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. Catecholamine Fractionation, Free, Plasma   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Catecholamine Fractionation, Free, Plasma
CPT Code: 82384

Specimen Type: Blood

Tube Type/Collection Container: Purple top (EDTA- with sodium metabisulfite solution) tube

Collection Volume: 20 mL

Storage: Frozen

Availability: Sent to Reference laboratory

Methodology: High- Pressure Liquid Chromatography (HPLC)

Special Instructions: Draw 20 mL of blood into two chilled tubes. Separate plasma in a refrigerated centrifuge within 30 minutes of draw. Freeze 7 mL of plasma immediately. Unless the purpose of the measurement is drug monitoring, discontinue any epinephrine, norepinephrine, or dopamine for at least 12 hours before specimen draw. Discontinue drugs that release epinephrine, norepinephrine, or dopamine or hinder their metabolism for at least 1 week before obtaining the specimen. If this is not possible for medical reasons contact the laboratory. Refrain from tobacco and drinking caffeinated beverages for at least 4 hrs. before specimen draw. Drawing from a catheter is required. Have patient rest for 30 min. in the supine position. Then withdraw and discard a minimum of 3mL of blood to remove saline out of the catheter. Days Peformed: Mon-Fri 9:00AM Call laboratory to make sure they have proper tubes for collection and to verify collection requirements.

TAT: 2-5 days

Panel Includes: Unconjugated norepinephrine,epinephrine, and dopamine


Lab/Phone: 330-543-8418

Additional Info: Reference range: Norepinephrine: Supine: 70-750 pg/mL Standing: 200-1700 pg/mL Epinephrine: Supine: undetectable-110 pg/mL Standing: undectable-140 pg/mL Dopamine: < 30 pg/mL ( no postural change)

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: