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)
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:
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
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