CBC S, BMP S, LFT S - OH MY! SATURDAY/3:15-4:15PM

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1 HOSPITAL FOCUS: CBC S, BMP S, LFT S - OH MY! SATURDAY/3:15-4:15PM ACPE UAN: L04-T 0.1 CEU/1 hr Activity Type: Knowledge-Based Learning Objectives for Pharmacy Technician: Upon completion of this CPE activity participants should be able to: 1. Identify normal values for common labs including a complete blood count (CBC) and basic metabolic panel (BMP) 2. Match a given lab with the associated organ or organ system 3. List important labs that should be monitored in patients receiving chemotherapy and TPN 4. Discuss which medications require routine monitoring of drug levels to optimize therapy Speaker: Caleb Warner, PharmD Caleb Warner is from a small town in northern Illinois and decided on pharmacy school after discussions with his mom (nurse) and his great aunt (pharmacy tech). Caleb graduated from Drake University College of Pharmacy and Health Sciences last year and chose to do a residency in Waterloo, IA. His fi rst pharmacy job was at Hy-Vee but he has spent the last four years working in hospital pharmacy. Caleb will be returning to Des Moines this year and getting married in September. Speaker Disclosure: Caleb Warner reports no actual or potential confl icts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this presentation. FEBRUARY 13, 2016 IOWA EVENTS CENTER DES MOINES, IOWA

2 CBCs, BMPs, and LFTs-Oh My! Caleb Warner PharmD PGY-1 Pharmacy Resident Disclosure I have no actual or potential conflicts of interest associated with this presentation Off-label use of medications will not be discussed in this presentation 1

3 Why learn about lab values? Professional Technicians are being asked to take on more tasks High cost of wasted medications Personal Improve understanding of your own healthcare Enjoy learning Learning Objectives Upon successful completion of this activity, pharmacy technicians should be able to: 1. Identify normal values for common labs including a complete blood count (CBC) and basic metabolic panel (BMP) 2. Match a given lab with the associated organ or organ system 3. List important labs that should be monitored in patients receiving chemotherapy and total parenteral nutrition 4. Discuss which medications require routine monitoring of drug levels to optimize therapy 2

4 How often do you make IV products? 1. Daily 2. Weekly 3. Rarely Basic Labs 3

5 The basic metabolic panel (BMP) Sodium Chloride Blood urea nitrogen Na + Cl - BUN Potassium Bicarbonate Creatinine K + HCO - 3 SCr Glucose Glu The basic metabolic panel (BMP) Na + Cl - BUN Glu K + HCO 3 - SCr 4

6 Quick osmosis review Wikipedia 2015 Sodium (Na + ) Importance: Maintains osmotic gradient and supports adequate blood pressure Normal range: mmol/l Effects of low sodium: nausea, malaise, confusion, coma Effects of high sodium: weakness, lethargy, seizures, coma In practice: most important in patients receiving several IVs, may effect diluent choice Nicoll 2012 Heckman

7 Potassium (K + ) Importance: Necessary for heart function and to maintain normal rhythm Normal range: mmol/l Effects of low potassium: muscle weakness(including respiratory and GI muscles) and irregular heart rhythms Effects of high potassium: muscle weakness and irregular heart rhythms In practice: Included in total parenteral nutrition (TPN) and often in IV fluids Nicoll 2012 Heckman 2015 Creatinine (SCr) Importance: byproduct of muscle metabolism, used to estimate kidney function Normal range: mg/dl (varies with muscle mass) Produced at constant rate Increase indicates decreased clearance by kidneys Used to adjust medication doses Viewing trends is more helpful than individual values In practice: Used to adjust medication doses Nicoll 2012 Heckman

8 Glucose Importance: fuel for body and brain Normal range: Inpatient diabetic <140mg/dl (fasting) and <180mg/dl (fed) Effects of low glucose: mental status changes, coma, death Effects of high glucose: Impaired immune system function, poor wound healing, damage to nerves and blood vessels In practice: Insulin is often used during hospitalizations to manage blood glucose and may require dose adjustment Hahn 2007 American Diabetic Association 2015 Patient case #1 A patient with a long history of heart issues comes in complaining of palpitations and just not feeling right. Which lab value from the BMP is most likely abnormal? 1. Sodium 2. Chloride 3. Potassium 4. Serum creatinine 7

9 The complete blood count (CBC) Hemoglobin Hgb White blood cells WBC Plt Platelets Hct Hematocrit White Blood Cells(WBC) during infection or inflammation Nonspecific Normal range x10^3/mcL Typically monitored daily to determine response to antibiotics Neutrophils Specific type of WBC which fights bacterial infection Chemotherapy may destroy some of these cells Used to determine if patient should receive chemo Nicoll 2012 Joel

10 Hemoglobin (Hgb) Protein found in red blood cells Transports 0 2 Normal range 12-17g/dl Determines oxygen carrying capacity Decreased by Acute blood loss Malnutrition Chronic kidney disease Nicoll 2012 Joel 2015 Hematocrit (Hct) Percentage of blood made up of RBCs Normal range 36-52% Nicoll 2012 Joel 2015 Image: CBR

11 Platelets Stops bleeding Normal range x10^9/L Decreased by Consumption Liver damage Increased risk of bleeding Hold anticoagulants "Blausen 0740 Platelets" by Bruce Blaus. " Nicoll 2012 Joel 2015 Liver Function Tests (LFTs) Aspartate aminotransferase (AST) and Alanine aminotransferase (ALT) Enzymes released into blood after liver damage Monitored in patients with suspected liver damage Cause may be diseases, drugs, or alcohol Ratio of AST/ALT can useful to determine offending agent Liver is bodies recycling center Breaks down and eliminates medications Murali

12 Patient case #2 Which of the following labs is least likely to be decreased in a patient recently hospitalized with a gastrointestinal bleeding event? 1. WBC 2. Hemoglobin 3. Hematocrit 4. Platelets Medications 11

13 Monitoring Drug Therapy Bringing it all together Patient Characteristics Disease State Interacting medications Why Monitor? Safety and efficacy Monitoring is more important for some medications than others: Narrow therapeutic window Little separation between an effective dose and a toxic one Many drug interactions Some classes of drugs effect the liver or kidneys and reduce the elimination of other medications Failure of therapy associated with morbidity or mortality 12

14 Warfarin Medication used to reduce the risk of blood clots and strokes Very effective but high risk of side effects The triple threat! Narrow therapeutic window Many drug interactions High cost of drug failure Clot Formation Pulmonary Embolism Stroke Warfarin Monitoring International normalized ratio (INR): measures how quickly blood will clot Goal range is most often 2-3 Frequency of monitoring depends on patients ability to stay in range 13

15 Practice A patient who takes warfarin chronically for history of DVT has had an INR reading in goal range at his last two appointments. He is prescribed a new medication (to start tomorrow), fluconazole, which is known to decrease the metabolism of warfarin. Assuming his INR reading is stable today, how should his warfarin dose be adjusted?? A. Increase the dose B. Decrease the dose Vancomycin Antibiotic often dosed by pharmacy Eliminated from body via the kidneys Goal levels Mild infection 10-15mg/L Moderate/severe infection 15-20mg/L Underdosing may lead Overdosing may lead to: to: Treatment failure Kidney damage Resistance Hearing loss 14

16 Practice A patient being treated with vancomycin had a trough level yesterday of 17mg/L (goal 15-20mg/L). The patient s creatinine has increased since yesterday, 0.7-->2.0mg/dl. Should the vancomycin dose be adjusted? A. Yes, the dose should be increased B. Yes, the dose should be decreased C. No, the dose should remain the same Total Parenteral Nutrition (TPN) Mixture of micro/macronutrients, electrolytes, and medications Provided via IV to patients unable to receive nutrition orally Cost per day is significant-ingredients, compounding equipment, and labor Madsen

17 Example TPN Label Mirtallo 2004 TPN Continued Multiple ingredients Various units Frequent changes Recipe for errors! Pharmacy techs provide 2 nd check See something, say something 16

18 TPN Practice You compounded a TPN yesterday which contained the following additives: 40 meq potassium chloride, 20 meq sodium chloride, and 10 units of insulin. Today you receive an order to make the same TPN. Today s labs from patient s BMP: Sodium 140mEq/L Potassium 6.0 meq/l Glucose 95 mg/dl TPN Practice Based on the patient s labs, which component of the TPN should be reduced or eliminated? 1. Sodium 2. Potassium 3. Glucose 17

19 Conclusion Technicians play an ever-expanding role in the safe delivery of pharmacy services and products. Understanding lab values improves the likelihood of recognizing inappropriate orders Questions 18

20 References Heckman A. Basic Metabolic Panel. Published Feb 21, Accessed 11/22/2015. Hahn K. The Top 10 Drug Errors and How to Prevent Them. Medscape Pharmacists. Published 5/16/2007. Accessed 11/22/2015. Joel. The complete blood count (CBC) part 1 and 2. Published July 14, Accessed 12/01/2015. Murali A, Carey W. Liver Test Interpretation Approach to the Patient with Liver Disease: A Guide to Commonly Used Liver Tests. Cleveland Clinic Center for Continuing Education. Published April Accessed December Madsen H, Frankel E, Parrish C. The Hitchhiker s Guide to Parenteral Nutrition Management for Adult Patients. Nutrition issues in gastroenterology. July (40) Wikipedia contributors. Osmosis. Wikipedia, The Free Encyclopedia. November 4, 2015, 07:10 UTC. Available at: Accessed December 11, Blausen gallery 2014". Wikiversity Journal of Medicine. DOI: /wjm/ ISSN Own work. Licensed under CC BY 3.0 via Commons - Blood centrifugation-scheme. Digital image. The Centre for Blood Research. Web. Accessed January 6 th, Nicoll D, Lu C, Pignone M, McPhee SJ. Lab Tests. In: Nicoll D, Lu C, Pignone M, McPhee SJ. eds. Pocket Guide to Diagnostic Tests, 6e. New York, NY: McGraw-Hill; Checking Your Blood Glucose. American Diabetes Association Available at: Accessed June American Diabetes Association. Standards of medical care in diabetes Diabetes Care. 2015;38(suppl 1):S1-S93. January 2015 Mirtallo J, Canada T, Johnson D et al. Safe Practices for Parenteral Nutrition. Journal of Parenteral and Enteral Nutrition. Vol 28;6. Published July 31 st