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 Gas   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Blood

Tube Type/Collection Container: heparinized syringe, 4 mL green top tube

Collection Volume: 2.0 mL in syringe or 4 mL green top - must be full

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

Storage: On Ice

Availability: Daily, 24 hours; STAT

Methodology: Ion selective electrode/Calculations

Special Instructions: Air bubbles should be expelled from the syringe. Notify lab if patient's temperature is other than 37C to correct results which are temperature dependent. Place specimen on ice and deliver to lab immediately.

TAT: 30 minutes

Panel Includes: Total Hgb, pH, PCO2, PO2, HCO3, TCO2, O2 Saturation, O2 Hgb, Std Base Excess


Lab/Phone: 330-543-8417

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: