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This is the problem with guidelines looking at numbers in isolation rather than looking at the UEs profile collectively and the clinical details. The clinical history and the first UE profile are highly suggestive of an Addisonian crisis which got worse on the second set of UEs. The GP however got the results electronically and should have either acted on them themselves and sent the patient urgently to paediatrics or should have asked for the clinical biochemist opinion if in doubt. Regards, Mohammad Dr. M. A. Al-Jubouri MBChB, FRCP Edin, FRCPath Consultant Chemical Pathologist Clinical Director of Pathology St. Helens & Knowsley Teaching Hospitals -----Original Message----- From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Niki Meston Sent: 04 May 2018 15:35 To: [log in to unmask] Subject: Friday afternoon case A 14 year old boy presents to GP with 2 weeks history of lethargy - request form states 'jaundice and lethargy'. Sample for U&E's, FBC and liver profile received in lab 16:30 on a Friday in April, results electronically transmitted back to GP surgery at 19:00. Na 122 (<121) K 6.2 (>6.5) Urea 18.8 (>30) Creat 106 Bili 19 This wasn't flagged for 'phoning based on cut-offs from RCPath guidance Nov 2010 on 'Out-of-hours reporting of results requiring urgent clinical attention to primary care' (in brackets above), and the results auto-authorised. The parents of the boy contacted the OOH service 3 times over the weekend. Results above were available and reviewed, but put down to 'artefactual change' and not repeated, despite the child becoming progressively more unwell. The child then re-presented to ED on the Monday: Na 114 K 7.0 Urea 24.7 Creat 150 No prizes for guessing his cortisol at that point was 169 nmol/L with an ACTH of 2817 ng/L (0-46). He was rapidly treated for newly presenting Addison's disease and made a good recovery. My point is that we only then became aware of the new guidance from RCPath Oct 2017, updating 'phoning limits for children <16 years old in terms of Na, K, urea, creat and Glucose. We instigated the new guidance within 24 hours of becoming aware of this case; the new cut-off for 'phoning Na at 130 mmol/L (and urea > 10 mmol/L) would have almost certainly lead to a more rapid diagnosis, and so treatment. Am I missing some way of being advised of new relevant guidance from the RCPath - we have actually been awaiting this guidance for some time? I hope this case can serve to bring the new guidance to anyone else's attention who has yet to read them. Dr Niki Meston Consultant Chemical Pathologist Salisbury NHS Foundation Trust ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk Green Laboratories Work http://www.laboratorymedicine.nhs.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/ --------------------------------------------------------------------------------------------------------------------- Virus Scanned and Verified by St Helens and Knowsley Health Informatics --------------------------------------------------------------------------------------------------------------------- DISCLAIMER: This email may contain confidential and/or proprietary information some or all of which may be legally privileged. It is for the intended recipient only. If any addressing or transmission error has misdirected this email, please notify the author by replying to this e mail and destroy any copies. If you are not the intended recipient you must not use, disclose, distribute, copy, print, or rely on this email. The information contained in this email may be subject to public disclosure under the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this email AND YOUR REPLY cannot be guaranteed. ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk Green Laboratories Work http://www.laboratorymedicine.nhs.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/