1 Tips & Techniques in Preanalytics 2 3 Foreword The brochure “Tips and Techniques in Preanalytics” is particularly aimed at doctors of medicine, healthcare providers, nurses and medical staff in clinics and doctors’ practices. By working through this brochure the reader should gain a comprehensive impression of the many different aspects of preanalysis. The sections concerning the collection of analysis materials are specially tailored to the use of Sarstedt systems (S-Monovette® , Microvette® , Minivette® , etc.) and, after specialised familiarisation has taken place, they make it easier to use the described collection techniques properly, particularly for new users. As a Clinical Chemist I am particularly well aware of the importance of preanalytics within the process as a whole – from the laboratory request and sample collection to the interpreted laboratory findings. After all, preanalytics in particular accounts for a major part of laboratory medicine quality management. Error-free application of laboratory medicine diagnostics is only possible if the relevant influencing factors and interfering factors are strictly taken into account. This brochure particularly addresses that issue and especially aims to sensitise clinical colleagues to the topic. It is they who, in their capacity as clients requesting medical laboratory diagnostics, make a major contribution towards ensuring that the process as a whole can take place with as little disruption as possible, by performing sample collection properly. Prof. Dr. Ralf Lichtinghagen Prof. Dr. rer. nat. Ralf Lichtinghagen obtained his doctorate after studying chemistry and biology at Ruhr University Bochum in the field of neurobiochemistry. At the beginning of the 1990s he undertook further training at Hannover Medical School (‘MHH’) to qualify as a Clinical Chemist/European Specialist in Laboratory Medicine (EuSpLM). He acquired his authorization to teach Clinical Chemistry at a university and he currently works as Chief Clinical Chemist in the Central Laboratory of MHH. In addition to his responsibilities in patient care and research, he also gives lectures in Clinical Chemistry / Laboratory Diagnostics in the medicine course of studies. He is also academic head of the Medical Laboratory Assistants School. Within the national laboratory medicine society (‘DGKL’) he organises revision courses in the subject of Clinical Chemistry for specialised scientists undergoing further training and for junior doctors. His main areas of research at the MHH’s Institute of Clinical Chemistry are Molecular Diagnostics and new biomarkers. Prof. Dr. Ralf Lichtinghagen 4 5 1 What is preanalytics? Pages 6-9 1.1 Principles of preanalytics? 7 1.2 Common consequences of preanalytical errors 8 1.3 Communication as a key to success 9 2 Influencing factors and interfering factors 10-19 2.1 Influencing factors 11 2.1.1 Non-modifiable influencing factors 12 - 14 2.1.2 Modifiable influencing factors 14-17 2.2 Interfering factors 18-19 3 Venous blood collection 20-27 3.1 Patient preparation 21 3.2 What is the responsibility of the person collecting the blood? 21 3.3 Identification 22-24 3.4 Application 25 3.5 Order of draw 26 3.6 Avoiding underfilling 27 4 Carrying out venous blood collection 28-43 4.1 Standard conditions for blood collection 29 4.2 Obtaining diagnostic samples: 12 steps 29 4.3 Tourniquet application and puncture sites 30-31 4.4 Problems before/during blood collection 32 4.5 Aspiration technique and vacuum technique 33 4.5.1 S-Monovette® aspiration technique 33-35 4.5.2 S-Monovette® vacuum technique 36 4.5.3 A summary of the 2 collection techniques 37 4.6 Blood collection from catheters 38-39 4.7 Blood collection for blood culture diagnostics 40 4.7.1 Hygienic requirements 41 4.7.2 Handling during blood collection 42 4.7.3 Sample volume and number of vials 43 5 Blood collection in paediatrics 44-55 5.1 Medical history 45 5.2 Prerequisites for blood collection 46 5.3 Blood collection in paediatrics 46 5.3.1 Venous blood collection 47-48 5.3.2 Capillary blood collection 49-51 5.4 The difference between capillary blood and venous blood 51 5.5 Reference ranges 52-54 5.6 Haemostasis in paediatrics 54-55 6 Blood gas 56-61 6.1 Type of blood collection 57 6.2 Storage 58 6.3 Avoiding errors 58-59 6.4 Collection technique – Blood Gas Monovette® 60-61 7 Safety when collecting blood 62-67 7.1 Safety needle 64 7.2 Safety-Multifly® needle 65 7.3 Multi-Safe disposal boxes 66-67 8 Centrifugation 68-73 8.1 Correct handling for centrifugation 69 8.2 Difference between fixed-angle and swing-out rotors 70 8.3 Serum collection 71 8.4 S-Monovette® centrifugation conditions 72 8.5 Gel ascent during centrifugation 73 9 Haemolysis – what is it? 74-79 9.1 In vivo haemolysis 76 9.2 In vitro haemolysis 77 9.3 Consequences of haemolysis 78 9.4 Clinical relevance 79 10 Storage and transport 80-87 10.1 Sample transport 81-82 10.2 Influence of temperature, time and cellular metabolism 83-87 11 Capillary blood collection 88-99 11.1 Carrying out capillary blood collection 89-91 11.1.1 Safety Lancet and Safety Incision Lancet 92-94 11.1.2 Microvette® – order of draw and techniques 95-97 11.2 Centrifugation conditions for capillary blood collection 98 11.3 Minivette® POCT 99 12 Urine sample collection 100-111 12.1 Sample collection 101 12.2 Storage and transport 101 12.3 Types of analyses 102 - 103 12.4 Types of urine samples 104 - 107 12.5 Handling urine sample collection systems 108-111 13 List of references 114 - 115 14 Index 116 - 122 15 Imprint 123 Table of contents 6 7 “Preanalytics comprises all the processes that occur before the laboratory analysis.” 1.1 Principles of preanalytics On average, the preanalytical phase accounts for about 57%1 of the entire process between the patient and the analysis result. This phase includes the indication, informing and identifying the patient, sample collection with subsequent transport, and storage until centrifugation and sample distribution. In short, it involves a large number of different steps and areas. 1 Guder et al.; Proben zwischen Patient und Labor; 2009 The range of possibilities for influencing and changing analytical results during individual steps in this process is correspondingly large. Note: About 25% of errors in preanalytics have consequences for the patient! It is all the more important for every participant to be informed of the potential influences and sources of error, so that with this awareness they can act appropriately in order to avoid errors. After all, a test result can only be as good as is permitted by the patient sample obtained. 1 What are preanalytics? 8 9 1.2 Common consequences of preanalytical errors Can values be changed during blood collection? Common errors Note: 70-85% of clinical decisions are based on the results of laboratory analyses!3 3 Foubister, Vida. Cap Today Bench press: The Technologist/technician shortfall is putting the squeeze on laboratories nationwide September 2000; Datta, P. Resolving Discordant Samples. Advance for the Administrators of Laboratories; July 2005: p.60. Haemolysis 44 %2 Underfilling 17 %2 Blood clot 8 %2 2 Adapted from: Bonini et al; Errors in Laboratory Medicine; Clin Chem 48:5; 691-698 (2002) 1.3 Communication as a key to success Communication between those persons involved in blood collection facilitates work procedures, avoids misunderstandings and prevents preanalytical errors due to missing or incorrect information. Note: Problems in the area of preanalytics can never be resolved by a single individual but only by close cooperation of the persons involved such as doctors, medical assistants, nursing personnel or the laboratory. Aim Standardised conditions for … Preparing for the blood collection Blood collection procedure Storage/transport to the laboratory Result Safety for patients Process cost reduction (working time!) Patient Medical laboratory Attending physician 10 11 “From blood collection and the generation of plausible analysis results to result interpretation, it is absolutely essential to have detailed knowledge of influencing factors and interfering factors, and take them into consideration.” 2.1 Influencing factors What responsibility does the patient bear? Correct details from their medical history Medication (list, possibly discontinue) Nutrition (particular diet, fasting) Correct collection (blood, urine, faeces, etc.) For correct details concerning medical history, it is important that appropriate questions are asked before sample collection. Taking into account possible influencing factors is important because: Influencing factors change the concentration of analytes. The effect on the concentration depends on the medical condition and must be considered when evaluating the results. The list of influencing factors and interfering factors in the following section is not exhaustive. Various examples are presented to illustrate the issues. 2 Influencing factors and interfering factors 12 13 4 Seelig et al; Präanalytik; 2008 -20 0 20 40 60 80 100 Triglycerides Leucocytes CHOL AP Iron Total protein +100 % Deviations in % Age With increasing age there is often an increase in the cholesterol value in both sexes. The activity of alkaline phosphatase in blood plasma is influenced by bone metabolism and is therefore highest in children during the growth phase and after bone fractures. In infants there are higher bilirubin, haematocrit and HbF levels (for more examples see Section 5 – Blood collection in paediatrics). That is why age-dependent reference ranges are desirable, but often non-existent, for many parameters. Biological rhythm Vitamin D production (25-OH) fluctuates over the course of a year. In summer, higher UV levels mean that more vitamin D is synthesised than in winter. 5 Sarstedt; Tips & Techniques in Preanalytics; 2014 5 Sarstedt; Tipps & Tricks in der Präanalytik; 2014 300 250 200 150 100 50 0 mg/dl 15 25 35 45 55 65 Years Cholesterol LDL HDL 2.1.1 Non-modifiable influence factors Population (Race) Significant differences in blood values can be found in African populations when compared with European populations. In African populations: - Leucocyte counts are significantly lower - The vitamin B12 concentration is 1.35 times higher - The reference ranges for creatinine, CK and alpha amylase are much higher In Asians the activity of alcohol dehydrogenase is lower than in Europeans. There is also a higher level of lactose intolerance in the Asian population. Gender Apart from other gender-specific components (e.g. hormones) muscle mass has an impact on various parameters. - CK and creatinine are dependent on muscle mass so men are usually found to have much higher levels - For many parameters it is appropriate to use gender-specific reference ranges Pregnancy There is a 5-fold increase in the erythrocyte sedimentation rate during pregnancy.1 1 Guder et al.; Proben zwischen Patient und Labor; 2009 14 15 Circadian rhythm Also known as rhythmical daily fluctuation, referring to expected differences in concentration throughout a day for certain clinical chemistry parameters and endocrinological parameters (e.g. renin, cortisol, adrenaline, noradrenaline, VMA and TSH). With such parameters the time of collection is of fundamental importance. Follow-up measurements should always be collected at the same time of day. As a rule, the time of the collection must be documented and communicated to the laboratory. Alternatively, 24 hour composite samples (e.g. urine or saliva) can be useful to establish comparable results. Cortisol as a stress indicator is a familiar example. The highest cortisol concentration can be measured in the mornings. 2.1.2 Modifiable influencing factors Drug use In the case of regular drug use, e.g. cannabis, heroin or morphines, clinical chemistry parameters can change in the blood. Below are some examples of these changes: With cannabis use the levels of chloride, urea, insulin, potassium and sodium increase in the blood. In contrast, glucose, uric acid and creatinine levels fall. The levels of cholesterol, potassium and thyroxine increase during heroin use. During the intake of morphines there is a rise in ALT, amylase, AP, bilirubin, lipase, prolactin and TSH. Insulin and noradrenaline decrease during morphine use. 5 Sarstedt; Tips & Techniques in Preanalytics; 2014 Note: The circadian rhythm (the biological clock) can be disrupted by travelling to different time zones and/or shift work. If parameters have been affected by daily rhythm, this issue should be included in questions concerning medical history. 30 25 20 15 10 5 0 μg/dl 0 6 12 18 24 Cortisol 4 Seelig et al; Präanalytik; 2008 3 Seelig et al; Präanalytik; 2008 -GT AST Noradrenaline Adrenaline Cortisol Triglycerides CHOL VMA LDL -50 0 50 150 250 350 450 +1000 % Deviations in % Deviations in % -60 -40 -20 0 20 40 60 80 ACE Prolactin -carotenoids Pyridoxal phosphate Selenium HDL cholesterol LDL cholesterol Cholesterol Haematocrit MCV Fibrinogen Copper MCHC Cadmium Monocytes Lymphocytes Granulocytes CEA Substance use: Alcohol Chronic alcohol abuse causes an increase in liver enzymes, e.g. -GT, AST/ALT whilst folic acid and vitamin B6 values decrease. Substance use: Nicotine Chronic nicotine use increases the counts of leucocytes, tumour markers such as CEA (highly significant in men) and placental AP (PLAP). 16 17 Physical activity Physical activity, as compared with the condition at rest, can cause an increase in various clinical chemistry parameters in the blood. Analyte Change in % Fasting Standard meal Albumin, total protein - 10 +5 Bilirubin +15 Calcium +5 -glutamyltransferase ( -GT) - 50 Glucose +15 AST (GOT) +30 +20 ALT (GPT) +10 Uric acid +20 +5 Urea - 20 +5 Potassium +10 Creatinine +20 Phosphorus +15 Triglycerides - 40 Substance use: Caffeine Even 200 mg caffeine (2 cups robusta coffee or 2-4 cups arabica coffee) increases levels of adrenaline, noradrenaline and cortisol (cortisol +40%). Medication use Under the influence of penicillin and ibuprofen, the level of potassium in plasma can increase, whilst under the influence of insulin it decreases. With penicillin use, the thromboplastin time (Quick) increases. Due to the intake of acetylsalicylic acid (ASA) the levels of AST (GOT), ALT (GPT), creatinine and uric acid rise, depending on the dose. The medication phenobarbital, which is used to treat epilepsy and for anaesthesia induction, has an enzyme-inducing effect. The activity of AP and y-GT increases whilst bilirubin concentration in the blood decreases. Diuretics also have an effect on the electrolyte balance. This is seen, dependent on the substance class, in the levels of potassium, calcium and magnesium, for example. If pantoprazole (proton pump inhibitor) has been administered, the concentration of calcium in the blood may be reduced. Laxatives can lead to a reduction in potassium. Effect of body position The distribution of water in the body depends on the position of the body. This leads to parameters such as blood cells, proteins and substances bound to proteins being more concentrated in seated patients than in lying patients. Diet-related changes Changes in analyte concentrations with 4 weeks of fasting or after a standard meal of 800 kcal. 4 Seelig et al; Präanalytik; 2008 5 Sarstedt; Tips & Techniques in Preanalytics; 2014 HDL cholesterol Haematocrit Erythrocytes Aldosterone Adrenaline Renin 0 10 20 30 40 50 60 Increase in % Creatine kinase (CK) Pyruvate kinase AST (GOT) Urea Uric acid Inorg. phosphate Glucose Albumin Calcium Alk. phos. Sodium Potassium x-fold increase in the values 5 Sarstedt; Tips & Techniques in Preanalytics; 2014 1 2 3 4 5 Physical activity in this case refers to exceptional physical stress. For healthy people, this can be a marathon whereas for bedridden patients just the journey to the clinic can count as exceptional physical stress. 18 19 2.2 Interfering factors Interfering factors can alter test results and cause disruptions, depending on methods used. By changing the test method it may be possible to eliminate interfering factors. A B C D Image Description Possible cause A Lipaemia Disease-related or patient did not fast B Jaundice Syndrome or disease-related C Haemolysis Preanalytical error or disease-related D Normal Good and correct preanalytical conditions Interference factors are classified as internal (endogenous) or external (exogenous). Examples of interference factors are described below: Internal interference factors (endogenous) Cause Consequence - Gilbert’s syndrome - Crigler-Najjar syndrome - Acute hepatitis - Acute liver failure Hyperbilirubinemia = jaundice Possible disruption, e.g. in cholesterol, creatinine, uric acid - Spherocytosis - Immune haemolysis - Haemolytic antibodies - Haemoglobinopathy Haemolysis Significant falsification of a large number of methods of optical measurement Higher measurements due to the release of erythrocytes (e.g. potassium, LDH, AST) - Hyperlipoproteinemia - Lipid metabolism disorder Lipaemia Patient not fasting at time of blood collection Significant distortion of a large number of methods of optical measurement False-low levels in electrolyte analyses (sodium, potassium) due to dilution effect - Haematocrit > 65% Elevation of PTT and aPTT6 - Haematocrit < 20% Reduction in PTT and aPTT 6 G. Endler et al; The importance of preanalytics for the coagulation laboratory; Hämostaseologie 2/2010; 30: 63-70 External interference factors (exogenous) Cause Consequence - Medication (infusion solution, antibiotics, blood products) - Anticoagulants (contamination due to carryover from preparation) - Contamination (bacteria, fungi, bacterial biofilm from CVC for blood culture) False measurements (elevation and reduction possible) - Cycling or riding Can increase the PSA value 20 21 “Venous blood is the most important material tested to answer medical questions. Correct blood collection technique is thus of considerable significance.” 3.1 Patient preparation Informing the patient Informing the patient about the forthcoming procedure helps to alleviate possible anxiety and stress. Explaining certain regulations that must be complied with should supplement the patient information, e.g. Use of medications Adherence to a particular diet Sample collection when fasting (except for emergency diagnostics) Children in particular require careful preparation but the information must be adapted to their ability to understand. 3.2 What is the responsibility of the person collecting the blood? Organisation of the blood collection Correct documentation (patient identification and time of day) Instructing and preparing the patient for the sample collection Preparation of the sample (centrifugation if necessary) Storage until collection (refrigeration/heating if necessary) Note: Communication with the laboratory and, where necessary, with the transport service is essential for the transport and correct storage! You can find more information in Section 10 – Transport & storage. 3 Venous blood collection 22 23 3.3 Identification Patient identification Surname First name Date of birth Possibly: admission number, ward, room number Errors occur not only with common names. Important: Always ask direct questions. Never: “You are Mr Miller?” When asked of patients who are partially/completely deaf or cognitively impaired, such questions may be simply answered with an affirmative nod. The person seated on the side of the bed may just be a visitor. If the identity of the patient is not clear, samples should not be collected until there is further clarification. Identification of the person collecting the blood It must be possible to determine the identity of the person who collected the sample. Place identification on the request form if appropriate Questions about the type and time of the collection, the patient’s condition and other important details may be of use in case of unclear results. Identification of the ordering doctor The identity of the requesting doctor makes it possible to ask questions in the event of illegible requests (e.g. referral notes) erroneous requests (e.g. prostate phosphatase for a female patient) restriction to the most relevant analyses if the volume of the sample material is too small Identification of the sample Never analyse sample containers that are not clearly identified. Barcode labels enable reliable identification. Identification should always be placed on the primary receptacle. Use only waterproof felt-tip pens for glass or plastic containers. Additives (anticoagulants, clot activators, gel) are identified by colour coding of the sample container. A lack of international standardisation means that additional identification may be necessary. Never use the lid, outer packaging or transport container to identify the sample. 24 25 Legal requirements & labelling The submitted analysis material and any parts of this material must be able to be clearly assigned to one patient. If this is not possible, the material must not be processed by the medical laboratory. 7 RiLiBÄK; § 6.1.7. Part A Sample tubes are correctly labelled if: the contents are still freely visible it is possible to check the filling volume the screw cap can be easily removed the tube and label do not get stuck or stick together in the centrifuge 3.4 Application Preparation Application Serum Clinical chemistry, serology, special analyses Serum gel Clinical chemistry, serology (only routine diagnostics) Lithium heparin Plasma collection for clinical chemistry, serology EDTA K Haematology (e.g. Hb, Ht, erythrocytes, leucocytes) Citrate 1:10 Coagulation analyses (e.g. Quick, PTT, TT, fibrinogen) Citrate 1:5 BSG determination according to Westergren or S-Sedivette® Fluoride Glucose determination Lactate GlucoEXACT Glucose determination (48 h stability, at RT) Solution: Label sample tube with the barcode immediately before collecting the blood. ® Name ® Name Name ® Name Name 26 27 3.5 Order of draw In the past, the correct order of draw was repeatedly and intensively discussed. The latest findings and studies show that when using a modern blood collection system, carryover of additives is highly unlikely with proper handling of a closed blood collection system. For example, when collecting with the Safety-Needle and the S-Monovette® , no carryover of EDTA is detected.8 In case of carryover of EDTA into a serum or heparin tube, potassium may be elevated and calcium lowered, for example.9 To ensure the greatest possible safety even for the worst possible conditions during blood collection, we nevertheless recommend adhering to one of the following drawing orders: 8 RA Sulaiman, Effect of order of draw samples during phlebotomy on routine biochemistry results; J Clin Pathol. 2011 Nov;64(11):1019–20 9 RR Calam et al; Recommended “Order of Draw” for Collecting Blood Specimens into Additive-Containing Tubes; Clin. Chem.; Vol. 28, No. 6, 1982 Recommended order of draw 10 Gurr et al “Musterstandardarbeitsanweisung Präanalytik” J Lab Med 2011 11 CLSI Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture, Approved Standard, 6th edition GP 41-A6 (former H3-A6), 27 (26) 2007 According to Gurr10 : Blood culture Serum/Serum-Gel blood Citrate blood Heparin/Heparin-Gel blood EDTA blood Fluoride/Citrate-fluoride blood According to CLSI11 : Blood culture Citrate blood Serum/Serum-Gel blood Heparin/Heparin-Gel blood EDTA blood Fluoride/Citrate-fluoride blood 3.6 Avoiding underfilling To avoid erroneous measurements or rejection of samples in the laboratory due to underfilling, a precise filling volume is necessary. This should be taken into account for all preparations. Precise filling of the blood collection system is of particular importance for citrate tubes for coagulation analyses. Underfilling here results in an excess of citrate in the tube (ratio of blood to preparation). Because citrate binds calcium, more calcium will thus be bound than is expected. This has a direct effect on the analysis results. If when collecting blood with a Safety-Multifly® -Needle, citrate blood is collected first, this leads to underfilling due to the dead volume in the tubing. Note: The longer the tubing used, the greater the underfilling Dead volume = volume in the tubing: 30 cm tubing: > 450 μL 20 cm tubing: > 300 μL 8 cm tubing: > 120 μL Therefore, to fill/vent the tubing, a tube (citrate/neutral) is first used and then discarded (empty tube/discard tube). Only then is the actual citrate tube to be used. Underfilling! 28 29 4 Carrying out venous blood collection “The technique for venous blood collection – step by step – for correct procedure in the clinic” 4.1 Standard conditions for blood collection No unusual, extreme physical activities in the 3 days prior to blood collection No alcohol excess on the day before (abstain from alcohol for 24 hours) Fasting between 7 pm and 9 am (i.e. no eating for 12 to 14 hours, drinking water is allowed) Rest for at least 10 minutes before the blood collection (sitting or lying) Avoid pumping! Opening and closing the fist leads to a considerable increase in the potassium level (up to 2 mmol/L) Apply a tourniquet for a maximum of 1 min. (better 30 seconds) Puncture vessel, loosen tourniquet, collect blood Medications: in consultation with the doctor, take or discontinue 4.2 Obtaining diagnostic samples: 12 steps 1. Disinfect hands! Wear gloves! 2. Apply tourniquet 3. Observe veins and select one 4. Disinfect! 5. Do not touch the puncture site again! 6. Remove the protective sleeve from the Safety-Needle! 7. Face the bevelled edge of the needle upwards! 8. Keep the puncture angle less than 30°! 9. Pull the skin until it is taut, fix the vein! 10. Possibly forewarn the patient! 11. Loosen the tourniquet when the blood starts to flow! 12. Collect sample; note the order of draw! 30 31 -5 0 5 10 15 Cholesterin TG Kalium Natrium Kreatinin CK AST, ALT GGT Glucose Bilirubin Eisen, Calcium Protein, Albumin, 2 4 6 A 4.3 Tourniquet application & puncture sites Disinfect in accordance with a valid hygiene plan Apply the tourniquet one hand’s width above the puncture site The pulse must be perceptible (tourniquet pressure: 50-100 mmHg) Maximum constriction time: 1 min. Puncture sites Basilic vein Median cubital vein (this refers to the non-blue translucent, thick, deep vein that is only visible as a bulge at this point) Cephalic vein, runs on the thumb side Cephalic vein Basilic vein Dorsal venous network of hand 1 2 3 4 6 5 A hand’s width above the puncture site Stasis time Stasis lasting longer than 1 minute can lead to shifts in the concentration of measurements. In the case of high-molecular substances (e.g. total protein) and protein-bound calcium, false-high measurements can occur (generally very relevant for parameters with relatively narrow reference ranges). Potassium levels can drop as constriction time increases. Comparison – 2 min stasis versus 6 min stasis 12 Lichtinghagen et al.: Einfluss der Stauzeit auf normalisierte Laborwerte; J Lab Med 2013; 37(3): 131–137 Constriction time (min) Bilirubin Cholesterin Iron, ALT Protein, GGT Albumin,CK AST, TG Calcium Creatinine Natrium Glucose Potassium Medicaldeviationoft0 in% 32 33 4.4 Problems before/during blood collection Very difficult vein conditions Look for another puncture site Apply a heat pack or warm cloth Use Safety-Multifly® needle Use the aspiration method to collect the blood 4.5 Aspiration and vacuum technique 4.5.1 S-Monovette® aspiration technique Stopping blood flow during collection Needle opening is up against the vein wall Solution: Withdraw the needle slightly until the flow is restored. Needle has pierced the vein Solution: Withdraw the needle slightly until the blood flow is restored. Vein has collapsed Solution: Wait until the vein has recovered, then carefully aspirate. Pumping the fist leads to an increase in K+ and Mg2+ due to muscle activity Extended stasis changes parameters such as K+ , -GT Bending the Safety-Needle is not necessary when using the S-Monovette® system because the penetration angle is very flat. Changing the lumen by bending the needle can damage cells (haemolysis). Haemolysis can also be caused by using a needle that is too narrow. IMPORTANT: Just before puncturing the skin, lock the Safety-Needle to the S-Monovette® by twisting it slightly clockwise. Use the thumb of the free hand to pull the skin taut. Hold the vein in place. Forewarn the patient and puncture the vein. As soon as the vein is successfully punctured, the first drop of blood enters the S-Monovette® . This lets the user know that the vein has been reached. Loosen the tourniquet and slowly withdraw the plunger. Wait until the blood flow stops. 34 35 Change the S-Monovette® for multiple collections. Remove the S-Monovette® from the Safety-Needle by turning it slightly anticlockwise. The needle remains in the vein. After blood collection First remove the S-Monovette® and then withdraw the Safety-Needle from the vein. Click Snap SNAP! CLICK! IMPORTANT: For all S-Monovettes, when blood collection is complete, withdraw the plunger into the “snap” position and break off. Pull the plunger straight back until the piston locks in with an audible CLICK. Pull the piston right out to the end Only then should you break the plunger off. SNAP! 36 37 Click Snap The Safety-Needle must already be in the vein before the collection. As a rule, we recommend filling the first S-Monovette® with the aspiration technique so that the blood collection starts gently. The collection can then continue using the vacuum technique. Immediately before blood collection, pull the plunger back and lock the piston into the base of the S-Monovette (“click”). Then break off the plunger (“snap”). Push the evacuated S-Monovette® onto the Safety-Needle and secure by twisting clockwise. Wait until the blood flow stops, remove the S-Monovette® from the Safety-Needle and then remove the Safety-Needle from the vein. 4.5.2 S-Monovette® vacuum technique 4.5.3 A summary of the 2 collection techniques Aspiration technique Vacuum technique 38 39 4.6 Blood collection from catheters Blood collection from catheters should be avoided due to possible distortion of measurements. Haemolysis and contamination from infusions are possible risks. However, if blood collection from a catheter is unavoidable, comply with the following: To avoid dilution effects and contamination, at least 15 minutes should elapse between the last infusion and the blood collection. The time depends on the infusion and should comply with internal hospital regulations.6 Recommendations for the time of blood collection after infusions1 If the catheter has been rinsed with solution containing heparin, it should be rinsed with saline before blood collection for coagulation analyses.13 Before the blood collection, at least 5-10 ml of blood should be discarded. To avoid any mix-ups, this tube should be appropriately labelled.13 As a rule, a note to the laboratory that the sample was collected from a catheter can simplify the interpretation of any implausible analytical results. For therapeutic drug monitoring (TDM), the risk of a contamination must be noted in particular. See page of traces of medication can lead to erroneously high results. 1 Guder et al; Proben zwischen Patient und Labor; 2009 6 G. Endler et al; The importance of preanalytics for the coagulation laboratory; Hämostaseologie 2/2010 13 M. Spannagl et al; Hämostaseologische Globaltests; Hämostaseologi 1/2006 Infusion Earliest time (hours) for blood collection after ending the infusion1 Lipid emulsion 8 Carbohydrate-rich solution 1 Amino acids, protein hydrolysate 1 Electrolytes 1 Haemolysis risk factor: Catheter With blood collection from catheters, the vacuum technique is not recommended due to the high flow velocities of the blood. This is associated with a high risk of haemolysis.14-17 Using the aspiration technique, slow, gentle filling18 of the S-Monovette® is possible. This greatly reduces the risk of haemolysis. 14 Margo A et al.; Obtaining blood samples from peripheral intravenous catheters: best practice; AJCC, 9.2009, 18 (5) 15 Lippi et al.; Prevention of hemolysis in blood samples collected from intravenous catheters; Clin Biochem 46: 561–564, 2013 16 Heyer et al.; Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory medicine best practices systematic review and meta-analysis Clin Biochem 45: 1012-1032, 2012 17 Grant MS; The Effect of Blood Drawing Techniques and Equipment on the Hemolysis of ED Laboratory Blood Samples; J Emerg Nurs 29:116-121, 2003 18 Benso S; Can a blood sample for diagnostic exams be drawn from a peripheral venous catheter?; Assist Inferm Ric; 34(2):86-92; Apr-Jun 2015 Multi-Adapter – the direct connection The S-Monovette® can be directly connected to the catheter with the Multi-Adapter. The use of single-use syringes and the associated risk of haemolysis and crosscontamination can be avoided. The Multi-adapter can be connected to the S-Monovette® with Luer connections, e.g. in vitro catheter or three-way stopcock. 40 41 4.7 Blood collection for blood culture diagnostics Sepsis is known colloquially as blood poisoning. What is not as well known is that the mortality (lethality) is about 50%19 . Common symptoms: Apathy/weakness Fever, chills Confusion Laboured and rapid breathing Rapid pulse, low blood pressure Cold hands and feet with poor blood flow (centralisation) Sepsis is an emergency that requires the earliest possible diagnosis and immediate treatment: international and national treatment guidelines stipulate administration of antibiotics within one hour. Before administering antibiotics, at least 2 blood cultures must be collected. It is recommended to collect the blood at the start of a fever episode from a peripheral vein. Blood collection from a venous access (e.g. CVC) is not suitable. The validity is affected to a high degree by the avoidance of contamination, the transport time, storage conditions and communication of clinical information.21 The following information should be communicated to the laboratory20 : Site of collection Date of collection Patient identification Suspected diagnosis Details of the ongoing antibiotic therapy if applicable 19 Pschyrembel; 2004 20 J. P. Borde et al; Abnahme von Blutkulturen; Dtsch Med Wochenschr; 135:355-358; 2010 21 Simon et al; Blutkulturdiagnostik – Standards und aktuelle Entwicklungen; J Lab Med; 36(4):199–207; 2012 21 Simon et al; Blutkulturdiagnostik – Standards und aktuelle Entwicklungen; J Lab Med; 36(4):199–207; 2012 4.7.1 Hygiene requirements False-positive blood cultures result, as a rule, from improper hygiene measures and may be associated with extended hospitalisation, unnecessary antimicrobial therapy, additional diagnostics and considerable extra costs.21 Blood collection using blood culture flasks must be done in accordance with the hygiene requirements. To avoid contamination, the following steps are necessary: 1. Hygienic hand disinfection 2. Wear gloves 3. Disinfection of the puncture site (e.g. with 70% isopropyl alcohol or skin disinfectant) a. Apply the disinfectant and distribute by wiping b. Apply disinfectant again and let it dry for 60 seconds Important: After the skin disinfection, do not palpate the puncture site again. 4. Disinfect the blood culture flasks a. Remove the cap b. Disinfect the rubber septum 42 43 4.7.2 Handling during blood collection 1. Carry out the hygiene steps listed above. Connect the universal blood culture adapter to the guide sleeve of the Safety-Multifly® needle. Puncture the vein and fix the needle in place. 4. You can then carry out the blood collection in the usual manner with the Safety-Multifly® needle. 2. Insert the blood culture flask in an upright/ vertical position into the holder. The culture medium of the flask must not contact the lid of the blood culture flask. Because of the vacuum in the blood culture flask, it fills automatically. Note: Note the filling volume. 3. If additional blood collections are required with the S-Monovette® , remove the universal blood culture adapter from the guide sleeve of the Safety-Multifly® needle. Important: The manufacturer’s instructions for handling the blood culture flasks must be followed. After the blood collection, the contents must be carefully mixed. Do not aerate the flask as this is not necessary. The inoculated flask must be sent at room temperature to the laboratory as quickly as possible. 4.7.3 Sample volume and number of flasks Note: The blood volume should be checked during the collection using the scale. The vacuum volume of the flask may be larger than the required filling volume. Marking the filling level on the flask before the collection simplifies checking the blood filling volume during the collection. The sensitivity of the blood culture diagnostics depends on the number of pairs collected and the sample volume. There are different recommendations regarding blood volume, number of blood culture pairs and the use of aerobic and anaerobic flasks. Always follow the manufacturer’s information for this reason. 2 2 21G 21G 21G 1 2 21G 1 2 1 1 1 2 44 45 5 Blood collection in paediatrics “Paediatric and neonatal patients have special needs and place high demands on personnel and collection systems” Paediatrics Paediatrics is the branch of medicine dealing with children and adolescents. An important focus of paediatrics is neonatology, the treatment of premature infants. Premature infants are viable from week 23 of pregnancy provided the infants have a birth weight of about 500 grams. These small patients have special needs and place high demands on personnel and collection systems. 5.1 Medical history24 The details of the paediatric medical history are obtained by asking a third party, usually a parent or legal guardian. School-aged children should always be asked directly. The medical history should include the following information Details of the current illness The complete medical history of the child Details of the pregnancy and birth The medical history of the families of the parents Important: A child may still present in relatively good general condition despite a life-threatening disease. The patient may deteriorate during the recording of the medical history, the clinical examination or even after hospitalisation. 24 Speer et al; Pädiatrie; 2013 46 47 5.2 Prerequisites for blood collection Between 7 months and 3 years of age, resistance from the child may prevent normal blood collection. To ease the situation, the following tips may help: Shorter waiting times Bright, warm and child-friendly rooms with toys for all ages Small gifts (particularly plasters, bravery awards, etc.) Friendly, understanding atmosphere If necessary, treat the child on the parent’s lap Warm hands and equipment Consider feelings of embarrassment even in childhood 5.3 Blood collection in paediatrics The total blood volume of a healthy neonate is about 300 ml. A premature infant of 1,000 g has a total blood volume of about 80 ml. Because of this small volume, it is essential to collect as little blood as possible while still ensuring as much blood as necessary is collected. In addition, sample collection from premature infants, neonates and infants can be problematical. Choosing the correct collection technique combined with suitable sample tubes eases these difficult conditions as much as is possible. 5.3.1 Venous blood collection For venous blood collection, there is a choice between closed venous blood collection and the drip technique (e.g. from a cephalic vein). Closed venous blood collection Thanks to the option for gentle blood collection using the aspiration technique (see Section 4 – Carrying out venous blood collection), the S-Monovette® combined with the short Safety-Multifly® needle is the optimal solution for difficult vein conditions in paediatrics. Puncture site Premature infant Neonate Infant Toddler School child Cephalic vein Only if < 1 week Recommended Recommended - Brachial vein Perhaps Perhaps Perhaps Recommended Recommended Back of hand Recommended Recommended Possible Recommended Recommended Top of foot Recommended Recommended Possible Perhaps (painful) - 48 49 Drip blood collection The Micro-Needle combined with the prepared Micro Tubes simplifies blood collection from the cephalic vein. Difficult handling of broken Luer needles is no longer necessary. Broken needles are small, cumbersome and may cause haemolysis (formation of burrs in the needle). Handling the Micro-Needle 1. Remove the protective cap. 2. Remove the Micro-Needle from the protective sheath. 3. Disinfect the puncture site. Puncture the vein and drip the blood into a prepared Micro Tube. If the blood flow stops, the Micro-Needle can be safely rotated by 360° using the handle. 4. Place the Micro-Needle in a suitable disposal box. 5.3.2 Capillary blood collection For capillary blood collection, the Neonatal Safety Lancet or the Safety Incision Lancet can be used depending on the patient and the blood volume required. Comparison of the Safety-Lancet and the Safety Incision Lancet Standard Lancet: Vertical firing direction of the blade Cylindrical puncture Haematoma formation Incision Lancet: Crescent-shaped incision path Shallow penetration depth Minimises formation of haematoma Safety-Lancets Mini and Neonatal are suitable for collecting small or medium to high volumes of blood, as required. If there is a risk of bone injury, however, Incision Lancets are recommended because these have a shallower penetration depth. Design Penetration depth Needle size Blood volume Neonatal 1.2 mm Blade 1.5 mm Medium to high Mini 1.6 mm Needle 28 G Low 50 51 Product range – Safety Incision Lancet Thanks to the special puncture technique, optimal blood flow with a high blood volume is possible even with a shallow penetration depth. The shallow penetration depth ensures rapid healing and minimises the formation of haematomas. Microvette® Microvette® – Collection methods To meet the specific requirements of capillary blood collection, there are two collection techniques available: Capillary method using the end-to-end capillary Gravitational principle using the collection rim Note: Letting blood drip into a capillary tube by means of a Luer needle does not constitute capillary blood collection. Handling the Safety Incision Lancet 1 2 3 4 5 EDTA 200 6 Design Application Penetration depth Incision length Neonates 1.0 mm 2.5 mm Premature infants 0.85 mm 1.75 mm Select and disinfect a suitable puncture site. After pressing the firing button, remove the lancet from the heel. Dispose of the lancet in a suitable disposal box Discard the first drop of blood. Then fill the capillary tube. Remove the safety mechanism by pressing sideways with the thumb. Lift the foot into a suitable position. Press the blade opening flat against the selected and disinfected puncture site and press the trigger button. The safety incision lancet must always be positioned and triggered parallel to the length of the foot (never across the heel)! The triangle points to the blade exit point. Depending on the requirements, Microvette® tubes with a cylindrical or conical inner tube shape and a volume range of 100 to 500 μl are available. There is the option to collect capillary blood using the capillary technique or the collection rim. The special cap design minimises any aerosol effects when the tube is opened. 5.4 The difference between capillary blood and venous blood Taking into account the sample material is important for assessing the analytical results. Between capillary blood and venous blood there are differences in the concentration of various parameters. For example, the serum concentrations of total protein, bilirubin, calcium, sodium and chloride are significantly lower in capillary blood compared to venous blood.23 Glucose, lactate and CK, however, have higher levels of concentration in capillary blood than in venous blood. 23 Kupke et al; On the composition of capillary and venous blood serum; Clin Chim Acta. 112(2):177–85; 5 May 1981 Collection 52 53 5.5 Reference ranges Depending on the age of the child, concentrations of analytes in different ranges are normal compared to adults. For this reason, it is important to always assess the analytical results relative to the age-appropriate reference/standard ranges56 . Some parameters are shown in the following table as examples. 56 Kohse et al.; National and international initiatives and approaches for the establishment of reference intervals in pediatric laboratory medicine; J Lab Med 2015; 39(4): 197-212 Analyte Sample source SI Conventional Remarks Bilirubin (total) μmol/L mg/dL Indirect bilirubin in neonates may be elevated due to increased breakdown of erythrocytes. Value > 16-18 mg/dl risk of kernicterus. In neonates, direct photometric measurement is possible, direct bilirubin cannot be detected in healthy children. Neonate Day 1 < 68 < 4 Day 2-3 < 154 < 9 Day 3-5 < 239 < 13-14 Infant 1.7-14 0.1-0.8 Adult 1.7-22 0.1-1.3 Lactate mmol/L mg/dL Neonates can have higher values on day 1. Elevated in mitochondriopathy, tissue hypoxia, etc. Child/Adult 0.5-2.2 4.5-20 Creatinine Neonate μmol/L mg/dL Values depend on muscle mass; women have lower values. Creatinine concentration in the serum only increases when the glomerular filtration rate is < 50%. Day 1 37-113 0.41-1.24 Week 1 14-86 0.15-0.95 Week 4 12-48 0.13-0.53 Infant 22-55 0.24-0.61 Toddler 25-64 0.28-0.70 Children 23-106 0.25-1.17 Adult 74-110 0.81-1.21 Analyte Sample source SI Conventional Remarks Erythrocytes Tpt/L (1012 /l) 106 /μl Rapid breakdown after birth. Elevated (polycythaemia) with dehydration and with/ after sustained high levels. Neonate Week 1 3.9-6.5 3.9-6.5 Neonate Week 2 3.6-5.8 3.6-5.8 Infant 3.0-5.4 3.0-5.4 Toddler Child 4.0-5.4 4.0-5.4 Adult (m) 4.5-5.9 4.5-5.9 Adult (f) 3.9-5.2 3.9-5.2 Haematocrit(HCT/Ht) Fraction I/I % Ht elevated with dehydration, lowered with hyperhydration Neonate 0.45-0.65 45-65 Infant 0.30-0.55 30-55 Toddler Child 0.31-0.48 31-48 Adult (m) 0.39-0.52 39-52 Adult (f) 0.35-0.47 35-47 Haemoglobin(Hb) mmol/l g/dl Neonate Week 1 9.3-13.7 15-22 Neonate Week 2 7.8-12.4 12.5-20 Infant 5.9-9.9 9.5-16 Toddler / Child 6.8-9.9 11-16 Adult (m) 8.1-11.2 13-18 Adult (f) 7.5-9.3 12-15 54 55 Analyte Sample source SI Conventional Remarks Platelets Gpt/l (109 /l) 103 Cells/μl Thrombocytopenia e.g. due to mumps 30 Gpt/L: increased bleeding tendency. Neonate 100-250 100-250 Toddler 220-500 220-500 Children 150-350 150-350 Adult 150-400 150-400 Leucocytes Gpt/l Cells/μl Changes in the leucocyte count during the first weeks of life/year. Increases (leucocytosis) are usually caused by elevated numbers of neutrophil granulocytes. Neonate Day 1 9-35 9,000-35,000 Neonate Weeks 1-4 5-20 5,000-20,000 Infant/Toddler/ Child 5-18 5,000-18,000 Adult (m) 4-10 4,000-10,000 24 Speer et al; Pädiatrie; 2013 5.6 Haemostasis in paediatrics Some components of the coagulation system change in childhood and dramatically so, particularly in the first year of life, to adapt to the change in conditions. Reduced thrombin formation with a simultaneous reduction in thrombin inhibition is a protective mechanism in neonates. As a rule, neonates have considerably lower values for most coagulation factors than an adult. The reduced liver synthesis rate in the neonate is usually considered responsible but an accelerated turnover is also a possibility, particularly regarding the birth. Many components reach adult reference values after 1 year of age. Antithrombin is about 10% higher compared to an adult from 1 month of age and into childhood. Values for aPTT are generally longer in childhood than in adults. Factor II and VII remain about 10-20% lower. Note: There are a number of special physiological characteristics of children of which the user must be aware so that they can be reliably differentiated from pathological changes. Age-related reference values (example reference value) * measured with Pathromtin SL 22 Barthels et al; Das Gerinnungskompendium; 2012 Age aPTT [s]* Age Antithrombin [%] D-dimers [μg/L] 1-3 Months 39 (28-49) 1 day 76 (58-90) 1470 (410-2470) 4-6 Months 36 (31-44) 3 days 74 (60-89) 1340 (580-2740) 7-12 Months 35 (29-42) 1-12 months 109 (72-134) 220 (110-420) Up to 4 years 33 (28-41) 1-5 years 116 (101-131) 250 (90-530) 5-9 years 34 (28-41) 6-10 years 114 (95-134) 260 (10-560) 10-18 years 34 (29-42) 11-16 years 111 (96-126) 270 (160-390) Adults 31 (26-36) Adults 96 (66-124) 180 (50-420) Due to a physiologically higher haematocrit, the quantity of plasma in neonates is lower. Haematocrit correction is not necessary here because the age-related reference values were determined under these conditions and a correction therefore does not have to be made. What is important is that sufficient sample material is collected for the required analyses in light of the low plasma yield. 56 57 6 Blood gas “It is also true for blood gas that the better the preanalytics, the more meaningful the result” 6.1 Type of blood collection Blood gas collection and blood gas analyses are carried out in many different areas such as emergency admissions, intensive care units, outpatient clinics, operating areas, cardiac catheterisation and pulmonary diagnostic laboratories. Because the parameters have different concentrations depending on the blood vessel (pCO2 is higher in venous blood, the concentration of pO2 and sO2 is lower in venous blood than in arterial), the puncture site for the sample should be noted and taken into account (e.g. arterial access, CVC, peripheral artery).25 Arterial blood should always be the material of choice. For children, arterialised capillary blood is often taken from the earlobe or fingertip or for infants from the side of the heel. For ventilated patients, the setting of the ventilation equipment should also be noted and taken into account. 25 Michael D Davis RRT et al.; AARC Clinical Practice Guideline: Blood Gas Analysis and Hemoximetry: Respiratory Care; 58(10); Oct. 2013 Important: For calcium measurement using blood gas analysers (ISE method), calcium-titrated heparin (balanced, equilibrated) as in the blood gas capillaries and the Blood Gas Monovette® must be used. Total calcium must therefore not be determined using the Blood Gas Monovette® . 58 59 6.2 Storage Always aim to measure parameters immediately after the blood collection. If the measurement cannot be done within 15 minutes, the sample should be stored refrigerated (about 4°C).25 25 Michael D Davis RRT et al; AARC Clinical Practice Guideline: Blood Gas Analysis and Hemoximetry: Respiratory Care; 58(10); Oct. 2013 After storage the samples must be carefully mixed because sedimentation can lead to erroneous measurements of the Hb. Cellular metabolism may lead to changes in the concentration over extended storage periods. 6.3 Troubleshooting Clotting Samples with clots cannot be correctly drawn up into the analytical equipment and the results will not be representative. Solution Use liquid-dosed heparin because this mixes more quickly with the sample.26 Mix the samples carefully and immediately after the samples are collected. Use the mixing aid for the blood gas capillaries. 26 Gruber et al; Heparin release is insufficient in syringes with platelets as heparin source; Clinica Chimica Acta, 395: 197, 2008 Lowered Elevated pH pCO2 pO2 Calcium Glucose Lactate Air bubbles To avoid erroneous measurements due to air contamination, air bubbles must be removed immediately after the blood collection (see venting). The longer the samples are stored with air bubbles and the larger the air bubble(s), the greater the change in the values. Blood collection from a catheter Contamination by infusions or flushing solutions are possible risks. Before the blood collection, it must be ensured that an adequate blood volume is discarded. Haemolysis Haemolytic samples have erroneously high potassium concentrations and erroneously low sodium and calcium concentrations. Possible causes of haemolysis Shearing forces: - Sample shaken too hard during mixing or sample transport Collection technique: - Too much pressure is applied (milking) to the puncture site during collection of arterialised capillary blood Temperatures: - Extremly high temperatures in summer - Extremly low temperatures, e.g. sample frozen or placed directly on ice Lowered Elevated pCO2 pH pO2 sO2 Contamination with liquid heparin Contamination with NaCl solution Lowered pO2 , Na+ , Cl- Na+ , ClElevated pCo2 , K+ , Ca++ , gluc, lactate, tHb 60 61 1. Select the puncture site and encourage blood flow. 2. Attach a cap loosely to the end of the capillary. 3. Insert a mixing wire into the capillary and advance until it reaches the attached cap. 2. 1. 3. 1 ab2 3 ® 1 2 3 4 6.4 Collection technique – Blood Gas Monovette® Mixing the Blood Gas Monovette® In contrast to mixing in the inverted position, which is encouraged by the air bubble in the standard S-Monovettes, the process of mixing the Blood Gas Monovette® is as follows: Mix the blood sample immediately after collection by rolling the Blood Gas Monovette® between the palms of the hands. The tubes must be mixed by rolling between the palms of the hands rather than inverting. Important: Blood gas analyses should be carried out as soon as possible after blood collection, at the latest 15 minutes after the samples are collected. Venting the Blood Gas Monovette® To avoid erroneous measurements due to air contamination, after completing the blood collection the air must be removed from the Blood Gas Monovette® as follows: Place the membrane adapter (item no.: 14.1112) on the Luer lock of the Monovette® (a) and complete the Blood Gas Monovette® with the Safety-Needle (b) or the Safety- Multifly® needle. Remove the blood sample according to the work instructions. When puncturing the artery, a 45° angle is recommended. Remove the orange protective cap from the Blood Gas Monovette® . Place the ventilator (item no. 14.1148) on the Blood Gas Monovette® . Carefully push the plunger upwards. Remove and dispose of the ventilator. Place the protective cap on for the mixing procedure. 7. Immediately before the analysis, mix the sample again. Then position the mixing wire at the end of the capillary. 8. Remove both caps. 9. Allow the analysis equipment to suction up the blood sample. 4. Clean the puncture site with disinfectant. Puncture the skin to produce a good blood flow. Discard the first drop. Remove the attached cap. Then place the capillary horizontally and hold one end in the middle of the blood drop and fill the capillary completely without any air bubbles. 5. Firmly close both ends of the capillary with the caps. 6. Using the magnet, move the mixing wire back and forth along the entire length of the capillary 10-15 times to mix the blood with the anticoagulant. 5. 5. 6. Collection technique – blood gas capillaries For skin puncture we recommend using the safety lancets, item no. 85.1015 to 85.1019. 62 63 7 Safety when collecting blood “Informing, training and providing safe working equipment are the keys to avoiding needle stick injuries and the associated risk of infection” Safety – why? The most important infectious agents that can be transmitted by needle stick injuries (NSI) are hepatitis B virus, hepatitis C virus and HIV. Using suitable protective measures, these incidents can be almost completely avoided.27 The EU Directive 2010/32/EU28 Prevention of sharps injuries in the hospital and healthcare sector requires the safest possible working environment for employees in the healthcare sector. 27 The underestimated workplace accident, infection risk due to needle stick injuries; SAFETY FIRST! initiative 28 EU Directive 2010/32/EU of the Council of the European Union from 10 May 2010 Prevention of sharps injuries in the hospital and healthcare sector Preventive and protective measures Introduction of safe working regulations Maintain general hygiene Vaccinations (against hepatitis B) Suitable personal protective equipment Wear gloves Cover any cuts and grazes with waterproof plasters Avoid unnecessary use of sharps Provide medical instruments with integrated safety and protective mechanisms Forbid the replacement of protective caps on used needles (no re-capping) Note: Over half of all needle stick injuries occur during disposal.57 57 SAFETY FIRST, Germany - www.nadelstichverletzung.de 64 65 7.1 Safety-Needle The Safety-Needle is ready to use, thus sparing the step of attaching the needle in the needle holder and thus reducing the potential risk of a needle stick injury at the back of the needle. 7.2 Safety-Multifly® needle The adapter of the Safety-Multifly® needle is already pre-assembled and forms a ready-to-use unit. The single-handed operation of the needle protector of the Safety-Multifly® needle offers maximum protection. Handling 1 Click 2a 3 2b Click After blood collection: Detach the last S-Monovette® from the Safety-Needle and then withdraw the Safety-Needle from the vein. Hold the Safety-Needle on the adapter, place the needle protector on a stable, flat surface and lock the needle into the needle protector by pressing gently downwards until it makes a noticeable and audible click. Alternatively, you can also activate the needle protector with your index finger. For reliable function, ensure that this is done at the bottom end of the protector. After activating the protective mechanism: Discard the safely locked Safety-Needle in a disposal box. needle ifly® needle Handling After blood collection: Remove the last S-Monovette® from the Safety-Multifly® needle. After activating the protective mechanism: Discard the safely locked Safety-Multifly® needle into a disposal box. Gently hold the tubing by pressing it slightly into the palm of your hand and push the needle protector over the needle… Hold the needle protector at its back end with your thumb on top and your forefinger below and withdraw the Safety- Multifly® needle from the vein. ...until the needle is noticeably and audibly locked into the protective casing. Click Safety activation is always done with one hand only! 66 67 Filling line noted See marking Overfilled 2/3 7.3 Multi-Safe disposal boxes For collecting sharps, waste containers must be provided and used that meet the relevant regulations TRBA 250 (Technical Rules for Biological Materials – German regulations) and ISO 23907. These regulations define the following features of the containers, for example: - Shape and appearance - Container must not rupture when dropped from a particular height in tests - Container walls must resist penetration up to an applied pressure of 15 N If the sharps containers are supposed to be disposed of through a medical waste disposal service and are placed on the street, UN certification of the disposal box is mandatory. The certified containers are identified by a multiple digit UN code that is normally located on the top of the lid. Disposal boxes without this identification must be disposed of inside a container with this identification. Safe disposal Recommendation: Only fill the Multi-Safe container to about 2/3 of its volume. Do not overfill the Multi-Safe: Risk of injury! Note the filling line As a rule, when disposing of potentially infected medical single-use items, ensure they are disposed of in a hygienically correct manner. Safety instructions Only use containers of a size that is suitable for holding the items to be disposed of. The lid must be on the container and locked into place before it is filled. Connect containers with the recommended adhesive adapter by rotating or fixing by hanging in the wall holder to prevent accidents. Do not use the day lid to press down the items to be disposed of. Scalpels must be disposed of in the container with particular care. If too much force is used when throwing scalpels in or if other items are placed on top, there is a risk of the angle changing and damaging the container walls or the base of the container. Only place items to be disposed of upright in the container. Do not press items into the container with force. Do not place any liquids in the container. Do not place hands or any other objects in the container (risk of injury). Do not throw, shake or drop the container. Before sealing the container, ensure that no items are projecting through the opening. Before disposing of the container, carefully check that the lid is tightly sealed. 68 69 8 Centrifugation “Centrifugation is a physical separation process that is based on the different density characteristics of substances such as blood cells and plasma” 8.1 Correct handling for centrifugation Most laboratory analyses require serum or plasma, the liquid component of the blood. This is obtained by centrifuging the sample. Inside a centrifuge a rotor with tube holders rotates at a speed of several thousand revolutions per minute. This rapid rotation produces a multiple of gravity (g) inside the tube holder. This causes the liquid and solid components of the blood to separate. What is important is to differentiate between the revolutions per minute and the g force (gravitational force). The g force is the value that is relevant for a good centrifugation result. For this reason the g force is of particular importance when setting the centrifuge. The g force can be calculated using the radius (cm) and the revolutions per minute (RPM): g = 11.18 × r × (min-1 /1,000)2 r = radius in cm min-1 = revolutions per minute To convert from g force to RPM [min-1 ] or vice versa, you can use the centrifugation calculator at www.sarstedt.com/en/service-consultation/centrifugation-calculator. The centrifuge radius r can be found in the information provided by the centrifuge manufacturer or it can be determined using the following image: Fixed-angle rotor Swinging bucket rotor 70 71 8.2 Difference between fixed-angle and swinging bucket rotors *For gel-prepared S-Monovettes, we recommend using swinging bucket rotors only. The sample holder is arranged at a fixed oblique angle in a fixed-angle centrifuge. The sample holder in a swinging bucket rotor moves during the centrifugation from a vertical position to a horizontal position. In this way, the force during centrifugation acts evenly from the lid towards the base. The result is a well-shaped, horizontal gel layer. Fixed-angle rotor Swinging bucket rotor 8.3 Serum collection After blood collection, the serum samples must coagulate for 15–30 minutes. This means that as the coagulation proceeds, the coagulation factors (e.g. fibrin) are consumed and the blood cells form a blood clot. The coagulum forms in the shape in which the blood cells are present in the tube. This means that if the S-Monovette® is placed horizontally after the blood collection, the blood cells sediment along the horizontal tube and form a long shape. The resultant shape can be compressed during the centrifugation. After the centrifugation, it springs back in a concertina shape (sausage phenomenon). The serum from such a sample cannot be automatically pipetted. It is therefore important to store serum samples upright after blood collection. S-Monovette® Serum-Gel with coated beads to accelerate coagulation Sample that has clotted upright after centrifugation Sample that has clotted horizontally after centrifugation 72 73 Preparation Min. Standard recommendation Alternative range Temperature S-Monovette® Serum 10 2,000 x g 1,800 - 2,500 x g 18 - 25°C S-Monovette® Serum-Gel* 10 2,500 x g 2,200 - 3,000 x g 18 - 25°C S-Monovette® Li-Heparin 10 2,000 x g 1,800 - 2,500 x g 18 - 25°C S-Monovette® Li-Heparin-Gel* or 10 15 3,000 x g 2,500 x g 2,700 - 3,300 x g 2,300 - 3,000 x g 18 - 25°C S-Monovette® EDTA-Gel* 10 2,500 x g 1,800 - 2,500 x g 18 - 25°C S-Monovette® Citrate 10 1,800 x g 1,800 - 2,300 x g 18 - 25°C S-Monovette® Fluoride/GlucoEXACT 10 2,000 x g 1,800 - 2,500 x g 18 - 25°C 8.4 S-Monovette® centrifugation conditions 0 1 2 3 4 5 10 minutes 0 1 2 3 54 10 8.5 Gel ascent during centrifugation These centrifugation conditions (see p. 72) are recommendations. The values are based on what we consider to be the worst-case conditions, e.g. an older model centrifuge that requires considerably more time to reach the necessary g force than a new high-performance centrifuge. In isolated cases, it may be that the centrifugation conditions deviate from the standard recommendations shown in the table while achieving the same results. The details of the standard centrifugation conditions are always printed on the label of the inner carton as well. * For gel-prepared S-Monovettes, we recommend using swinging bucket rotors only. 74 75 9 Haemolysis – what is it? “The destruction of erythrocytes due to damage of the cell membrane leads to leakage of haemoglobin into the plasma/serum. A reddish discolouration of the serum/plasma can be seen.” mg/dl29 0 50 150 250 525 - + ++ +++ ++++ Characteristic feature of haemolysis If more than 0.5% of the erythrocytes are destroyed, the serum/plasma is discoloured. After centrifugation, this can be seen as a reddish colour of the plasma or serum. The cause is leakage of haemoglobin, which gives the erythrocytes their red colour. Above a concentration of about 20 mg haemoglobin/dl , haemolysis can be seen in the serum/plasma. The absence of a red colour does not exclude interference due to haemolysis. Haemolysis – the destruction of erythrocytes – is classified as in vivo haemolysis (pathological) or in vitro haemolysis (physiological) based on its cause. 29 CLSI; Hemolysis, Icterus, and Lipemia/Turbidity Indices as Indicators of Interference in Clinical Laboratory Analysis; Approved Guideline; C56-A; 32(10); 2012 76 77 9.1 In vivo haemolysis Disease can cause the destruction of erythrocytes within the body. This is referred to as in vivo haemolysis or haemolytic anaemia. Such a disease may be inherited or acquired. Inherited Acquired Haemoglobinopathy e.g.: sickle cell anaemia, thalassaemia Mycoplasma pneumoniae infection Cold agglutinin disease Autoimmune haemolytic anaemia (AIHA) Autoimmune diseases, e.g.: Lupus erythematosus, chronic lymphatic leukaemia (CLL) Glucose-6-phosphate dehydrogenase deficiency Infections (e.g.: malaria, babesiosis, Clostridium) Defects in the erythrocyte membrane (e.g. hereditary spherocytosis or hereditary elliptocytosis) Mechanical stress in the circulatory system e.g.: Disseminated intravascular coagulation (DIC) Haemolytic uraemic syndrome (HUS) Thrombotic thrombocytopenic purpura (TTP) HELLP syndrome Pyruvate kinase deficiency = erythrocyte enzymopathy Burns Drugs, toxins Blood transfusion from incompatible blood group 30 Lippi et al; In vitro and in vivo hemolysis, an unresolved dispute in laboratory medicine; 2012 9.2 In vitro haemolysis This type of haemolysis develops outside the body and is responsible for more than 90% of haemolytic samples. The cause is always due to preanalytics. Common causes during blood collection Prolonged/too tight venous stasis Physical shearing forces (needle too thin, bent needle) Traumatic venous puncture (poking) Blood collection from catheters using the vacuum technique15 Intravenous catheter combined with too large vacuum force31-38 Infusion solutions (dilution, distortion) 15 Lippi et al.; Prevention of hemolysis in blood samples collected from intravenous catheters Clin Biochem 46: 561–564, 2013 31 Ong, et al. Reducing blood sample hemolysis at a tertiary hospital emergency department. Am J Medicine 2009;122:1054e1–e6. 32 Halm, et al. Obtaining blood samples from peripheral intravenous catheters: best practice? Am J Crit Care 2009;18:474–8. 33 Wollowitz, et al. Use of butterfly needles to draw blood is independently associated with marked reduction in hemolysis compared to intravenous catheter. Ac Emerg. Med 2013;20:1151–1155. 34 ENA’s Translation Into Practice. Reducing Hemolysis of Peripherally Drawn Blood Samples. December, 2012 (Emergency Nursing Association). 35 Heyer et al.; Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory medicine best practices systematic review and meta-analysis; Clin Biochem 45: 1012-1032, 2012 36 Grant MS; The Effect of Blood Drawing Techniques and Equipment on the Hemolysis of ED Laboratory Blood Samples; J Emerg Nurs 29:116-121, 2003 37 Straszewski et al J; Use of seprate venipunctures for IV access and laboratory studies decreases hemolysis rates; Intern Emerg Med 6(4):357-359, 2011 38 Dugan et al.; Factors Affecting Hemolysis Rates in Blood Samples Drawn from Newly Placed IV Sites in the Emergency Department; J Emerg Nurs 31(4): 338-345, 2005 Common causes after blood collection Too vigorous mixing/shaking Transport influences (too much mechanical stress, e.g. pneumatic tube system) Sample too old (the risk of haemolysis increases as the sample ages) Sample cooled / heated too much / frozen 78 79 Released cell content Affects analysis Free haemoglobin Bilirubin Adenylyl kinase CK, CK-MB Hydrolase Coagulation 9.3 Consequences of haemolysis Release of cell contents – differences in concentration Substances that are present in erythrocytes in higher concentration (intracellular concentration) are released into the serum/plasma (extracellular concentration) because the erythrocyte membrane is destroyed during haemolysis. The result is erroneously higher measurements. 9.4 Clinical relevance The following parameters are affected: Release of cell contents – visual interference During haemolysis haemoglobin, which gives blood its red colour, is released into the serum/plasma. This can lead to erroneous measurement signals during photometric analyses due to the absorbance of haemoglobin itself. Erroneous measurement signal = incorrect result Release of cell contents – method-specific interference The individual test methods may be affected and interfered with due to the enzymes released from the cells. Release of cell contents – shifts in volume In cases of extensive or severe haemolysis, there may be an increase in the volume of the liquid fraction in the sample (because there are hardly any or no cells present any more). This leads to a dilution of the serum/plasma. Iron LDH AST ALT K+ Note: The analytical results are altered by haemolysis and do not reflect the conditions in the patient. This can lead to an incorrect diagnosis, no diagnosis or unnecessary diagnostics. In many cases, repeat blood collection to determine the correct analytical values is necessary. This causes avoidable patient stress, time wasting and additional costs.31,40,41,42 31 Ong, et al. Reducing blood sample hemolysis at a tertiary hospital emergency department. Am J Medicine 2009;122:1054e1–e6. 40 Cadamuro et al; The economic burden of hemolysis; CCLM 2015 41 Jacobs et al; Cost of hemolysis; AnnClinBiochem 2012; 49: 412–413 42 P Jacobs et al; Haemolysis Analysis; An Audit of Haemolysed Medical Admission Blood Results; AcuteMed 2010; 9(1): 46-47 39 Lippi et al Hemolyzed specimens: a major challenge for emergency department and clinical laboratories, Crit Rev Clin Lab Sci 48:143–153, 2011 Slight haemolysis ( 30-60 mg/dl): LDH, potassium, AST, ALT Severe haemolysis ( 200 mg/dl): All parameters Moderate haemolysis ( 60-200 mg/dl): Troponin*, ß-HCG, glucose, CK, PTT, aPTT, D-dimer (*depends on the method) 80 81 10.1 Sample transport To ensure correct storage, transport conditions and sample shipping, the relevant shipping regulations43, 44 and the stability of the individual parameters must be taken into account. This assumes optimal organisation. Important: The sender is responsible for shipping the sample and choosing the correct transport system. 43 P650 IATA/ADR 44 TRBA 100 Sample transport compliant with the Packaging Instruction P650 of the ADR and IATA Before transporting samples of liquid biological materials in category B in connection with transport boxes and cases, the sender should enquire whether the samples will be shipped via a land, rail or air transport route. The P650 Packaging Instruction, which is also incorporated in the ADR (European Agreement concerning the International Carriage of Dangerous Goods by Road) and in the IATA (International Air Transport Association), applies specifically for these individual routes. These regulations state that samples must be transported in packaging that consists of 3 components: Primary receptacle (leakproof) Secondary packaging (leakproof) Outer packaging (rigid; with a minimum dimension of 100 × 100 mm; labelled ‘BIOLOGICAL SUBSTANCE, CATEGORY B’ with the UN code ‘UN3373’ printed in a rhombus with a minimum dimension of 50 × 50 mm) The primary receptacle or the secondary packaging must also be able to withstand an internal pressure of 95 kPA without leakage. There must also be an absorbent material placed between the primary receptacle and the secondary packaging that can absorb the entire contents of the primary receptacle. 10 Storage and transport “Sample transport and storage must be chosen so that the analytical results are not affected by transport/storage” 82 83 In-house transport / TRBA 100 For safe in-house transport of samples of biological working materials and substances, these must be transported in containers that are enclosed, rigid, non-breakable and leakproof and have an external surface that can be disinfected and permanently labelled. These containers must also not be able to be inadvertently opened by external impacts.44 44 TRBA 100 Transporting “exempt medical samples” Samples that are not considered infectious substances in category A and B are not subject to the ADR/IATA regulations but must be packaged as follows. 3-component packaging consisting of: Primary receptacle (waterproof) Secondary packaging (waterproof) Outer packaging (minimum dimension 100 × 100 mm with the label “EXEMPT MEDICAL SAMPLE” or “EXEMPT VETERINARY SAMPLE”) An absorbent material that can absorb the entire contents of the primary receptacle must also be placed between the primary receptacle and the secondary packaging. As a rule, the P650 is the same in both regulations. Exception: Shipping boxes and transport cases that are used to transport samples of biological substances in category B must be tested in accordance with the P650 Packaging Instruction. Parameter Value Lactate Increases Ammonia Increases Potassium Increases Glucose Falls pCO2 Falls 10.2 Influence of temperature, time and cellular metabolism Concentrations that are measured, change due to the stability of the individual parameters and cellular metabolism. Mechanical or physical stresses placed on the sample materials may also produce changes. Cellular metabolism Blood is a living substance. This means that there are metabolic processes, that is, cellular metabolism, occurring in the sample tube after blood collection. Note: Blood is alive! Effect of storage on various parameters Depending on the parameter, the changes in the values may be prevented by special stabilisers in the various preparations or by physical separation (gel, Seraplas® filter, preparing aliquots). 84 85 Influence of storage temperature on glucose and potassium Note: There is no ideal temperature. Correctly collected, fresh samples ensure correct results. Sample storage and transport Blood samples should be taken to the laboratory for analysis as soon as possible. After centrifugation, separating gels or filters prevent diffusion of substances from the erythrocytes into the serum/plasma. Whole blood without serum/plasma separation using gel or a filter must not be frozen under any circumstances. This would result in complete haemolysis. Clinical chemistry: For long-term storage, the serum should be stored at 2-4°C in closed containers. Serum or plasma samples can be stored at -20°C for extended periods. Special cool transport containers should be used to protect samples during prolonged transit. For some analyses, the sample must be transported promptly (e.g. ammonia within 15 min.). Coagulation diagnostics: For coagulation diagnostics, the sample should be transported at room temperature (18-25°C) as a rule.6 Haematology: EDTA blood for a blood count can be stored at room temperature (18-25°C) for up to 24 hours.45 6 G. Ender et al; The importance of preanalytics for the coagulation laboratory; Hämostaseologie 2/2010; 30: 63-70 45 N. Tatsumi et al; Specimen Collection, Storage, and Transmission to the Laboratory for Hematological Tests; International Journal of Hematology 75; 261-268; 2002 5 Sarstedt; Tips & Techniques in Preanalytics; 2014 5 Sarstedt; Tips & Techniques in Preanalytics; 2014 mg/dLmg/dL 90 80 70 60 50 40 30 20 10 0 0 2 4 6 8 24 48 hours 0 2 4 6 8 24 48 hours 12 10 8 6 4 2 0 Storage temperature 4 °C Storage temperature 23 °C Storage temperature 30 °C Storage temperature 4 °C Storage temperature 23 °C Storage temperature 30 °C Glucose Potassium 86 87 Checklist for transport Seal sample (prevent evaporation) Store serum/plasma at 4-8°C Store upright Store EDTA for blood count at room temperature Avoid repeated freezing & thawing Protect from exposure to sunlight for light-sensitive parameters (e.g. bilirubin) Use special preparation for stabilisation (e.g. S-Monovette® HCY-Z-Gel for homocysteine) 46 Koessler et al; The preanalytical influence of two different mechanical transport systems on laboratory analysis; Clin Chem Lab Med; 49(8): 1379 1382; 2011 47 Kratz et al; Effects of a pneumatic tube system on routine and novel hematology and coagulation parameters in healthy volunteers; Arch Lab Med; 131: 293 6; 2007 48 Sodi et al; Pneumatic tube system induced haemolysis: assessing sample type susceptibility to haemolysis; Ann Clin Biochem; 41:237 40; 2004 49 Steige et al; Evaluation of pneumatic-tube system for delivery of blood specimens; Clin Chem; 17:1160 4; 1971 Pneumatic tube transport systems Pneumatic tube transport systems can considerably shorten the time between blood collection and analytical result.46 However, it is not a case of the faster the better. Poor quality or incorrectly set transport systems can lead to haemolysis and activation of coagulation.47,48,49 For monitoring, the LDH values, potassium value, leucocyte count, PTT and D-dimers are compared with and without pneumatic tube transport. By complying with the following tips, samples can be transported using a pneumatic tube system without significant effects on the values.50,51 Maximum speed 5 m/s “Gentle” curves and shapes Brake gently before curves Use cushioning lining in pneumatic tube system carriers Cushioned horizontal sending and receiving zones Send serum samples only after the coagulation is complete 50 Koçak et al; The effects of transport by pneumatic tube system on blood cell count, erythrocyte sedimentation and coagulation tests; Biochemia Medica;23(2):206-10; 2013 51 Tiwari et al; Speed of sample transportation by a pneumatic tube system can influence the degree of hemolysis; Clin Chem Lab Med; 50(3):471-474;2012 88 89 11 Capillary blood collection “Particularly in paediatrics and for POCT, obtaining samples from the finger tip, heel or earlobe is of particular importance” What is capillary blood? Capillary blood is a mixture of fluids and is comprised of the blood from arterioles, venules and capillaries as well as interstitial and intracellular fluids. Note: This mixture of fluids cannot be used for a precise coagulation analysis due to its composition. For this reason, capillary tubes are not provided with a citrate preparation. Applications of capillary blood collection Paediatrics Geriatrics In adults for blood gas analyses, glucose and lactate measurements Point-of-care testing Exclusion criteria for capillary blood collection Quantities > 1 ml (e.g. blood culture) Coagulation analyses Inflammations Patients in shock 11.1 Carrying out capillary blood collection Preparation - Materials - Patient - Puncture site Puncture Sample collection 90 91 Materials required Gloves Swab Skin disinfectant Semi-automatic single-use lancet (Safety-Lancet) Sample tube (BGA capillary tube, Microvettes, bilirubin capillary tubes, etc.) Multi-Safe Box for disposal Plaster, if required (not advised for small children because they are a choking hazard) Patient preparation Identify the patient Inform the patient about why the blood is being collected and explain the procedure Select the puncture site If necessary, encourage blood flow at the puncture site by warming the area Puncture sites Finger tip Heel Earlobe Advantages of warming the puncture site Up to 7x increase in blood flow Requirement for capillary blood gas analyses Encouraging blood flow leads to arterialisation of the capillary blood and thus to acceptable comparability with the analytic values obtained from arterial blood. Procedure for warming the puncture site The foot or hand of the patient is wrapped in a cloth warmed to 39°C to 40°C. For the best result, pull a rubber glove over the top. Leave for 3-5 min. For capillary BGA in adults, the earlobe can be rubbed with a hyperaemiainducing ointment. Puncturing and sampling Pull on gloves Skin disinfection - Disinfectant - Leave to air dry (until the disinfectant has completely dried) Correct hand movement to fix the finger or the foot Puncture with a Safety-Lancet Important information Discard the first drop of blood Hold the puncture site downwards Avoid smearing the blood drop Ensure that the sample tube is held in the correct position Avoid applying repeated strong pressure (milking) Causes haemolysis and contamination of the samples with tissue fluid 92 93 11.1.1 Safety-Lancet and safety incision lancet The sterile single-use products prevent needle stick injuries because the needle and blade are always safely enclosed within the lancet body before and after use. The secure trigger button prevents inadvertent, unintentional activation and inactivation of the system. The Safety-Lancets and the safety incision lancets also comply with the EU Directive 2010/32/EU28 , BioStoffV52 and TRBA 25053 . 28 EU Directive 2010/32/EU of the Council of the European Union from 10 May 2010 Prevention of sharps injuries in the hospital and healthcare sector 52 Biological Agents Regulations – BioStoffV; regulations on occupational health and safety at workplaces using biological working materials from 15 July 2013 53 TRBA 250 Biological working materials in the healthcare sector and social welfare organisations; Edition of March 2014 amended on 21.7.2015, GMBI no. 29 Design Mini Normal Extra Super Neonatal Penetration depth 1.6 mm 1.8 mm 1.8 mm 1.6 mm 1.2 mm Needle size 28 G 21 G 18 G Blade 1.5 mm Blade 1.5 mm Blood volume Low Medium Medium to high High Medium to high Design Application Penetration depth Incision length Neonates 1.0 mm 2.5 mm Premature infants 0.85 mm 1.75 mm Product range – Safety-Lancet The 5 versions of the Safety-Lancets provide a range of different needle sizes and blades with different penetration depths for sampling from the finger, earlobe and heel. Product range – Safety Incision Lancet Thanks to the special puncture technique, optimal blood flow with a high blood volume is possible even with a shallow penetration depth. The shallow penetration depth ensures rapid healing and minimises the formation of haematomas. 94 95 1 2 3 4 Product range – Safety-Lancet The handle with its secure, flattened surface enables the lancet to be held in various ways with a defined wing and notch on the serrated lancet body. 11.1.2 Microvette® – order of draw & techniques Depending on the requirements, Microvette® tubes with a cylindrical or conical inner tube shape and a volume range of 100 to 500 μL are available. There is the option to collect capillary blood using the capillary technique or the collection rim. The special cap design minimises any aerosol effects when the tube is opened. Microvette® – order of draw54 1. Twist the protective cap (1/4 turn). 2. Hold the Safety-Lancet against the selected and disinfected puncture site. The small and transparent contact area enables precise puncturing. Press the trigger button. 3. Place the Safety-Lancet in a suitable disposal box. 4. Discard the first blood drop and then collect blood. EDTA Lithium Heparin / Lithium Heparin-Gel Fluoride Serum / Serum-Gel 54 CLSI Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens; Approved Standard – 6th edition GP42-A6 (formerly H04-A6); 28 (25) 2008 96 97 Microvette® – Collection methods To meet the specific requirements of capillary blood collection, there are two collection techniques available: Capillary method using the end-to-end capillary Gravitational principle using the collection rim Note: Letting blood drip into a capillary tube by means of a Luer needle does not constitute capillary blood collection. B. Sampling with the collection rim 1. Hold the Microvette® in a horizontal or slightly inclined position and collect the blood sample with the end-to-end capillary. 2. Collection is complete when the capillary is entirely filled with blood. 3. Hold the Microvette® upright to allow blood to flow into the collection tube. 4. Twist to remove the cap including the capillary and discard as a complete unit. 1. Remove the cap by turning it slightly. 2. Attach the cap to the base of the tube. 3. Collect the blood dripping from the puncture site using the collection rim. 4. Remove the cap from the tube base and close the Microvette® (“click” position). 5. Mix the sample gently but thoroughly. 5. Remove the cap from the tube base and close the tube (“click” position). 6. Mix the sample gently but thoroughly. A. Capillary method using the end-to-end capillary EDTA 200 1 EDT 200 2 200 EDTAK 3 200 EDTAK 4 200 5 200 EDTAK 200 EDTAK 6 500 EDTAK 500 EDTAK EDTAK 500 EDTAK 500 EDTAK 500 EDTAK 500 EDTAK 1 2 3 4 5 98 99 11.2 Centrifugation conditions for capillary blood collection These centrifugation conditions are recommendations. The values are based on what we consider to be the worst-case conditions, e.g. an older model centrifuge that requires considerably more time to reach the necessary g force than a new high-performance centrifuge. In isolated cases, it may be that the centrifugation conditions deviate from the standard recommendations shown in the table while achieving the same results. The details of the standard centrifugation conditions are always printed on the label of the inner carton as well. * For gel-prepared tubes, we recommend using swinging bucket rotors. Preparation Min. Standard recommendation Min. (alternative) Alternative range Temperature Microvette® Serum Microvette® CB 300 Serum Multivette® Serum 5 10,000 × g 10 2.000- 10,000 × g 20°C Microvette® Serum-Gel* Multivette® Serum-Gel* 5 10,000 × g 10 4,000- 10,000 × g 20°C Microvette® Heparin Microvette® CB 300 Heparin Multivette® Heparin 5 2,000 × g 10 2.000- 10,000 × g 20°C Microvette® Heparin-Gel* Multivette® Heparin-Gel* 5 10,000 × g 10 4,000- 10,000 × g 20°C Microvette® Fluoride Microvette® CB 300 Fluoride Multivette® 5 2,000 × g 10 2.000- 10,000 × g 20°C 1 2 3a 3b 11.3 Minivette® POCT The Minivette® POCT is used for capillary blood collection for immediate bedside diagnostics (also known as POCT). POCT (point-of-care testing) or immediate bedside diagnostics is rapid diagnostics with no preparation of reagents and/or analysis material. The Minivette® POCT is available in different versions with a range of different volumes and preparations for collecting capillary whole blood, saliva or urine. Handling the Minivette® POCT The Minivette® POCT is used for collecting and directly dispensing samples with a small volume. The drip-free handling enables easy sample collection and direct dispensing with no-drip transfer to the test card or sample tubes. 2. The blood collection is automatically finished when the capillary is filled with blood to the white blocking filter. 1. The Minivette® POCT is held on the sides below the wings in a horizontal or slightly angled position. When collecting blood drops with the capillary tip, the ventilation hole at the piston end should not be covered. Do not push the piston down - fill the capillary ensuring there are no air bubbles. 3a. Place the capillary tip on the test field and dispense the complete blood sample by gently pressing on the piston. 3b. Alternatively, the sample can be dispensed into a micro tube. 100 101 12 Urine sample collection “Hippocrates analysed the odour and colour of urine as long ago as 400 BC and urinalysis still plays a key role in the diagnostic examination” 12.1 Sample collection Any type of urine sample requires a hygiene procedure that complies with the following rules: The patient should have the correct procedure for collecting urine samples explained. Before collecting the sample, the patient should thoroughly wash their hands and genital area and then remove any traces of soap. To avoid contamination, the sample should be collected from mid-stream urine where possible. The urine should be collected in the single-use collection container/bottle55 provided. The containers must be clean and dry and for bacteriological testing they should also be sterile. The containers must be labelled carefully with a waterproof pen to prevent mix-ups. Avoid collecting urine during or shortly after menstruation (this results in contamination of the urine with blood). 12.2 Storage and transport Urine samples should not be exposed to direct sunlight or heat. The analysis should be carried out within two hours of collection. If this is not possible, the urine should be stored at a temperature of +4°C to +8°C. Extended storage may cause the following changes, e.g. Disintegration of leucocytes and erythrocytes Bacterial growth Bacterial decomposition of glucose Before the analysis, samples should be brought to room temperature and thoroughly mixed just before applying to a test strip. Depending on the parameter, appropriate stabilisers should be used for the storage. 55 CLSI Urinalysis; Approved Guideline – 3rd edition GP16-A3; 29(4) 2009 102 103 Microbiological tests With a suspected urinary tract infection after a positive test strip result and abnormal urinary sediment, it is essential to carry out microbial identification (microbial differentiation, bacterial count and subsequent monitoring of the antibiotic therapy). This provides information about the type and quantity of pathogen (usually bacteria, possibly fungi). IMPORTANT: The samples should be collected before starting any antibiotic therapy. For subsequent therapeutic monitoring, provide the laboratory with details of any antibiotic therapy. Drug detection Drug detection is a sensitive examination due to the consequences of a positive test result. Urine is often used as a sample material because it is easily collected and drugs and their metabolites can be easily detected for long periods after use (compared to blood or saliva). However, urine can also be easily manipulated. Drug users often try to generate negative results. This can be caused by excessive drinking, applying third-party urine, addition of acid or mixing in urine-coloured liquids (e.g. apple juice, energy drinks, etc.). 12.3 Types of analyses Urine can be analysed in a wide range of ways. Here are some of the most common methods: Test strips Depending on the number of test fields, the test strips enable a range of different values to be tested such as specific gravity, haemoglobin, glucose, pH, protein, leucocytes, etc. Information obtained by comparing the colour change of the test field is only an initial indicator and should be specified using additional tests. What is important is that the test strip is completely and thoroughly wetted and then appropriately dried before reading the result. The correct incubation times must be complied with and the relevant information about these times can be found in the manufacturer’s instructions. Urine sediment testing Urine sediment is a preparation of the urine to assess the solid components of the urine using microscopy or flow cytometry. These assessments can provide information about kidney or urinary tract diseases. To prepare the urine sediment, a defined fraction (e.g. 10 ml) of a urine sample is centrifuged (5 min at 400 × g) and the supernatant is decanted so that about 0.5 ml of urine remains; the sediment is mixed with the residual urine and then analysed microscopically. The following parameters can be assessed using microscopy, for example: Cells such as erythrocytes, leucocytes, epithelial cells, etc. Urinary casts such as hyaline tests, granular casts, cellular tests, etc. Other elements such as yeast cells, bacteria, urine crystals f p f i i Clinical chemistry tests Clinical chemistry tests provide semi-quantitative and quantitative results for greater specificity for screening tests (e.g. during pregnancy) or when preparing diagnoses for heart, liver or kidney diseases or cancer. The following parameters can be analysed using clinical chemistry analytics: Electrolytes, creatinine, albumin, 2-macroglobulin, 1-microglobulin, BenceJones proteins, glucose, 5-hydroxyindoleacetic acid, immunoglobulins, proteins, catecholamines, porphyrins, vanillylmandelic acid (VMA) 104 105 1 100 ml100 ml00100 ml 90 80 70 60 50 40 30 20 10 75/40 a b c 2 3 12.4 Types of urine samples Urine samples are differentiated by the time and type of collection. Mid-stream urine Collecting a urine sample using mid-stream urine is recommended in principle to obtain the purest possible sample Correct sample collection: 1. Correct cleaning and drying of the hands and external genital area. 2. Release the first urine in the toilet (a) and then collect the mid-stream urine with the urine container (b). The remaining urine is also disposed of in the toilet (c). Avoid contamination. 3. Securely close the container with the lid. Note: Mid-stream urine collection is divided into: First morning urine The components in the first urine passed in the morning are more concentrated. Application: Suitable for bacterial tests, test strips, sediment, clinical chemistry tests, protein diagnostics. Advantage: Due to the long retention time in the bladder, the morning urine is ideally suited to nitrite and protein measurement. Spontaneous urine The urine can be collected at any time. Spontaneous collection is useful in cases of suspected urinary tract infection or intoxication. Application: Is completely adequate for many chemical and microscopic parameters Advantage: Easily collected Drawback: Dilution errors – for correct assessment always take the specific gravity (density) into account Second morning urine The second morning urine can possibly provide the mean values for individual parameters and can be used in isolated cases as a substitute for 24-h urine collection. Application: Test strips, glucose, protein Drawback: Not suitable for the nitrite test 106 107 Suprapubic aspiration of urine The bladder is punctured suprapubically while ensuring strict aseptic technique. The invasive nature of this type of urine collection means that although this method has the smallest risk of contaminating samples, it is rarely used. However, in paediatrics the advantages of this method can outweigh the drawbacks of classic collection (particularly for bacterial tests). Catheter urine For sample collection from catheters, single-use catheters and indwelling urinary catheters are differentiated. Intermittent catheter urine Collecting urine using intermittent catheterisation is very rarely carried out because it is painful for the patient and the risk of infection is high. Note: For diagnostic purposes, urine should not be collected from the urine bag. Indwelling catheter urine For patients with an indwelling urinary catheter, this type of urine sample collection is the easiest and most hygienic method. The urine should be collected from a special adapter on the inlet tube and not from the collection bag, however. Urinary catheter Urethra Prostate Bladder Pubic bone Splittable trocar 24 Hour urine collection The entire urine produced is collected over a period of 24 hours. Collection over this period compensates for any variations in concentration of parameters during the day. Typical applications for 24 hour urine collection include measuring catecholamines or creatinine clearance. When measuring catecholamines and other unstable parameters, adding a stabiliser (e.g. 20% HCl) to the urine is necessary. There are ready-to-use products such as the UriSet 24 available for this purpose. Collected urine volume Because the patient is usually responsible for collecting the urine, it is essential to provide the patient with clear instructions for correct handling. The volume of the bottle is of particular importance here. Studies have shown that collection bottles with a volume of 2,000 ml were only adequate for 60% of all volunteers. That is, in these cases a second bottle must be used and a tube must be filled from each bottle. The particular quantity of urine in the collection bottle must then be noted on both tubes. The urine from the two tubes is then mixed in the laboratory in the correct ratio. To circumvent this potentially error-prone process, a collection bottle with a volume of 3,000 ml should be used. Number of donors Volume in litre 3 litres 91,4 % Volumes of the 116 24 hour urine collections 108 109 Time 5:00 6:00 7:00 8:00 9:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 10:00 SA Mo Bacteriology 10/06 UrineZ S M Bacteriology UrineZ Abfall S M Bacteriology UrineZ 12.5 Handling urine sample collection systems Collection procedure for 24 hour urine START END (24 hours) IMPORTANT: During the collection period, about 1.5-2 litres should be drunk throughout the day. Thoroughly wash hands and the genital area before each collection step and rinse away any traces of soap. 1. Discard the first morning urine Note the time, e.g. 7:00 am 2. Collect the second morning urine and add stabiliser if necessary 3. Collect all urine and mix 4. Collect the first morning urine on the next day at the same time as the day before, e.g. 7:00 am 1 2 3 Urine-Monovette® The Urine-Monovette® is suitable for sample collection, transport, as a container for immersing the test strip and for centrifugation. Urine-Monovette® with boric acid In a filling volume of 10 ml, the boric acid concentration is 1.5%. Microorganisms are stabilised for up to 48 hours when stored at room temperature. Important: Adhere to the stated volume Thoroughly mix after urine aspiration Not suitable for clinical chemistry tests, strip tests, etc. Insert the suction tip into the cup and and draw up the Urine-Monovette® piston to the base line. Hold the Urine-Monovette® with the suction tip upwards and withdraw the plunger in downward direction until the suction tip is empty. Withdraw the tip, break off the plunger, attach the cap.. . . 110 111 /Exp. V-Monovette® Urine By using a closed system, hygiene and comfort is significantly improved both for the patient and for the user. A: Immerse the transfer device into the urine sample. Insert the V-Monovette® into the transfer device and press firmly until the needle penetrates the cap. B: Remove the safety label from the lid using the flap. Please do not touch the collection area in the lid Risk of injury! First insert the V-Monovette® Urine with the cap in the collection area and press firmly. The tube fills with urine by itself. Only remove the tube when the flow stops. Mix the V-Monovette® Urine with preparation, e.g. boric acid. A B C: Grasp the safety label on the flap and remove from the lid of the collection bottle. Please do not touch the collection area in the lid Risk of injury! The collection bottle is placed with the recessed grip facing upwards on a flat surface. Insert the tube into the collection area and press firmly. For small collection volumes between 700 and 1200 ml, the V-Monovette® Urine can also be filled upside down. For collection volumes < 700 ml, the collection bottle must be opened. The collected urine is then transferred to a container. 1200 ml 1200 ml 700 ml C A B 112 113 13 List of references 1. Guder et al.; Proben zwischen Patient und Labor; 2009 2. Bonini et al.; Errors in Laboratory Medicine; Clin Chem 48:5; 691-698 (2002) 3. Foubister, Vida. Cap Today Bench press: The Technologist/technician shortfall is putting the squeeze on laboratories nationwide September 2000; Datta, P. Resolving Discordant Samples. Advance for the Administrators of Laboratories; July 2005: p.60. 4. Seelig et al.; Präanalytik; 2008 5. Sarstedt; Tips and Techniques in Preanalytics; 2014 6. G. Ender et al.; The importance of preanalytics for the coagulation laboratory; Hämostaseologie 2/2010; 30: 63-70 7. RiLiBÄK § 6.1.7 Part A5 8. 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Heyer et al.; Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory medicine best practices systematic review and meta-analysis Clin Biochem 45: 1012-1032, 2012 17. Grant MS; The Effect of Blood Drawing Techniques and Equipment on the Hemolysis of ED Laboratory Blood Samples; J Emerg Nurs 29:116-121, 2003 18. Benso S; Can a blood sample for diagnostic exams be drawn from a peripheral venous catheter?; Assist Inferm Ric; 34(2):86-92; Apr-Jun 2015 19. Pschyrembel 20. J. P. Borde et al.; Abnahme von Blutkulturen; Dtsch Med Wochenschr; 135:355-358; 2010 21. Simon et al.; Blutkulturdiagnostik – Standards und aktuelle Entwicklungen; J Lab Med; 36(4):199-207; 2012 22. Barthels et al.; Das Gerinnungskompendium; 2012 23. Kupke et al.; On the composition of capillary and venous blood serum; Clin Chim Acta. 112(2):177-85; 5 May 1981 24. Speer et al.; Pädiatrie; 2013 25. Michael D Davis RRT et al.; AARC Clinical Practice Guideline: Blood Gas Analysis and Hemoximetry: Respiratory Care; 58(10); Oct. 2013 26. Gruber et al.; Heparin release is insufficient in syringes with platelets as heparin source; Clinica Chimica Acta, 395: 197, 2008 27. Der unterschätzte Arbeitsunfall, Infektionsrisiko durch Nadelstichverletzungen; Initiative SAFETY FIRST! 28. EU-Richtlinie 2010/32/EU des Rates der Europäischen Union vom 10. Mai 2010 Zur Vermeidung von Verletzungen durch scharfe/spitze Instrumente im Krankenhaus- und Gesundheitssektor 29. CLSI; Hemolysis, Icterus, and Lipemia/Turbidity Indices as Indicators of Interference in Clinical Laboratory Analysis; Approves Guideline; C56-A; 32(10)2012 30. Lippi et al.; In vitro and in vivo hemolysis, an unresolved dispute in laboratory medicine; 2012 31. Ong, et al. Reducing blood sample hemolysis at a tertiary hospital emergency department. Am J Medicine 2009;122:1054e1-e6. 32. Halm, et al. Obtaining blood samples from peripheral intravenous catheters: best practice? Am J Crit Care 2009;18:474-8. 33. Wollowitz, et al. Use of butterfly needles to draw blood is independently associated with marked reduction in hemolysis compared to intravenous catheter. Ac Emerg. Med 2013;20:1151-1155. 34. ENA’s Translation Into Practice. Reducing Hemolysis of Peripherally Drawn Blood Samples. December, 2012 (Emergency Nursing Association). 35. Heyer et al.; Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory medicine best practices systematic review and meta-analysis; Clin Biochem 45: 1012-1032, 2012 36. Grant MS; The Effect of Blood Drawing Techniques and Equipment on the Hemolysis of ED Laboratory Blood Samples; J Emerg Nurs 29:116-121, 2003 37. Straszewski et al J; Use of separate venipunctures for IV access and laboratory studies decreases hemolysis rates; Intern Emerg Med 6(4):357–359, 2011 38. Dugan et al.; Factors Affecting Hemolysis Rates in Blood Samples Drawn from Newly Placed IV Sites in the Emergency Department; J Emerg Nurs 31(4): 338-345, 2005 39. Lippi et al Hemolyzed specimens: a major challenge for emergency department and clinical laboratories, Crit Rev Clin Lab Sci 48:143–153, 2011 40. Cadamuro et al.; The economic burden of hemolysis; CCLM 2015 41. Jacobs et al.; Cost of hemolysis; AnnClinBiochem 2012; 49: 412-413 42. P Jacobs et al.; Haemolysis Analysis; An Audit of Haemolysed Medical Admission Blood Results; AcuteMed 2010; 9(1): 46-47 43. P650 IATA/ADR 44. TRBA 100 45. N. Tatsumi et al.; Specimen Collection, Storage, and Transmission to the Laboratory for Hematological Tests; International Journal of Hematology 75; 261-268; 2002 46. Koessler et al.; The preanalytical influence of two different mechanical transport systems on laboratory analysis; Clin Chem Lab Med; 49(8): 1379-1382; 2011 47. Kratz et al.; Effects of a pneumatic tube system on routine and novel hematology and coagulation parameters in healthy volunteers; Arch Lab Med; 131: 293-6; 2007 48. Sodi et al.; Pneumatic tube system induced haemolysis: assessing sample type susceptibility to haemolysis; Ann Clin Biochem; 41:237-40; 2004 49. Steige et al.; Evaluation of pneumatic-tube system for delivery of blood specimens; Clin Chem; 17:1160-4; 1971 50. Koçak et al.; The effects of transport by pneumatic tube system on blood cell count, erythrocyte sedimentation and coagulation tests; Biochemia Medica;23(2):206-10; 2013 51. Tiwari et al.; Speed of sample transportation by a pneumatic tube system can influence the degree of hemolysis; Clin Chem Lab Med; 50(3):471-474;2012 52. Biostoffverordnung – BioStoffV; Verordnung über Sicherheit und Gesundheitsschutz bei Tätigkeiten mit Biologischen Arbeitsstoffen vom 15. Juli 2013 53. TRBA 250 Biologische Arbeitstoffe im Gesundheitswesen und in der Wohlfahrtspflege; Ausgabe März 2014 mit Änderung vom 21.7.2015, GMBI Nr. 29 54. CLSI Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens; Approved Standard – 6th edition GP42-A6 (ehemals H04-A6); 28 (25) 2008 55. CLSI Urinalysis; Approved Guideline– 3th edition GP16-A3; 29 (4) 2009 56. Kohse et al.; National and international initiatives and approaches for the establishment of reference intervals in pediatric laboratory medicine; J Lab Med 2015; 39(4): 197-212 57. SAFETY FIRST, Germany - www.nadelstichverletzung.de 114 115 14 Index 24-h urine collection 107 5-Hydroxyindoleacetic acid (5-HIAA) 103 1-microglobulin 103 2-macroglobulin 103 ACE (angiotensin-converting enzyme) 15 Acetylsalicylic acid (ASA) 16 Adrenaline 14, 15, 16 Adrenaline 17 Age 13, 52, 54, 55 Albumin 16, 17, 31, 103 Alcohol 15, 29 Alcohol abstention 29 Aldosterone 17 Alkaline phosphatase (AP) 12, 13, 14, 16 ALT, alanine transaminase (GPT) 14, 15, 16, 17, 31 Ammonia, NH3 + 83, 85 Amylase 12, 14 Antithrombin (AT III) 55 aPTT (activated partial thromboplastin time) 19, 54, 55, 79, 86 Arterial access 57 Arterial blood 57 ASA (acetylsalicylic acid) 16 Aspiration technique 33-37, 39, 47 AST, aspartate aminotransaminase (GOT) 15, 16, 17, 19, 31, 78, 79 AT III (antithrombin, antithrombin III) 55 -carotenoids 15 -HCG (chorionic gonadotropin) 79 Bacteria 19, 102, 103 Bacterial count 103 Bence-Jones proteins 103 Bilirubin 13, 14, 16, 17, 19, 31, 51, 52, 78, 86, 90 Biological rhythm 13 Blood clot 8, 58 Blood collection technique, capillary 61, 96-97 Blood collection technique, venous 20, 37, 46, 60 Blood collection, arterial, collection technique 60 Blood collection, capillary 49-51, 57, 58, 59, 61, 88-99 Blood collection, capillary, collection technique 61, 96-97 Blood collection, capillary, preparation 89-91 Blood collection, capillary, procedure 61, 89-91, 96-97, 99 Blood collection, venous 20-43, 47-48 Blood collection, venous, collection technique 20, 37, 46, 60 Blood collection, venous, ending 34 Blood collection, venous, for blood culture diagnostics 26, 40-43 Blood collection, venous, from a catheter 38-39, 59, 77 Blood collection, venous, preparation 9, 21 Blood collection, venous, procedure 28-43 Blood collection, venous, with butterfly needle 27, 32, 42, 43, 47, 60, 65 Blood collection, venous, with Safety-Needle 26, 29, 32, 33, 34, 36, 60, 64 Blood culture adapter 42-43 Blood culture diagnostics 40-43 Blood gas 56-61, 89, 91 Blood gas analysis, clotting 58 Blood gas analysis, collection technique 60, 61 Blood gas analysis, haemolysis 59 Blood gas analysis, storage 58 Blood gas analysis, ventilation 59, 60 Blood sedimentation (BSR = blood sedimentation rate) 12, 25 Blood-collecting person 21 Body position 17 BSR (blood sedimentation, blood sedimentation rate) 12, 25 Cadmium 15 Caffeine 16 Calcium (Ca++ ) 16, 17, 26, 27, 31, 51, 57, 58, 59 Cannabis 14 Carryover of additives / preparation 19, 26 Casts (urinary) 102 Catecholamines 103, 107 Catheter urine 106 CEA (carcinoembryonic antigen) 15 Cellular metabolism: Temperature, time 58, 83 Centrifugation 7, 21, 68-73, 75, 85, 98, 109 Centrifugation conditions, capillary 98 Centrifugation conditions, venous 72, 73 Chloride (Cl) 14, 51, 59 Cholesterol (Chol) 12, 13, 14, 15, 17, 19, 31 Chorionic gonadotropin ( -HCG) 79 Circadian rhythm 14 116 117 CK (creatine kinase) 12, 16, 31, 51, 78, 79 CK-MB 78 Cl(chloride) 14, 51, 59 Coagulation analyses 25, 27 Coagulation diagnostics 85 Collected urine volume 107 Collection rim 51, 95, 97 Collection techniques, capillary 61, 96-97 Collection techniques, venous 20, 37, 46, 60 Colour code 23 Communication 9, 21 Copper 15 Cortisol 14, 15, 16 Creatine kinase (CK) 12, 16, 31, 51, 78, 79 Creatinine 12, 14, 16, 17, 19, 31, 52, 103, 107 Crystals (urinary) 102 CVC 19, 40, 57 D-dimers 55, 79, 86 Dead volume 27 Decisions, clinical 8 Diet 11, 17 Disposal box 48, 50, 64, 65, 66-67 Diuretics 16 Drip technique 47 Drug detection 103 Drug use 14 End-to-end capillary 51, 96 Endogenous interference factors 19 Epithelial cells 102 Error, preanalytical 7, 8, 18, 113 Erythrocytes 17, 19, 25, 52, 53, 74, 75, 76, 78, 85, 101, 102 Exempt medical sample 82 Exogenous interfering factors 19 Fasting 1, 18, 21, 29 Fe (Iron) 12, 31, 78 Fibrinogen 15, 25 First morning urine 105 Fixed-angle rotor 69, 70 Folic acid 15 Gender 12, 13 -Glutamyltransferase ( -GT, GGT) 15, 16, 17, 31, 32 Glucose 14, 16, 17, 25, 31, 51, 58, 59, 79, 83, 84, 89, 101, 102, 103, 105 Glucose-6-phosphate dehydrogenase deficiency (G-6-PDH deficiency) 76 GOT, aspartate aminotransaminase, see AST 15, 16, 17, 19, 31, 78, 79 GPT, alanine transaminase, see ALT 14, 15, 16, 17, 31 Granulocytes 15, 54 Haematocrit (HCT, Ht) 13, 15, 17, 19, 25, 53, 55 Haematology 25, 85 Haemoglobin (Hb) 13, 25, 53, 58, 59, 74, 75, 78, 102 Haemoglobinopathy 76 Haemolysis 8, 18, 19, 32, 38, 39, 48, 59, 74-79, 85, 86, 91 Haemolysis risk factors 77 Haemolysis, in vitro 77 Haemolysis, in vivo 76 Haemostasis, paediatrics 54-55 HDL-Cholesterol 13, 15, 17 Heroin 14 Hyperbilirubinaemia = jaundice 19 Hyperlipoproteinaemia = lipid metabolism 19 Identification of the ordering doctor 22 Identification of the person collecting the blood 22 Identification of the sample 23 Immunoglobulins 103 In vitro haemolysis 77 In vivo haemolysis 76 In-house transport 82 Indwelling catheter urine 106 Infection risk 62, 106 Influence of sample storage 58, 83, 84, 85, 101 Influencing factors 10 Influencing factors, modifiable 14-17 Influencing factors, non-modifiable 12-14 Infusion 19, 38, 59, 77 Inorg. phosphate 16 Insulin 14, 16 Interference factors 18-19 Intermittent catheter urine 106 Iron (Fe) 12, 31, 78 Jaundice 18, 19 118 119 Labelling 24 Lactate 25, 51, 52, 58, 59, 83, 89 Lactate dehydrogenase (LDH) 19, 78, 79, 86 Laxatives 16 LDH (lactate dehydrogenase) 19, 78, 79, 86 LDL cholesterol 13, 15 Leucocytes 12, 15, 25, 54, 86, 101, 102 Lipaemia 18, 19 Lipase 14 Lymphocytes 15 Magnesium (Mg++ ) 16, 32 MCHC (mean corpuscular haemoglobin concentration) 15 MCV (mean corpuscular volume = mean red cell volume) 15 Medical history 11, 14 Medications (see also Medicinal drugs) 16, 19, 21, 29, 38 Medicinal drugs (see also Medications) 16, 19, 21, 29, 38 Mg++ (Magnesium) 16, 32 Microbial differentiation 103 Microbiological tests in urine 103 Mid-stream urine 101, 104-105 Modifiable influencing factors 14-17 Monocytes 15 Morphine 14 Na+ (sodium) 14, 16, 19, 31, 51, 59 Needle stick injury 62, 63, 64, 92, Neonatology 45 Nicotine 15 Nitrite 105 Non-modifiable influencing factors 12-14 Noradrenaline 14, 15, 16 Order of draw (blood), capillary 95 Order of draw (blood), venous 26 P650 81, 82 Packaging instructions for sample transport 81, 82 Paediatrics 44-55, 88-99 Patient identification 21, 22, 40 pCO2 57, 58, 59, 83 Penicillin 16 pH 58, 59, 102 Phenobarbital 16 Phosphorus 17 Physical activity 16 PLAP (placental AP) 15 Plasma 13, 16, 25, 29, 55, 68, 69, 74, 75, 78, 85, 86 Platelets 54 Pneumatic tube system for sample transport 77, 86-87 pO2 57, 58, 59 POCT 88, 99 Porphyrins 103 Potassium (K+ ) 14, 16, 17, 19, 26, 29, 31, 32, 59, 78, 79, 83, 84, 86 Preanalytical errors 7, 8, 18, 113 Pregnancy 12, 45, 103 Preparation 19, 25, 27, 72, 83, 86, 89, 98, 99 Prolactin 14, 15 PSA (prostate-specific antigen) 19 PTT (thrombin time = TT) 19, 25, 79 Puncture sites, capillary blood collection 90 Puncture sites, venous blood collection 30 Pyridoxal phosphate 15 Pyruvate kinase 16, 76 Quick (thromboplastin time = TPT, prothrombin time) 16, 25 Race 12 Reference ranges, paediatrics 52-55 Release of cell contents 78 Renin 14, 17 Rhythmic daily fluctuation 14 RPM 69 RPM and g force 69, 72, 98 Safety products 26, 27, 29, 32, 33, 34, 36, 42, 47, 49, 50, 60, 61, 62-67 Sample identification 23, 24 Sample storage 21, 58, 80-87 Sample transport 81-87 Samples for clinical chemistry 25, 85 Second morning urine 105 Selenium 15 Sepsis 40 Serum 51, 52, 69, 71, 72, 74, 75, 78, 85, 86, 87, 95, 98 120 121 sO2 57, 59 Sodium (Na+ ) 14, 16, 19, 31, 51, 59 Specific weight 102 Spontaneous urine 105 Stasis time 30, 31 Storage 58, 59, 80-87, 101 Substance use 15, 16 Suprapubic aspiration urine 106 Swinging bucket rotor 69, 70, 73, 98 Test strip test 101, 102, 103, 105, 109 TG (triglycerides) 12, 15, 17, 31 Thrombin 54 Thrombin time (PTT, TT) 19, 25 Thromboplastin time = TPT (Quick) 16, 25 Thromboplastin time, activated partial (aPTT) 19, 54, 55, 79, 86 Thyroxine 14 Tips for difficult vein conditions 32, 47 Total protein 12, 17, 31, 51, 102, 103, 105 Tourniquet application 30-31 TRBA 100 81, 82 TRBA 250 66, 92 Triglycerides (TG) 12, 15, 17, 31 Troponin 79 TSH (thyrotropin) 14 TT (thrombin time, PTT) 19, 25, 79 Underfilling 8, 27 Urea 14, 16, 17 Uric acid 14, 16, 17, 19 Urinary tract infection 103, 105 Urine sample 100-110 Urine sediment (see Urinary sediment) 102, 103 Vacuum technique 36, 37, 39, 77 Vanillylmandelic acid (VMA) 14, 15, 103 Venous puncture 29, 30, 47, 48, 77 Vitamin B12 12 Vitamin B6 15 Vitamin D 13 VMA (vanillylmandelic acid) 14, 15, 103 Yeast cells 102 15 Imprint Legal notice: We would like to point out that the topics addressed in ‘Tips and Techniques in Preanalytics’ covering the fields of venous blood collection, capillary blood collection and urine collection are recommendations only and do not, under any circumstances, replace medical, scientific or technical advice. Subject to technical modifications. This publication may contain information about products that may not be available in all countries. © 2015 · SARSTEDT AG & Co. Postfach 12 20 · D-51582 Nümbrecht Telefon +49 22 93 305 0 · Telefax +49 22 93 305-3450 info@sarstedt.com · www.sarstedt.com 122 123 Notes 21-453-0000-200 If you have any questions, we’ll be happy to help! Tips&TechniquesinPreanalytics SARSTEDT AG & Co. P.O. Box 12 20 D-51582 Nümbrecht Phone +49 2293 305-0 Fax +49 2293 305-2470 info@sarstedt.com www.sarstedt.com