El nivel textual

- understand understand pulse pulse oximetry oximetry and and arterial arterial gases/acid-basegases/acid-base -

- know know about tabout training, and raining, and monitoring tmonitoring the he quality quality of bedside of bedside proceduresprocedures -

- know know about about lactate, lactate, renal, renal, septicaemic, septicaemic, glycol-induced, glycol-induced, and and other other acidosesacidoses Know that the fluid balance is charted in detail as it happens

Know that the fluid balance is charted in detail as it happens -

- understand understand how clinical how clinical problems are problems are solved and solved and antipated in antipated in this this wayway -

- understand understand how a how a detailed sodium detailed sodium balance can balance can help in help in diagnosis diagnosis and careand care -

- know know effects effects of age, of age, renal imrenal impairment, other pairment, other organs, and organs, and of tof treatmentreatment -

- note tnote that blood hat blood products equal products equal saline, and saline, and dextrose is wdextrose is water, if ater, if given ivgiven iv ICU renal monitoring relies on creatinine clearance (despite disadvantages) ICU renal monitoring relies on creatinine clearance (despite disadvantages) -

- understand the understand the effects on effects on serum urea serum urea and creatinine and creatinine of age, of age, nutrition, organ fnutrition, organ function, and munction, and muscle wasting uscle wasting duringduring prolonged acute illness

prolonged acute illness -

- understand tunderstand the dihe diagnostic use agnostic use of of urine testurine tests in s in acute acute oliguriaoliguria -

- note note use use and and limitations limitations of of tests tests for for rhabdomyolysisrhabdomyolysis -

- note note “stix” “stix” screening is screening is fallible fallible in ICU in ICU patients anpatients and needs d needs lab confirmationlab confirmation Be aware that routine lab monitoring may give problems:

Be aware that routine lab monitoring may give problems:

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- understand that understand that a low a low serum albumin means serum albumin means an acute phase an acute phase reaction, but does reaction, but does not reflect nutrition not reflect nutrition or synthesisor synthesis -

- know know about “corrected” about “corrected” calcium, calcium, and that and that other metals other metals behave behave similarlysimilarly -

- note note effects of effects of tissue tissue damage, drugs, damage, drugs, or hypothermia or hypothermia on serum on serum enzymesenzymes -

- know know that serum that serum phosphate falls phosphate falls on iv on iv glucose, especially glucose, especially in alin alcoholicscoholics -

- note note methods and methods and results vary results vary between labs between labs for albumin for albumin and enzymesand enzymes -

- avoid tavoid thyroid testing, hyroid testing, if if possible, until possible, until a patient a patient is is well and well and recuperatedrecuperated

ACUTE TOXICOLOGY ACUTE TOXICOLOGY

Main topics:

Main topics: overdoses – salicylate, paracetamol and common poisons; therapeutic overdose; drugs of addiction, forensicoverdoses – salicylate, paracetamol and common poisons; therapeutic overdose; drugs of addiction, forensic issues, rare poisons

issues, rare poisons

Assays in possible overdose patients only if a result may alter treatment given Assays in possible overdose patients only if a result may alter treatment given

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- understand understand relevant relevant epidemiologico-social epidemiologico-social aspects, aspects, assay assay if if in in doubtdoubt -

- understand understand the the metabolic metabolic effects effects of of different different serum serum salicylate salicylate levelslevels -

- know know about principles, about principles, pros, anpros, and cons d cons of fof forced orced alkaline alkaline diuresisdiuresis -

- be be aware of aware of the the metabolic basis metabolic basis of paof paracetamol toxicity racetamol toxicity and antidoteand antidote -

- know the know the use of a use of a timed assay ftimed assay for the or the predictive graph in predictive graph in the BNF the BNF and the effects and the effects of chronic factors of chronic factors increasingincreasing paracetamol risk

paracetamol risk -

- understand the understand the use of use of urgent assays urgent assays in potential in potential iron, carbon iron, carbon monoxide, methanol, monoxide, methanol, or glycol or glycol poisoningpoisoning

-- be aware of the use of different measurements of ethanol excessbe aware of the use of different measurements of ethanol excess Serum assays are routinely crucial for a few causes of iatrogenic toxicity:

Serum assays are routinely crucial for a few causes of iatrogenic toxicity:

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- assay lithiassay lithium if um if in doubt, in doubt, always if always if unwell unwell or if or if any fluid any fluid disturbancedisturbance -

- understand careful dunderstand careful digoxin use igoxin use and assays in and assays in susceptible patients, and susceptible patients, and the use the use and limitations and limitations of itsof its immunological antidote

immunological antidote -

- note note reasons freasons for monitoring or monitoring aluminium aluminium in in a few a few renal patientsrenal patients

Addiction patients may present in many medical ways, or psychiatric, or social Addiction patients may present in many medical ways, or psychiatric, or social

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- be be aware of aware of effects of effects of honesty & honesty & compliance on compliance on samples and samples and assaysassays

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- be be aware of aware of common drugs common drugs of of abuse, also abuse, also solvents, and solvents, and sports dopingsports doping -

- understand understand the the causes causes and and effects effects of of hyperthermia, hyperthermia, rhabdomyolysisrhabdomyolysis

Assays for possible forensic or legal evidence are planned before taking samples:

Assays for possible forensic or legal evidence are planned before taking samples:

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- know know about about chain chain of of custody; custody; assay assay methods methods differ fdiffer from rom routine labroutine lab -

- be aware be aware of consent difficulties, of consent difficulties, and that a and that a non-consenting live non-consenting live patient can now patient can now be over-ridden only be over-ridden only on the on the order order  of a Judge

of a Judge

A few rarer causes of poisoning must not be overlooked, and are easily tested:

A few rarer causes of poisoning must not be overlooked, and are easily tested:

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- be be aware aware of lead, of lead, mercury, mercury, cadmium as cadmium as occupational and occupational and other other risksrisks -

- note note organophosphates organophosphates need need red-cell red-cell enzyme enzyme assayassay -

- note note “herbal” “herbal” drugs drugs may may contain contain steroids, steroids, oestrogens, oestrogens, or or metalsmetals -

- remember remember arsenic, arsenic, thallium, thallium, etc etc in in the the rarest mystrarest mystery patiery patientent

EMERGENCIES EMERGENCIES

Main topics:

Main topics: plan for emergencies; illneplan for emergencies; illness and age affect investigations; acute abdomen; diabetss and age affect investigations; acute abdomen; diabetes mellitus; neuro and muscular es mellitus; neuro and muscular  problems

problems

Be prepared what to do and when;

Be prepared what to do and when; know local arrangements for agreed protocols, data transmission, and specimenknow local arrangements for agreed protocols, data transmission, and specimen transport

transport -

- understand understand times times and tand temperatures emperatures needed to needed to sample unstsample unstable able analytesanalytes -

- understand tunderstand the nehe need for ed for training training & & quality quality testing testing in in bedside bedside proceduresprocedures -

- note note differing differing analytical analytical methods methods and and reference ranges reference ranges between between labslabs -

- know know the ithe importance mportance of of using fusing full ull correct correct patient patient identityidentity -

- distinguish distinguish urgent takiurgent taking of ng of samples fsamples from urgent rom urgent need need for for analysisanalysis Effects of a patient’s age and illness on lab testing:

Effects of a patient’s age and illness on lab testing:

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- understand understand acute phase acute phase effects - effects - low allow albumin, high bumin, high glycoproteins eg glycoproteins eg CRP; CRP; calcium may calcium may be be “correctable”, other “correctable”, other  albumin-bound tests are also low

albumin-bound tests are also low -

- understand understand common presenting common presenting syndromes syndromes due to due to abnormal abnormal fluids, fluids, salts, salts, and and diet; diet; also also sick sick euthyroideuthyroid syndrome;

syndrome; all all these commoner these commoner in elin elderlyderly -

- understand understand children need children need faster investigation faster investigation and consequent and consequent action; also action; also collecting pre-treatment collecting pre-treatment or pre-or pre-mortem inborn error samples

mortem inborn error samples

Acute problems in patients with diabetes mellitus:

Acute problems in patients with diabetes mellitus:

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- know know limitations of limitations of blood glblood glucose metucose meters; confirm ers; confirm extreme resultsextreme results -

- understand how understand how to diagnose to diagnose ketoacidosis, how ketoacidosis, how to monitor to monitor treatment, and treatment, and the pros the pros & cons & cons of bicarbonateof bicarbonate administration

administration -

- understand understand acute syndromacute syndromes es of of non-ketotic anon-ketotic and nd of of lactate lactate acidosisacidosis Acute abdomen syndromes

Acute abdomen syndromes -

- understand understand the the use use of of routine routine urine urine and and blood blood teststests -

- use use the the local lab’s local lab’s criteria, not criteria, not textbook data, textbook data, to ito interpret serum nterpret serum amylaseamylase -

- note note local local protocols protocols for for cardiac cardiac markers markers and and pre-treatment tepre-treatment testssts -

- note note occasional value occasional value of tests of tests for pregnancy for pregnancy and fand for acute or acute porphyriasporphyrias Know how to manage acute neuro and muscular problems

Know how to manage acute neuro and muscular problems -

- understand understand the the role role of of cerebrospinal cerebrospinal fluid fluid studiesstudies -

- be be aware aware hypothermia may hypothermia may affect eaffect enzymes nzymes and and other metaboliother metabolismsm -

- be be aware of aware of the the various causes various causes and effects and effects of of acute hyperthermiaacute hyperthermia -

- know know about about inherited inherited and and acquired acquired cholinesterase cholinesterase deficienciesdeficiencies -

- understand tunderstand the whe wider aider and fnd faster investigation aster investigation of of undiagnosed siundiagnosed sick babick babieses