Rapid ACTH Stimulation Test

Popular but often unnecessary test

  • – perform at any time of day or night
  • – obtain blood sample for baseline (random) plasma cortisol level
  • – give synthetic ACTH IV (Cosyntropin) 250 ug X11
  • – repeat plasma cortisol 1 hour after injection



  1. Random cortisol <10 ug/dL OR
  2. Increment in plasma cortisol <9 ug/dL after ACTH



  • – check random plasma cortisol
  • – if >=35 ug/dL – likely normal or adequate adrenal function
  • – if <10 ug/dL – evidence of adrenal suppression
  • – if 10-34 ug/dL – do rapid ACTH stim test as above

** In septic shock, do not check cortisol levels – trial of IV hydrocortisone is recommended if hypotension refractory to volume resuscitation.



Marino, P. (n.d.). The ICU book.

Checklist: Autoimmune Encephalitis Work-up

Serum studies:

  • C3 C4 CH50
  • ANA
  • RF
  • sjogren’s SSA SSB
  • SPEP
  • Thyroid peroxidase, thyroglobulin antibody
  • Glutamic acid-decarboxylase antibody
  • paraneoplastic panel (includes VGKC and NMDA)


MRI brain w/wo con
CTA head/neck


Lumbar Puncture

  • opening pressure
  • CSF protein, glucose, cell count
  • CSF IgG index, oligoclonal bands (check in serum as well)
  • CSF myelin basic protein
  • Gram stain and bacterial culture
  • Fungal culture

*withdraw at least 30 cc of CSF and save extra for additional studies if necessary



CSF WBC Correction for Traumatic Tap

If peripheral WBC is normal, then use ratio of 1:500 or 1:750.

If peripheral WBC abnormal, then use the following formula:

  • WBCcsf = WBCblood x RBCcsf / RBCblood
  • or  WBCc * RBCb = WBCb*RBCc
  • or WBCc/RBCc = WBCb/RBCb

The result is the number of artificially introduced WBCs.

True WBCcsf is then calculated by subtracting the artificially introduced WBCs from the actual WBCcsf


“WBC Correction For Traumatic Tap – Labce.Com, Laboratory Continuing Education”. Labce.com. N.p., 2016. Web. 17 Aug. 2016.

Interpretation of Hepatitis B Serologic Test Results



Hepatitis B surface antigen (HBsAg):

  • protein on surface of virus
  • high levels during acute or chronic infection
  • indicates that person is infectious

Hepatitis B surface antibody (anti-HBs)

  • indicates recovery and immunity
  • also develops in a person successfully vaccinated, persists for life


  • indicates previous or ongoing infection in an undefined time-frame
  • IgM antibody core antigen indicates recent infection (<6 months) – indicates acute infection.



2016. Web. https://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf 11 June 2016.

Platelet Response / ARU / PRU

VerifyNow for Clopidogrel:

  • Values less than 194 PRU are specific evidence of a P2Y12 inhibitor effect


VerifyNow for Aspirin:

  • ≤ 549: Evidence of platelet dysfunction due to aspirin
  • > 550: No evidence of aspirin-induced platelet dysfunction



ASA-specific VerifyNow uses arachidonic acid as an agonist for platelet aggregation onto fibrinogen-coated beads.

VerifyNow (P2Y12) uses adenosine diphosphate and is more commonly utilized to detect platelet dysfunction due to clopidogrel.

Degree of platelet aggregation is recorded as aspirin reaction units (ARUs) or P2Y12 reaction units (PRUs).

Abnormally functiong platelets are defined as ARU <550 or PRU 208 (U of Cincinnati lab normal value, cutoff not universally defined).


VerifyNow Reference Guide

Clinical Value of the VerifyNow System



Click to access mvn0005_-_verifynow_pocket_guide_1.pdf

Click to access CLMA_Educ_Day_Presentation_-VerifyNow_2-18-14.pdf

Martin, G., Shah, D., Elson, N., Boudreau, R., Hanseman, D., Pritts, T., Makley, A., Foreman, B. and Goodman, M. (2018). Relationship of Coagulopathy and Platelet Dysfunction to Transfusion Needs After Traumatic Brain Injury. Neurocritical Care.