HOSPITAL FOCUS:

CBCS, BMPS, LFTS - OH MY!

SATURDAY/3:15-4:15PM

ACPE UAN: 0107-9999-16-024-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 first 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 conflicts 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

 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

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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

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How often do you make IV
products?

1. Daily
2. Weekly
3. Rarely

Basic Labs

3
The basic metabolic panel (BMP)

Sodium Chloride Blood urea nitrogen

Na+ Cl- BUN Glucose

Glu
Potassium Bicarbonate Creatinine

K+ HCO3- SCr

The basic metabolic panel (BMP)

Na+ Cl- BUN

Glu
K+ HCO3- SCr

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 Quick osmosis review

Wikipedia 2015

Sodium (Na+)
Importance: Maintains osmotic gradient and supports
adequate blood pressure
Normal range: 135-145 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 2015

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Potassium (K+)
Importance: Necessary for heart function and to maintain
normal rhythm
Normal range: 3.5-5.0 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: 0.8-1.3 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 2015

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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

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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 4.6-11.0x10^3/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 2015

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Hemoglobin (Hgb)

Protein found in red blood cells

Transports 02
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 2015

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Platelets

Stops bleeding
Normal range 150-400x10^9/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 2014

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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

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 Monitoring Drug Therapy
Bringing it all together

Patient Disease State

Characteristics

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

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 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
Stroke
Embolism

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

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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

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Practice

A patient being treated with vancomycin had a trough

level yesterday of 17mg/L (goal 15-20mg/L). The patients
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 2006

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Example TPN Label

Mirtallo 2004

TPN Continued

Multiple Recipe for errors!

ingredients Various
units Frequent
changes

Pharmacy techs provide 2nd check

See something, say something

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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. Todays labs from
patients BMP:
Sodium 140mEq/L
Potassium 6.0 mEq/L
Glucose 95 mg/dl

TPN Practice

Based on the patients labs, which component of the TPN

should be reduced or eliminated?
1. Sodium
2. Potassium
3. Glucose

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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

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References
Heckman A. Basic Metabolic Panel. https://www.youtube.com/watch?v=zik1tvQbaoA. Published Feb 21, 2015. Accessed 11/22/2015.
Hahn K. The Top 10 Drug Errors and How to Prevent Them. Medscape Pharmacists. http://www.medscape.org/viewarticle/556487.
Published 5/16/2007. Accessed 11/22/2015.
Joel. The complete blood count (CBC) part 1 and 2. https://www.youtube.com/watch?v=4DCCm5o92q8. Published July 14, 2015. 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 2014. Accessed December 2015.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/guide-to-common-liver-tests/
Madsen H, Frankel E, Parrish C. The Hitchhikers Guide to Parenteral Nutrition Management for Adult Patients. Nutrition issues in
gastroenterology. July 2006. (40) 48-68.
Wikipedia contributors. Osmosis. Wikipedia, The Free Encyclopedia. November 4, 2015, 07:10 UTC. Available at:
https://en.wikipedia.org/w/index.php?title=Osmosis&oldid=688990679. Accessed December 11, 2015.
Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work. Licensed under CC BY
3.0 via Commons - https://commons.wikimedia.org/wiki/File:Blausen_0740_Platelets.png#/media/File:Blausen_0740_Platelets.png
Blood centrifugation-scheme. Digital image. The Centre for Blood Research. Web. Accessed January 6th, 2016.
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; 2012.
Checking Your Blood Glucose. American Diabetes Association 2015. Available at: http://www.diabetes.org/living-with-diabetes/treatment-
and-care/blood-glucose-control/checking-your-blood-glucose.html?referrer=https://www.google.com/. Accessed June 2016.
American Diabetes Association. Standards of medical care in diabetes2015. 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 31st 2004.

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