Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Arterial Blood Gases   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Arterial Blood Gases
CPT Code: 82805

Specimen Type: Blood

Tube Type/Collection Container: Heparinized syringe, capillary tubes

Collection Volume: 0.5 mL heparinized syringe; or (2) 125 uL capillary tubes

Cause for rejection: Clotted,specimen not sent in ice,air bubbles

Storage: On Ice

Availability: Daily, 24 hours; STAT

Methodology: Ion selective electrode/Calculations

Special Instructions: Notify lab if patient's temperature is other than 37C to correct results (temperature dependent). If collecting blood in capillary tubes from a finger or heel, place a warm, moist towel on hand or foot for 10 minutes prior to lancet puncture. Place specimen on ice and deliver to lab immediately. For Outpatients, test should only be drawn in outpatient locations within the Hospital on the Beeghly campus

TAT: 30 minutes

Panel Includes: Total Hgb, pH, PCO2, pO2, HCO3, TCO2, O2 Saturation, O2 Hgb, Std Base Excess


Lab/Phone: 330-746-9623

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: