pathology

1. HEMATOLOGICAL
TESTS FOR THE
DIAGNOSIS OF
BLOOD DISORDER
PRAKASH SELVARAJ , BSN

2. LEARNING OBJECTIVES
•Describe various laboratory tests in
assessment and monitoring of disease
condition

3. CBC
• Complete blood count
• With or without differential
• Peripheral venous blood is collected in a lavender
tube (contains the anticoagulant EDTA) and should be
thoroughly mixed
• Unacceptable specimen:
• Clotted or greater than 48 hours old

4. WHAT IS MEASURED?
• Red blood cell data
• Total red blood cell count (RBC)
• Hemoglobin (Hgb)
• Hematocrit (Hct)
• Mean corpuscular volume (MCV)
• Red blood cell distribution width (RDW)
• White blood cell data
• Total white blood cell (leukocyte) count (WBC)
• A white blood cell count differential may also be ordered
• Platelet Count (PLT)

5. TOTAL RED BLOOD CELL COUNT
• Count of the number of circulating red blood cells in
1mm3 of peripheral venous blood

6. HEMOGLOBIN
• The hemoglobin concentration is a measure of the amount of
Hgb in the peripheral blood, which reflects the number of red
blood cells in the blood
• Hgb constitutes over 90% of the red blood cells
• Decrease in Hgb concentration = anemia
• Increase in Hgb concentration = polycythemia

7. HEMATOCRIT
• Hematocrit is a measure of the percentage of the total blood
volume that is made up by the red blood cells
• The hematocrit can be determined directly by centrifugation
(“spun hematocrit”)
• The height of the red blood cell column is measured and compared
to the column of the whole blood

8. MEAN CORPUSCULAR VOLUME
• The MCV is a measure of the average volume, or size, of
an RBC
• It is determined by the distribution of the red blood cell
histogram
• The mean of the red blood cell distribution histogram is the
MCV
• The MCV is important in classifying anemias
• Normal MCV = normocytic anemia
• Decreased MCV = microcytic anemia
• Increased MCV = macrocytic anemia

9. RED BLOOD CELL DISTRIBUTION WIDTH
• RDW is an indication of the variation in the RBC size
(referred to anisocytosis)
• It is derived from the red blood cell histogram and represents
the coefficient of variation of the curve
• In general, an elevated RDW (indicating more variation in the
size of RBCs) has been associated with anemias with various
deficiencies, such as iron, B12, or folate
• Thalassemia is a microcytic anemia that characteristically
has a normal RDW

10. WHITE BLOOD CELL COUNT
• A count of the total WBC, or leukocyte, count in 1mm3 of
peripheral blood
• A decrease in the number of WBCs =
• Leukopenia
• An increase in the number of WBCs =
• Leukocytosis
• WBCs with shift to the left …
• Increased immature and very immature neutrophils – elevated total
WBCs
• Sign of acute infection!

11. WBC DIFFERENTIAL
• When a differential is ordered, the percentage of each type of
leukocyte present in a specimen is measured.
• Name the types of leukocytes
• Neutrophils (includes bands)
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
• WBC differentials are either performed manually or by an
automated instrument

12. MANUAL DIFFERENTIALS
• “Manual” WBC differentials are performed by trained medical
technologists who count and categorize typically 100 white blood
cells via microscopic examination of a Romanowsky-stained
peripheral blood smear
• In addition to the differential count, evaluation of the smear provides
the opportunity to morphologically evaluate all components of the
peripheral blood, including red blood cells, white blood cells and
platelets
• The manual differential allows for the detection of disorders that
might otherwise be lost in a totally automated system
• This applies to < 20% of specimens
• The instrument is programmed with criteria to flag an operator
when a manual differential should be performed

13. PLATELET COUNT (PLT)
• A count of the number of platelets (thrombocytes) per
cubic milliliter of blood
• A decreased number of platelets = Thrombocytopenia
• An increased number of platelets = Thrombocytosis

14. MCH AND MCHC
• Both MCH and MCHC are of little clinical diagnostic
use in the vast majority of patients (so we did not talk
about them in any detail)
• MCH is the hemoglobin concentration per cell
• MCHC is the average hemoglobin concentration per total
red blood cell volume

15. INTERPRET THIS CBC
CBC
WBC 19.5 [4.0-10.0] k/ul
RBC 3.49 [3.60-5.50] m/ul
Hgb 10.4 [12.0-16.0] gm/dl
Hct 31.2 [34.0-51.0] %
MCV 82 [85-95] fl
MCH 28.3 [28.0-32.0] pg
MCHC 33.3 [32.0-36.0] gm/dl
RDW 6.6 [11.0-15.0] %
Plt Count 98 [150-400] k/ul

16. ONE FINAL CBC PEARL
Clinicians have a short-hand way to report CBC values:
WBC
HgB
HCT
PLT

17. BASIC METABOLIC PROFILE
• BMP
• Blood test that measures glucose levels, electrolytes, acid/base balance and
kidney function.
• BMP Components
• Sodium – normal 135 – 145 mEq/L
• Potassium – normal 3.7 – 5.2 mEq/L
• Calcium - normal 8.5 - 10.4
• Chloride – normal 101 – 111 mmol/L
• Carbon Dioxide (CO2) – normal 20 -29 mmol/L
• Glucose – normal 64 - 128 mg/dL
• Blood Urea Nitrogen (BUN) – normal 7– 20 mg/dL
• Creatinine – normal 0.8 to 1.4 mg/dL

18. SODIUM
• Sodium is the major cation in the extracellular space where
serum levels of approximately 140mmol/L exist
• Sodium salts are major determinants of extracellular osmolality.
• Increased serum sodium level = Hypernatremia
• Decreased serum sodium level = Hyponatremia

19. POTASSIUM
• Potassium is the major intracellular cation with levels of ~ 4
mmol/L found in serum
• Elevated serum potassium level =
• Hyperkalemia
• Decreased serum potassium level =
• Hypokalemia
• If a specimen is hemolyzed (such as by traumatic venipuncture or
drawing blood with a needle that is too small) potassium levels may be
“falsely” elevated. Why?
• There are high concentrations of K in red blood cells. If RBCs are
lysed during phlebotomy, K is released into the serum resulting in
elevated measured levels

20. CHLORIDE
• Chloride is the major extracellular anion with serum
concentration of ~ 100 mmol/L
• Hyperchloremia and hypochloremia are rarely isolated
phenomena.
• Usually they are part of shifts in sodium or bicarbonate to maintain
electrical neutrality.

21. CARBON DIOXIDE CONTENT
• The carbon dioxide content (CO2) measures the H2CO3,
dissolved CO2 and bicarbonate ion (HCO3) that exists in the
serum
• Because the amounts of H2CO3 and dissolved CO2 in the
serum are so small, the CO2 content is an indirect measure
of the HCO3 anion
• Therefore, clinicians most often refer to the CO2 measurement in the
BMP as the “bicarbonate level” or “bicarb level”

22. BLOOD UREA NITROGEN
• The BUN measures the amount of urea nitrogen in the
blood
• Urea is formed in the liver as the end product of protein metabolism
and is transported to the kidneys for excretion.
• Nearly all renal diseases can cause an inadequate
excretion of urea, which causes the blood concentration to
rise above normal.
• The BUN is interpreted in conjunction with the creatinine
test – these tests are referred to as “renal function studies”

23. CREATININE
• The creatinine test measures the amount of creatinine
in the blood.
• Creatinine is a catabolic product of creatinine phosphate
used in skeletal muscle contraction
• Creatinine, as with blood urea nitrogen, is excreted entirely
by the kidneys and blood levels are therefore proportional
to renal excretory function

24. GLOMERULAR FILTRATION RATE (GFR)
• The GFR estimates how much blood passes through the tiny filters
in the kidneys, called glomeruli, each minute. Rate decreases with
age
• Normal results range from 90 - 120 mL/min
• High GFR occurs with normal to higher blood pressures
• Decreased GFR and increased fluid retention occurs during
hypotension
• Levels below 60 mL/min for 3 or more months are a sign of
chronic kidney disease
• Those with GFR results below 15 mL/min are a sign of kidney
failure

25. GLUCOSE
• Plasma glucose levels should be evaluated in relation
to a patient’s meal
• i.e., postprandial vs fasting
• Elevated glucose levels may also be indicative of diabetes
mellitus
• Glucose is the most commonly measured test in the
laboratory

26. DIAGNOSING DIABETES
• The criteria for the diagnosis of diabetes:
• Fasting Plasma Glucose ≥126 mg/dL
• 2 hour Post-Prandial Glucose ≥200 mg/dl
• Random Plasma Glucose >200 mg/dL in the presence of
symptoms
• Any one of these criteria must be repeated on subsequent
testing of a new specimen

27. TOTAL CALCIUM
• The total serum calcium is a measure of both
• Free (ionized) calcium
• Protein bound (usually to albumin) calcium
• Therefore, the total serum calcium level is affected by
changes in serum albumin
• As a rule of thumb, the total serum calcium level
decreases by approximately 0.8mg for every 1gram
decrease in the serum albumin level

28. INTERPRET THE BMP
• Component Value Flag Low High Units
• SODIUM 142 136 144 MM/L
• POTASSIUM 3.9 3.3 5.1 MM/L
• CHLORIDE 107 98 108 MM/L
• CO2 27 20 32 MM/L
• BUN 10 7 22 MG/DL
• CREATININE 0.80 0.7 1.5 MG/DL
• GLUCOSE 100 70 100 MG/DL
• CALCIUM 8.5 L 8.9 10.3 MG/DL

29. FRACTIONAL EXCRETION OF NA (FENA)
• Fraction of Na+ filtered at the glomerulus that is then
excreted in the urine
• The FENa is helpful when the provider is trying to
decide what the cause is of the renal failure
• Not a lab, but a mathematical equation from the labs.

30. IONIZED CALCIUM LEVELS
• Normal levels for adults: 4.4 - 5.3 mg/dL
• Ionized calcium is calcium that is freely flowing in your
blood and not attached to proteins

31. COMPLETE METABOLIC PANEL
• The CMP provides a more extensive laboratory evaluation of organ dysfunction and
includes:
• Sodium
• Potassium
• Chloride
• Carbon Dioxide Content
• Albumin
• Total Bilirubin
• Total Calcium
• Glucose
• Alkaline Phosphatase
• Total Protein
• Aspartate Aminotransferase
• Blood Urea Nitrogen
• Creatinine

32. TOTAL PROTEIN
•Albumin and globulin constitute most of the
protein within the body and are measured in the
total protein test

33. ALBUMIN
• Albumin comprises ~ 60% of the total protein within
the extracellular portion of the blood (Hgb is the most
abundant protein in whole blood and is intracellular)
• Albumin’s major effect within the blood is to maintain
colloid osmotic pressure
• Transports many important blood constituents
• drugs, hormones, enzymes
• Albumin is synthesized in the liver and therefore is a
measure of hepatic function

34. ALKALINE PHOSPHATASE
(ALK PHOS OR ALP)
• Alkaline phosphatase is an enzyme present in a
number of tissues, including liver, bone, kidney,
intestine, and placenta, each of which contains distinct
isoenzyme forms
• Isoenzymes are forms of an enzyme that catalyze the
same reaction, but are slightly different in structure
• The two major circulating alkaline phosphatase
isoenzymes are bone and liver.
• Therefore elevation in serum alkaline phosphatase is most
commonly a reflection of liver or bone disorders.
• Levels of alk phos are increased in both extrahepatic and
intrahepatic obstructive biliary disease

35. BILIRUBIN, TOTAL
• The total serum bilirubin level is the sum of the
conjugated (direct) and unconjugated (indirect)
bilirubin.
• Normally the unconjugated bilirubin makes up 70-85% of
the total bilirubin
• Remember that bilirubin metabolism begins with the
breakdown of red blood cells in the reticuloendothelial
system and bilirubin metabolism continues in the liver
• Elevation in total bilirubin may therefore be a reflection of
any aberrations in bilirubin metabolism or increased levels
of bilirubin production (such as hemolysis)

36. ASPARTATE AMINOTRANSFERASE
(AST)
•AST is an enzyme that is present in
hepatocytes and myocytes (both skeletal
muscle and cardiac)
• Elevations in AST are most commonly a reflection
of hepatocellular injury
• But they may also be elevated in myocardial or skeletal
muscle injury

37. CMP CASE
The following CMP is from a patient who presented with systolic congestive
heart failure exacerbation
Complete Metabolic Panel
• Glucose 112 H [70 – 100]mg/dl
• Blood Urea Nitrogen 39 H [7 - 22] mg/dl
• Creatinine 1.6 H [0.7 - 1.5] mg/dl
• Calcium 8.9 [8.5 - 10.5] mg/dl
• Sodium 32 L [136 - 146] mmol/L
• Potassium 4.0 [3.5 - 5.3] mmol/L
• Chloride 93 L [98 - 108]mmol/L
• Carbon Dioxide 3 [20 - 32] mmol/L
• Albumin 3.1 L [3.6 - 5.0] gm/dl
• Protein, Total 5.8 L [6.2 - 8.0] gm/dl
• Alkaline Phosphatase 200 [25 - 215]IU/L
• AST 35 [5 - 40] IU/L
• Bilirubin, Total 1.9 H [0.2 - 1.4] mg/dl

38. INTERPRETATION?
• BUN and creatinine are elevated with a BUN:Creat ratio
greater than 20:1 consistent with pre-renal azotemia, the
result of inadequate renal perfusion and resulting reduced
urea clearance
• Hepatic congestion leads to hypoxia and altered function of
the liver cells
• Bilirubin, especially the indirect fraction, and enzymes, like
alkaline phosphatase, may be elevated. Total protein may
decline at the expense of the decreased albumin produced in
the liver.
• The electrolyte changes, especially hyponatremia, reflect a
dilutional effect with water retention and decreased
glomerular filtration rate (poor perfusion)
• Hyperglycemia is present but it is not known whether this was
a fasting or random sample

39. CPKS – CREATININE PHOSPHOKINASE
• Increases within 4-6 hours, peaks at 12-24 hrs and returns to
normal within 3 days
• Normal range = 30 -170 u/L
• Lacks specificity
• Grossly hemolyzed samples may elevate and increases with
exercise (skeletal muscle release), trauma, alcoholism
• Not cardiac specific

40. CK ISOENZYMES – (CK-MB)
• CK-MB trumps the CK. It is looking at the cardiac
isoenzymes, so more reliable.
• CK-MB < 5% of total CK is normal
• > 5% implication for MI
• Limitation is the lack of early elevation in an acute MI in some
patients

41. TROPONIN I
• Preferred test, highly specific marker of myocardial injury.
• Normal < 0.4 ng/L (>1.4 suggests MI)
• Elevated 3-6 hours post MI.
• Peaks in 24 hours (and this is what drives the protocol for
labs over 24 hours) and continues to be released over the
next several days
• Stays elevated for 14 days so can be a clue to a recent MI as
well

42. BNP - B-TYPE NATRIURETIC PEPTIDE
• Aides in the diagnosis and assessment of severity of
heart failure.
• Normal < 100 ng/L
• Elevated signs –
• 400 - 800 or > points to CHF
• 100 - 400 may support findings of an MI
• 150-400 may point to need to test for PE

43. PRO-BNP
• PRO-BNP
• The precursor to the BNP – so more commonly used with
chronic failure.
• Normal ≤ 300 pg/ml
• CHF very likely if > 450 pg/mlThe precursor to the
BNP – so more commonly used with chronic failure.
• Normal ≤ 300 pg/ml
• CHF very likely if > 450 pg/ml

44. C REACTIVE PROTEIN
• C-reactive protein (CRP) test is a blood test that measures the
amount of a protein called C-reactive protein in your blood
• C-reactive protein measures general levels of inflammation in
your body
• Use the CRP to evaluate risk of heart disease
• Current risk levels used:
• Low risk: a CRP level of less than 1.0 milligram per liter (mg/L).
• Average risk: a CRP level between 1.0 and 3.0 mg/L.
• High risk: a CRP level greater than 3.0 mg/L
• CRP level greater than 10 mg/L is a sign of serious infection, trauma or chronic
disease

45. CARDIAC CASE STUDY
• A man, 65, comes to the ED with worsening shortness of
breath over the last 3-4 days. After your verbal assessment of
the facts, you learn he has had chest pain intermittently over
the same period of time. It was worse 2 days ago, and he
treated it with Maalox and ibuprofen. He thought they “may
have helped.”
• PMH – Overweight, smoker 1 ppd, HTN

46. ASSESSMENT FINDINGS
• Distant heart tones
• III/VI murmur loudest at right 2nd intercostal space,
radiates to neck. Loudest when patient sitting forward.
• Patient states he has not been told before that he has a
murmur.
• Heart - regular rate and rhythm – 90’s
• On 2 liters O2 95% and RR 24. You hear crackles in the
bases bilaterally.
• What tests are we initially going to order?

47. ASSESSMENT FINDINGS
• ECG – Right bundle branch block and new Q wave when compared to
old ECG.
• Some mild ST depression in V2-V4
• Troponin I – 2.2 (normal <0.4)
• CK- 120
• CK/MB – 7 (Normal 0-5)
• BNP 1110
• CMP/CBC in normal ranges
• What diagnosis are we thinking? Anterior MI with aortic valve
involvement
• What upcoming events should we expect?

48. ABG
• Preferred when determining the relationship between
ventilation and perfusion – respiratory status!
• An ABG is an important reflection of overall pulmonary
function.
• It also determines acid base interpretation

49. MIXED VENOUS BLOOD GAS
• Drawn from the pulmonary artery using a Swan-Ganz catheter
• Drawn from the pulmonary artery, assures the venous return from
the body
• organs are thoroughly “mixed.”
• Is preferred to reflect the oxygenation and acid base at the tissue level
in the settings of circulatory failure or when the cardiac output is markedly
reduced
• Mixed venous blood gas values are usually close to those of an ABG,
except for the PaO2 and SaO2. They will both run lower.
• Normal findings for a PaO2 is 35-40 (instead of > 60)
• Normal findings for a SaO2 is 65-75% (instead of 93-98%)

50. VENOUS BLOOD GAS
• A venous blood gas is sufficient if the
focus is acid base interpretation instead
of pulmonary function
• When is a venous blood gas OK instead of
• an ABG?
– When we don’t need to determine oxygenation status
• Can be helpful determining acid/base status

51. ABG COMPONENTS
• pH (percent Hydrogen): Numeric value associated with the hydrogen
ions (H+) in the blood.
• The greater the number of H+ ion concentration, the more acidic the
blood
• Acidosis: pH < 7.35
• Alkalosis: pH > 7.45
• PaO2: is the circulating oxygen in the arterial blood sample – normal >
60
• SaO2: Percentage of oxygenation – should correlate with O2 sat
reading from the finger probe

52. VENOUS BLOOD GAS
• Easier to draw & less painful for patients!
• Decreased risk to patient – less chance of hematoma, arterial
laceration/thrombosis
• When is a venous blood gas OK instead of an ABG?
• When we don’t need to determine oxygenation status. Can be helpful determining
acid/base status
• Reference Range Critical Range
• pH 7.32-7.43 <7.20 or >7.65
• pCO2 40-60 mm Hg <20 or >65 mm Hg
• pO2 30-55 mm Hg (at RA)
• HCO3- 22-27 mmol/L
• O2 Sat 40%-85%

53. LACTATE
• Serum Lactate Levels:
– Used to detect and evaluate the severity of hypoxia and lactic
acidosis occurring at the organ level
• Lactate > 2 mEq/L are abnormal
• Per the Surviving Sepsis Campaign website, if > 4 mEq/L
supports septic shock

54. PROCALCITONIN LEVELS (PCT)
• Helps differentiate sepsis from nonbacterial infections
(viral/fungal)
• It’s a precursor to calcitonin
• < 0.5 ng/ml – low risk of
• Progressing to severe sepsis
• 0.5 to 2 ng/ml – moderate risk or progressing
• > 2 ng/ml – high risk

55. GRAM STAIN
• How to read it?
• After processing a slide with the sample on it, then looking
under the microscope
• Gram + bacteria are stained purple and Gram – ones red or
pink
• Gram stains are quicker than cultures and can guide us in
which antibiotics will be most beneficial to the patient.
• If we had to wait for cultures to return, we would not have as
many good outcomes and would have to use the big guns
(broad spectrum) antibiotics on all!

56. GRAM STAIN
• Focusing on which drugs will be most effective
• Gram positive bacteria have a thick waxy layer
• Gram negative bacteria have an extra fat layer that can
act as a barrier to some antibiotics

57. NORMAL RESULTS FOR CSF/LP
• Gross appearance: Normal CSF is clear and colorless.
• CSF opening pressure: 50 – 175 mm H2O
• Specific gravity: 1.006 – 1.009
• Glucose: 40 – 80 mg/dL
• Total protein: 15 – 45 mg/dL
• Lactate: less than 35 mg/dL
• Leukocytes (WBCs) 0 – 5/microL (adults and children); up to 30/microL (newborns)
• Differential: 60% – 80% lymphocytes; up to 30% monocytes and macrophages; other cells
2% or less
• Gram stain: negative
• Culture: sterile
• Syphilis serology: negative
• Red blood cell count: None

58. THYROID FUNCTION TESTS (TFTS)
• Used to determine how well the thyroid gland is functioning.
The thyroid affects virtually all metabolic processes in
the body.
• It controls how quickly the body uses energy, makes
proteins and how sensitive the body is to other hormones
that regulate the growth and rate of function of many other
systems.
• The thyroid also produces calcitonin, which plays a role in
calcium homeostasis

59. TSH
• Normal Range TSH: 0.4 – 4.0 MIU/L
• The American Association of Clinical Endocrinologists has proposed a
range of 0.3 to 3.0 for normal TSH levels
• Using these cutoff values would lead to more people being diagnosed
with an underactive thyroid (hypothyroidism).
• Medications can impact TSH levels
• Steroids, levodopa, lithium, heparin
• If TSH is abnormal, then we start looking for more clues like running a
T4 and possibly a T3.

60. T3 LEVELS = 100 – 200 MCG/DL
• HIGH
• Rises in pregnancy or use of
birth control pills/estrogen
replacement
• Hyperthroidism
• Thyroiditis
• T3 thyroid toxicosis
• Toxic Adenoma
• LOW
• Hypothyroidism
• Acute or chronic illness,
including
• kidney or liver disease
• Severe malnutrition
• Medications as listed in manual

61. T4 LEVELS – TOTAL OR FREE?
• Total T4 levels = T4 bound to proteins + floating in blood
available for conversion to T3
• Normal range 4.8 – 10.4 mcg/dl
• Free T4 level = Just what is floating in the blood not bound to
proteins
• Normal range 0.9 – 2.0 mcg/dl

62. T4
• HIGH
• Acute thyroiditis
• Birth control or estrogen
• IVP contrast with iodine
• Pregnancy
• Drugs: Heparin and heroine
• Thyrotoxicosis or toxic and
thyroid adenoma
• LOW
• Hypothryoidism
• Drugs:
• Steroids, antithyroid
medications, lithium, phenytoin,
propanolol
• Kidney failure
• Myxedema
• Cretinism

63. APTT (OR PTT)
• APTT (Activated Partial Thromboplastin Time) – measures
one part of the clotting pathway known as the “intrinsic
pathway.” It is compared against a sample of normal blood,
the “control” value.
• It is increased by therapy with heparin, hemophilia, severe
liver disease (cirrhosis) or DIC
• Normal levels are 25-50 seconds

64. PROTHROMBIN TIME (PT)
• PT – Elevated in patients taking warfarin (Coumadin) or in
those who are vitamin K deficient.
• Normal is 11-12.5 seconds.

65. INR
• INR (International Normalized Ratio) – measures one part of
the clotting pathway known as the “extrinsic pathway.”
• It is increased by warfarin (Coumadin) therapy, liver
dysfunction or DIC
• Measured as a ratio – normal 1-1.5. Re-expression of the PT

66. PLATELETS
• Platelets – the number of platelets in the bloodstream
• Platelets are important for clot formation.
• Reminder – normal findings are 150,000 to 400,000/cmm
• What can cause platelet dysfunction?
• End-Stage Renal Disease (ESRD)
• Viral infections
• Platelet inhibitor medications, like clopidogrel (Plavix), Brilinta, or ASA
• NSAIDs

67. FIBRINOGEN
• Fibrinogen – this protein is a precursor to fibrin, which is an
essential part of a blood clot.
• May be consumed by conditions such as DIC.
• Decreased fibrinogen results in an increased bleeding
tendency
• Normal levels are about 1.5-3 g/L

68. ANTITHROMBIN III (ATIII)
• Antithrombin III (ATIII) is a nonvitamin K-dependent protease
• Inhibits coagulation by neutralizing the enzymatic activity of
thrombin (factors IIa, IXa, Xa)
• Antithrombin III activity is markedly potentiated by heparin
• Antithrombin III activity is the principal mechanism by which
both heparin and low–molecular-weight heparin result in
anticoagulation
– Nonvitamin K-dependent protease that inhibits coagulation by
neutralizing the enzymatic activity of thrombin (factors IIa, IXa, Xa) is
how these drugs work

69. D-DIMER
• A product of clot breakdown (fibrinolysis)nand is increased in conditions
of increased clotting activity in the body.
• Relatively nonspecific
• D-dimer levels normally 2 mg/L
• When do we see it commonly ordered?
– Pulmonary Emboli
– DIC
• False Positives can occur
– D-dimer concentrations may rise in the elderly, patients with rheumatoid arthritis or
high triglycerides, or if a sample is hemolyzed

70. LAB VALUES – DIC PANEL
• Decreased platelets (<100,000)
• Increased PTT (>60-90 sec)
• Increased PT (>15 sec)
• Decreased fibrinogen (<200 mg/100ml)
• Increased FDP/FSP (>10 g/ml)
• Increased D-dimer (>2 mg/L)
• Decreased antithrombin III (<70%)

71. CRYOPRECIPITATE
• Indicated for specific factor replacement
• Factor VIII and Factor XIII
• Fibrinogen
• Prevents and controls bleeding
• Complications: viral infection
• Use immediately after thawing.
• Can give it fast. Each unit raises fibrinogen levels by 75
mg/dL.

72. CASE STUDY COAGS
• A woman, 36, delivered a full-term baby by C-section 1 week
ago. She has continued to have ongoing pain issues. She
experienced shortness of breath increasing over the past 3
days.
• Vitals on arrival: Sats 84% on room air, RR 28, HR 104, BP
128/64. Afebrile
• Assessment findings – Decreased breath sounds in bases,
more so on right.
• What tests initially?

73. COAG CASE CONTINUED
• Place on O2 to achieve sats > 92%
• Chest X-ray
• Labs – BMP, CBC, D-dimer and consider an ABG.
• BMP and CBC WN range. D-dimer grossly positive.
• What diagnosis is the patient at the greatest risk for?

74. URINALYSIS (UA)
• A routine urinalysis usually includes the following
tests:
• Color, transparency, specific gravity, pH, protein,
glucose, ketones, blood, bilirubin, nitrite, urobilinogen
and leukocyte esterase
• Microscopic evaluation – will see bacteria, RBCs,
WBCs and strands of protein through the microscope

75. UA NORMAL VALUES
• Color Pale yellow to amber
• Turbidity Clear to slightly hazy
• Specific gravity 1.015-1.025
• pH 4.5-8.0
• Glucose Negative
• Ketones Negative
• Blood Negative
• Protein Negative
• Bilirubin Negative
• Urobilinogen 0.1-1.0
• Nitrate Negative
• Leukocyte esterase Negative
• Casts Occasional hyaline casts
• Red blood cells Negative or rare
• Crystals Negative
• White blood cells Negative or rare
• Epithelial cells Few

76. UA COMPONENTS
• Nitrites are byproducts of bacterial metabolism
• Protein is detected because the bacteria are made of
it
• Blood is present in the urine as a result of the
inflammation caused by the bacteria
• Positive leukocyte esterase results from the presence
of WBCs either as whole cells or as lysed cells
• If negative, an infection is unlikely!

77. UA CASE
• An elderly woman is found wandering confused in a park.
When taken to the ER, a multitude of blood tests are done
and a UA is sent
• Neuro – She knows her name, but is confused to place and
time. She does not know her phone number or address and
does not have her
• purse with her.
• Vitals: Temp 100.8, BP 82/60, HR 116, RR 30.
• Saturating 90% on room air

78. CASE CONTINUED
• Abnormal Lab findings include:
• WBCs 18,400; glucose 160
• Lactate 2.7
• Hgb 15.2 and HCT 46
• Na+ 148, K+ 5.2, Mag 2.4
• Creatinine 1.8 and BUN 36 – ratio?
• Urine – Dark amber, foul-smelling, lots of sediment and
positive for WBCs, protein and leukocyte esterase
• INR 2.1

79. CASE CONTINUED
• What do we know?
• Possible neuro changes but unclear of her baseline
• WBCs – elevated
• Hgb/HCT – elevated
• Electrolytes and BUN/Creatinine – elevated
• INR – Elevated – Why? Possibly on warfarin
(Coumadin).
• Urine – suspicious for UTI

80. CASE CONTINUED
• Appears dehydrated
– Low BP, Tachy, elevated Hgb/Hct, electrolytes
– BUN/Creatinine ratio high
• Probable UTI
– Urine characteristics, WBCs, leukoesterase
– Fever and confusion
• Awaiting culture results. What is your treatment Plan?

81. TREATMENT PLAN UA CASE
• Admit to hospital
• Rehydrate with isotonic IV fluids – NS
• Blood cultures in case urosepsis – labs?
• Start IV antibiotics – broad spectrum
• Consider Head CT, ECG and chest X-ray
• Admit for treatment and contact police related to missing
person – Jane Doe to find her identity
• Social work consult