07-May-14

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Critical Value in
Clinical Chemistry
Irwan Idris
Nilai Kritis
adalah suatu hasil pemeriksaan lab
yang abnormal dan mengindikasikan
kelainan atau gangguan yang dapat
mengancam jiwa dan memerlukan
perhatian/ tindakan

PEDOMAN INTERPRETASI
DATA KLINIK KEMENKES 2011
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A Critical Value
Is defined as a value that represents a patho-
physiological state at such variance with
normal (expected values) as to be life-
threatening unless something is done
promptly and for which some corrective
action could be taken
Mayo clinic 2012
Regulation of Critical Values
The Joint Commission National
Patient Safety Goals
Documentation & read back
Define Critical Values and Critical Tests
CAP Checklists
Procedure, documentation, read
back, turnaround times





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Patient Safety

No Hospital Delayed (admin, nursing and Lab)
Stat test (TAT < 1 hour)
Report Critical Value Immediately

Regarded as Stat test (PIK Hospital)
New In-Patient
Emergency room
ICU & NICU

Test Result Depend on :
Patient Factor
Pre-analytical Variation
Biological Variation
Interference substances (HIL/metabolic
component)
Medicine
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Test Result Depend on :
Good Laboratory Practice
Quality Management System
Test Method
Reagent
Analytic variation < (good precision)


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Reference Range
Method
Reagent
Race
Age
Time of specimen collection
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Cirlulation 2011:124:2350-54
Cirlulation 2011:124:2350-54
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Cirlulation 2011:124:2350-54
System Causes of Troponin Elevation
Cardiovascular
Acute aortic dissection , Arrhythmia, Hypotension
Heart failure, Hypertension
Cardiac inflammation
Endocarditis, myocarditis, pericarditis
Infiltrative disease
Amyloidosis, sarcoidosis, hemochromatosis, scleroderm
Myocardial Injury
Blunt chest trauma
Cardiac procedures
Ablation, cardioversion, percutaneous intervention
Chemotherapy
Respiratory Acute PE , ARDS
Infectious/Immune Sepsis/SIRS , Viral illness, TTP
Gastrointestinal Severe GI bleeding
Nervous system
Acute stroke (Ischemic stroke/ Hemorrhagic stroke)
Head trauma
Renal Chronic kidney disease
Endocrine Diabetes , Hypothyroidism
Musculoskeletal Rhabdomyolysis
Integumentary Extensive skin burns
Cardiac Biomarker,
September 8, 2010
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Critical Values Current Issues
Communication
Contacting licensed caregiver (dr/nurse)
Hand offs of critical information
Documentation
TAT
Employee time (technologists & caregivers)

Laboratory Medicine of
Emory University
Critical Values Current
Issues (2)
Defining Cutoff values
How are they currently determined ?
Are they appropriately chosen to reflect a
true critical situation
Should we have site /service specific
values ?
Laboratory Medicine of
Emory University
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How are critical cutoffs
determined ?
Medical Practice Committees
Experience
Usually represent diverse group of physicians with
unique perspectives
Specific clinical needs: eg. Special Programs
Understand the resources and limitations of the
system
Value: Clinician perspective
Caveat: Critical can become courtesy
Laboratory Medicine of
Emory University
Best Strategy for Determining Critical
Level
Compare to peers
Literature
Local, national
Medical input
Service groups
Medical Practice Committee
Laboratory Medicine of
Emory University
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Laboratory Medicine of
Emory University

Laboratory Medicine of
Emory University
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Standardization
Setting Limits (peer, local, national)
Great start, need MPC input

Use Standard Templates
Critical results called to and read back by ______ Date____
Time_____ by lab personnel _______.

Attempted to call critical result to ______ @______
Date____ Time_____ by lab personnel _______.
This template can be helpful for call times documented
(time spent by staff)
Can not give up on the call, need clear escalation policy
Laboratory Medicine of
Emory University
A Critical Value
Validation the result (I and II level)

In patient
Inform the user (doctor, nurse)
Record the name of doctor or nurse in charge
Repeat the result by user




PIK Hospital
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A Critical Value (2)
Out Patient :
Inform the doctor
Record the name of doctor
Repeat the result by user

Walk in
Inform the patient
Record patients name
Repeat the result by patient


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Souce Result Ref. Range
RNICU/3010 Hemoglobin 6.10 g/dL LL 14-20
UGD-N Sodium (Na) 110.0 mmol/L LL 135 - 150
UGD-N pH 7.008 LL 7.38 - 7.44
UGD-N pCO2 5.5 mmHg LL 35 - 40
UGD-N HCO3 1.4 mmol/L LL 21 - 28
UGD-N Random Glucose 515.0 mg/dL HH 70 - 140
DIA-N Creatinine serum 22.3 mg/dL HH 0.8 - 1.5
RG6 Amonia 326.0 umol/L HH 11.0 - 32.0
ICU1/3002 Chloride (Cl) 120.2 mmol/L HH 98 - 107
ICU1/3001 Troponin I 1.03 ng/mL HH < 0.10
UGD-N Potasium (K) 1.3 mmol/L LL 3.5 - 5.0
RG5/7508 WBC 0.87 Th/uL LL 4.1-10.9
UGD-N Random Glucose 34.0 mg/dL LL 70 - 140
ICU1/3003 APTT 122.0 Second HH 30 - 44
ICU1/3002 Natrium (Na) 115.4 mmol/L LL 135 - 150
Parameter Critical Value Note
Ammonia > 100 mg/dl (59
mmol/l)
Risk of hepatic encephalopathy.
Comatose states do not usually occur
unless levels exceed 300 mg/dl (176
mmol/l).
Anion gap > 20 mmol/l. Indicative of ketoacidosis or
lactacidosis, uraemia, alcohol
consumption, salicylate intoxication,
poisoning from methanol or ethylene
glycol
Bilirubin > 15 mg/dl (257
mmol/l)
Hepatobiliary disease caused mainly by
hepatotropic viruses and thus of
infectious origin with risk of contagion.
Inorganic
phosphate
< 1.0 mg/dl
(0.32mmol/l)
> 9.0 mg/dl (2.9
mmol/l)
Muscle weakness, muscle pain, central-
nervous symptoms such as
disorientation, confusion, convulsions,
coma, respiratory insufficiency with
metabolic acidosis.
Occurs in acute tumour lysis syndrome
and in terminal renal failure.


eJIFCC:www.ifcc.org/ejifcc
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ANALYTE CRITICAL VALUES
Blood Gases, Adult
pH
pCO2
pO2

<7.20 or >7.58
<9 or >65 mmHg
<40 mmHg
Calcium, ionized <0.78 or >1.58 mmol/L
Calcium, total <6.0 or >13.0 mg/dL
Carbon Dioxide (Total) <10 or >40 meq/L
Glucose
Newborn (under 30 days old)
Adult
1. <40 or >200 mg/dL
2. <45 or >500 mg/dL
Glucose, CSF <20 mg/dL
Glucose, POCT
Newborn
Adult

1. <50 or >200 mg/dL
2. <50 or >500 mg/dL
Magnesium <1.2 or >4.7 mg/dL
Osmolality < 250 or >350 mOsm/kg
Phosphate <1.0 mg/dL
Potassium <2.5 or >6.0 meq/L
Sodium <120 or >160 meq/L
Sodium, CSF <120 or >160 meq/L
Troponin I
0.40 ng/mL
(first critical value per 48 hour period for each patient)
Dept of Lab. Medicine Washington Edu 2012
Conclusion
Determine Parameter and Cutoff for
Critical value should be :
Collaboration with medical staff (doctor & nurse)
Test method
Reagent
Compare to peers
Literature
Local, national


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Conclusion
Standard procedure to inform Critical
Value :
Procedure
Documentation
Read back
Turnaround times


Thanks you
For your attention