Clinical-toxicology-lab-1-2019-2020.pptx

Toxicology lab

1. Clinical toxicology - Definition. - Pain management. - Clinical toxicology testing types. - References ranges ( Lab.I ) 10 th Oct. 2019 A. L. Ghazwan Ahmed Brifkani M.Sc. In Toxicology

2. Definition Clinical toxicology: Can be defined as the analysis of drugs and toxins in body fluids for the purpose of patient care . The mission of the clinical toxicology laboratory is to effectively utilize available laboratory resources and expertise to provide clinically useful toxicology tests to support the needs of the patients.

3. The two traditional clinical toxicology services are therapeutic drug monitoring (TDM) and emergency toxicology . These involves testing for drugs in a patient who comes to the emergency department in a hospital with signs and symptoms related to drug toxicity . In this case, laboratories may perform a "drugs of abuse screen" by a technology known as immunoassay on blood or urine obtained from a patient . The most commonly abused drugs , such as amphetamines, barbiturates, benzodiazepines, cocaine, marijuana, methadone, and opioids, are screened first, and therapeutic drugs , such as valproic acid , salicylate, carbamazepine, and cyclosporine.

4. In patients who are taken to the emergency department for a drug overdose or toxicity, confirmation testing can be performed using more sophisticated instrumentation such as chromatography (gas, liquid, or thin layer) alone or in combination with mass spectrometry if it is needed.

5. Pain Management Management of the patient can be summarized in two meaning: 1- (what to test for)!!!?, by the availability of suitable analytical methods and technical resources 2- (how to test for) !!!?.

6. Clinical Toxicology KEY CONCEPTS Poisoning can result from exposure to excessive doses of any chemical, with medicines being responsible for most childhood and adult poisonings. Immediate first aid may reduce the development of serious poisoning, and consultation with a poison control center may indicate the need for further therapy. The use of ipecac syrup , gastric lavage , whole bowel irrigation , and cathartics has fallen out of favor as routine therapies , whereas activated charcoal remains useful for gastric decontamination of appropriate patients. Antidotes can prevent or reduce the toxicity of certain poisons, but symptomatic and supportive care is essential for all patients. Acute acetaminophen poisoning produces severe liver injury and occasionally kidney failure.

7. A determination of serum acetaminophen concentration may indicate whether there is risk of hepatotoxicity and the need for acetylcysteine therapy. Anticholinesterase insecticides may produce life-threatening respiratory distress and paralysis by all routes of exposure and can be treated with symptomatic care, atropine , and pralidoxime . (benzodiazepines). An overdose of calcium channel antagonists will produce severe hypotension and bradycardia , which can be treated with supportive care , calcium , insulin with supplemental dextrose , and glucagon .

8. Poisoning with iron-containing drugs produces vomiting , gross gastrointestinal bleeding , shock , metabolic acidosis , and coma and can be treated with supportive care and deferoxamine . Acute opioid poisoning and overdose can produce life threatening respiratory depression that can be treated with assisted ventilation and naloxone . Overdoses of tricyclic antidepressants can cause arrhythmias , such as prolonged QRS intervals. and ventricular dysrhythmias , coma , respiratory depression , and seizures , are treated with symptomatic care and IV sodium bicarbonate.

9. Clinical toxicology testing types By automated analytical methods. 1- Immunoassay & hormonal tests ( Elecsys , Chorus) 2- Biochemical assay ( Cobas , Vidase ) 3- Identification of microorganism & antibiotic sensitivities test (ID, AST) by phoenix & Vitek instruments.

10. Vitek - - Identification of microorganisms (Infectious disease diagnosis) - AST

11. Vitek

12. Elecsys (Immunoassay & hormonal tests)

13. Cobas ( biochem . Immunoassay)

14. Cobas ( biochem . Immunoassay)

15. Drugs of Abuse Amphetamines Barbiturates Benzodiazepines Cannabinoids Cocain Metabolite Ethanol Methadone Opiates Phencyclidine Propoxyphene Cobas analyser Assay menu

16. Examples of the Influence of DrugOverdosage on Pharmacokinetic and Pharmacodynamic Characteristics

17. Following are toxic levels for some of the drugs of abuses that are commonly checked: Drug of abuse in urine Positive cut-off levels Min & max. detection time in urine Good reactivity Cocaine Metabolite 300 ug /L 2 d to 4 d (occasional use) & 22 d (depends on frequency & intensity of use) Benzoylecgonine Opiates 300 ug /L 0.5 d to 3 d (small dose) & 11 d (large dose) Morphine, Codeine, Heroin Cannabinoids 50 ug /L 1 d to 7 d (occasional use)-95 d (chronic use) Cannabis Amphetamines (stimulant amines ) 1000 ug /L 1 d to 3 d (small dose) & 6 to 9 d (large dose) d-Amphetamine d-Methamphetamine (Crystal Meth) Barbiturates 300 ug /L 1 h to 4 d (Shorting-acting) 7 d to weeks (long acting) Phenobarbital Glutethimide Benzodiazepine 300 ug /L 3 d to weeks (Have variable pharmacokinetic variables ) Diazepam Flurazepam Clonazepam Alcohol 10 mg/ dL 0.01 gm /dl GLC identification of volatiles Ethanol, Acetone

18. Therapeutic drugs monitaring Following are some of the drugs that are commonly checked, followed by the normal target levels: •Acetaminophen: varies with use • Amikacin : 15 to 25 mcg/mL •Carbamazepine: 5 to 12 mcg/ mL •Chloramphenicol: 10 to 20 mcg/ mL , if <<< Aplastic anemia •Digoxin: 0.8 to 2.0 ng /mL •Gentamicin: 5 to 10 mcg/mL •Lithium: 0.8 to 1.2 mEq /L •Phenobarbital: 10 to 30 mcg/mL •Phenytoin: 10 to 20 mcg/mL •Salicylate: 100 to 250 mcg/mL •Tobramycin: 5 to 10 mcg/ mL <<< if Ototoxicity   . • Valproic acid: 50 to 100 mcg/mL Note: mcg/mL = microgram per milliliter ng /mL = nanogram per milliliter mEq /L = milliequivalents per liter mcmol = micromole

19. Following are toxic levels for some of the therapeutic drugs that are commonly checked: •Acetaminophen: greater than 250 mcg/mL • Amikacin : greater than 25 mcg/mL •Carbamazepine: greater than 12 mcg/mL •Chloramphenicol: greater than 25 mcg/mL •Digoxin: greater than 2.4 ng /mL •Gentamicin: greater than 12 mcg/mL •Lithium: greater than 2.0 mEq /L •Phenobarbital: greater than 40 mcg/mL •Phenytoin: greater than 30 mcg/mL •Salicylate: greater than 300 mcg/mL • Valproic acid: greater than 100 mcg/mL

20. Substrates Albumin Ammonia Bicarbonate Bilirubin-direct Bilirubin-total Calcium Cholesterol HDL-Cholesterol LDL-Cholesterol VLDL Creatinine . Fructosamine Glucose Iron Lactate Magnesium Phosphorus Total Protein Total Protein U / CSF Triglycerides Urea Uric Acid

21. Proteins Albumin ( immuno .) IgG ASLO ( Antistreptolysin O titre ) CRP Prealbumin CRP High Sensitivity RF Microglobulin HbA1c (whole blood) Beta-2 microglobulin

22. Enzymes ALP ( Alkaline phosphatase ) ALT/GPT AST / GOT Amylase–total serum <<< Evaluation of pancreatic function Amylase- pancr . Serum <<< diagnosis and management of pancreatitis Cholinesterase CK Lipase

23. Electrolytes Sodium Chloride Potassium 25-(OH)2 Vitamin D3 Intact PTH N-MID Osteocalcin Bone markers

24. Anemia related tests Ferritin Vitamin B12 Folate RBC Folate

25. Thyroid Function / Hormones Anti TSH-receptor T3 T4 T-Uptake TSH

26. Fertility / Hormones ACTH ( Adrenocorticotropic hormone ) C-peptide Cortisol Estradiol Insulin Progesterone Prolactin SHBG ( Sex hormone-binding globulin ) Testosterone

27. Cardiac related tests CK-MB (mass) ( creatine kinase isoenzyme MB) CK-MB (mass) STAT Digoxin Digitoxin Myoglobin Troponin T Troponin T STAT

28. Reference range