Implementation, validation and review of a critical values list in a
               cardiac emergency room

Torres, Dilênia de Oliveira Cipriano; Allegro, Liliana; Silva, Maria Cleide Freire Clementino da; Monteiro Júnior, José Gildo Moura; Barros, Maria das Neves Dantas da Silveira; Villachan, Lúcia Roberta Rego; Ramos, Thadzia Maria de Brito

doi:10.5935/1676-2444.20140036

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Laboratory Medicine • J. Bras. Patol. Med. Lab. 50 (5) • Sep-Oct 2014 • https://doi.org/10.5935/1676-2444.20140036 copy

Implementation, validation and review of a critical values list in a cardiac emergency room

Implantação, validação e revisão da lista de valores críticos em um pronto-socorro cardiológico

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction:

Laboratory critical values (CV) can indicate threatening conditions that require rapid clinical intervention. The aim of this study was to implement, validate and review a critical values list (CVL) at Pronto-Socorro Cardiológico de Pernambuco - Universidade de Pernambuco (PROCAPE-UPE).

Method:

This study was conducted between 2011 and 2013. To formulate the CVL, laboratory tests performed at PROCAPE were analyzed and compared with those of the Journal of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) and the College of American Pathologists (CAP). A draft CVL was validated by physicians; staff training and the standard operating procedure were developed covering the entire clinical analysis laboratory, in order to formalize the procedure of critical result reporting. The CVL was updated every six months.

Results:

Changes were made in CV intervals for the measurement of total serum calcium, serum sodium, serum potassium, the international normalized ratio (INR) and total leukocyte count. Thyroid-stimulating hormone (TSH) was also included in the CVL. In the pediatric CVL, dosages of serum sodium and INR were included, and a change in the value of serum potassium was made. Thus, periodic reviews of CVL allowed greater adequacy to the needs of the study population and avoided overloading the notification process.

Conclusion:

Clinical laboratories must be responsible for the implementation, validation and review of their CVL to ensure patients’ health.

implementation; critical values; laboratory tests; cardiology

Analytes	IFCC		CAP
	High critical value	Low critical value	High critical value	Low critical value
Biochemistry
Uric acid	> 13 mg/dl	-	-	-
Amylase	-	-	> 200 UI/l	-
Aminotransferases	> 1,000 U/l	-	-	-
Total bilirubin	> 15 mg/dl	-	-	-
Ionized calcium	> 1.6 mmol/l	< 0.78 mmol/l	> 1.6 mmol/l	< 0.8 mmol/l
Total calcium	> 14 mg/dl	< 6.6 mg/dl	> 13 mg/dl	< 6.5 mg/dl
Chloride	> 125 mmol/l	< 75 mmol/l	-	-
Creatinine	> 7.4 mg/dl	-	> 6 mg/dl	-
CK	> 1,000 U/l	-	-	-
Inorganic phosphorus	-	-	-	-
Glucose	-	< 45 mg/dl	> 450 mg/dl	< 45 mg/dl
Lactate	> 45 mg/dl	-	> 30.6 mg/dl	-
Lactate dehydrogenase	> 1,000 U/l	-	-	-
Lipase	> 700 U/l	-	-	-
Magnesium	-	-	> 4.9 mg/dl	< 1 mg/dl
Potassium	> 7.7 mmol/l	< 2.6 mmol/l	> 6.2 mmol/l	< 2.8 mmol/l
Sodium	> 160 mmol/l	< 120 mmol/l	> 160 mmol/l	< 120 mmol/l
TSH	-	-	-	-
Urea	> 240 mg/dl	-	-	-
Hematology
Leukocyte count	> 50,000 μl	< 2,000 μl	> 40,000 μl	< 2,000 μl
Platelet count	> 1,000,000 μl	< 20,000 μl	> 1,000,000 μl	< 40,000 μl
Hematocrit	> 61%	< 18%	> 60%	< 20%
Hemoglobin	> 19.9 g/dl	< 6.6 g/dl	> 20 g/dl	< 7 g/dl
Bleeding time
Fibrinogen	-	< 0.8 g/l	> 8 g/l	< 0.9 g/l
PT (INR)	-	-	-	-
apTT	75 s	-	80 s	-

Analytes by sector	High critical value	Low critical value
Biochemistry
Uric acid	> 13 mg/dl	-
Amylase	> 200 UI/l	-
Aminotransferases	> 1,000 UI/l	-
Total bilirubin	> 15 mg/dl	-
Ionized calcium	> 1.6 mmol/l	< 0.38 mmol/l
Total calcium	> 10 mg/dl	< 6.6 mg/dl
Chloride	> 125 mmol/l	< 75 mmol/l
Creatinine	> 7.4 mg/dl	-
CK	> 1,000 UI/l	-
Inorganic phosphorus	> 9 mg/dl	< 1 mg/dl
Glucose	> 450 mg/dl	< 45 mg/dl
Lactate	> 5 mmol/l	-
Lactate dehydrogenase	> 1,000 U/l	-
Lipase	> 700 U/l	-
Magnesium	> 4.9 mg/dl	< 1 mg/dl
Potassium	> 5.5 mmol/l	< 3.5 mmol/l
Sodium	> 160 mmol/l	< 120 mmol/l
TSH	> 10 mUI/l	< 0.01 mUI/l
Urea	> 214 mg/dl	-
Hematology
	Presence of malaria parasites
	Sickle cells
Leukocyte differential count	Suspected aplasia
	Suspected leukemia
	Leukemoid reaction
Leukocyte count	> 50,000 μl	< 3,000 μl
Platelet count	> 1,000,000 μl	< 20,000 μl
Hematocrit	> 61%	< 18%
Hemoglobin	> 19.9 g/dl	< 6.6 g/dl
Bleeding time
Fibrinogen	-	< 0.8 g/dl
PT (INR)	> 3.5 (INR)	-
apTT	> 75 s	-

Analytes by sector	High critical value	Low critical value
Hematology
Leukocyte count	> 25,000 μl	< 5,000 μl
Platelet count	-	< 100,000 μl (normal-weight newborn)
		< 50,000 μl (newborn weighing less than 2.5kg)
Hematocrit	71%	33%
Hemoglobin	> 23 g/dl	< 8.5 g/dl
Biochemistry
Glucose	> 325 mg/dl	< 30 mg/dl
C-reactive protein	> 5 mg/l	-
Potassium	> 5.5 mmol/l	< 3.5 mmol/l
Sodium	-	< 126 mmol/l
Coagulation
INR	> 3.5	-

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