SPECIAL COLLECTIONS AND POINT-OF-CARE TESTING

BLOOD BANK SPECIMENS

 Specimen requirements: use of lavender or pink-top EDTA tubes. In some cases, a
nonadditive glass red-stoppered tube
 Identification and labelling requirements:
 Patient’s full name (including middle initial)
 Patient’s hospital ID no. (Social security no. for outpatients)
 Patient’s DOB
 Date and time of collection
 Phlebotomist’s initials
 Room no. and bed no. (optional)
Special Identification Systems
 Special ID bracelet (PDC Securline Blood Bank)- contains unique ID no. **self-carbon
adhesive label
 Blood ID-band systems with linear bar-coded BBID nos. (Typenex Medical created two:
Next Generation Barcode Blood Bands, FlexiBlood bar-coded band and form system)
**Before the healthcare provider physically starts the transfusion, the Patient Identification
check can require a second nurse validation.
Type, Screen, and Cross-Match
 Most common tests performed in BB (blood typre and screen)
 Determines a patient’s blood type (ABO) and Rh factor (+ or -)
 During a cross-match, the patient’s plasma or serum and the donor’s RBC are mixed
together to determine compatibility
 A transfusion of incompatible blood can be fatal because of agglutination (clumping) and
lysis (rupture) of the RBCs within the patient’s circulatory system
Blood Donor Collection
 Involves collecting blood to be used for transfusion purposes rather than for diagnostic
testing
 Blood is collected from volunteers in amounts referred to as units
 Facilities that provide blood products for transfusion purposes are called Donor Blood
Banks
 Blood banks follow guidelines set by the American Association of Blood Banks (AABB)
for purposes of quality assurance and standardization
 Regulation by the U.S. Food and Drug Administration (FDA) is required, since blood
products are considered pharmaceuticals
FYI:
 The anticoagulant and preservative CPD (Citrate-Phosphate-Dextrose) or CPDA1 (CPD
+ adenine) is typically used in collecting units of blood for transfusion purposes.
 Citrate- prevents clotting by chelating calcium
 Phosphate compound- stabilizes the pH
 Dextrose- provides energy to the cells and helps keep them alive
Lookback Program
 A unit of blood can be separated into components: RBCs, plasma, and platelets
 A lookback program requires notification to all blood recipients when a donor for a blood
product they have received has turned positive for a transmissible disease
Autologous Donation
 Autologous donation is the process by which a person donates blood for his or her own
use
 This is done for elective surgeries when it is anticipated that a transfusion will be needed
 To be eligible to make an autologous donation, a person must have a written order from a
physician
**Minimum time between donation and surgery: as little as 72 hrs.
**Errors such as drawing blood samples from the wrong patient for blood transfusion present
even more of a risk than transmissible diseases
Cell Salvaging
 Aqueous solutions, plasma, and serum samples or banked erythrocytes often contain
lysed RBCs that have released hemoglobin into solution
 A high free hemoglobin level indicates that too many red cells were destroyed during the
salvage process and renal dysfunction could result if blood were reinfused
 Free hemoglobin can be detected using point-of-care instruments such as the HemoCue
Plasma/Low Hemoglobin analyzer
BLOOD CULTURES
 During the disease process, bacteria may also enter the circulatory system, causing
bacteremia (bacteria in the blood) or septicemia (microorganisms or their toxins in the
blood)
 Best time to detect bacteremia: 30 mins. to 2 ½ hrs. prior to fever peak, before the
body eliminate some of the microorganisms
 Blood cultures help determine the presence and extent of infection as well as indication
the type of organism responsible and the antibiotic to which it is most susceptible
 **Blood cultures should be ordered on the basis of whether the patient has a condition in
which bloodstream invasion is possible and not only when a patient experiences a fever of
unknown.
Specimen Requirements
 For optimum results, specimens should be drawn 30-60 mins. apart
 If in critical condition or antiobiotic should be given right away, cultures should be
drawn consecutively and immediately from different sites
 “second site” blood cultures are more useful when drawn 30 mins. Apart
 Specimen collection:
 Specimen are collected in special bottles containing nutrient broth (medium) that
encourages growth of microorganisms
 Specimens are collected in sets of two: one aerobic and one anaerobic
 Syringe: anaerobic is filled first
 Butterfly: aerobic first due to air in the tubing
KEY POINT:
Volume of blood drawn for infants and younger children: 1% to 4% of total blood volume
Adults or people weighing more than 80 pounds: 20 to 30 mL per culture with a minimum 10mL
per draw
Skin Antisepsis
 Skin antisepsis, the destruction of microorganisms on the skin, is a critical part of blood
culture procedure
 30 to 60 second friction scrub is required
 Tincture of iodine, chlorhexidine gluconate, and a povidone/70% ethyl alcohol
combination
 10% povidone or 1% to 2% tincture of iodine compounds in the form of swab
sticks or special cleaning pad kits such as benzalkonium chloride have been used
to clean the collection site
 In using povidone-iodine or chlorhexidine gluconate ampule swab, swab should
be placed at the site of needle insertion and move outward in concentric circles (3
to 4 in. in diameter)
 If there is an iodine sensitivity, use chlorhexidine gluconate/isopropyl alcohol
Collection Procedure
*Maximum area of treatment of one applicator is approximately 2.5 by 2.5 inches.
*Culture bottles with plastic caps can be cleaned with 60% isopropyl alcohol after removing the
flip-off cap. It is also suggested that a clean alcohol prep pad be placed on top of each bottle after
cleaning
*Mark the minimum and maximum fill on culture bottles
  A blood culture has a vacuum that usually exceed 10 mL
 Adult blood culture requirement: 10-20 mL per set
 Pediatric: 1-2 mL per set

Media Inoculation Methods

 Direct inoculation
 Use of butterfly and specially designed holder
 Aerobic vial filled first
 Syringe inoculation
 When syringe method is used, blood must be transferred to the bottles after the
draw is complete
 Never hold the culture bottle in your hand during inoculation process. Place it on
a solid surface or in a rack
 When delivering blood to the bottles, direct the flow along the side of the
container
 As with the transfer device, do not push on the syringe plunger
 Intermediate collection tube
 Yellow-top SPS tube
 Other anticoagulants: ECHO are not recommended
 Use of an intermediate tube is discouraged
A. SPS in the collection tube when added to the blood culture bottle increases
the final concentration of SPS
B. Transfer of blood from the intermediate tube to the blood culture bottles
presents another opportunity for contamination
C. Transfer of blood to the culture bottles presents an exposure risk to
laboratory staff
ANTIMICROBIAL NEUTRALIZATION PRODUCTS
 It is not unusual for patients to be on antimicrobial (antibiotic) therapy at the time blood
culture specimens are collected
 In such cases, the physician may order blood cultures to be collected in fastidious
antimicrobial neutralization (FAN) or antimicrobial removal device (ARD) bottles
 An ARD contains a resin that removes antimicrobials from the blood
 FAN bottle contains activated charcoal which neutralizes the antibiotic
 ARDs and FANs should be delivered to the lab for processing as soon as possible
COAGULATION SPECIMENS
 At one time it was customary to draw a ‘clear’ or discard tube prior to collection of blue-
top tube
 A few ml of blood were collected into a plain red-top tube to clear the needle of
thromboplastin contamination picked up as it penetrated the skin
  New studies have shown that a clear tube is not necessary when collective for a
PT or PTT
 A clear tube is required for all other coagulation tests (e.g., factor VIII) because
the CLSI still recommends that they be the 2 nd or 3rd tube drawn
 Blood to anticoagulant ratio of sodium citrate: 9:1
 A blue-top CTAD tube is available for special coagulation testing
 CTAD tube contains citrate, theophylline, adenosine, dipyridamole to inhibit
thrombocyte activation between blood collection and test
 Never pour two partially filled tubes together to create a full tube
 Cooling on ice during transport may be required for some test specimens to protect the
coagulation factors
 If the testing is delayed, the specimen must be centrifuged and the plasma frozen
 If a coagulation specimen must be drawn from an indwelling catheter, the CLSI
recommends drawing and discarding 5 ml of blood or six times the dead space volume of
the catheter before collecting the specimen
 If heparin is introduced: flush with 5mL saline before drawing discard blood and
collecting specimen
2-HOUR POSTPRANDIAL GLUCOSE
 Postprandial (PP) means after meal
 It is rarely elevated in normal persons but may be increased in diabetic patients
 It is an excellent screening test for diabetes and other metabolic problems
 It is also used to monitor insulin therapy
Principle of 2-hour PP Specimen Collection
 The patient is placed on a high-carbohydrate diet for 2 to 3 days prior to the test
 The patient fast prior to the test (atleast 10 hours before the test)
 A fasting glucose specimen may be collected before the start of the test
 The patient is instructed to eat a special breakfast (typically containing the equivalent of
100 grams of glucose) or given a measured dose of glucose beverage on the day of the
test
 A blood glucose specimen is collected 2 hours after the patient finished eating
GLUCOSE TOLERANCE TEST
 It is used to diagnose problems of carbohydrate metabolism
 aka: Oral Glucose Tolerance Test (OGTT)
 It evaluates the body’s ability to metabolize glucose by monitoring the patient’s tolerance
of high levels of glucose without adverse effects
 2 major disorders: Hyperglycemia and Hypoglycemia
 Insulin, produced by pancreas, is primarily responsible for regulating blood glucose
levels
  GTT length is typically 1 hour for gestational diabetes and 3 hours for other glucose
metabolism evaluations
 The method used to collect blood must be consistent for all specimens (if it is collected
first by venipuncture, all succeeding must be venipuncture. If skin puncture, all
succeeding must be skin puncture)
 In normal patients: Blood glucose levels peak within 30 mins. to 1 hr. following glucose
ingestion
 The peak triggers the release of insulin, which brings glucose levels back down to
fasting levels within about 2 hours and no glucose spills over into the urine
 Diabetics: inadequate or absent insulin response
 Glucose levels peak at higher levels and are slower to return to fasting levels
CAUTION: If the patient vomits during GTT procedure, the physician must be consulted to
determine if the test should be continued
LACTOSE TOLERANCE TEST
 It is used to determine if a patient lacks the enzyme (mucosal lactase) that is necessary to
convert lactose, or milk sugar, into glucose and galactose
 Symptoms are relieved by eliminating milk from the diet
 Typically performed in the same manner as 2-hour GTT; however, an equal amount of
lactose is substituted for the glucose
 Patient with mucosal lactase: resulting glucose curve similar to a GTT curve, and result is
considered negative
 Lactose intolerant: glucose curve will be flat
 Some individuals normally have a flat GTT curve (resulting in a false-positive
result)
 It is then suggested that they have a 2-hour GTT performed the day before the
LTT
 False positive: small bowel resections, slow gastric emptying, Chron’s disease,
cystic fibrosis
 Can also be performed on breath samples

PATERNITY/PARENTAGE TESTING
 Paternity testing is performed to determine the probability that a specific individual
fathered a particular child
 The mother, child, and alleged father are all tested
 Blood samples are preferred for testing: however, buccal (cheek) swabs are increasingly
being used
 Paternity testing can also be performed before the infant is born on specimens obtained
by amniocentesis or by chorionic villus sampling
THERAPEUTIC DRUG MONITORING
 Involves the analysis, assessment, and evaluation of circulating concentrations of drugs in
serum, plasma, or whole blood
 Testing of drug levels at specific intervals
 Used of management of patients being treated with certain drugs in order to help establish
a drug dosage
 Maintain dosage at therapeutic (beneficial) level and avoid drug toxicity
 A quantitative evaluation of circulating concentrations of drugs
 Provides a basis for estaensure that a given drug dosage produces maximal therapeutic
benefit and minimal toxic adverse effects establishing a rational dosage regimen to fit
individual situations
 It is the periodic measurement of blood drug levels
 It is performed to ensure that the level of drug in the blood is within the therapeutic range
TERMS:
 Onset of action is time from drug administration to the first observable effect
 Duration of action is the length of time that a drug continues to produce its effect
 Termination of drug action is the time when plasma drug concentration falls below the
therapeutic range
Things to remember:
 Peak levels screen for drug toxicity and specimens are collected when the highest serum
concentration of the drug is anticipated
 Peak times occur approximately 30 minutes after IV administration, 60 minutes
after IM administration, and 1 to 2 hours after oral intake
 Trough levels are monitored to ensure that levels of the drug stay within the therapeutic
range
 Trough-level specimens are collected prior to administration of the next scheduled
dose
THERAPEUTIC PHLEBOTOMY
 It involves the withdrawal of large volumes of blood usually measured by the unit (as in
blood donation), or approximately 500 ml
 It is used as a treatment for a certain condition such as polycythemia and
hemochromatosis
 Polycythemia is a disease involving the body’s overproduction of RBCs
 RBC level is monitored using Hematocrit test
 Hemochromatosis is a disease characterized by excess iron deposits in the tissues
 It can be caused by a defect in iron metabolism or result from multiple
blood transfusions or excess iron intake
TOXICOLOGY SPECIMENS
 Clinical toxicology is concerned with the detection of toxins and treatment for the effects
they produce
 Forensic toxicology is concerned with the legal consequences of toxin exposure, both
intentional and accidental
 Specimen used: blood, hair, urine, and other body substances
 Forensic specimens:
 Breath or blood for alcohol
 Urine drug screens and blood specimens for drugs and DNA analysis
 Chain of custody must be strictly followed, a special protocol when forensic specimens
are collected used to identify the specimen and the person or persons who obtained and
process it
Blood Alcohol (Ethanol Specimens)
 A law enforcement agency may request a Blood Alcohol Concentration (BAC) on an
individual who has been involved in a traffic accident
 Most frequently used antiseptics are aqueous povidone-iodine and aqueous benzalkonium
chloride (BZK)
 Alternative: Soap and water
 Specimen requirement: glass gray-top sodium fluoride tube, with or without an
anticoagulant (depending upon the need for serum, plasma, or whole blood in the test
procedure)
Drug Screening
 Preemployment drug screening
 Specimen: urine rather than blood
 They are legal implications to drug screening, and a chain-of-custody protocol is required
whether or not the test is being performed for legal reasons
 Follow the National Institute on Drug Abuse (NIDA) protocol for patient preparation and
specimen collection
 Patient preparation requirements
 Explain the test purpose and procedure
 Advise the patient of his or her legal rights
 Obtain a witnessed, signed consent forms
*Alcohol- detectable: 2-12 hrs.
TRACE ELEMENTS
 Include aluminum, arsenic, copper, lead, iron, and zinc
 These elements are measured in such small amounts that traces of them in the glass,
plastic, or stopper material of evacuated tubes may leach into the specimen, causing
falsely elevated test values
  Specimens for these tests must be collected in special trace element-free tubes
 These tubes are typically royal blue and contain EDTA, heparin, or no additive
 Tube labels may be color-coded to indicate the type of additive, if any, in the
tube.

POINT-OF-CARE TESTING
 AKA: alternate site testing (AST) or ancillary, bedside, or near-patient testing,
decentralization
 Brings laboratory testing to the location of the patient
 Benefits:
 Convenience to the patient
 A short turnaround time (TAT)
 Disinfect POC instrument: 1:10 bleach solution; EPA-registered bleach wipes
 Wipes reduce cross-contamination between patients of various bacteria including
Clostridium difficile, MRSA, Vancomycin-Resistant Enterococcus (VRE)
*CLIA- Clinical Laboratory Improvement Amendments
*OSHA- Occupational Safety and Health Administration
*CDC- Centers for Disease Control
*HICPAC- Healthcare Infection Control Practices Advisory Committee
COAGULATION MONITORING BY POCT
 PT and International normalized ratio (INR)
 APTT or PTT
 Activated clotting time (ACT)
 Platelet function
The numerous POCT instruments available to perform various coagulation tests include:
 Cascade POC- ACT, APTT, PT/INR
 CoaguChek XS Plus- PT/INR
 GEM Premier 4000- ACT, APTT, PT/INR
 I-STAT- ACT, PT/INR
 Verify Now- Platelet function
ACT
 Test analyzes activity of the intrinsic coagulation factors and is used to monitor heparin
therapy
 Heparin is given intravenously to patients who have blood clots or whose blood is
apt to clot too easily; it is also given as a precaution following certain surgeries
 Too much heparin can cause the patient to bleed; therefore, heparin therapy is
closely monitored
  Once a patient’s condition is stabilized, the patient is placed on oral anticoagulant
therapy (such as warfarin) and monitored PT testing
PT/INR
 It is used to monitor warfarin (e.g. Coumadin therapy)
 This uses whole blood from a fingerstick to provide timely laboratory results
 INR= (PTpatient/PTnormal)ISI
PTT
 It is used to screen for bleeding disorders prior to surgery, investigate bleeding or clotting
disorders, detect clotting factor deficiencies, and monitor low-dose heparin therapy
Platelet Function
 It is used to determine a patient’s response to medication before open heart surgery or
cardiac catheterization
 This can help prevent excessive bleeding or blood clots
Bleeding Time
 It is the time required for blood to stop flowing from a standardized puncture on the inner
surface of the forearm
 Evaluates platelet plug formation in the capillaries to detect platelet function disorders
and capillary integrity problems
 It is used in diagnosing problems with hemostasis and as presurgical in screening test
 Performed on the volar (inner)lateral surface of the forearm, using a blood pressure cuff
(inflate to 40 mmHg)
*quickly remove the safety clip and place the puncture device firmly on the lateral aspect of
the forearm (without pressing hard) approximately 5 cm below and parallel to the antecubital
crease
ARTERIAL BLOOD GASES AND ELECTROLYTES
 Arterial blood gases (ABGs) measured by POCT methods include pH, partial pressure of
carbon dioxide, oxygen saturation, and partial pressure of oxygen
 Normal blood pH: 7.35-7.45
Below normal: acidosis
Above normal: alkalosis
 Abnormal increase in PCO2: hypoventilation
Decrease: hyperventilation
 SO2 is the measure of percentage of hgb binding sites occupied by O2 in the
bloodstream
Normal: 98%
Hypoxemia and may be cyanotic: below 90%
  The most common electrolytes measure by POCT are sodium, potassium, chloride,
bicarbonate ion, and ionized calcium
 Sodium- most plentiful electrolyte in the blood
Hyponatremia- reduced, Hypernatremia- elevated
 Potassium- primarily concentrated within the cells, with very little found in the
bones and blood
U wave on ECG: potassium deficiency
Hypokalemia- decrease, Hyperkalemia- elevated
 Chloride- exists mainly in extracellular spaces in the form of NaCl
 Bicarbonate ion- plays a role in transporting CO2 to the lungs and in regulating
blood pH
Hypoventilation- acidosis, Hyperventilation- alkalosis
 Ionized calcium- accounts for approximately 45% of the calcium in blood
Uses: muscular contraction, cardiac function, transmission of nerve impulses,
blood clotting
MULTIPLE-TEST PANEL MONITORING BY POCT
 Examples of instruments that have a menu of several different tests are:
 GEM Premier
 i-STAT
 NOVA Stat Profile Analyzer
 ABL80 Flex
 All the testing devices listed measure of a multitude of analytes (sodium, potassium,
chloride, bicarbonate, blood gases, glucose, BUN Hgb, Hct, ACT, lactate, troponin
OTHER TESTS PERFORMED BY POCT
1. Cardiac Troponin T (TnT) and troponin I (TnI)
 Proteins specific to heart muscle
 Measurement of these proteins is a valuable tool in the diagnosis of acute
myocardial infarction (AMI) or heart attack
 Blood levels of cardiac TnT begin to rise within 4 hrs. of the onset of
myocardial damage and may stay elevated for up to 14 days
 Cardiac TnI rise within 3 to 6 hrs. and return to normal in 5 to 10 days
2. Lipid testing (Cholesterol, TAG/TGY, LDL, HDL)
3. B-type Natriuretic Peptide
 BNP is a cardiac hormone produced by the heart in response to ventricular
volume expansion and pressure overload
 Detects congestive heart failure (CHF)
4. C-reactive protein- inflammation
5. Glucose- DM
6. Glycemic Index Control
 Most institutions use a practice of intensive insulin therapy, tight glycemic control
(TCG)
  Involve monitoring a patient’s glucose level every half hour and administration of
insulin as required
 TCG requires frequent and fast glucose results
7. Glycosylated Hemoglobin
 Diagnostic tool for monitoring diabetes therapy
 Primary diagnostic test for type 2 diabetes
 HBA1c: the one measured since it is present in larger quantity
8. Hematocrit or Packed Cell Volume
 Measurement of the volume of RBCs
9. Hemoglobin- anemia
10. Lactate- acid-base disorder, metabolic acidosis
 Lactic acidosis is associated with major metabolic issues and is due to
hyperlactemia (increase lactate in blood) which is usually present in patients with
severe sepsis or septic shock
11. Occult Blood/Guiac- detection of occult (hidden) blood in stool
12. Pregnancy Test- to detect human chorionic gonadotropin (hCG)
A positive result means, in most cases, that the person is pregnant.
• Some tests will produce a faint positive test result if read after the instructed time due to
the formation of something called an “evaporation line.”
• Expired tests can also lead to false positive results. Always check the expiration date
before testing.
• Certain rare medical conditions, such as ectopic pregnancy, and some drugs can give a
false positive pregnancy test.
Note: If a female receives shots of hCG for ovulation, it is possible to have a positive
urine for two to three weeks after the shot and not be pregnant. After delivery or an
abortion, hCG may remain detectable for a few days to several weeks.
13. Strep Testing- detection of group A streptococci
14. Urinalysis
15. Skin Tests
 To determine whether an individual has come in contact with a specific allergen
(antigen) and developed antibodies against it
o Tuberculin test- aka PPD test after the purified protein derivative used in it
Used to determine whether an individual has developed an immune
response to M. tuberculosis
o Aspergillus test- detects hypersensitivity to Aspergillus, a type of mold
o Coccidioidomycosis test- tests for an infectious fungal disease caused by
Coccidioides immitis
o Histoplasmosis test- tests for past or present infection by fungus
Histoplasma capsulatum