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How To Detect Adrenalin And Its Concentration In The Blood?
Question: Hello Doctor,
My question is about detecting adrenalin and its concentration in the blood.
A toxicology report recently reported that post mortem blood is not suitable for adrenalin measurement.
Apparently adrenalin is also rapidly removed from the blood whilst alive and not stable in vitro blood unless the plasma is separated and frozen within 15 minutes of blood collection.
I would appreciate any comments that you may have on these statements.
I have an interest in identifying adrenalin and its concentration specifically in the post mortem blood of a deceased person 19 January and would appreciate any suggestions and advice that you may have.
Thanks.
My question is about detecting adrenalin and its concentration in the blood.
A toxicology report recently reported that post mortem blood is not suitable for adrenalin measurement.
Apparently adrenalin is also rapidly removed from the blood whilst alive and not stable in vitro blood unless the plasma is separated and frozen within 15 minutes of blood collection.
I would appreciate any comments that you may have on these statements.
I have an interest in identifying adrenalin and its concentration specifically in the post mortem blood of a deceased person 19 January and would appreciate any suggestions and advice that you may have.
Thanks.
Brief Answer:
Congrats for your topic of interest,need more data
Detailed Answer:
Hi,
Adrenalin is one of the catecholamines of our body. As the other catecholamines, it is contributing to stress responses of our body.
I find your interest toward identifying adrenalin in the post portem blood of a deceased person very interesting and challenging also.
I have come through other studies that have concluded that indeed, post portem levels of catecholamine may give data over the physical stress responses of the body during the process of death.
Can you please specify when the blood sample was taken from the deceased person:
- within the first days after death
- is it frozen blood/serum?
- was the blood collected from any specific location (abdomen, peripheral, etc.)
Can you also provide the toxicology report you are referring to?
Thank you!
Dr.Albana
Congrats for your topic of interest,need more data
Detailed Answer:
Hi,
Adrenalin is one of the catecholamines of our body. As the other catecholamines, it is contributing to stress responses of our body.
I find your interest toward identifying adrenalin in the post portem blood of a deceased person very interesting and challenging also.
I have come through other studies that have concluded that indeed, post portem levels of catecholamine may give data over the physical stress responses of the body during the process of death.
Can you please specify when the blood sample was taken from the deceased person:
- within the first days after death
- is it frozen blood/serum?
- was the blood collected from any specific location (abdomen, peripheral, etc.)
Can you also provide the toxicology report you are referring to?
Thank you!
Dr.Albana
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello Dr Albana,
Thanks for your reply and interest.
The adrenalin that I referred to is not natural adrenalin produced by the body but artificial adrenalin which relates to another medcial question that I want to ask at the end of my reply.
The adrenalin was administered in the upper left arm but I don't know where the blood sample was taken from. Is this significant?
The blood sample was taken about two months after decease and presumaby from frozen blood as the deceased is in a mortuary.
I can give you details of the toxicology report because it is only a few lines.
Another and importent question is the status of the adrenalin injection.
The deceased died of a cardiac arrest about ten minutes after the injection which was in an ambulance on the way to hospital.
Adrenalin I know can be given when there has been a cardiac arrest but is it usual to adminster adrenalin to a 95 year old lady perhaps only to give her an energy lift? Are the effects dangerous for an elderly heart and how long would it take for the adrenalin to reach the heart?
I hope that you can answer these questions...
Thanks
Good morning Dr Albana,
Just a few details regarding the toxicology report taht you mentioned.
You can note that I have been authorised by the Coroner to discuss the PM report with third parties if I want.
Adrenalin is described as mentioned before as;
a) rapidly removed from the blood (when the patient is alive) and not stable in the blood in vitro unless the plasma is separated and frozen within 15 minutes of blood collection.
b) Post mortem blood is not suitable for adrenalin measurement.
So my question is how can injected adrenalin be identified and measured?
It is further stated;
c) Parcetamol is marginally above the therapeutic range (10-35 mg/l) and is unlikely to be of significance.
What do you consider the phrase "unlikely to be of significance" to mean?
d) The UTI antibiotic "nitrofurantoin" is generally considered a substance of low toxicity and may not be detectable in toxicology screens after therapeutic use.
Perhaps you might have a comment to make. What does "generally" mean?
It is further stated that the measurement of blood concentration levels is only done as part of research studies.
Why is this "only" done as part of research studies?
Perhaps you could inform me about such research studies and how the concentration of nitrofurantoin might be established?
Thanks.
Green XXXXXXX
Brief Answer:
Following answers to your queries....
Detailed Answer:
Hi dear Green,
Let me start answering your questions from the last one:
D) It is true that nitrofurantoin is generally considered with low toxicity. However, there are few cases of liver damages (failure) and lung damages reported with nitrofurantoin use especially in elderly.
I have gone through other studies that have been studying cases of death among elderly who have been used nitrofurantoin as a prophylaxis to urinary tract infection and chronic liver damages (hepato-toxicity have been reported).
- http://onlinelibrary.wiley.com/doi/10.1002/hep.23937/full
- http://www.clinicsandpractice.org/index.php/cp/article/view/490
- http://casereports.bmj.com/content/2014/bcr-2013-203136.abstract
- http://www.jmedicalcasereports.com/content/2/1/169
- http://www.medsafe.govt.nz/profs/PUarticles/nitrofurant.htm
In this particular case, if I was the doctor in charge, would investigate first about nitrofurantoin use:
- if the patient was using it at the moment of death and in what dosage (maintance/prophylactic/therapeutic)
- if she has been suffering of any heart/kidney/liver disease prior to using nitrofurantoin and death
- take liver material for biopsy to exclude acute liver failure
- take lung material for biopsy to evaluate possible changes
My question is: "Why was this lady on her way to hospital on an ambulance? What was her diagnosis on her way to hospital" This is the very first thing to determine. Then, to analyze all other problems.
Routinely, the purpose of autopsy is to determine the final cause of death or underlying problems. Specifically, when a researcher is studying a particular topic of interest, he/she might need to run further tests (which have also high cost).
To my opinion, this lady might have been suffered of preexisting heart problems. The use of nitrofurantoin might have been induced liver/lung problems.
C) Paracetamol signed as " of no significance" means that although in high dosage, it might not cause death-leading damages.
A) and B) Post-mortem adrenalin levels can be measured in serum of cadavers. Peripheral blood together with intra-cardiac blood can be used as samples. Studies have shown higher levels of intracardiac serum adrenalin in cases where it was therapeutically injected as compared to peripheral blood.
In this case, blood was extracted 2 month after the death from a frozen cadaver. So, I should have the toxicology report to see what type of lab test they conducted to conclude on adrenalin after such long time after death.
At the end, distance makes it difficult to come into conclusions, as many medical data are absent. However, to my opinion, the late lady might have been sufferent of pre-existing cardiac/pulmonary problems, who might have been aggravated by use of nitrofurantoin. The adrenalin shot might have been triggered fatal pulmonary/cardiac reactions, leading to death.
Once again, there are many missing data regarding the health condition of the late lady at the moment of death.
Hope it answered to your questions! Let me know if you need further clarifications!
Dr.Albana
Following answers to your queries....
Detailed Answer:
Hi dear Green,
Let me start answering your questions from the last one:
D) It is true that nitrofurantoin is generally considered with low toxicity. However, there are few cases of liver damages (failure) and lung damages reported with nitrofurantoin use especially in elderly.
I have gone through other studies that have been studying cases of death among elderly who have been used nitrofurantoin as a prophylaxis to urinary tract infection and chronic liver damages (hepato-toxicity have been reported).
- http://onlinelibrary.wiley.com/doi/10.1002/hep.23937/full
- http://www.clinicsandpractice.org/index.php/cp/article/view/490
- http://casereports.bmj.com/content/2014/bcr-2013-203136.abstract
- http://www.jmedicalcasereports.com/content/2/1/169
- http://www.medsafe.govt.nz/profs/PUarticles/nitrofurant.htm
In this particular case, if I was the doctor in charge, would investigate first about nitrofurantoin use:
- if the patient was using it at the moment of death and in what dosage (maintance/prophylactic/therapeutic)
- if she has been suffering of any heart/kidney/liver disease prior to using nitrofurantoin and death
- take liver material for biopsy to exclude acute liver failure
- take lung material for biopsy to evaluate possible changes
My question is: "Why was this lady on her way to hospital on an ambulance? What was her diagnosis on her way to hospital" This is the very first thing to determine. Then, to analyze all other problems.
Routinely, the purpose of autopsy is to determine the final cause of death or underlying problems. Specifically, when a researcher is studying a particular topic of interest, he/she might need to run further tests (which have also high cost).
To my opinion, this lady might have been suffered of preexisting heart problems. The use of nitrofurantoin might have been induced liver/lung problems.
C) Paracetamol signed as " of no significance" means that although in high dosage, it might not cause death-leading damages.
A) and B) Post-mortem adrenalin levels can be measured in serum of cadavers. Peripheral blood together with intra-cardiac blood can be used as samples. Studies have shown higher levels of intracardiac serum adrenalin in cases where it was therapeutically injected as compared to peripheral blood.
In this case, blood was extracted 2 month after the death from a frozen cadaver. So, I should have the toxicology report to see what type of lab test they conducted to conclude on adrenalin after such long time after death.
At the end, distance makes it difficult to come into conclusions, as many medical data are absent. However, to my opinion, the late lady might have been sufferent of pre-existing cardiac/pulmonary problems, who might have been aggravated by use of nitrofurantoin. The adrenalin shot might have been triggered fatal pulmonary/cardiac reactions, leading to death.
Once again, there are many missing data regarding the health condition of the late lady at the moment of death.
Hope it answered to your questions! Let me know if you need further clarifications!
Dr.Albana
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Good evening Dr Albano,
Thank you very much for your information and advice to consider.
On considering nitrofurantoin it does seem that there is an opinion against it from the medical profession and the British Medical Journal 1982 and the Beers Report seem to have almost banned it for elderly people.
Some doctors seem unaware of this and others make a distinction between short and long term use..
What do you think of the opinion of the British Medical Journal and Beers Report? Is there cause for more concern?
In elderly people there is normally impairment of the kidneys and doses of this medication can become a problem causing pulmonary fibrosis, liver damage etc as you mention. 1 cm of myo cardial fibrosis was found in the heart. Do you know if there is the possibiity of a causal link between the antibiotic nitrofurantoin and myo cardial fibrosis?
The elderly lady (my mother actually) was transported to hospital because of a difficulty in breathing and a feeling of malaise. She had minor UTI infection and apparently a chest infection. However, she seemed okay to me a few hours before but the post mortem diagnosis was broncho pneumonia (and vascular dementia but no MRI scan had been done). As far as I know she had no prior heart problems to aggravate and was very healthy for 95.
Perhaps she had a hyper sensitive reaction to the antibiotic nitrofurantoin and a blood test etc could identify specific antibody or bacterial presence of what might have been causing the malaise and breathing problems?
I am trying to ask the Coroner for a second level lung biopsy to confirm broncho pneumonia. The only sign in the PM report seems to be fragility or friability of the lower right lobe. Clinical impressions should be confirmed by second level scientific objective tests I presume and in any event?
Your comment about the possibility of identifying /measuring adrenalin in post mortum blood seems to contradict the toxicology report. What are the ways of detecting adrenalin? I will have a look at the report again.
The facts surrounding the administration of adrenalin have to be clarified. It seems that you consider that adrenalin injection unadvisable in an elderly person. Maybe she was drifting away with a low pulse rate and it was administered to give a bit of energy? Or perhaps it is only advisable if there had been a cardiac arrest?
You mention liver failure and I note that the PM reports mentions that the liver is recticular on cutting and that this is consistent with a failure of the right ventricle. Does that mean that there has been a liver failure caused by the cardiac failure or vice versa in some way?
Thanking you.
Green XXXXXXX
Brief Answer:
Following answers...
Detailed Answer:
Hi back dear Green,
I am sorry for your mother. Apart medical advice, I am talking as a daughter to a daughter. I understand your worries about your deceased mother. I have gone through the same situation too.
When it comes to death, nothing can be predicted although we conduct a research. Only God knows what has really happened at that particular moment.
Now, to my personal experience, I rarely prescribe nitrofurantoin, especially in elderly. However, the doctor's prescriptions are based on international protocols.
It is true that recommendations are also advising doctors to monitor liver, kidney, heart and lungs functions while on medications. I always advise my patients to get back to me if they notice anything unusual when on medications.
You are saying that your mother had difficulty to breathing and general malaise. This makes me think that the health condition of your mother prior to arrival of ambulance was not good. I also suspect that she might have been suffered of cardiac arrest, constraining paramedics to inject adrenalin.
You are saying that your mother was fine prior to this complains. I have gone through many patients who have reported no problem at the time when I have diagnosed them with a particular and serious heart or other health problems.
This is because, the body is accustomed with the disease (heart, high blood pressure, etc.) and no symptoms are noticed. When my patients got treated, they were referring that they felt good changes, a general relief feeling.
With regards to measuring the adrenalin levels, my statement are based on the scientific reports. However, should have a look at the final report to see the type of test they run and sample source they used to determine adrenalin level.
Once again, as you are clarifying that your mom suffered breath problems, I can assume that she might have been suffered of cardiac arrest when on paramedics. This might have constrained them to give injections of adrenalin.
My earlier statements were only general, that's why I have asked to have more of the medical data of your mom (have a look at the reports myself).
Regarding all other organs' problems, no final conclusions can be made as long as no medical/autopsy report I have. Please bare in mind once again that my statements are based on general rules and protocols. Medicine gives space for individual approaches based on related health conditions/problems and tests reports.
Hope it was of help!
Dr.Albana
Following answers...
Detailed Answer:
Hi back dear Green,
I am sorry for your mother. Apart medical advice, I am talking as a daughter to a daughter. I understand your worries about your deceased mother. I have gone through the same situation too.
When it comes to death, nothing can be predicted although we conduct a research. Only God knows what has really happened at that particular moment.
Now, to my personal experience, I rarely prescribe nitrofurantoin, especially in elderly. However, the doctor's prescriptions are based on international protocols.
It is true that recommendations are also advising doctors to monitor liver, kidney, heart and lungs functions while on medications. I always advise my patients to get back to me if they notice anything unusual when on medications.
You are saying that your mother had difficulty to breathing and general malaise. This makes me think that the health condition of your mother prior to arrival of ambulance was not good. I also suspect that she might have been suffered of cardiac arrest, constraining paramedics to inject adrenalin.
You are saying that your mother was fine prior to this complains. I have gone through many patients who have reported no problem at the time when I have diagnosed them with a particular and serious heart or other health problems.
This is because, the body is accustomed with the disease (heart, high blood pressure, etc.) and no symptoms are noticed. When my patients got treated, they were referring that they felt good changes, a general relief feeling.
With regards to measuring the adrenalin levels, my statement are based on the scientific reports. However, should have a look at the final report to see the type of test they run and sample source they used to determine adrenalin level.
Once again, as you are clarifying that your mom suffered breath problems, I can assume that she might have been suffered of cardiac arrest when on paramedics. This might have constrained them to give injections of adrenalin.
My earlier statements were only general, that's why I have asked to have more of the medical data of your mom (have a look at the reports myself).
Regarding all other organs' problems, no final conclusions can be made as long as no medical/autopsy report I have. Please bare in mind once again that my statements are based on general rules and protocols. Medicine gives space for individual approaches based on related health conditions/problems and tests reports.
Hope it was of help!
Dr.Albana
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Dr Albana,
Thank you for your reply and condolances.
As you might have noted I would like to gain supporting evidence to legally request a second specialised post mortem investigation. If you are interested I would appreciate your comments and more so a formal written and official sounding second medical opinion by yourself and a Pathologist (perhaps about a page long?).
I do have authorisation from the Coroner to release information but I suppose it is still confidential and sensitive so I would cancel names in it and just leave the medical information.
If you send me your e-mail address I could send you the reports and you could reply by giving information on-line and to my e-mail address.
My concern is that the first autopsy report is like a clinical impression of signs given but requires a lung/liver biopsy; X rays-HRCT; MRI scan etc to confirm or disregard first level medical signs. If I can persuade the Coroner then the expense is paid for by the Coroner's Office.
I don't know how you and the Pathologist that you might collaborate with would consider the situation/written second opinion report requested, as work done for applied teaching medical research purposes (Faculty of Medicine) or to be paid for time if not given through Healthcare on-line or considered as an exchange for the opportunity in the pursuit of knowledge? This would require specific clarification and agreement.
Thanking you for your interest.
Green XXXXXXX
Brief Answer:
It's against our laws...
Detailed Answer:
Hi back dear Green,
What you are asking me is against our laws, I am sorry for that. If you have a look at the disclaimer section, it is written:
"Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also. "
So, an online doctor's advice is given for general purposes based on the little information you are providing. No online doctor can give a formal or written comment without being an Expertise (and I am not) and without studying the case personally.
I understand your concerns regarding the expenses. However, unfortunately, what you are requesting is against our laws.
What I can suggest is to find another local medical-legal expertise team at the place you are living. If you hire it from another country, it could be more expensive.
I did some search and I found an medical-legal expertise office at the place you live:
http://www.consultant-medical.com/
You can contact them and hope they will help you better!
All the best!
Dr.Albana
P.s. Do not forget to close this thread if you do not have more questions! Thank you!
It's against our laws...
Detailed Answer:
Hi back dear Green,
What you are asking me is against our laws, I am sorry for that. If you have a look at the disclaimer section, it is written:
"Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also. "
So, an online doctor's advice is given for general purposes based on the little information you are providing. No online doctor can give a formal or written comment without being an Expertise (and I am not) and without studying the case personally.
I understand your concerns regarding the expenses. However, unfortunately, what you are requesting is against our laws.
What I can suggest is to find another local medical-legal expertise team at the place you are living. If you hire it from another country, it could be more expensive.
I did some search and I found an medical-legal expertise office at the place you live:
http://www.consultant-medical.com/
You can contact them and hope they will help you better!
All the best!
Dr.Albana
P.s. Do not forget to close this thread if you do not have more questions! Thank you!
Note: For more detailed guidance, please consult an Internal Medicine Specialist, with your latest reports. Click here..
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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