Clinical Advice

  • Haematinic Guidelines

    HEFT Pathology Guideline Investigation and Referral Pathways for Anaemia in Primary Care

    Produced by:

    Dr Sukhbir Kaur (Senior Clinical Biochemist)

    Approved by:

    Dr Kartsios Charalampos (Consultant Haematologist)

     

    Dr Marcus Mottershead (Consultant Gastroenterology)

    This guidence covers the following areas

    1. Anaemia Testing in Adults

    2. Iron Deficiency Anaemia Testing in Adults

    3. Iron Deficiency Anaemia Treatment and Monitoring Advice

    4. Vitamin B12 Deficiency Testing, Treatment and Monitoring

    5. Folate Deficiency Testing, Treatment and Monitoring Advice

    6. Renal Anaemia Testing in Adults

    Read more

  • Clinical Decision Limits

    Phoning limits for biochemistry tests are as follows:

    Decision limits for phoning

    Analyte

    Phone results below or equal to:

    Phone results above or equal to:

    Units

    Notes

    Sodium

    120

    150

    mmol/L

     

    Potassium

    2.5

    6.5

    mmol/L

     

    Urea

    -

    Adults: 30

    Paediatrics: 10

    mmol/L

    Except those on renal wards or under renal consultants.

    Creatinine

    -

    Paediatrics: 200

    umol/L

    eGFR

    Adults: 15

    -

    ml/min

    AKI

    -

    2

     

    Not CKD patients (AKI 2 discretionary)

    Glucose

    2.5

    25

    mmol/L

     

    Calcium adjusted

    1.8

    3.5

    mmol/L

     

    Magnesium

    0.4

    -

    mmol/L

     

    Phosphate

    0.3

    -

    mmol/L

     

    AST

    -

    600

    U/L

     

    ALT

    -

    600

    U/L

     

    Total CK

    -

    5000

    U/L

     

    Amylase

    -

    500

    U/L

     

    Digoxin

    -

    2.5

    ng/mL

     

    Theophylline

    -

    25

    mg/L

     

    Phenytoin

    -

    25

    mg/L

     

    Lithium

    -

    1.5

    mmol/L

     

    Troponin T

    -

    GP only: >14

    ng/L

    GP only

    Ammonia

    -

    100

    umol/L

     

    Ethanol

    -

    Paediatrics only: any detectable

    mg/L

    Paediatrics only

    Paracetamol

    -

    10

    mg/L

    Not ED patients

    Salicylate

    -

    300

    mg/L

    Not ED patients

    Conj bilirubin (DBIL)

    -

    Paediatrics only:

    25

    umol/L

    Paediatrics only

    Total bilirubin

    -

    Paediatrics only: 225

    umol/L

    Paediatrics only

    Carbamazepine

    -

    25

    ug /mL

     

    Iron

    -

    ED only: 70

    umol/L

    ED only

    Phenobarbitone

    -

    70

    mg/L

     

    CSF Gluc

    3.3

    -

    mmol/L

     

    CSF Prot

    -

    0.45

    g/L

     

    Lactate

    -

    2.3

       

    CRP

    -

    300

       

    Total bile acids

    -

    20

       

    Methotrexate

    Phone all

    umol/L

     

     

    Immunology results to be telephoned:

    • CD4 count <200 cells/cumm or <10% on new patients (paediatric levels are different, but agreed with Paed consultants)
    • Lymphocyte subsets in infants <2yo: Any T cell subset below age-related normal range, any other abnormality suggesting SCID (e.g. MHC class II deficiency). (Note this is not exclusive: any abnormality may be discussed with requesting clinician)
    • New positive GBM antibodiest
    • New positive MPO antibodies
    • New positive PR3 antibodies
    • New paraprotein IgG , A or M  > 20g/L
      • IgD or IgE (any size)
      • serum monoclonal free light chains (any size, whether or not with intact paraprotein)

    Abnormal Laboratory Test Results – Triggers for Telephoning Results Haematology

    HaemoglobinWhite Blood Cell Count
    <8.0 g/dl normochromic and normocytic Low result – neutropenia <0.5 x 10 9/L
    <7.0 g/dl microcytic and hypochromic   High result – White cell count >40 x 10 9/L
    <7.0 g/dl macrocytic  or Lymph count > 20 x 10 9/L
    <5.0 g/dl renal patients Any presence of blast cells
    PlateletsClotting Studies
    Lower limit - <70 x 10 9/L   INR - >5.0
    Upper limit - >1000 x 10 9/L   PTT - >180 seconds
      Fibrinogen < 1.0g/l
    • All Positive Malaria Screens
    • All Anti FXa results >1.20 iu/ml
    • If the patient is known to the department and has had a similar result within the previous 7 days then the urgent contact is not necessary.

    HPA Microbiology – List of abnormal results telephoned to clinical staff

    Bacteriology

    • Gram stain results of positive blood culture on Day 1
    • Positive CSF results
    • Positive sterile site results
    • Significant in-patient results from enteric bench
    • Multi resistant gram negative and gram positive isolates including mupirocin resistant MRSA
    • Group B streptococcal isolates from neonates
    • Group A in patient isolates
    • Positive Legionella urinary antigen and Pneumococcal urine antigen results
    • Smear and culture positive Mycobacteria
    • Antibiotic assay results outside normal ranges
    • Any other significant results at the discretion of Medical Microbiologists

    Virology

    • Serological evidence of acute infection with Hep A, Hep B and in pregnant patients CMV, Parvovirus and Rubella
    • New diagnoses of HIV
    • VZV IgG negative from exposed patients at risk of severe VZV infection
    • New diagnosis of Hep B, Hep C and HIV in haemodialysis patients
    • Evidence of Hep B/Hep C and HIV in needle stick injury source patients
    • Clinically important positive respiratory PCR results i.e.: influenza, RSV in immunocompromised patients
    • Positive PCR results in outbreaks
    • Positive blood PCR for CMV and Adenovirus
    • Negative blood results for CMV PCR
    • Significant blood PCR results for EBV and Polyomavirus
    • All positive PCR results on CSF specimens
    • All positive Chlamydia PCR results on eye swabs
    • All positive PCR results from neonatal unit

    Read more

  • Tumour Marker Use in Primary Care

    In the last 5 years requests for tumour marker tests from Primary Care have more than doubled. This high use in Primary Care is worrying because the majority of tumour markers (eg. CEA, CA19-9) are neither specific nor sensitive enough for use in the diagnosis of malignancy. See this link for a summary of the main tumour markers, their uses and limitations.

    The main use for tumour markers is in monitoring disease progression, treatment or recurrence of a histologically diagnosed cancer. A recent audit of Primary Care requests for tumour markers found that only 9% of CEA and 4% of CA19-9 were requested for these reasons; the rest being for non-specific symptoms.

    In contrast to the above, CA125 and PSA do have use in diagnosis of their related cancers, however it should also be noted that these are still only a diagnostic aid and should be used with caution as both can be raised in a number of other benign conditions (see table). Please click the relevant links below of links to guidelines relating to their use in Primary Care.

    CA125 link https://pathways.nice.org.uk/pathways/ovarian-cancer

    PSA link https://www.gov.uk/guidance/prostate-cancer-risk-management-programme-overview

    For symptoms and referral guidelines of other malignancies see the NICE Suspected Cancer Recognition and Referral guidelines. http://pathways.nice.org.uk/pathways/suspected-cancer-recognition-and-referral

    You can also use the search bar or test database on this website to find more specific information on the use of each tumour marker.

    Tumour marker

    Main application

    Other tumour elevations

    Other limitations

    CEA

    Monitoring colorectal adenocarcinomas

    Breast, lung, gastric, mesotheliomas, oesophageal and pancreatic

    Raised in smokers

    Raised in other benign renal, liver, lung or GI disease

    Poor sensitivity in early disease and may be absent/low in poorly differentiated tumours

    CA19-9

    Monitoring pancreatic carcinoma

     

    Raised in obstructive jaundice, cholestasis, cirrhosis, pancreatic hepatitis and non-malignant GI disease.

    Not present in those negative for the Lewis blood group determinant.

    CA125

    Monitoring ovarian carcinoma

     

    Raised in patients with ascites, pleural effusions or free fluid in the pelvis

    Raised in patients with congestive heart failure

    Raised in benign renal and liver disease and other adenocarcinomas

    Mildly raised in menstruation and the first two trimesters of pregnancy

    Can be raised in endometriosis

    CA15-3

    Monitoring breast cancer

    Lung, colon, ovary

    Raised in benign liver, breast, ovarian disease

    AFP

    Diagnosis and monitoring of hepatocellular carcinoma and germ cell tumours

    Gastric and other GI (oesophageal, pancreatic)

    Raised in pregnancy and neonates

    Raised in benign liver disease

    PSA

    Diagnosis and monitoring of prostate carcinoma

     

    Also elevated in benign prostatic conditions

    Increases with age (as prostate size increases)

    Elevated in UTI, catheterisation, prostatitis or other prostate manipulation

    hCG

    Diagnosis and monitoring of germ cell tumours and gestational trophoblastic neoplasia

    Lung

    Raised in pregnancy

    Transiently elevated with cannabis use

    LDH

    Diagnosis and monitoring of germ cell tumours

     

    Elevated in cardiac disease and benign liver disease

    Elevated in some anaemias relating to non-malignant disease

    Read more

Clinical Protocols

Investigation Protocols

Read more

Pathology Phone Limits

Read more

PREDNISOLONE METABOLISM TEST

Read more

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