconvulsant s t o cont rol
delirium. (See Table L. 3, t ransmission risk of STDs)
Table L.3 Risk of STDs after Sexual Assault
Sexually Transm itted

Disease
Transm ission Risk

(%)
Trichomoniasis
3085 or 0.300.85
Chlamydia
3070 or 0.300.70
Gonorrhea
2090 or 0.200.90
Syphilis
3060 or 0.300.60
HPV
6070 or 0.600.70
HSV-2
<5 or <0.05
Hepatitis B
<5 or <0.05
HIV
<5 or <0.05
Adapted from Olshaker JS, Jackson MC, Smock

W S: Forensic Emergency Medicine, p. 135.
Philadelphia, Lippincott W illiams & W ilkins, 2001
Clin ical Alert It is best if rape crisis profession als can evalu ate
th e victim an d collect specimen s. Prior to th e start of th e
Sexu al Assau lt Nu rse Examin er (SANE) programs, victims of
sexu al assau lt w ere taken to h ospital ERs an d may n ot h ave
been triaged in to th e h ealth system as a h igh priority for care.
Assau lt victims n eed immediate care, bu t n ot n ecessarily
tech n ical care. SANE n u rses are train ed in foren sic
in vestigation , w h ereas most ER staff can h an dle medical
screen in g appropriately, bu t n ot th e foren sic aspects of th e
situ ation .
How t he SANE program w orks w hen a w oman is assault ed:
1. Police off icer or rape crisis line counselor not if ies SANE on-call nurse.
2. Nurse meet s vict im in a designat ed privat e room aw ay f rom t he ER.
Seriously injured persons or possible vict ims of dat e rape drugs w ould be
t reat ed f irst .
3. Forensic examinat ion is perf ormed, medical t reat ment provided,
nonjudgment al support off ered, and ref errals f or ongoing care complet ed.
4. SANE nurse provides evidence t o police depart ment and may lat er t est if y
in court .
5. Specially t rained prof essionals may also aid in ident if ying missing children
and t heir abduct ors.
BIBLIOGRAPHY
Brow n K: Evidence collect ion and preservat ion, 2002 Healt h Care Set t ing.
Nursing Spect rum, 15(21): 223, O ct ober 21, 2002
I nt ernat ional Associat ion of Forensic Nurses. (O nline. ) Available at :
w w w. f orensicnurse. org
O lshaker JS, Jackson MC, Smock WS: Forensic Emergency Medicine,
Saf erst ein R: Criminalist ics: An I nt roduct ion t o Forensic Science, 7t h ed.
Englew ood Cliff s, Prent ice Hall, 2001
Spit z WU: Spit z and Fisher's Medicolegal I nvest igat ion of Deat h: G uidelines
f or t he Applicat ion of Pat hology t o Crime I nvest igat ion, 3rd ed. Springf ield,
Charles C Thomas Publisher Lt d. , 1993
Trossman S: Making a diff erence: O klahoma nursing program recognized f or
assist ing w ebsit e communit y. The American Nurse 34(5): 20,
Sept ember/ O ct ober, 2002
Williams RH: Club drugsw hat 's all t he rave?. Clin Lab New s, 1013,
December 2001

A Manual of Laboratory &amp; Diagnostic Tests

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A Manual of Laboratory &amp; Diagnostic Tests

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Editors:

Fischbach, Frances Talaska T itle: Manual of Laboratory &

CONSULTANTS, REVIEWERS, AND RESEARCH

Lynn Mehlberg ES, CNMT

Editors: Fischbach, Frances Talaska

Editors: Fischbach, Frances Talaska T itle: Manual of Laboratory &

Chapter 2: Blood Studies

Chapter 4: Stool Studies

Chapter 6: Chemistry Studies

Chapter 8: Immunodiagnostic Studies

Chapter 10: X-ray Studies

Chapter 12: Endoscopic Studies

CHAPTER CONTENT AND FEATURES

NEW INFORM ATION IN THE SEVENTH EDITION

CURRENT DEVELOPM ENTS IN LABORATORY AND

Editors: Fischbach, Frances Talaska T itle: Manual of Laboratory &

Editors: Fischbach, Frances Talaska T itle: Manual of Laboratory &

Table 1.1 Examples of Selecting Tests

Stool occult blood

Yearly screening after 45

Yearly in patients on diuretic

Liver enzyme levels

In the presence of abdominal

In sexually active persons

Baseline study; abnormal

Yearly for all women 18

Positive rapid plasma reagin

Easiest test to use for TB

Every 3 years starting at 45

Signs or history of recurrent

Screen men 50 years of

Monitor for lung lesions and

Screen by 40 years of age in

Colon x-rays and

cancer beginning at age 45;

Before and after treatment

DNA testing of hair,

Some tests are mandated by government agencies

Edu cation Alert

Ch art 1.1 Grading Guidelines for Scientific Evidence

Draw fasting blood

Table 1.2 Examples of Inappropriate Tests and

Prostatic acid phosphatase

Crossmatch (needed if blood is

PSA, prostate-specific antigen; AST, aspartate

FI G URE 1. 1 Model* f or t he role** of t he clinical t eam in diagnost ic care***

Table 1.3 Standards for Diagnostic Evaluation

State and federal

8. Uncont rolled pain

PRETEST PHASE: ELEM ENTS OF SAFE, EFFECTIVE,

Basic Knowledge and Necessary Skills

Sensitivity ref ers t o t he abilit y of a t est t o correct ly ident if y t hose individuals

Incidence ref ers t o t he prevalence of a disease in a populat ion or communit y.

Table 1.4 Sample Test Results

Have Gene for

problems. This can include preemployment baseline screening, periodic

History and Assessment

Reimbursement for Diagnostic Services

Ch art 1.3 Tests Covered by Most Insurance Carriers

Blood glucose testing

Collagen crosslinks, any

Digoxin therapeutic drug

Fecal occult blood

a. Maint ain NPO (ie, not hing by mout h) st at us w hen necessary.

A Manual of Laboratory & Diagnostic Tests

A Manual of Laboratory & Diagnostic Tests

FI G URE 1. 1 Model* f or t he role of t he clinical t eam in diagnost ic care*