CLINICAL CHEMISTRY LEC

LECTURE 1: LABORATORY SAFETY AND

PATIENT PREPARATION
Prof. JC Louise Bandala, RMT
August 17, 2021
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Laboratory Safety - rules used in every lab to keep everyone safe ● Focuses on safety related to
blood-borne pathogens that
LABORATORY SAFETY AND REGULATIONS can be present
● Safety Agencies and Organizations
○ U.S. Department of Labor’s Occupational Safety Awareness for Clinical Lab. Personnel
Safety and Health Administration (OSHA)
○ Clinical and Laboratory Standards Institute Employer’s Responsibilities Employee’s Responsibilities
(CLSI)
○ CDC, part of the U.S. Department of Health and Establish lab work methods & Know and comply with the
Human Services (DHHS), Public Health Service safety policies established lab works safety
○ College of American Pathologists (CAP) methods
○ The Joint Commission (The Joint Commission Provide supervision & guidance Have a positive attitude toward
on Accreditation of Healthcare Organization) to employees supervisors, coworkers, facilities
■ Formerly known as JCAHO & safety training
● Each of these organizations has its own rules Provide safety info, training, Give prompt notification of
● CLSI - formerly known as NCCLS (National Committee PPE & medical surveillance to unsafe conditions or practices to
for Clinical Laboratory Standards) employees the immediate supervisor and
○ Provides excellent general laboratory safety ensure that unsafe conditions
and infection control guidelines and practices are corrected
○ They already created 2 documents
■ The first is about clinical laboratory Provide and maintain equipment Engage in the conduct of safe
safety and lab facilities that are work practices and use of PPE
■ Second is the protection of laboratory adequate for the tasks required
workers from occupationally acquired ● Employer and employee should share safety
infections responsibility
● CAP - publishes an extensive inspection checklist as ○ The individual employee has on obligation to
part of the lab accreditation program which includes follow safe work practices, and be attentive to
section dedicated to lab safety potential hazards in the place their working at
● TJC - publishes a yearly accreditation manual for ○ Employers has the ultimate responsibility for
hospitals and the accreditation manual pathology and safety and delegates authority for safe
clinical laboratory services which actually includes a operation to laboratory managers and
detailed section on safety requirements supervisors
● If we summarize their roles, it's basically more on setting ○ No matter how careful we are, if the workplace
guidelines and accreditation of different laboratories in itself do not have the correct policies while
relation to if it reached the required safety present in a working = it disregards the safety
workplace ● Being an employer, you are liable to your employees.
○ Whatever may happen to employees means
Occupational Safety and Health Act that the workplace is harmful
● Public Law 91-596 ● Employees should be aware and should understand how
● Enacted by US Congress in 1970 everything works
● Goals: Provide all employees with a safe work ○ Identify the different threats (electrocution, etc.)
environment
● OSHA (Occupational Safety and Health Administration) Laboratory Hazards Prevention Strategies
○ Inspection ● Engineering Controls
- Authorized to conduct on-site ● Administrative Controls
inspections to determine whether an ● Work Practice Controls
employer is complying with the ● Personal Protective Equipment (PPE)
mandatory standards in terms of
safety OSHA’s Three Lines of Defense
- Safety is no longer a moral obligation
but also a federal law
○ Accreditation
● There are a lot of standards under OSHA
○ There are different standards that is explained
■ Blood-borne pathogen standard
■ Hazard communication standard
■ Respiratory protection standard
○ Basically, it pertains to safety specific to those
standard
■ Ex. blood-borne pathogen standard

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 ● Hierarchy of Controls Color of container/bag Type of waste
○ Elimination Black Non-infectious dry waste
■ Most effective way to ensure safety
Green Non-infectious wet waste (kitchen, dietary,
■ To completely remove the hazard and
etc.)
if not possible the next thing we can
do is substitution Yellow Infectious and Pathological waste
○ Substitution Yellow with black band Chemical waste including those with heavy
■ Replace the hazard or at least find metals
safer alternatives to those existing
hazards Orange Radioactive waste
○ Engineering controls Red Sharps and pressurized containers
○ Administrative controls
Purple Cytotoxic or cytostatic waste must be
○ PPE
incinerated in a licensed or permitted facility

4. Splash guards
5. Volatile liquid carriers
- Designed to keep intact chemicals
6. Centrifuge safety buckets

● Example on how we plan and ensure safety to the

workplace
● Ex. for people checking packages
○ Involves the use of utility knives
■ Hazard: prone to certain accidents
like cutting yourselves
○ If we think about elimination, we are telling
ourselves that we need to stop our workers in
performing a task that involves using utility 7. Biological safety cabinets
knives - HEPA filtration of air intake and exhaust
○ If we can't eliminate such hazards (using utility - Recirculates filtered air into laboratory
knives), the next thing we can do is look for - Ensure sterility
alternatives. 8. Fume hoods
■ Safe utility knives - No filtration of air
○ Engineering control - Exhausts chemical fumes outside the
■ Machines do the work (to avoid being laboratory
exposed to certain chemicals) - Suitable for chemicals and non-sterile work
○ Administrative Control - Never used for infectious agents
■ Trainings to ensure that the employee 9. Mechanical pipetting devices
has lesser chance of getting injured 10. Computer wrist/arm pads
○ PPE 11. Sensor-controlled sinks
■ Cut resistant gloves 12. foot/knee/elbow-controlled faucets
13. Eyewash station
Engineering Controls 14. Chemical Storage Cabinet
● Engineering controls remove the hazard from the - In terms of storage, corrosive and flammable
workplace create a barrier between the worker and the chemicals must be in small quantities as much
hazard i.e., installing physical barriers such as as possible
bullet-resistant enclosures 15. Safety showers
● Preferred among others because they make permanent - Installed where corrosive chemicals are being
changes that reduce exposures to hazards and do not used
rely on the worker’s behavior - Readily available to all personnel

Examples of Engineering Controls Administrative Controls

1. Puncture-resistant containers ● Are those that modify workers’ work schedules and tasks
2. Safety needles in ways that minimize their exposure to workplace
3. Biohazard bags hazards
○ Biohazard- refers to biological substances that ● Examples:
pose a threat to the health of living organisms ○ Developing a chemical hygiene plan
primarily that of humans ○ Developing SOP for chemical handling
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 ○ Warning alarms ● Employers of health care workers must establish and
○ Labeling systems implement an infectious waste program
○ Trainings ● All biomedical waste should be placed in a bag marked
with the biohazard symbol and then placed into a
Work Practice Controls leak-proof container that is puncture-resistant and
● Practices that reduce the risk of exposure altering the equipped with a solid, tight-fitting lid. All containers must
way in which a task is performed to make it safe be clearly marked with the word biohazard or its symbol.
● Intended to reduce the likelihood of exposure by ● All sharp instruments, such as needles, blades, and
changing the way a task is being performed glass objects, should be placed into special
puncture-resistant containers before placing them inside
that bag and container
Laboratory Hazard Prevention Strategies
● All biomedical waste must then be disposed of, according
Work practice controls ● Hand washing after each patient to one of the recommended procedures
(general procedures or contact ● Highly pathogenic waste should undergo preliminary
policies that mandate ● Cleaning surfaces with disinfectants treatment on-site.
measures to reduce or ● Avoiding unnecessary use of ● Potentially biohazardous material, such as blood
eliminate exposure to needles and sharps and not products and contaminated laboratory waste, cannot be
hazard) recapping directly discarded. Contaminate noncombustible waste,
● Red bag waste disposal such as glassware, should be autoclaved before being
● Immunization for hepatitis discarded. Special attention should be given to the
● Job rotation to minimize repetitive discarding of syringes, needles, and broken glass that
tasks could also inflict accidental cuts or punctures.
● Orientation, training, and continuing Appropriate containers should be used for discarding
education these sharp objects.
● No eating, drinking, or smoking in
the laboratory FIRE HAZARD
● Warning signage ● Four factors causing fire: (Fire Tetrahedron)
○ Fuel
Personal Protective Equipment ○ Heat
○ Oxygen
1. Gloves
○ Uninhibited Reaction
2. Lab gown
■ The continuous reaction of fuel, heat,
3. Eyewash stations
and oxygen
4. Protective eyewear
● In order for fire to start, the four must be completed
5. Face shield
6. Face mask
7. Safety showers
8. Appropriate footwear

HAZARDS CLASSIFICATION: TYPES OF HAZARDS

Safety Hazards General Classification

1. Biological
2. Fire
3. Electrical
4. Chemical
5. Mechanical (physical)
6. Radiation
7. Compressed gasses
8. Cryogenic Materials
9. Ergonomic

BIOLOGICAL HAZARD
● Medical Waste - “may transmit infectious diseases”
○ Blood and body fluids, stool, urine, body
tissues, etc.
○ 3 types of disposal
■ Incineration
■ Chemical treatment
■ Autoclaving
● Discard sharps in puncture-resistant containers located
within the work area
● Needles should NOT be transported, recapped, bent,
or broken by hand

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● The type of fire extinguisher hat can be used for all
classes is the Dry Powder

ELECTRICAL HAZARD
● Direct effect:
NFPA (National Fire Protection Agency) Hazard Label
○ Shock
○ Burns ● Each diamond represents different hazards
○ Death ● Flash Point
● Indirect effect: ○ Lowest temp. at which a liquid can give off
○ Explosion vapor to form an ignitable mixture in air near
○ Fire the surface of the liquid
● What to look out for to prevent hazards ○ The lower the flashpoint, the easier it is to ignite
○ Free cords
○ Removed grounding prongs sa plug
○ Any type of grounding shock being used

CHEMICAL HAZARD
● Employees must be notified of the potential health
hazards of the handled chemicals
○ Chemical storage equipment must be arranged
& labeled accordingly
○ Take note of storage requirements
○ MSDS (Material Safety Data Sheets)
■ Compiled information about the
chemicals being handled
■ Must be on file and available for every
chemical in the lab
■ Control measures in case of exposure

MECHANICAL HAZARD
● A.k.a Physical Hazards
● Hazards created by the use of or exposure to either
powered or annually operated equipment, machinery,
and plant
○ Centrifugation lapses
○ Lab glassware

RADIATION HAZARD
● Ionizing radiation can damage living tissue in the human
body
● Strips away electrons from atoms and break some
chemical bonds
● When these particles come in contact with organic
materials like the human tissue, it damages them causing
burns and cancer
● To reduce radiation exposure remember:
○ Distance
■ The farther from the source of
radiation, the lesser exposure
○ Shielding
■ Wearing pieces of equipment that
shield us from it
○ Time
■ The longer the exposure, the more
hazard

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 COMPRESSED GASES ● 10-14hrs: lipids and lipoproteins
● All compressed gases are hazardous because of the ● 48 hrs fasting- increase serum bilirubin
high pressures inside the cylinders. ○ Increase clearance of bilirubin which decreases
● Mixture of gases n a container having a certain pressure during fasting.
● We are putting pressure in the container ● 72 hrs fasting-increase triglycerides while glucose
○ Pressure: 40 psi at 21.1 degree celsius decreases in women to 45 mg/dL.
● All are hazardous because of the high pressure inside ● Basal state collection: glucose, cholesterol, triglyceride
the cylinders. and electrolytes
○ Can become certain missile Note: Basal state collection is early morning blood
collection, 12 hrs after the last ingestion of food.
● Requires fasting specimen: FBS, GTT, TAG, Lipid Profile
CRYOGENIC MATERIAL
test, gastrin and insulin.
● Liquid Nitrogen
● Cryogens DIET
○ Substances used to produce low very ● High protein diet-increase urea
temperature ○ Urea- breakdown products of proteins
■ Low as -153 degree celsius ○ Ammonia can be further converted into urea
● Ex: liquid nitrogen ● Glucose, lipids and catecholamines may show variation
○ Major hazard of liquid nitrogen are associated postabsorptive hormonal effects.
with the properties of extreme cold evaporation. ● High protein, low carbohydrate diets- increased ketones
in urine.
ERGONOMIC HAZARD ○ Ketones- comes breakdown of fats
● Factors in our environment that can harm our ○ High protein, low carbohydrate→ fats used as
musculoskeletal system energy
● Causes strain disorders ● Fat-rich food may increase potassium, ALP, TAG, and 5
● Primary contributing factors: HIAA
○ posture/ position ○ HIAA- 5-hydroxyindoleacetic acid
○ Applied force
■ Breakdown product of serotonin
○ Frequency of repetition
■ Serotonin- a hormone in the brain that
Prevention strategies
can affect our mood.
● Job rotation to minimize repetitive tasks (work practice
● Serotonin-rich food (banana, pineapple, tomato, and
controls)
avocado) increase the urinary excretion of 5-HIAA.
● Computer wrist/ arm pads (engineering controls)
● Caffeine increases concentrations of glucose; it promotes
● Placing comfortable seats
the release of catecholamines from the adrenal medulla
and brain tissue.
"Safety begins with the recognition of hazards and is achieved
○ Catecholamines- increases glucose,
through the application of:common sense,a safety-focused
decreasing release of insulin
attitude,good personal behaviour,good housekeeping in all
■ Flight and fight hormones.
laboratory work and storage areas,and above all, the continual
practice of good laboratory technique." ● Increased in obese person: LD, cortisol and glucose.

POSTURE AND POSITION

PATIENT PREPARATION
● Preferred position during phlebotomy: upright position
Pre-analytical Variables/ Factors contributing to the variation of
or supine
results:
● Changing from supine to sitting or standing position-
● Exercise
increased levels of albumin, enzymes, and calcium
● Fasting
○ Causes constriction of blood vessels and
● Diet
reduction of plasma volume
● Posture and Position
● Changing from sitting to supine- increase levels of
● Tourniquet application
proteins, lipids, BUN, iron, and calcium
● Tobacco Smoking
○ Since there will be a shift of water and
● Alcohol ingestion
electrolytes into your tissues, it causes
● Stress (anxiety)
hemoconcentration
● Drugs
● Changing from standing to supine position- decreased
levels of cholesterol, triglycerides, and lipoproteins
EXERCISE
○ Since this causes exovascular water to transfer
● Volume shifts between the vascular and interstitial
to your vascular systems and dilutes your non
compartments, volume loss by sweating and changes in
diffusible plasma constituents
hormone concentrations.
● Prolonged standing for more than 30 minutes- increased
● Transient increased in lactate, fatty acid, ammonia.
potassium
○ Lactate- produced when there is a lack of
○ due to the release of potassium to your
oxygen
muscles
○ Ammonia- waste product of your amino acids
● Prolonged bedrest- decreased plasma albumin
and proteins; product of deamination of ATP
○ Due to fluid retention
● Long-term increased in CPK, AST, LD and aldolase.
○ Enzymes found in skeletal muscle
Thus, it is advisable that we need to let patients rest for at least 15
● Increased in prolactin, testosterone and luteinizing
minutes to regulate and stabilize their bodily substances
hormone (LH)
● Elevated levels of proteins in urine (proteinuria)
TOURNIQUET APPLICATION
● Vigorous hand exercise (fist clenching) increases
● 1 minute application is recommended
potassium, lactate and phosphate.
● Prolonged application= hemoconcentration and
● Decreased plasma levels of FSH and LH in long distance
anaerobiosis
athletes.
○ Anaerobiosis - increase in the substances
○ FSH and LH- reproductive hormones
present in our body that does not need oxygen
● Increase levels: potassium, proteins (albumin), enzymes,
FASTING
lactate, cholesterol, and ammonia.
● 8-10 hrs: glucose

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● Prolonged use of tourniquet with fist exercise- increase ○ Alkaline, phosphatase, cholesterol, and
potassium 1mmol/L phosphorus
● For measurement of lactate - tourniquet use should be ● Affected by gender (increased levels):
minimal and the patient should not clench his or her fist ○ Male: Albumin, ALP, creatinine, uric acid,
otherwise will result to elevated levels of lactate cholesterol, BUN
○ Female: HDL, iron, and cholesterol
TOBACCO SMOKING ● Affected by recent food ingestion:
● Increased in plasma catecholamines and cortisol ○ Increased levels: glucose, TAG, astrin, free
● Increased in glucose, growth hormone, cholesterol, calcium
triglycerides, ammonia, urea, lactate, insulin and urinary ○ Decreased levels: electrolytes (Cl-,K+,P+), ALP,
5- HIAA. AMS
● Increased plasma non esterified acid concentration
● Decreased plasma levels of vitamin B12 and elevated
thiocyanate
○ Tobacco has nicotine, which has an endocrine
effect on our body, thus elevating endocrine
hormones

ALCOHOL INGESTION
● Increased level of urate, triglycerides, and gamma
glutamyl transferase (GGT).
○ GGT= liver enzyme; test requested by the
physician since it is a serum marker for alcohol
related diseases
● Hypoglycemia (chronic alcoholism)
○ Alcohol consumption causes an increase in
insulin secretion which leads to lowering your
blood sugar level causing hypoglycemia

STRESS (ANXIETY)
● Affects adrenal hormone secretion
● Increased: catecholamines, cortisol, ACTH, prolactin,
insulin, albumin, glucose, and lactate
● Total cholesterol has been reported to increase with mild
stress, and HDL cholesterol to decrease by as much as
15%.
● Hyperventilation - affects acid-base balance
○ Conserving or needing of increased oxygen
● Since there is body tension, we begin to breathe a little
more shallow and lower our oxygen levels in the blood,
which sends signals to our brain that we are at stress.

DRUGS
● Hepatotoxic drugs can elevate liver function enzymes.
● Diuretics can cause decreased plasma sodium and
potassium.
○ Diuretics
■ also known as water pills
■ Common treatment for high blood
pressure
● Opiates cause increases in liver and pancreatic enzymes
○ Pang high na drugs
○ 1 content - Acetaminophen which has a direct
effect to our liver causing toxicity

PHYSIOLOGIC VARIATION
● changes that occur within the body such as cyclic
changes (diurnal or circadian) or those resulting from
exercise, diet, stress, gender, age, drugs, posture or
underlying medications.
● Affected by diurnal variation:
○ increased in AM: ACTH, aldosterone, cortisol,
and iron
○ decreased in PM: Acid phosphatase, Growth
hormone, Parathyroid hormone, Thyroid
stimulating hormone
- There is fluctuation in our body
- Most substances with diurnal variation are hormones
- That is why it is very tricky when we are ing requested to
collect samples for hormonal testing
- Timing is needed for collection Ex. ACTH - highest peak
is at 8AM
● Affected by age (increased levels):