Standard Operating Procedure

Subject Sodium, Potassium, Chloride (ISE) – Cobas c501

Index Number Lab-4007
Section Laboratory
Subsection Chemistry
Category Departmental
Contact Amy VanLin
Last Revised 9/12/2018

References
Required document for Laboratory Accreditation by the College of American Pathologists (CAP), Centers
for Medicare and Medicaid Services (CMS) and/or COLA.

Applicable To
Employees of the Gundersen Health System and Gundersen Tri-County Hospital laboratories.

Detail
INTENDED USE:
The ISE module of the Roche/Hitachi cobas c system is intended for the quantitative determination of
sodium, potassium, and chloride in serum or plasma using ion-selective electrodes.

PRINCIPLE:
An Ion-Selective Electrode (ISE) makes use of the unique properties of certain membrane materials to
develop an electrical potential (electromotive force, EMF) for the measurements of ions in solution. The
electrode has a selective membrane in contact with both the test solution and an internal filling
solution. The internal filling solution contains the test ion at a fixed concentration. Because of the
particular nature of the membrane, the test ions will closely associate with the membrane on each side.
The membrane EMF is determined by the difference in concentration of the test ion in the test solution
and the internal filling solution. The complete measurement system for a particular ion includes the ISE,
a reference electrode and electronic circuits to measure and process the EMF to give the test ion
concentration. The sodium and potassium electrodes are based on neutral carriers and the chloride
electrode is based on an ion exchanger.

CLINICAL SIGNIFICANCE:
Electrolytes are involved in most major metabolic functions in the body. Sodium, potassium and chloride
are amongst the most important physiological ions and the most often assayed electrolytes. They are
supplied primarily through diet, absorbed in the gastrointestinal tract, and excreted by the kidneys.

Sodium is the major extracellular cation and functions to maintain fluid distribution and osmotic
pressure. Some causes of decreased levels of sodium include prolonged vomiting or diarrhea,
diminished reabsorption in the kidney and excessive fluid retention. Common causes of increased
sodium include excessive fluid loss, high salt intake, and increased kidney reabsorption.

Potassium is the major intracellular cation and is critical to neural and muscle cell activity. Some causes
of decreased potassium levels include reduced intake of dietary potassium or excessive loss of
potassium from the body by prolonged vomiting, diarrhea, or increased kidney excretion. Increased

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 Standard Operating Procedure

potassium levels may be caused by dehydration or shock, severe burns, diabetic ketoacidosis, and
retention of potassium by the kidney.

Chloride is the major extracellular anion and serves to regulate the balance of extracellular fluid
distribution. Similar to the other ions, common causes of decreased chloride include reduced dietary
intake, prolonged vomiting, reduced renal reabsorption as well as some forms of acidosis and alkalosis.
Increased chloride values are found in dehydration, kidney failure, some forms of acidosis, high dietary
or parenteral chloride intake, and salicylate poisoning.

SPECIMEN:
Serum or heparinized plasma collected using standard sampling tubes or tubes containing separating
gel. Samples should be separated from the clot or cells promptly after collection. Specimens to be tested
for potassium must be centrifuged within one hour of collection. Grossly lipemic specimens should be
cleared by ultracentrifugation. Specimens should be sent to La Crosse for sites that do not have an ultra-
centrifuge. Universal precautions apply.

Stability: 8 hours at 2-8°C in primary tube, 3 days at 2-8°C if removed from gel tube.

REAGENTS / MATERIALS:
Sodium Electrode
Potassium Electrode
Chloride Electrode
Reference Electrode
ISE Diluent Gen.2
ISE Internal Standard Gen.2
ISE Reference Electrolyte
ISE Cleaning Solution

Precautions and warnings: For in vitro diagnostic use. Exercise the normal precautions required for
handling all laboratory reagents. Disposal of all waste material should be in accordance with local
guidelines.

Storage:
Store Reference Electrolyte, Internal Standard, and Diluent at 15-25°C.
Store ISE Cleaning Solution at 2-8°C.
Store electrodes at 7-40°C.
See labels for expiration dates.

On-board stability:
ISE Reference Electrolyte 4 weeks
ISE Diluent 2 weeks
ISE Internal Standard 2 weeks

To achieve the stated on-board stability, an Internal Standard insert (chimney) must be used.
1. Place a new insert (chimney) in the Internal Standard bottle.

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 Standard Operating Procedure

2. Slowly push the chimney downwards into the bottle. Do not cover the hole of the chimney as it
is being pushed down.
3. Ensure the chimney is inserted as far as possible.
4. Place the bottle, with chimney, into its slot on the analyzer.
5. Use a new chimney for each Internal Standard bottle.

If always closed immediately after usage and stored at 2-8°C the ISE Cleaning Solution can be used up to
the expiration date. For daily maintenance, use only fresh cleaning solution.

NOTE: If one of the reagent bottles is nearly empty do not refill the bottle with new reagent. Discard
the old reagent bottle, including any remaining reagent.

Electrodes
Sodium 2 months or 9000 tests
Potassium 2 months or 9000 tests
Chloride 2 months or 9000 tests
Reference at least 6 months

EQUIPMENT / INSTRUMENTATION:
Roche c501 analyzer - Refer to the Operator’s Manual for operating instructions, maintenance, and
troubleshooting.

Calibration: This method has been standardized against primary calibrators prepared gravimetrically
from purified salts.

Calibrators: ISE Standard Low and ISE Standard High. After opening, a calibrator vial should be used for
one calibration only.

Calibration Frequency: Calibration must be performed with each new bottle of ISE Internal Standard
Gen.2. Renewed calibration is recommended as follows:
1. Every 24 hours
2. After ISE cleaning and maintenance
3. After replacing any electrode
4. As required following quality control procedures

After calibration, the sodium slope must be 55-63 and the EMF readings should be as close to 0 as
possible, indicating that there aer no large changes in the slope. Refer to the appropriate calibration
section of the Cobas 6000 Operator's Manual for additional calibration instructions.

QUALITY CONTROL:
Refer to Lab-4405 Quality Control Criteria for Chemistry for interpretation of QC. Two levels of quality
control should be performed at a minimum:
1. Once every twenty-four hours.
2. If a new pack of reagent is put into use.
3. If a calibration is performed.

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 Standard Operating Procedure

Implementation
Refer to the Cobas 6000 Operator’s Manual Located in the chemistry department.

PROCEDURE NOTES:
Sodium and chloride are reported to the nearest whole number in mmol/L. Potassium is reported to the
nearest tenth in mmol/L.

AMR (Analytical Measurement Range):

Sodium: 80 - 180 mmol/L
Potassium: 1.5 - 10 mmol/L
Chloride: 60 - 140 mmol/L

CALCULATIONS:
The COBAS c501 System automatically calculates the electrolyte concentration of each sample. When
electrolytes (LYTES) are ordered, the LIS calculates the anion gap.

Anion Gap = Sodium – (Chloride + CO2)

INTERPRETATION:
Expected Values:
Sodium 135 - 146 mmol/L

Potassium (plasma)
Adult: 3.4 - 5.0 mmol/L
Infant (Day 0 - 30): 3.7 - 5.9 mmol/L
Child (1mo. - 2 yrs): 4.1 - 5.3 mmol/L
Plasma potassium levels are reported to be approximately 0.3 mmol/L lower than serum levels.

Chloride 96 - 108 mmol/L

REPORTING CRITICAL RESULTS:

Please refer to Lab-0130 Critical Call Values, Lab Reporting Protcol.

LIMITATIONS:
Elevated White Cell Count: False elevation in potassium can be seen in heparin plasma samples from
patients with elevated white cell counts. Compare plasma potassium results with serum potassium
values. If serum potassium results are lower, the elevated plasma potassium value is false and
probably due to heparin-mediated cell membrane leakage in the setting of an elevated white cell
count. Notify the physician and then monitor serum potassium in these patients until the white cell
count is reduced and plasma values are equal to or lower than serum values.
Hemolysis:
Sodium and chloride: No significant interference up to an H index of 1000 (approximate hemoglobin
concentration: 1.0 g/dL).

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 Standard Operating Procedure

Potassium: No significant interference up to an H index of 70 (approximate hemoglobin

concentration: 0.07 g/dL). Potassium concentration in erythrocytes is 25 times higher than in
normal plasma.
Icterus: No significant interference up to an I index of 60 (approximate total bilirubin concentration: 60
mg/dL).
Lipemia: No significant interference up to an L index of 2000. There is poor correlation between the L
index (corresponds to turbidity) and triglycerides concentration. Pseudo hyponatremia may be seen
with lipemic specimens as a result of fluid displacement.
See package insert for additional interference and cross-reactivity studies. The results should always be
assessed in conjunction with the patient’s medical history, clinical examination and other findings.

Special Wash Requirements: The determination of certain analytes interferes with this assay requiring a
special wash step. Refer to the NaOHD/SMS/SmpCln1+2/SCCS method sheet and the operator manual
for further instructions.

REVIEW AND CHANGES:

This document and all attached forms should be reviewed optimally on an annual basis, with 2 years as
the maximum review date. Review will be done by the Technical Leader, Supervisor, Manager, Medical
Director or designated person. Changes require retyping the document or form and review by the
Medical Director.

REFERENCES:
1. Roche ISE indirect Na, K, Cl for Gen.2 package insert
2. Roche Cobas 6000 Operator’s Manual
3. Clinical Chemistry 54: 449 - 451, 2008. (Pseudo hyperkalemia)

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