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. Venous Blood Gases   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Blood

Tube Type/Collection Container: Heparinized syringe, Green top (lithium heparin)

Collection Volume: 0.5 mL syringe or 4 mL green top - must be full

Cause for rejection: Clotted, Specimen not sent on ice, air bubbles Sample collected in microtainer will not be accepted

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 which are temperature dependent. Place specimen on ice and deliver to laboratory immediately.

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 Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

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


Physician Signature: Date: