Transcript ROLE OF LABORATORY MEDICINE IN CARE OF CRITICALLY …
ROLE OF LABORATORY MEDICINE IN CARE OF CRITICALLY ILL MOTHERS AND INFANTS
DR ANDREW K. GACHII
INTRODUCTION
Laboratory tests play a crucial role in practice of medicine Estimated that up to 70% of diagnosis in medical practice is made in the lab.
Implies that lab. tests are a necessary tool before treatment is instituted More crucial in Emergencies including management of acute obstetric/neonatal cases
INTRODUCTION
Pregnancy is considered a normal physiologic process.
However it is associated with significant alterations in the ‘normal’ values ‘Normal’ values are higher or lower in pregnancy than in non-pregnant state
INTRODUCTION
Examples of ‘normal values’ affected in pregnancy include.
Hb and Haematocrit- reduced by 43% due to haemodilution.
Blood urea Nitrogen(BUN) as well as creatinine tend to reduce from 13 and 1.1 to 4-7 and 0.4-0.7 respectively.
Due to increased renal clearance.
PHYSIOLOGIC CHANGES IN PREGNANCY
Test
Bilirubin
Effect of Pregnancy
Unchanged ALS & AST Unchanged Prothrombin time Unchanged Increase 2 4 fold (2 X ULN) Alkaline phosphates (placenta) 2 Bile acids Increase 2 3 fold (glycocholate, taurocholate, chenodeoxycholate) 2 Fibrinogen Increases 50% Globulins Increases alpha & beta; Decreases gamma Alpha fetoprotein Increases (specially with twins) Hemoglobin Decrease in late pregnancy
PHYSIOLOGIC CHANGES IN PREGNANCY
Leukocyte count Increases Ceruloplasmin Increase Cholesterol Increases 2 fold 2 Triglycerides Increase
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Recommended laboratory tests in the initial prenatal care visit
Hct, Hb U/A,U/C BG,Rh Pap smear Antibody screen Rubella status Syphilis screen Hbs Ag Offer HIV testing
CRITICALLY ILL MOTHERS
• Pre-eclampsia • HELLP Syndrome • Amniotic fluid embolism Eclampsia • Septic pelvic • Acute Fatty Liver of pregnancy • PeripartumCardiomyopathy • Peripartum Hemorrhage • Sheehan’s syndrome thrombophlebitis • Supine hypotension syndrome
• Ectopic pregnancy • DIC after fetal demise
BLOOD TRANSFUSION
Obstetric emergencies are almost always associated with blood transfusion A life saving procedure but is not without risks Recipient may develop transfusion – transmitted infection as well as suffer from immunological sequel e.g. red call alloimmunisation.
BLOOD TRANSFUSION
Hence strict adherence to correct sampling, cross-match and administration procedures is of paramount importance even in emergency.
Careful evaluation in utilization of blood and blood products necessary. At KNH we are able to provide, Whole blood (ideally should not be used unless in dire emergency), red cell concentrates, fresh frozen plasma, platelet concentrates.
BLOOD TRANSFUSION
Lab is able to do initial blood grouping and cross-matching, antibody screening and identification.
Investigate blood transfusion reactions Main challenges in blood transfusion is the availability of blood and blood products, manual procedures with associated delay in release of blood and delays in supplies of reagents.
Minimized when the new-blood transfusion centre is opened.
Host state of the art lab. And transfusion centre.
BLOOD TRANSFUSION
Plasma fractions Blood components Whole blood
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Cryoprecipitate Fresh Frozrn Plasma Clotting factor concentrates Immunoglobulin preparations Saline albumin solution Salt-poor albumin Initially a tx for VW Dz, Hemophilia platelets Packed red cells when fibrinogen level is less than 80-100mg/dl Fresh Now a source of fibrinogen in obstetric emergencies All clotting factors; no platelets Can supplement RBC’s when whole blood not available for exchange transfusion when platelet. count less than 50000/cmm or when massive blood loss or replacement has occurred -Washed RBC’s Pts with allergic reactions to plasma proteins -Leuko-poor RBC’s Pts with febrile, non-hemolytic reactions to plasma WBC’s when PT & PTT are higher than 1.5 times control levels DIVC Massive haemorrhage Major liver trauma Bleeding associated with liver disease Liver disease Clotting disorders Haemophilia dose: 1- 1.5 -2 packs/ 10 kg (8-10 packs) (4-5packs) (1 pack/10kg) dose : 6units RDP or 1 unit SDP normal dose: 12 - 15ml/ kg Platelet concentrates
OTHER HAEMATOLOGICAL INVESTIGATIONS
Total white cell counts especially in patients with sepsis Platelet counts in cases of thrombocytopenia and DIC Coagulation factors including monitoring of fibrinogen and d dimers level in cases of DIC.
Blood culture --
MICROBIOLOGY
Of major importance in cases of sepsis both in mothers and neonates.
Tests include direct staining of micro-organisms e.g. gram stain- may provide quick diagnosis Cultures are the hall-mark- include urine, csf, and most important blood cultures. Main challenge is the cost of reagents and in particular the bottles Cost cannot be sustained by the KNH charges.
Ideal is to automate cultures and sensitivity testings.
IMMUNOLOGY
Rapid tests for pregnancy especially in cases of suspected ectopic pregnancy.
Testing for viral infections including Hepatitis B as C as well as HIV.
Especially crucial in in acutely ill mothers who may require dialysis.
Main challenge is the supply of reagents and outdated equipment.
CLINICAL CHEMISTRY
Forms backbone of laboratory support in diagnosis and management of critically ill mothers and neonates.
Ranges from liver function tests, renal function tests to endocrinology.
At KNH we have been able to place Clinical Chemistry Equipment at no cost. The supply of reagents is through contract with the owner’s of the equipment. Through these equipment we are able to do liver function tests within minutes.
CLINICAL CHEMISTRY
We are able to reduce the turn-around time from two day to one hour or less Main advantage is the back-up whereby several equipments are available in various labs that utilize the same reagents Main challenge is reagent supply.
Maintaining the Internal and external quality control (IQA and EQA) due to cost.
CLINICAL CHEMISTRY-CT
Of importance in neonatal jaundice and sepsis Levels of bilirubin can be availed within 5-10 minutes We have developed an SOP on communicating on critical values Clinician should be informed immediately such values are detected.
CLINICAL CHEMISTRY
Main challenge is the delay in communicating the results.
We are in the process of automating at least six of its key laboratories including chemistry and microbiology.
Clinicians will be able to receive and retrieve the results from their workstations.
CLINICAL CHEMISTRY
Complete automation likely to be complete this financial year.
Delayed reports can be avoided through introduction of more POINT OF CARE testing.
Already familiar with use of Hb meters glucometers-can more tests e.g bilirubin be introduced.
Main challenge is calibration and quality control.
THE END
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