Electrolytes
Electrolytes
What do our patients with chest pain, altered mental status, belly pain, diabetes, alcohol withdrawal, seizures, and trauma have in common? They all have "basic labs" sent as part of our diagnostic evaluation. A basic metabolic panel (BMP or Chem-7) is often sent reflexively based on chief complaint or comorbidity without specific intention, or simply to get a "head start" in EDs with significant wait times.
But who really needs a BMP? Which patients are likely to have a clinically significant electrolyte abnormality and benefit from us finding it?
In a study of 1,093 patients that made an emergency department (ED) visit that included a basic metabolic panel, approximately 50% of patients had an electrolyte value that was out of the normal range. However, only about 15% of these 1,093 patients had what the researchers called a "clinically significant electrolyte abnormality (CSEA)" — defined as an abnormality that affected diagnosis, led to further diagnostic testing, or affected therapy. In reviewing their data, the researchers found that 98.8% of CSEAs were in patients with one or more of the following 10 characteristics: poor oral intake, vomiting, chronic hypertension, diuretic use, recent seizure, muscle weakness, age over 65, alcoholism, abnormal mental status, and recent history of electrolyte abnormality. When the authors went back and studied the question again to validate their original findings, they found that the presence of these characteristics were 95% sensitive for picking up a CSEA in the 982 patients in their validation study group.
So what?!
While we often order blood tests without knowing exactly what we are looking for, a BMP is most likely to give us a clinically significant result in patients with one or more of the characteristics above. Lowe et al. have provided supporting evidence to reduce unnecessary testing in the ED. Clearly, you should not hold back from ordering electrolytes when you think they are indicated (such as in diabetics with an elevated finger stick glucose to look for acidosis), but realize that these ten characteristics are most predictive of patients who are likely to have an electrolyte abnormality.
What do our patients with chest pain, altered mental status, belly pain, diabetes, alcohol withdrawal, seizures, and trauma have in common? They all have "basic labs" sent as part of our diagnostic evaluation. A basic metabolic panel (BMP or Chem-7) is often sent reflexively based on chief complaint or comorbidity without specific intention, or simply to get a "head start" in EDs with significant wait times.
But who really needs a BMP? Which patients are likely to have a clinically significant electrolyte abnormality and benefit from us finding it?
In a study of 1,093 patients that made an emergency department (ED) visit that included a basic metabolic panel, approximately 50% of patients had an electrolyte value that was out of the normal range. However, only about 15% of these 1,093 patients had what the researchers called a "clinically significant electrolyte abnormality (CSEA)" — defined as an abnormality that affected diagnosis, led to further diagnostic testing, or affected therapy. In reviewing their data, the researchers found that 98.8% of CSEAs were in patients with one or more of the following 10 characteristics: poor oral intake, vomiting, chronic hypertension, diuretic use, recent seizure, muscle weakness, age over 65, alcoholism, abnormal mental status, and recent history of electrolyte abnormality. When the authors went back and studied the question again to validate their original findings, they found that the presence of these characteristics were 95% sensitive for picking up a CSEA in the 982 patients in their validation study group.
So what?!
While we often order blood tests without knowing exactly what we are looking for, a BMP is most likely to give us a clinically significant result in patients with one or more of the characteristics above. Lowe et al. have provided supporting evidence to reduce unnecessary testing in the ED. Clearly, you should not hold back from ordering electrolytes when you think they are indicated (such as in diabetics with an elevated finger stick glucose to look for acidosis), but realize that these ten characteristics are most predictive of patients who are likely to have an electrolyte abnormality.
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