Reviewing & Requesting Bloods Webinar
Summary
This on-demand teaching session is relevant to medical professionals, such as F-1 doctors and first responders, to understand the fundamentals of blood tests in a hospital setting. We will be covering how to request and interpret blood tests, as well as discussing common order sets for various scenarios and a couple of cases. We will be looking at each component of the routine bloods: full blood count, urea and electrolytes, CRP, and LFTs. Finally, we will explore how to detect and adapt to common hypo and hyper conditions. At the end of the session, questions can be posed in the comment section or over messaging. The session will be recorded and materials will be made available to those who register.
Learning objectives
Learning objectives:
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Demonstrate an understanding of when to order blood tests and when not to.
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Describe the components of a complete routine blood test and how to interpret them in clinical practice.
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Explain the importance of assessing patient fluid status when dealing with hyponatremia and hypernatremia.
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Develop an understanding of the differences between inflammatory proteins and white blood cells in determining infection.
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Analyze case studies to come up with appropriate order sets for various scenarios.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
no welcome. Everyone on thank you for joining their weekly minded league series on how to prepare. Had to be an excellent um, thank you very much on. But if you have any questions, please pose them under the comment section. If he forgets, answer. Or if something comes up two minds they John, just please send us a message, and we happy to answer all the questions. Um, the session is going to be recorded on. We will send you the link after the session and all the materials are going to be available to you. If you register at our website mind oblique dot com slash webinar hyphen registration. I'm going to post this under the common section as well. Before to start. Um, I'd like to give a quick shot site or responsibility. The MD at least Don't forget the sore tight. You're empty. Foundation membership before you start shadowing. Because unless you fail foundation application for him, your student members chip will seize in the summer. It's essential that you do have, um, genetic ovary. So check I They're saying the blanks, which I'm also going to post under the common section very short. Say, um night. I'm going to handle the the T doctor and it'll brain. He's going to give us a session on reviewing and requesting Bloods. Hope you enjoy it. And maybe if you have any question, just please praise them in the end of that box on Facebook. Thank you. So, uh so Hello, everyone. Thanks so much for joining us today. Today we'll be talking about blood tests in the hospital setting. So it's a common anxiety. Um, all new doctors and a source of much uncertainty. This talk is aimed at primarily at foreign doctors or F one doctors to be, but also it will be relevant to first responders. Now it's is another healthcare professionals, other members of the MBT a swell. Exactly. So I said they'll be questions at the end. On if anything needs clarifying, let us know. So have a nice on the chat on. We will also all we can at the end, so this session will be recorded exactly so set, and we'll send you the lake and materials afterwards if you're already stirred. So let's get started. Uh, just to introduce myself. My name is not about on one of the F ones in the northwest London hospital on today, I'll be giving this presentation. So as a junior doctor, I do requesting bloods and interaction the day in, day out on DTA those F ones to be You were also doing the same. So but don't be a good place for us to stop. So today will be covering to bleed or not to bleed or when to request blood. And we're not to request Bloods interpreting the results on urgent conditions. And finally, common order sets for various scenarios and a couple of cases at the end of swell. So why is it important? Well, blood tests are crucial part for still life as they provide a window into how the body is working and whether the treatments that we're providing a making a difference. There's a lot of variety of tests EKG request from your hospital lab on with the most disciplinary team, such as your bottom, it's nuts. Is doctors dieticians Together, you can get some answers by bleeding the patients to get to better improve that cat. However, it comes with the caveat that no blood test should be considered completely in. Isolation must be considered within the whole clinical picture in order to be used effectively. So the we do know. So we know that their comment on we know that you deal with them day in, day out on. We know that in about life threatening and balances can be detected on bloods often before clinical symptoms manifest, including some of the electrolytes that will be talking through later on. It requires practice. As with any new system, it takes time to get used to. So when should you order blood tests? Well, indications for blood testing very on do pathologies from every system in the body. For example, if someone has an acute kidney injury or a k I monitoring the urea crap mean and electrolytes could give a crucial update a swear the kidney injury is getting better or worse on as to whether the treatment you're giving them is working. On the other hand, a look at white blood cells and CRP, which is a marker of information. Comptel, your if in infection is improving or worsening, and Congar your antibiotic choice and further management. So when should we not be ordering blood tests? Well, this is just it's important dated bloods are not needed for these groups. For those patients that are stable on medically fit for discharge, once a week will often suffice on for most patients. We can blood's not needed unless they're essential. Now. This will be very different, depending on the department that you're working. And I'm also depending on the type of patients that you're treating. So some people some patients will need weekend bloods on others works on. It's always good to ask if you're unsure. And there's two reasons why it's just it's important to know not to order blood tests as it is to know when to order them. So at best they're a nuisance for patients and painful at worst. So you've really got it. Ask yourself, Is your blood test going to affect your management plan? Secondly, the cost of blood tests very hugely from a few pence up to 10 lbs, which for international listeners is about $14 on all of these costs. The NHS, which is nothing to worry about if the T need that blood guideline ical management. But if you don't actually need them, then it's a needless cost. So what are routine bloods when people say do teen bloods. They tend to mean these four full blood count using news or urea and electrolytes, CRP or C reactive protein and LFTs. Often lft is the liver function. Tests are not required with the routine bloods, but this is very job specific, such as if you're in a gastroenterology or upper GI I surgery firm. You might need these with the routine bloods, but otherwise they're often not need it. This is an easy one to check. If you're unsure. So how we interpret all reteam bloods. We're gonna look at each component of the routine bloods in turn, starting with the full blood count. Now there's lots of info to be gained from a full blood count on it includes hemoglobin, white cell count, including a breakdown of the different white cells and how high the levels are all over levels on your patient on more useful bits like platelets and mean corpuscular volume and all sorts of useful things. So starting with the hemoglobin, if you know, says human globin drop of more than five grand for leader, this tends to be concerning The reason we say roughly five is because sometimes when people get a lot of fluids, it can dilute their blood on you. Congestion HB Drop without actual bleeding It's just that the blood test is affected because you've had it's flu. It's, however, more than five it usually warrants looking into. So does your patient have bleeding anywhere such a hematuria for blood and urine, dark black sticky stools or melena bloody diarrhea or menstrual bleeding? Otherwise, it's helpful to look into other blood tests, such as he knew Tenex on B 12 and folate to see if there's a reversible cause of the anemia moving onto neutrophils it. Congar, I'd you as to how an infect, whether there's an infection, Andi, even the type of infection So we know the neutrophils, the primary white blood cells that respond to bacterial infection. Neutrals can react with, uh, now uh, off tissue injury on ah, whole mark of acute information. The most common cause of a march neutrophilia, or high neutrophils, is a bacterial infection, but they can also rise after myocardial infarction or other stresses. Even smoking neutrophils below normal range on the other hand, or neutropenia, is potentially associated with life threatening infection is most significant when the total neutrophil count is left in north 0.5 per 10 to the nine, particularly when the neutropenia is due to impaired. Production, such as every patient has had chemotherapy in routine clinical practice. The most frequent cause of the low neutrophil count is is an obvious or hidden viral infection, including borrow hepatitis. So that takes us onto another key character in the routine bloods, the CRP or C reactive protein. So, as you can see here, CRP is an inflammatory protein produced by the liver. It rises in inflammatory states such a Zen infection, but it can like behind the white cell count. A detailed history and exam could be incredibly helpful on looking for infective systems. That symptoms can be the reason for risen CRP. So headaches, cough, mama eating, nausea, diarrhea, abdominal pain feels etcetera, all manner of symptoms, and it could be really helpful is why the CRP is rising in your patient. Investigations convey helpful include a full septic scream, so for those that are familiar with the septic, six is a give three and take three approach on. It includes taking blood cultures, giving fluids, getting a lactate on giving antibiotics as well other parts of the sect extreme, apart from the septic six our chest X ray and a urine dip for culture to basically find the source of why they haven't infection. So assessing a patient that has a raised CRP in a white cell count, you want to be going talk to toe looking for any source of infection. So, as you can see here on the top left, we've got this swollen hand associated with the phlebitis after a cannula insertion point has become effective. Any breaks, the skin can be a source of infection, and you're basically looking for any where, where the skin's natural barrier has broken down, Moving to the top right image on. There's a catheter in place here, and you know you could note the appearance of the urine. It's quite cloudy, which would suggest urine infection, so you definitely water. You're injecting a urine culture for this patient as well. Um, moving on to the next patient on the bottom, right? We can see this patient's got a red swollen leg suggestive of cellulitis, which is an infection of the soft tissue. On the fourth picture. There is to represent pain, so I found that when you're on call and your bit tired structures such as talk to Toe can help you cover all the important questions off a new fever or reason. CRP or reason. White cell count without missing anything. So you started the top and asked about headaches, still throat and went to a down the entire body, so this can help you find the source is an infection and help you best treat the patient. So that was full blood count and CRP moving onto urea and electrolytes. These are really crucial part or routine bloods on today we're going to be looking at the hypo and hyper in a dream here, hypo and hyper Kaleena and your A and correct mean ratio. Now where is hyper and how poetry? Mia, You really need to know the fluid status of your patient in order to treat this for a deep dive into hypo and hyper know. Trina, we've got a really excellent webinar from a couple of weeks ago that I recommend you have a look up because it's it can be quite a tricky topic, but with some walking you through the examples and how best to assess someone with a high or low sodium. Um, it can really help you, especially for if you're not when you're next, all cool. Similarly, with hyper and hypokalemia, these are usually concerning because we know that these abnormalities can meet to life threatening car arrhythmias again. We've got dedicated webinar for this from a few weeks ago for a deep dive. So we're just touching on this today, finally, in the foot in the area and electrolytes theory, a and creatinine ratio is usually helpful to diagnose a monitor acute kidney injury. It can also help you to see whether your treatment is working on to monitor and a K I. The other important thing to know about your Ian crap mean, is not only the ratio, but if someone has chronic kidney disease or long term kidney disease in different stages, knowing their baseline creatinine in from, say, GP records or their last time in hospital could be really helpful for you to understand whether they're getting back to their baseline from the AKI. So moving on to the final of the routines, we've got liver function tests, including LP, which stands for alkaline. Phosphatase is an inhaled T standing for alanine transaminase is so a little pee a lot. E and another one galaxy T are used to distinguish between the pasta, cellular damage and cholestasis bilirubin. Albumin on prothrombin are used to assess the liver synthetic function or how well it can make those substances. We know that they'll pee. The alkaline phosphatase is particularly concentrated in the liver. Wild up on bone tissues and LP is often raised in liver pathology. Do to increase synthesis in response to code. It's a status Coke Cola Stasis excusing. As a result, LP is a really useful in direct marker of code a Stasis a All T. On the other hand, the alanine transaminase is is found in high concentrations with into practice I to the cells off the liver on it enters the blood following participating injury or injury within the liver itself, rather than within the course the Golden system. Therefore, the A L T. Is a really useful marker of Pattison. You know, injury on. You can use the ratio of the reason AARP and lt to determine between a hepatic picture or a kolasinac. Take a picture. Bilirubin, on the other hand, is a breakdown product of hemoglobin on our see about patient's symptoms, like the color of the urine and color of stools, can give an indication as to the cause of jaundice, where the problem is prehepatic intrahepatic, or post hepatic. Small fluctuations are to be expected in LFTs, especially as a A P, in particular, comprises acute infection. However, large fluctuations need investigating, and that's a really good one to discuss with your team, especially if you're on a gastro firm where you're likely to see during shell of teas a lot. So we've been through when to order blood. We're not order blood on the's routine Bloods on a quick overview of how to interpret thumb for our final segment today is the final said. We're going to be looking at common order sets for clinical presentations, so these tend to be routine bloods. Plus the reason why I have included this in the talk is for those of you assumed to be F ones when you are on tape or seeing new patients coming into the first time, it's quite useful to have an idea off the investigations that you want to know. So when you're the one in charge of ordering the Bloods for your patient. It's useful to have a bit of a cheat cheat to know what would be a helpful blood test for this particular presenting complaint. But like we said at the beginning, or blood tests need to be taken into account with the full clinical picture and no blood test in isolation. So with that, let's go on to common order sets for physical presentations or routine bloods. Plus, So the first one that we're talking about today is tachycardia. On the's are some common order sets that you could reasonably order with with routine bloods. When assessing someone who's coming with tachycardia, the main street do you need? Ah, so I would personal magnesium on a bone profile. So the thyroid profile will include the TSH for thyroid stimulating hormone on the free T four, which is the thyroxine hormone that's circulating in response to the TSH. On is the reason why you would want to. These three is because you're looking for any other causes of tachycardia that could be contributing to that presenting complaint. We also know that bone profile it will come up quite a lot in these, both in clinical practice that also in these order sets because it can be really helpful to understand what's going on with someone's Phoslo, the patient's phosphate on with the rest of their bone profile as well. So moving onto our next order set for someone with chronic anemia, we touched upon this a bit before any of being a low H B or hemoglobin. The extras that you could want include a blood cell, B 12 and folate and iron studies, also known as hematinic 6 30 be above two. Identify a cause for the anemia. We know that B 12 folate can cause anemia, so investigating these is important with any patient to see if as easily reversible cause such as replacing that B 12 and folate. So as we are coming to the second half of our common order sets, I thought we discussed a case. So you are on the tape, which is seeing new patients in the front door on, says a 78 year old gentleman who's been admitted from a nursing home confused with low urine output the last three days. His past medical history is that usually mobilizes with a stick in his nurse and home. He has high BP, hypertension. He has high cholesterol hypercholesterolemia. He has atrial fibrilation on. He also has chronic kidney disease stage for him. So we're skipping ahead a little bit by saying you've examine tip of your nose and calling is kind of taking an observation for you on your now thinking about what investigations you want to order. So just have a thing to yourself. What blood tests you putting in the request box? You may be thinking full blood count. Check for anemia and signs of infection. Using these to establish whether there's a cause for whether there's an a k I on electrolyte imbalance and see how his CKD is doing. CRP is a marker of information for this potential urinary tract infection on. Finally, we have this. He's confused and more confused than normal. According to the nursing home on, We know that the moment he doesn't have any cognitive disorder such as Alzheimer's. Is this a new confusion for him on? For those of you already familiar, we would say that this gentleman most likely is has delirium, which is an acute confusion else. Tate, usually due to an underlying insult in this place. Likely urine tract infection. So what we might want for him, a swell is a confusion screen, so common order sets for dilute. Another common order set will be 14 delirium. For that, it's a lot of the same characters. We want a bone profile. We want fire and function tests on. We want hematinic. So all of these are potentially reversible causes. They can show you a prevention, potentially reversible cause of delirium on an easy fix if need be. So our final case before we close 26 year old female comes in with abdominal pain for the last 24 hours. On a bit more history this time. So pain started in the epigastrium now arm or in the right iliac fossa. The pain severity is seven out of 10. No diarrhea, no constipation, no PR bleeding on examination, tender in the right iliac fossa. So some people may be thinking about some different diagnoses already past medical history. Our previous knee surgery in 2005 and last menstrual period was three weeks ago. So you have examined observations of being taken. Which investigations do you want to order? So I'd imagine some of you will be thinking routine bloods, plus abdominal pain. Blood now a really important one. To not forget, especially in a female patient who has come in with abdominal pain, will be a beauty HCG, also known as a pregnancy test. The reason that we ask for this when women present is because when we examined abdominal pain is no only for a possibly an unknown pregnancy, but also for ectopic pregnancies, which we know is a very serious cause of abdominal pain that requires urgent treatment. But if Ms is very bad, so other things we want for abdominal pain is a bone profile on a VBG is really helpful, also known as a venous blood gas. So those unfamiliar that's when a blood you take a blood sample and you run it in a gas on analyzer, and it tells you a number off different parameters about patient when they come in, including if someone has a respiratory presentation, it can tell you whether they have a type one respiratory failure. Type two is true true failure. It can also give you a snapshot of their electrolytes, a swell for all purposes. For this 24 year old patient we wanted for the lactate and the glucose, so that can tell us a lot about whether perhaps she septic has a high or low blood sugar on. It's a really good first test when people come in the door because you get the results much quicker than sending off bloods, which can take a couple of hours. Um, whereas the blood gas analyzer you can take in as much time as it takes you to go and find the machine and put it in and you get a print out there and then now lie pays amylase and ldh. This is particularly useful in abdominal pain if pancreatitis is suspected, so not particularly high on our differentials for the late for the patient. We've just had but important to throw in there because we know that either, like hazel amylase, depending on which hospital which one your hospital uses could be really helpful on first presentation off pancreatitis because it can allow you to establish the severity. So we've been through Went or bloods were not order blood. The routine blood tests and how to interpret them on some common order sets on what you might want. Additionally, when you see a patient on the table on call so it is summary. Bloods are incredibly useful to when used correctly. Secondly, always interpret blood in the context of your patient. Thirdly, ask if unsure, because patient safety is your priority. So that's one for me. Let me know if you have any questions, and we've got so here is well to help with that, um, and I'll see what we've got. Otherwise, I think, uh, I think that's all from us. And thank you so much for listening. Thank you very much, Annabelle. Um and thank you, everyone for attending our webinar on requesting bloods. Please make sure you complete the feedback for him, which we're going to pose very short, say on. Be very useful for Annabelle on that will also help us to improve the sessions in future. Um, she we should answer some questions, and we had a question on what the Metanx include. Well, just think I have a bar she on Syria that we can just read to write that so and that ever is the Where would you like Teo give us an expiration on the boat? Yeah, of course. So chemo Tenex conversion slightly in whatever hospital you're in. But usually that ordered after you are looking after, you know that someone is anemic, so we know that the main hematinic so our iron B 12 and folate. But depending on your hospital, depending on your lab, you get a full iron profile. So that would include things like transparency actuation theater down of iron on also the total iron binding capacity as well. So, usually for any patient that's anemic or has a low H b your want hematinic six, you're also on them, for if someone has had a full if someone has delirium, or if someone has underlying blood disorder that's brought them in hospital with any anything back So and I think that is, is it very good on So thank you very much. I'm just looking for the comments. Mm. There are no other comments regarding the session content. Unless you guys would like to Oh, that there is a question, and I think somebody's asking about a test that you used Teo related to sexual them in that ratio. Would it be possible to repeat their the question? I just liked it, Um somebody is asking whether you could say a bit more if I do bone profile. A zit seems to need it for a lot of presentations on Why are we not in creating it as a part of routine investigation? Well, it's really good. Yeah, that's a really good point. A really good question. So is a particularly useful test. It tells you about someone's phosphate, which, as you know, me high, low or normal on um, it can be replaced if it's low on D, um, managed with fluid. If it's high, depending on the cause on it is, it's a really good question because it is a very useful test, especially when people come in with abdominal pain or full or elderly. Put patient as well on a Z. Far as I know during the research for this presentation, it's also quite a cheek test on. Don't think that would be a really interesting project to look into as to why isn't requested more. I think that perhaps it's partly dogma. Perhaps it partly tradition that the common order sets are, but the routine bloods are FBC you and the CRP on lft. But for instance, there will be a lot of patients that would benefit for a bone profile from the get go. But I think it would be anything want to look at because for every medic that I've met that orders it, there's others that don't find it as helpful only the cause. I think maybe if you're not thinking eso if if any, members of the MBT like nutritionist or anything like that, if we have anyone listening also like to chime in, I think it is really helpful. But I think it's often forgotten. Yeah, I, um I think I'm on. I'm on the same page. I, um, be interesting to see Um, yeah, if if they're any audits availability. If you could do something to see whether it should be used more often, Um, you know, be very interesting. Um, somebody has commented and said, That's it's usually requested medications who are in TPN and PM, and that's correct. We when we're giving patients and TPN or PN, which is, um, feedings. I, uh, the vein essentially, and it can cause the range electrolytes and there is the risk of re feeding syndrome. So this is something that's an absolute must invasions you aren't Ethiopian, and somebody has asked the question on, um I think things that they've mentioned blood sets for tachycardia. Are there any specific? That's for, um, Brad, A cardio. Oh, yeah. Good question. So I think you would also want to know about thyroid profile because we know that if you have a low thyroid or your hypo thyroid that can cause you to have a low heart rate. I think magnesium would be helpful. But I'm no expert on, um, the ends and outs off Cody ology. But I think my amazing would be helpful quite often, because in that patients management, you would want to know whether you could correct their magnesium on whether it would help. Um, and I also think what else would be helpful in a bradycardia. We know the d a good go to me to think what else? Um, differential. That's why they have bradycardia and then think, Is there a blood test that could help us work that out? Um, and at the moment, the main two that come to mind our thyroid and magnesium, unless anymore at and I'd say that's with any red and disturbances, it's Yeah, I would say that any electrolytes are doing the real Nile on a boat breath away profile be useful. But again, I would say that it probably requires a specialist knowledge to, to be sure, but this is something that comes to my mind, but yeah, really great thing. Other. Any other questions before we before we finish? Okay, thank you very much for all the questions. I think we're going to pose the link to the feedback for um, no. Um, say Annabelle might have a Q R codes that she can share with Great to you is dead. Yes, I got that. So this is the last slide. So please do give us feedback. We really want to improve on the's presentations, if you guys. So if you could give us any detail feedback that we really helpful on, it's also helpful for our portfolios. A swell by filling in the feedback form, you also get certificate of attendance. Um, on do the small details about that in the link below, which could also be helpful for your port for news as well. Onda have posted the link Teo feedback in the comments, Um, and the yes, all the sections are recorded. All you have to do is sign up for using the link, which I will the repost again. And this is the registration link foolery the webinars. So if you follow this thing, have disposed it, then you'll have access to all the recordings. Um, and all the future Webinars. 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