A practical guide to critical parameters in acute care testing

The acute care testing handbook is a practical guide to critical parameters in acute care testing such as pO2, lactate and troponin.

This practical handbook provides you with each parameter’s physiological role and pathophysiology, reference intervals and the most likely causes of abnormalities.

More than 20 parameters are presented:

Blood gases

pH – Potential of hydrogen

The degree of acidity or alkalinity of any liquid (including blood) is a function of its hydrogen ion concentration [H+], and pH is simply a way of expressing hydrogen ion activity. The relationship between pH and hydrogen ion concentration is described thus [1]:

pH = -log aH+
where aH+ is hydrogen ion activity.

Low pH is associated with acidosis and high pH with alkalosis.

The pH parameter is available in these products:

ABL9 analyzer
ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX BASIC analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX analyzer

pCO2 – Partial pressure of carbon dioxide

Carbon dioxide (CO2) is an acidic gas; the amount of CO2 in blood is largely controlled by the rate and depth of breathing or ventilation. pCO2 is the partial pressure of CO2 in blood. It is a measure of the pressure exerted by that small portion (~5 %) of total CO2 that remains in the gaseous state, dissolved in the blood plasma [2]. pCO2 is the respiratory component of acid-base balance and reflects the adequacy of pulmonary ventilation. The severity of ventilator failure as well as the chronicity can be judged by the accompanying changes in acid-base status.

The pCO2 parameter is available in these products:

ABL9 analyzer
ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX BASIC analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX analyzer

pO2 – Partial pressure of oxygen

The amount of oxygen in blood is controlled by many variables, e.g. ventilation/perfusion. pO2 is the partial pressure of oxygen in a gas phase in equilibrium with the blood. pO2 only reflects a small fraction (1 – 2 %) of total oxygen in blood that is dissolved in blood plasma [3]. The remaining 98 – 99 % of oxygen present in blood is bound to the hemoglobin in the erythrocytes. pO2 primarily reflects the oxygen uptake in the lungs.

The pO2 parameter is available in these products:

ABL9 analyzer
ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX BASIC analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX analyzer

Electrolytes

cNa+ – Sodium

Sodium (Na+) is the dominant cation in the extracellular fluid, where it has a 14-fold higher concentration (∼140 mmol/L) than in the intracellular fluid (∼10 mmol/L). Na+ is a major contributor of the osmolality of the extracellular fluid and its main function is largely in controlling and regulating water balance, and maintaining blood pressure. Na+ is also important for transmitting nerve impulses and activating muscle concretion.

The cNa+ parameter is available in these products:

ABL9 analyzer
ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX BASIC analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX analyzer

cK+ – Potassium

Potassium (K+) is the major cation in the intracellular fluid, where it has a 25 – 37-fold higher concentration (∼150 mmol/L in tissue cells, ∼105 mmol/L in erythrocytes) than in the extracellular fluid (∼4 mmol/L) [4, 5]. K+ has several vital functions in the body, e.g. regulation of neuromuscular excitability, regulation of heart rhythm, regulation of intracellular and extracellular volume and acid-base status.

The cK+ parameter is available in these products:

ABL9 analyzer
ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX BASIC analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX analyzer

cCa2+ – Calsium

The calcium ion (Ca2+) is one of the most prevalent cations in the body, where approximately 1 % is present in the extracellular fluid of blood. Ca2+ plays a vital role for bone mineralization and many cellular processes, e.g. contractility of the heart and the skeletal musculature, neuromuscular transmission, hormone secretion and action in various enzymatic reactions such as, e.g. blood coagulation.

The cCa2+ parameter is available in these products:

ABL9 analyzer
ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX BASIC analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX analyzer

cCl- – Chloride

Chloride (Cl-) is the major anion in the extracellular fluid and one of the most important anions in blood. The main function of Cl- is to maintain osmotic pressure, fluid balance, muscular activity, ionic neutrality in plasma, and help elucidate the cause of acid-base disturbances.

The cCl- parameter is available in these products:

ABL9 analyzer
ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX BASIC analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX analyzer

Metabolites

cGlu – Glucose

Glucose, the most abundant carbohydrate in human metabolism, serves as the major intracellular energy source (see lactate). Glucose is derived principally from dietary carbohydrate, but it is also produced – primarily in the liver and kidneys – via the anabolic process of gluconeogenesis, and from the breakdown of glycogen (glycogenolysis). This endogenously produced glucose helps keep blood glucose concentration within normal limits, when dietary-derived glucose is not available, e.g. between meals or during periods of starvation.

The cGlu parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX analyzer

cLac – Lactate

Lactate, the anion that results from dissociation of lactic acid, is an intracellular metabolite of glucose. It is produced by skeletal muscle cells, red blood cells (erythrocytes), the brain, and other tissues during anaerobic energy production (glycolysis). Lactate is formed in the intracellular fluid from pyruvate; the reaction is catalyzed by the enzyme lactate dehydrogenase (LDH) [6].

The cLac parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX BASIC analyzer

cCrea – Creatinine

Creatinine is an endogenous waste product of muscle metabolism, derived from creatine, a molecule of major importance for energy production within muscle cells. Creatinine is removed from the body in urine and its concentration in blood reflects glomerular filtration and thereby kidney function.

The cCrea parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer

cUrea – Urea

Urea (molecular formula CO(NH2)2) is the principal nitrogenous waste product of protein catabolism, which is eliminated from the body in urine. It is the most abundant organic component of urine.
Urea is transported in blood from the liver to the kidneys, where it is filtered from the blood and excreted in the urine. Renal failure is associated with the reduced excretion of urea in urine, and a consequent rise in blood (plasma/serum) urea concentration.

The cUrea parameter is available in this product:

ABL90 FLEX PLUS analyzer

Oximetry

ctHb – Total hemoglobin

The concentration of total hemoglobin (ctHb) in blood includes oxyhemoglobin (cO2Hb), deoxyhemoglobin (cHHb), as well as the dysfunctional hemoglobin species that are incapable of binding oxygen:

carboxyhemoglobin (cCOHb) (see COHb), methemoglobin (cMetHb) (see MetHb) and sulfhemoglobin (cSulfHb).

Thus:

ctHb = cO2Hb + cHHb + cCOHb + cMetHb + cSulfHb

The rare sulfHb is not included in the reported c tHb in most oximeters.

The ctHb parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX CO-OX OSM analyzer

MetHb – Methemoglobin

FMetHb is the fraction of total hemoglobin (ctHb) that is present as methemoglobin (MetHb). By convention the fraction is expressed as a percentage (%) [1].

In most medical text boxes MetHb(a) is referred to as simply methemoglobin (MetHb).

The MetHb parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX CO-OX OSM analyzer

COHb – carboxyhemoglobin

FMetHb is the fraction of total hemoglobin (ctHb) that is present as methemoglobin (MetHb). By convention the fraction is expressed as a percentage (%) [1].

In the range of 0 – 60 % COHb in arterial (COHb(a)) and venous blood (COHb(v)) is similar, i.e. either venous or arterial blood may be analyzed [7]. In most medical texts FCOHb(a) is referred to as simply COHb.

The COHb parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX CO-OX OSM analyzer

sO2 – Oxygen saturation

Oxygen saturation (sO2) is the ratio of oxyhemoglobin concentration to concentration of functional hemoglobin (i.e. oxyhemoglobin (O2Hb) and deoxyhemoglobin (HHb) capable of carrying oxygen [1].

The sO2 reflects utilization of the currently available oxygen transport capacity.

In arterial blood 98 – 99 % of oxygen is transported in erythrocytes bound to hemoglobin. The remaining 1–2 % of the oxygen transported in blood is dissolved in the blood plasma – this is the portion reported as partial pressure of oxygen (pO2) [8].

The sO2 parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX CO-OX OSM analyzer

FO2Hb – Fraction of oxyhemoglobin

Fraction of oxyhemoglobin in total hemoglobin in blood.

The FO2Hb parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX CO-OX OSM analyzer

FHHb – Fraction of deoxyhemoglobin

Fraction of deoxyhemoglobin in total hemoglobin in blood.

The FHHb parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer
ABL80 FLEX CO-OX analyzer
ABL80 FLEX CO-OX OSM analyzer

FHbF – Fraction of fetal hemoglobin

Fraction of fetal hemoglobin in total hemoglobin in blood.

The FHbF parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer

ctBil – Bilirubin

Bilirubin is the yellow breakdown product of the degradation of the heme group of hemoglobin. It is transported in blood from its site of production – the reticuloendothelial system – to the liver, where it is biotransformed before excretion in bile. Jaundice, the pathological yellow discoloration of skin, is due to abnormal accumulation of bilirubin in the tissues, and is always associated with elevated blood concentration of bilirubin (hyperbilirubinemia).

The ctBil parameter is available in these products:

ABL800 FLEX analyzer
ABL90 FLEX PLUS analyzer
ABL90 FLEX analyzer

Hematocrit

Hct – Hematocrit

Hematocrit, the ratio between the volume of erythrocytes and the volume of whole blood.

The Hct parameter is available in these products:

ABL9 analyzer
ABL80 FLEX analyze

References

CLSI. Blood gas and pH analysis and related measurements; Approved Guidelines. CLSI document CA46-A2, 29, 8. Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2009.
Higgins C. Parameters that reflect the carbon dioxide content of blood. www.acutecaretesting.org Oct 2008.
Wettstein R, Wilkins R. Interpretation of blood gases. In: Clinical assessment in respiratory care, 6th ed. St. Louis: Mosby, 2010.
Burtis CA, Ashwood ER, Bruns DE. Tietz textbook of clinical chemistry and molecular diagnostics. 5th ed. St. Louis: Saunders Elsevier, 2012.
Engquist A. Fluids/Electrolytes/Nutrition. 1st ed. Copenhagen: Munksgaard, 1985.
Robergs RA, Ghiasvand F, Parker D. Biochemistry of exercise-induced metabolic acidosis. Am J Physiol Regul Integr Comp Physiol 2004; 287: R502-16.
Lopez DM, Weingarten-Arams JS, Singer LP, Conway EE Jr. Relationship between arterial, mixed venous and internal jugular carboxyhemoglobin concentrations at low, medium and high concentrations in a piglet model of carbon monoxide toxicity. Crit Care Med 2000; 28: 1998-2001.
Higgins C. Why measure blood gases? A three-part introduction for the novice. Part 1. www.acutecaretesting.org Jan 2012.