Laboratory testing in the intensive care unit.

Laboratory testing is ubiquitous among hospitalized patients and is more common among patients in the intensive care unit (ICU). Despite its high cost and prevalence, there are few data to support the current practice of laboratory testing in most ICUs. Although testing offers considerable potential benefits, it is not without risk, including misleading results, iatrogenic anemia, and therapeutic actions of uncertain benefit. Laboratory testing should be conducted as part of a therapeutic approach to a clinical problem, mindful of pretest probability of disease, the performance of the selected test, and the relative benefits and risks of testing. Considering the indication for a particular test can lead to a more rational approach to laboratory testing and better use of available tests.

[1]  N. Halpern,et al.  Critical care medicine in the United States 1985–2000: An analysis of bed numbers, use, and costs* , 2004, Critical care medicine.

[2]  Anand S Dighe,et al.  Analysis of laboratory critical value reporting at a large academic medical center. , 2006, American journal of clinical pathology.

[3]  E. Vamvakas,et al.  Allogeneic blood transfusion, hospital charges, and length of hospitalization: a study of 487 consecutive patients undergoing colorectal cancer resection. , 1998, Archives of pathology & laboratory medicine.

[4]  M. Harvey.  Point-of-care laboratory testing in critical care. , 1999, American journal of critical care : an official publication, American Association of Critical-Care Nurses.

[5]  M. Quiñones,et al.  Optimal Noninvasive Assessment of Left Ventricular Filling Pressures: A Comparison of Tissue Doppler Echocardiography and B-Type Natriuretic Peptide in Patients With Pulmonary Artery Catheters , 2004, Circulation.

[6]  K. Werdan,et al.  Plasma atrial natriuretic peptide and brain natriuretic peptide are increased in septic shock: impact of interleukin-6 and sepsis-associated left ventricular dysfunction , 2003, Intensive Care Medicine.

[7]  B. Mokhlesi,et al.  Noninvasive ventilation for persistent weaning failure. , 2004, American journal of respiratory and critical care medicine.

[8]  D. R. Wright,et al.  The desaturation response time of finger pulse oximeters during mild hypothermia * , 2005, Anaesthesia.

[9]  S. Fink,et al.  Clinical use of continuous arterial blood gas monitoring in the pediatric intensive care unit. , 1999, Pediatrics.

[10]  W. Knaus,et al.  Evaluating laboratory usage in the intensive care unit: patient and institutional characteristics that influence frequency of blood sampling. , 1997, Critical care medicine.

[11]  M Bissell.  Point-of-care testing at the millennium. , 2001, Critical care nursing quarterly.

[12]  B. Littenberg,et al.  Usefulness of blood culture for hospitalized patients who are receiving antibiotic therapy. , 2001, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[13]  E. Ivers,et al.  Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock , 2001 .

[14]  C. Roongsritong,et al.  Common causes of troponin elevations in the absence of acute myocardial infarction: incidence and clinical significance. , 2004, Chest.

[15]  G Sherman,et al.  The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. , 2000, Chest.

[16]  Yuchiao Chang,et al.  A utilization management intervention to reduce unnecessary testing in the coronary care unit. , 2002, Archives of internal medicine.

[17]  M. Levy,et al.  The CRIT Study: Anemia and blood transfusion in the critically ill—Current clinical practice in the United States* , 2004, Critical care medicine.

[18]  A. Lyon,et al.  Strategies to promote rational clinical chemistry test utilization. , 1996, Clinical biochemistry.

[19]  G. Cohen,et al.  APNEIC OXYGENATION IN MAN , 1959, Anesthesiology.

[20]  D. O'Hare,et al.  Arterial blood sampling practices in intensive care units in England and Wales , 2001, Anaesthesia.

[21]  L Goldman,et al.  Contaminant blood cultures and resource utilization. The true consequences of false-positive results. , 1991, JAMA.

[22]  Alan S Maisel,et al.  Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. , 2002, The New England journal of medicine.

[23]  A. Sauaia,et al.  Blood Transfusion: An Independent Risk Factor for Postinjury Multiple Organ Failure , 1997 .

[24]  G. Gourley,et al.  Transcutaneous bilirubin measurement: a multicenter evaluation of a new device. , 2001, Pediatrics.

[25]  B Chan,et al.  Effect of population-based interventions on laboratory utilization: a time-series analysis. , 1998, JAMA.

[26]  P. Brill-Edwards,et al.  D-dimer in patients with clinically suspected pulmonary embolism. , 1993, Chest.

[27]  H. Joller-jemelka,et al.  Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes. , 2003, Journal of the American College of Cardiology.

[28]  D. Cook,et al.  Elevated cardiac troponin measurements in critically ill patients. , 2006, Archives of internal medicine.

[29]  M. Haller,et al.  Continuous intra-arterial blood gas and pH monitoring in critically ill patients with severe respiratory failure: a prospective, criterion standard study. , 1994 .

[30]  D. Cook,et al.  Elevated troponin and myocardial infarction in the intensive care unit: a prospective study , 2005, Critical care.

[31]  T. Lim,et al.  B-type natriuretic peptide: Issues for the intensivist and pulmonologist , 2005, Critical care medicine.

[32]  P. Marik.  Fever in the ICU. , 2000, Chest.

[33]  J. R. Beck,et al.  Biochemical profiles. Applications in ambulatory screening and preadmission testing of adults. , 1987, Annals of internal medicine.

[34]  C. Dempfle,et al.  The Fibrin Assay Comparison Trial (FACT) , 2001, Thrombosis and Haemostasis.

[35]  L. Hydo,et al.  Learning to not know: results of a program for ancillary cost reduction in surgical critical care. , 1996, The Journal of trauma.

[36]  D. Chalfin.  Analysis of cost‐effectiveness in intensive care: an overview of methods and a review of applications to problems in critical care medicine , 1996 .

[37]  J. Mahoney,et al.  Glucose Measurement: Confounding Issues in Setting Targets for Inpatient Management , 2007, Diabetes Care.

[38]  G. Horowitz,et al.  Reducing adult phlebotomy blood loss with the use of pediatric-sized blood collection tubes. , 1989, American journal of clinical pathology.

[39]  Mitchell M. Levy,et al.  Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock , 2004, Critical care medicine.

[40]  P. Barie,et al.  Practice parameters for evaluating new fever in critically ill adult patients , 1998, Critical care medicine.

[41]  Frederick Mosteller,et al.  Guidelines for Meta-analyses Evaluating Diagnostic Tests , 1994, Annals of Internal Medicine.

[42]  A. Shorr,et al.  D-dimer correlates with proinflammatory cytokine levels and outcomes in critically ill patients. , 2002, Chest.

[43]  M. Kollef,et al.  Predictive value of a rapid semiquantitative D‐dimer assay in critically ill patients with suspected venous thromboembolic disease , 2000, Critical care medicine.

[44]  Eric Schwam,et al.  B-type natriuretic peptide for diagnosis of heart failure in emergency department patients: a critical appraisal. , 2004, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[45]  D. Spahn,et al.  Accuracy and Clinical Performance of a Continuous Intra‐arterial Blood‐Gas Monitoring System During Thoracoscopic Surgery , 1997, British journal of anaesthesia.

[46]  B. Chernow,et al.  Bedside diagnostic blood testing. Its accuracy, rapidity, and utility in blood conservation. , 1991, JAMA.

[47]  C. Sprung,et al.  Myocardial ischemia, cardiac troponin, and long-term survival of high-cardiac risk critically ill intensive care unit patients* , 2005, Critical care medicine.

[48]  Sunil V. Rao,et al.  Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. , 2004, JAMA.

[49]  G. Wells,et al.  A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. , 1999, The New England journal of medicine.

[50]  John W. Severinghaus,et al.  Effects of Skin Pigmentation on Pulse Oximeter Accuracy at Low Saturation , 2005, Anesthesiology.

[51]  M. Feinleib.  National Center for Health Statistics (NCHS) , 2005 .

[52]  K. Eckardt,et al.  Important role of nondiagnostic blood loss and blunted erythropoietic response in the anemia of medical intensive care patients* , 1999, Critical care medicine.

[53]  Anand S Dighe,et al.  Physician survey of a laboratory medicine interpretive service and evaluation of the influence of interpretations on laboratory test ordering. , 2004, Archives of pathology & laboratory medicine.

[54]  R. Warters,et al.  The simultaneous measurement of ionized and total calcium and ionized and total magnesium in intensive care unit patients. , 2002, Journal of critical care.

[55]  Jesse B. Hall,et al.  Principles of Critical Care , 1992 .

[56]  J Bormanis,et al.  Application of a Diagnostic Clinical Model for the Management of Hospitalized Patients with Suspected Deep-vein Thrombosis , 1999, Thrombosis and Haemostasis.

[57]  J. Chiche,et al.  Brain natriuretic peptide: A marker of myocardial dysfunction and prognosis during severe sepsis , 2004, Critical care medicine.

[58]  K. Riederer,et al.  Repeating blood cultures during hospital stay: practice pattern at a teaching hospital and a proposal for guidelines. , 2004, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[59]  N. Hampson.  Pulse oximetry in severe carbon monoxide poisoning. , 1998, Chest.

[60]  G. Guyatt,et al.  Neither baseline tests of molecular hypercoagulability nor D-dimer levels predict deep venous thrombosis in critically ill medical-surgical patients , 2004, Intensive Care Medicine.

[61]  M. Suistomaa,et al.  Sampling rate causes bias in APACHE II and SAPS II scores , 2000, Intensive Care Medicine.

[62]  T P Clemmer,et al.  Results of a collaborative quality improvement program on outcomes and costs in a tertiary critical care unit. , 1999, Critical care medicine.

[63]  W. Knaus,et al.  Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. , 1992, Chest.

[64]  M. Weir,et al.  The Cardiac Arrhythmia Suppression Trial Investigators: Preliminary Report: Effect of Encainide and Flecainide on Mortality in a Randomized Trial of Arrhythmia Suppression After Myocardial Infarction. , 1990 .

[65]  S. Inomata,et al.  Continuous monitoring of mixed venous oxygen saturation for detecting alterations in cardiac output after discontinuation of cardiopulmonary bypass. , 1994, British journal of anaesthesia.

[66]  J. Mckenney,et al.  National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) , 2002 .

[67]  M. Quiñones,et al.  Comparative accuracy of B-type natriuretic peptide and tissue Doppler echocardiography in the diagnosis of congestive heart failure. , 2004, The American journal of cardiology.

[68]  W. Rogers,et al.  Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. , 1989, The New England journal of medicine.

[69]  B. Smoller,et al.  Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. , 1986, The New England journal of medicine.

[70]  G J Kuperman,et al.  What proportion of common diagnostic tests appear redundant? , 1998, The American journal of medicine.

[71]  J. Marshall,et al.  Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? , 2001, Critical care medicine.

[72]  G. Miller,et al.  Continuing education and patient care research. Physician response to screening test results. , 1967, JAMA.

[73]  Joseph J. Frassica.  Case Report: Frequency of Laboratory Test Utilization in the Intensive Care Unit and Its Implications for Large-Scale Data Collection Efforts , 2005, J. Am. Medical Informatics Assoc..

[74]  J. Dale,et al.  Specimen collection volumes for laboratory tests. , 2009, Archives of pathology & laboratory medicine.

[75]  C. Barton,et al.  Prediction of outcome of cardiopulmonary resuscitation from end‐tidal carbon dioxide concentration , 1990, Critical care medicine.

[76]  M. Leathley,et al.  Practice guideline for arterial blood gas measurement in the intensive care unit decreases numbers and increases appropriateness of tests. , 1997, Critical care medicine.

[77]  H. Krumholz,et al.  Blood transfusion in elderly patients with acute myocardial infarction. , 2001, The New England journal of medicine.

[78]  A. Yinnon,et al.  Routine surveillance blood cultures: their place in the management of critically ill patients. , 1997, The Journal of infection.

[79]  J. Stoller,et al.  Reduction of blood loss from diagnostic sampling in critically ill patients using a blood-conserving arterial line system. , 1993, Chest.

[80]  E. Roupie.  Equipment review: Continuous assessment of arterial blood gases , 1997, Critical care.

[81]  M Plebani,et al.  Mistakes in a stat laboratory: types and frequency. , 1997, Clinical chemistry.

[82]  J Woo,et al.  The advance of technology as a prelude to the laboratory of the twenty-first century. , 1994, Clinics in laboratory medicine.

[83]  M. Borggrefe,et al.  Prognostic Value of Plasma N-Terminal Pro-Brain Natriuretic Peptide in Patients With Severe Sepsis , 2005, Circulation.

[84]  W. Knaus.  The APACHE III Prognostic System , 1992 .

[85]  L. Oppenheimer,et al.  Eliminating needless testing in intensive care—An information‐based team management approach , 1993, Critical care medicine.

[86]  W. Knaus,et al.  APACHE II: a severity of disease classification system. , 1985 .

[87]  A S Gross.  Best practice in therapeutic drug monitoring. , 1998, British journal of clinical pharmacology.

[88]  L. Ouanes-Besbes,et al.  Association of left-heart dysfunction with severe exacerbation of chronic obstructive pulmonary disease: diagnostic performance of cardiac biomarkers. , 2006, American journal of respiratory and critical care medicine.

[89]  D. Cook,et al.  Elevated cardiac troponin levels in critically ill patients: prevalence, incidence, and outcomes. , 2006, American journal of critical care : an official publication, American Association of Critical-Care Nurses.

[90]  J. Vincent,et al.  Anemia and blood transfusion in critically ill patients. , 2002, JAMA.

[91]  H. Corwin.  Blood transfusion in the critically ill patient. , 1999, Disease-a-month : DM.

[92]  W. Knaus,et al.  The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. , 1991, Chest.

[93]  S. Saul,et al.  Blood culture positivity: suppression by outpatient antibiotic therapy in patients with bacterial endocarditis. , 1982, Archives of internal medicine.

[94]  P Garnerin,et al.  Linking guideline to regular feedback to increase appropriate requests for clinical tests: blood gas analysis in intensive care , 2001, BMJ : British Medical Journal.

[95]  J. Zimmerman,et al.  Diagnostic marker cooperative study for the diagnosis of myocardial infarction. , 1999, Circulation.

[96]  P. Marik,et al.  Anemia, allogenic blood transfusion, and immunomodulation in the critically ill. , 2005, Chest.

[97]  S. Mehari,et al.  A Written Guideline Implementation Can Lead to Reductions in Laboratory Testing in an Intensive Care Unit , 1997, Anaesthesia and intensive care.

[98]  T. Fiore,et al.  Use of N‐terminal pro‐brain natriuretic peptide to detect acute cardiac dysfunction during weaning failure in difficult‐to‐wean patients with chronic obstructive pulmonary disease* , 2007, Critical care medicine.

[99]  S. Woodhouse.  Complications of critical care: lab testing and iatrogenic anemia. , 2001, MLO: medical laboratory observer.

[100]  E. Shapiro,et al.  Relationship between B-type natriuretic peptides and pulmonary capillary wedge pressure in the intensive care unit , 2005 .

[101]  A. Garland,et al.  Physician-attributable differences in intensive care unit costs: a single-center study. , 2006, American journal of respiratory and critical care medicine.

[102]  C. Naylor,et al.  Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits. , 1998, JAMA.

[103]  M. Kollef,et al.  A rapid assay for the detection of circulating D-dimer is associated with clinical outcomes among critically ill patients. , 1998, Critical care medicine.

[104]  R. Pino,et al.  Utility of B-type natriuretic peptide for the evaluation of intensive care unit shock* , 2004, Critical care medicine.

[105]  Kevin B. Johnson,et al.  The Impact of Peer Management on Test-Ordering Behavior , 2004, Annals of Internal Medicine.

[106]  H. Rosman,et al.  Utility of B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide in evaluation of respiratory failure in critically ill patients. , 2005, Chest.

[107]  P. T. Phang,et al.  The oxygen delivery/consumption controversy. Approaches to management of the critically ill. , 1994, American journal of respiratory and critical care medicine.

[108]  J. Berlin,et al.  Effect of anaemia and cardiovascular disease on surgical mortality and morbidity , 1996, The Lancet.

[109]  J. Widness,et al.  Clinical performance of an in-line point-of-care monitor in neonates. , 2000, Pediatrics.

[110]  D. Schoenfeld,et al.  Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[111]  D. Slosman,et al.  Measurement of D-dimer in plasma as diagnostic aid in suspected pulmonary embolism , 1991, The Lancet.

[112]  M. Shirk,et al.  Epoetin alfa protocol and multidisciplinary blood-conservation program for critically ill patients. , 2005, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[113]  D. Young,et al.  Laboratory costs in the context of disease. , 2000, Clinical chemistry.

[114]  P. Moerloose,et al.  D-dimer plasma concentration in various clinical conditions: implication for the use of this test in the diagnostic approach of venous thromboembolism. , 1993, Thrombosis research.

[115]  S. Lemeshow,et al.  Outcome prediction for individual intensive care patients: Useful, misused, or abused? , 1995, Intensive Care Medicine.

[116]  Y. Mallédant,et al.  Effects of price information on test ordering in an intensive care unit , 2002, Intensive Care Medicine.

[117]  M. Aronson,et al.  Diagnostic Decision: Blood Cultures , 1987 .