Therapeutic and Critical Drug Levels

6 Results Reporting As a convenience for our clients and their patients, result reports are printed daily at your facility by means of remote printer/fax machine via internet platforms (4Medica, EMR, ecare/mdoffice) and/or delivered by the Sentara Laboratory Services couriers on their first rounds each day. To discuss which type of result reporting is right for your practice, please contact your Sales Representative. Tests are categorized by laboratory section, and individual tests are listed vertically along the left side of the page. Results are printed across the page with the most recent collection days and times listed first. Reference ranges are printed on the right side of the page. Important information identifying your patient and facility print at the top and bottom of each page of the report, along with a page number and prompt letting you know the last page of the report has printed. Samples of outpatient, inpatient, cytology, surgical pathology and 4Medica generated reports are located at the end of this chapter. A Quick Help Guide is also included at the end of this section to assist you with problems with your Sentara supplied remote printer or with 4Medica. If after reviewing the troubleshooting steps listed in this guide you are still experiencing printer problems, please contact Client Services at (757) 388-3621 or (800) 822-0468. 60

Therapeutic and Critical Drug Levels Therapeutic Range Critical Value Antibiotics Gentamicin peak 5-10 mcg/ml > 12 mcg/ml Gentamicin trough 0.5 2.0 mcg/ml > 2.0 mcg/ml Tobramycin peak 5-10 mcg/ml > 12 mcg/ml Tobramycin trough 0.5 2.0 mcg/ml > 2.0 mcg/ml Analgesics Acetaminophen 10-30 mcg/ml Salicylate 15-30 mcg/ml > 30 mcg/ml Antiepileptics Carbamazepine 4-12 mcg/ml > 12 mcg/ml Ethosuximide 40-100 mcg/ml > 100 mcg/ml Phenobarbital 15-35 mcg/ml > 40 mcg/ml Phenytoin 10-20 mcg/ml > 20 mcg/ml Primidone 5-12 mcg/ml > 14 mcg/ml Valproic acid 50-100 mcg/ml > 200 mcg/ml Antidepressants Lithium 0.5-1.5 mcg/ml > 2.0 mcg/ml Imipramine 150-250 mcg/ml > 500 mcg/ml Amitriptyline 120-250 mcg/ml > 500 mcg/ml Antidepressants Desipramine 50-250 mcg/ml > 500 mcg/ml Nortriptyline 50-150 mcg/ml > 500 mcg/ml Protriptyline 70-250 mcg/ml > 500 mcg/ml Doxepin 150-250 mcg/ml > 500 mcg/ml Antidysrhythmics Lidocaine 1.5-5.0 mcg/ml > 6.0 mcg/ml Procainamide 4-10 mcg/ml > 21 mcg/ml NAPA 5-30 mcg/ml Proc + NAPA 5-30 mcg/ml > 30 mcg/ml Disopyramide 2-5 mcg/ml > 6.0 mcg/ml Quinidine 2-5 mcg/ml > 6.0 mcg/ml Theophylline 10-20 mcg/ml > 20 mcg/ml Digoxin 0.8-2.0 mcg/ml > 2.3 mcg/ml 61

Critical Values Critical or panic values are, by definition, potentially life-threatening values. Because all patients differ in both metabolic and physiologic make-up, no one list can be directly applicable to all patients and all situations. The table on the following page represents generally accepted reference points that may create lifethreatening conditions. These values have been reviewed and agreed upon by the pathologists and medical staffs of the Sentara Healthcare System. When a critical result is obtained, Sentara Reference Laboratory adheres to the following protocol: For outpatients and Sentara Reference Laboratory patients, the ordering physician s office or number provided on requisition is contacted; For Sentara Reference Laboratory patients between hours of 2300-0900: Physicians will be paged for the following tests only: PT-INR, Potassium, Positive Blood Cultures. Notification for all other critical results will take place after 9 a.m. For referred outpatient specimens (physician unknown), the referring laboratory will be contacted. SRL will communicate that the result is critical and verify the test result by having the person receiving the result read-back the complete test result. All calls will be documented in the Laboratory Information System (LIS) and will include the following information: test name, critical result called, place and full name of person receiving the result, confirmation of read-back, the date and time the call was made, tech number and/or initials. 62

Critical Values Chart* Test Low Value High Value Bilirubin (newborn) greater than 10 mg/dl Calcium ess than 7 mg/dl greater than 12 mg/dl Fibrinogen less than 50 mg/dl Glucose (greater than 1 yr.) less than 50 mg/dl greater than 450 mg/dl Magnesium less than 1.1 mg/dl greater than 3.9 mg/dl Osmolality less than 241 mosm/kg greater than 319 mosm/kg Phosphorus (greater than 18 yr.) less than 1.0 mg/dl greater than 8.9 mg/ml Potassium (less than 1 yr.) less than 3.0 mmol/l greater than 6.4 mmol/l Potassium (greater than 1 yr.) less than 3.0 mmol/l greater than 6.0 mmol/l Procainamide greater than 12 mcg/ml Procainamide + NAPA greater than 30 mcg/ml Quinidine greater than 5.0 mcg/ml Sodium less than 121 mmol/l greater than 159 mmol/l Total CO2 less than 15 mmol/l greater than 50 mmol/l Valproic acid greater than 100 mcg/ml Vancomycin Peak greater than 40 mcg/ml Hemoglobin 0-15 days less than 8.0 gm/dl greater than 22.0 gm/dl 15 days-18 years less than 8.0 gm/dl greater than 20.0 gm/dl 18 years-150 years less than 6.0 gm/dl greater than 20.0 gm/dl Hematocrit 0-15 days less than 25.0 % greater than 70.0 % 15 days-18 years less than 25.0 % greater than 60.0 % 18 years-150 years less than 18.0 % greater than 60.0 % WBC 1-18 years less than 1.0 k/ul greater than 30.0 k/ul 18-150 years less than 1.0 k/ul greater than 50.0 k/ul Platelet 0-17 years less than 50.0 k/ul greater than 1000.0 k/ul 18 years -150 years less than 25.0 k/ul greater than 750.0 k/ul APTT greater than 100.0 sec Thrombin Time greater than 60.0 sec INR greater than 5.0 sec Urinalysis (all values applicable to patients 2 years of age or younger) Reducing substance less than or equal to 1+ Protein less than 300 mg/dl Glucose less than or equal to 500 mg/dl Blood Large *Please Note: Aforementioned critical values are based on adult patients. Some tests may have different critical values for newborns. 63

Microbiology/Serology* Defined critical results for immediate notification include any positive report for cultures, smears and bacterial antigens testing for these sources: AFB (Mycobacteria) Blood Cultures Body Fluids including blood, spinal, synovial, pleural, vitrous, pericardial and peritoneal (NOT urine) CSF India Ink RSV Antigen * Please Note: Aforementioned critical values are based on adult patients. Some tests may have different critical values for newborns. 64