To eliminate this effect on calcium, potassium and sodium, some sampling devices come with electrolyte-balanced heparin, which compensates for the binding effect within the normal range of the electrolytes. They are also necessary for all clinical laboratories accredited by International Organization for Standardization (ISO) document 15189. Clipboard, Search History, and several other advanced features are temporarily unavailable. If not, specimens should be shipped from peripheral collection facilities to the core laboratory utilizing current CLSI guidelines (non-refrigerated at ambient temperature in as short a time as possible, preferably within the first hour after collection) [5, 57]. The project results showed a 25% reduction in Antecedents of anemia, iron supplementation, hospitalization or blood transfusion can also guide the clinician [11, 12]. Under-filling of tubes is another important source of error and severely affects laboratory results. when updating procedures or when conducting refresher training. WebSome of the pre-analytical errors include hemolyzed sample, insufficient sample, incorrect label, incorrect requisition, clotted sample and tube broken in centrifuges. J Thromb Haemost. PMC The recommendation to avoid using a rotor brake is based on expert opinion and should be demonstrated in appropriate studies. 1. Clin Chem 1990; 36,3: 541-44. Training and supervision were conducted during regular office hours every weekday. Spandrio L. Pre-analysis variability: the effect of evaporation on the error of measurement, with special reference to sodium and potassium. The anticoagulant effect of sodium citrate is attributed to its ability to bind calcium, making the calcium unavailable to promote clot formation [4]. a) haemorrhagic diathesis: In an attempt to standardize the diagnostic criteria of von Willebrand disease (VWD), the most prevalent congenital bleeding disorder which occurs with equal frequency among men and women and affecting up to 1% of the general population, a BS has been developed [26]. A study of pre-analytical variables in clinical biochemistry laboratory. Contraception. Universit catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NARILIS, Haematology Laboratory, B-5530, Yvoir, Belgium, A. Magnette,M. Chatelain,B. Chatelain&F. Mullier, Maastricht University Medical Centre and Cardiovascular Research Institute (CARIM), Department of Internal Medicine, Maastricht, The Netherlands, You can also search for this author in Arch Pathol Lab Med. The following chapters concern the sample collection and sequence of drawing blood. Conclusions: 2008 Sep;45(Pt 5):463-6. and Clin Lab. This step, based on a variety of manual activities, is the most vulnerable part of the total testing process and is a major component of the reliability and validity of results in haemostasis and constitutes the most important source of erroneous or un-interpretable results. Other measures for avoiding preanalytical errors that have proven successful are: never accept an unlabelled sample. Epub 2011 May 13. Biologie des anomalies de lhmostase. These recommendations are in line with those issued in the United States and in the United Kingdom by the National Institute for Health and Clinical Excellence (NICE). The major effect of exposure to air is alteration of p ao 2, with less pronounced changes in pH, p CO 2 and ionized calcium (iCa). For samples coming from external laboratories, it is important to check prior to analysis whether the aliquot external samples (fresh or frozen) really consist of citrated plasma. Under-filling increases the dilution of the sample due to the volume of liquid anticoagulant, and may increase the clotting time due to the excess calcium-binding citrate present [4, 5, 47]. Intensive care committee on evaluation of routine preoperative T, French society of a, intensive C. Pre-interventional haemostatic assessment: guidelines from the French society of anaesthesia and intensive care. J Thromb Haemost. J Thromb Haemost. For LTA, the platelet count of PRP samples should not be adjusted to a standardized value by addition of autologous PPP, unless the platelet count is >600x109/L [8, 15]. The article is a part of a series of articles dealing with preanalytical errors in blood gas testing. Raps M, Helmerhorst FM, Fleischer K, Dahm AE, Rosendaal FR, Rosing J, Reitsma P, Sandset PM, van Vliet HA. This may strongly influence some of the coagulation assays and may lead to platelet activation, activation of factor VII, which in turn can give shorter clotting times and hence lower PT-INR and PT-sec results. Makhumula-Nkhoma N, Teggert AK, Young JS. As more laboratories use electronic readers for orders and patient identification, one of the major sources of error will decrease. Blood Coagul Fibrinolysis. 1 shows, an addition of 0.05 mL liquid heparin to 1 mL whole-blood sample (Hct 45 %) will dilute the plasma phase by 10 %. 3.3 van Vliet HA, Bertina RM, Dahm AE, Rosendaal FR, Rosing J, Sandset PM, Helmerhorst FM. Key factors influencing the incidence of hemolysis: A critical appraisal of current evidence. Clin Chem 1991; 37,10: 1730-33. Caffeine enhances fibrinolytic potential as whole blood fibrinolysis time is shortened and PAI-1 levels are decreased, whereas tPA activity increases after consumption of coffee and such effects are blunted during caffeine abstinence [42]. Lillo R, Salinas M, Lopez-Garrigos M, Naranjo-Santana Y, Gutirrez M, Marn MD, Miralles M, Uris J. Al-Ghaithi H, Pathare A, Al-Mamari S, Villacrucis R, Fawaz N, Alkindi S. Sultan Qaboos Univ Med J. 2014;4:2337. The testing process has been divided into three major parts (pre-, intra- and post-analytical), each with a few aspects that can be identified and, in many cases, quantified. Verify Patient Identity Apart from value-added benefits, lab services can also validate a The vast majority of the samples should be collected into trisodium citrate, buffered anticoagulant to help keep the pH stable during processing and testing [15, 36]. Thromb Haemost. 2nd ed. Lysis of the red cell membranes induces the release of red cells contents (many intracellular enzymes, ADP ) into plasma and may lead to activation of the plasma sample altering coagulation parameters and activation of other bloodlines (leucocytes, platelets). b) short term plasma storage: PPP should be stored at room temperature (2025C) or at 80C until analysis. The effects of pneumatic tube system transport on ROTEM analysis and contact activation assessed by thrombin generation test. This means that if the general recommendation for storage of samples for blood gas measurement is followed, the diffusion across the cell membrane and cell metabolism can be ignored. Sample tubes for haemostasis analyses generally contain an anticoagulant. Some special coagulation assays, such as those that measure thrombin generation markers (e.g., thrombin antithrombin complex (TAT) and prothrombin fragment 1+2), should be drawn without the use of a tourniquet because that may lead to spurious elevation of these markers, particularly if the tourniquet is left in place for more than one minute [5]. CLSI H21-A5: Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays and Molecular Hemostasis Assays; Approved GuidelineFifth Edition. 3. Nicotine and cocaine addictions interfere with some hormones. Transporting blood tubes in a vertical rather than a horizontal position limits the extent of in vitro microparticles (MP) generation [62, 63]. Specimens must be labeled: Immediately and in front of the patient. AM drafted the manuscript. It is important to use an automatic pipette because it permits slow and linear suction, unlike plastic pipettes that pose a risk of getting a high rate of residual platelets. 2015;71:708. Br J Haematol. Incomplete laboratory request forms: the extent and impact on critical results at a tertiary hospital in South Africa., Ann Clin Biochem. 2001;31:618. Terms and Conditions, It should also be mentioned that hemolysis has several lowering effects on plasma cCa2+: 3.8 Biochem Med (Zagreb). Non-compensated heparin may cause an error on cCa2+ of as much as 6 %. Cite this article. Different effects of oral contraceptives containing different progestogens on protein S and tissue factor pathway inhibitor. A study [19] shows that the rate of calcium increase is about 5.3 % for a pH decrease of 0.1. Standardization efforts are essential to control and prevent errors and to ensure the quality of exploration in haemostasis. 2017 Jul;50(10-11):568-573. doi: 10.1016/j.clinbiochem.2017.02.021. Conversely, in patients with a positive history of haemorrhagic diathesis, haemostasis testing should be requested depending on the suspected disease [9]. If double centrifugation is not done when preparing a sample to be frozen this can lead to a lysis of residual platelets upon freezing of plasma sample and lead to shortened APTT results in heparinized patients [80]. Blood Gas News 1998; 7,1: 4-11. Determination of the electrolyte parameters is one of the most frequent tests performed in laboratory medicine, both in central laboratories and at the point of care. 2011 Jul;44(10-11):944-5. doi: 10.1016/j.clinbiochem.2011.05.003. Improper storage of whole blood at cold temperature may cause VWF and factor VIII values to fall below normal reference threshold levels, which may potentially lead to a false suspicion of haemophilia A or VWD due to inappropriate pre-analytical handling of blood [4, 5, 25, 44, 82]. An official website of the United States government. Inaccuracy attributable to hyperbilirubinemia is less significant using modern instruments equipped with dedicated wavelengths (i.e., with readings at 650 nm or above), so that test results in samples with a bilirubin concentration up to 20 mg/dL can still be analytically reliable. Article This applies also to fibrinolysis parameters [35, 47, 52, 81, 83]. WebMost preanalytical errors are rooted outside of the clinical laboratory, although laboratory professionals are the main work force to detect these errors. Although existing BS have limitations (e.g. The .gov means its official. WebClinical labs have several tools at their disposal to detect pre-analytical errors. Blood Coagul Fibrinolysis. That means handling stress, getting good women's health care, and nurturing yourself. Thromb Haemost. Appropriate Test Selection. MeSH These account for the vast majority of what we shall term laboratory errors. More quantitative BATs have been proposed to improve the diagnostic criteria for MBD because most patients with an MBD do not show a definitive bleeding history, and are difficult to distinguish from normal subjects [7]. Working group for preanalytical phase EFoCC, laboratory M. Patient identification and tube labelling - a call for harmonisation. 2014;24:2530. These are errors that occur due to patient misidentification, improper sample, improper sample handling and the amount of time to deliver the sample to the laboratory. WebThe pre-analytical phase begins: When the test is ordered by the physcian. In order to prevent disturbing pre-analytical influences, any interfering drugs should be administered after collecting a blood sample. This is largely due to placental derived plasminogen activator inhibitor type 2 (PAI-2), which is present in substantial quantities during pregnancy [19]. Fortunately, many of these errors can be detected by the laboratory analyst so that corrections can be made before testing begins or before resulting and reporting the test. Procedures for the collection of arterial specimens. The authors declare that they have no competing interests. Some studies have evaluated the impact of high acceleration centrifugation conditions on routine coagulation testing (including especially PT, aPTT and fibrinogen; no data were found for the thrombin time) and concluded that rapid centrifugation does not modify results and contributes, by decreasing duration of the pre-analytical variable, to reduce the turnaround time for these tests [7076]. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Presented by Ellis Jacobs, PhD, Assoc. Some studies evaluated the need for discard tubes in a variety of others coagulation tests (e.g. Young DS. The less dense components of the sample, such as the plasma phase, will be thrown out of the vial. 4. This phase is part of the total laboratory procedure consisting of several stages and beginning with the physician requesting the performance of a laboratory investigation on a patient. 2023 BioMed Central Ltd unless otherwise stated. External influences (like temperature, light ) may be of major impact (Table6). Similar results were obtained in further studies [45, 56]. 2011 Jul;49(7):1113-26. Reduced concentrations of protein S can be caused by functional impairment of this protein by differences in modulation of its activity by other plasma proteins that change during the oral contraceptives use or by changes induced in the protein S molecule that impair its anticoagulant activity [24]. 2008;6:34651. Frozen aliquots should be transported on dry ice [36]. 2013; 2244. Care must be taken to follow manufacturers expiry dates. Samples: From the patient to the laboratory. Br J Anaesth. Lippi G, Chance JJ, Church S, et al. This will avoid serum contamination by EDTA which can cause false elevations of potassium and false decrease of calcium. Christiansen TF. 2012;38:57685. Article WebThe most commonly reported types of pre-analytical error are: a) missing sample and/or test request, b) wrong or missing identification, c) contamination from infusion route, d) A record of all the drugs that the subject took during the week prior to testing should be collected [15]. Our experience shows it is important to check the absence of vibration (during acceleration/deceleration processes) due to lack of centrifuge maintenance. Google Scholar. The accurate standardization of the pre-analytical phase is of pivotal importance for achieving reliable results of coagulation tests and should reduce the side effects of the influence factors. 3.7 Blood samples should be obtained in a relatively atraumatic fashion, and during collection the blood should flow freely into the collection container [4]. Service valuation des actes professionnels. 1 ed. Lippi G, Salvagno GL, Adcock DM, Gelati M, Guidi GC, Favaloro EJ. Bonhomme F, Ajzenberg N, Schved JF, Molliex S, Samama CM, French A. Up to 70% of all errors in blood gas testing occurs in the The glycolysis, which occurs mainly in the red blood cells [17], is a process where glucose is converted into lactic acid. Standardization efforts are essential to control and prevent errors and to ensure the quality of exploration in haemostasis. WebThis article provides useful tips for avoiding preanalytical errors on total bilirubin measurements; tips, which you can incorporate in the standardized procedures, training of your staff or whenever method comparisons of c tBil are conducted. WebDiagnostic Errors / prevention & control* Humans Quality Assurance, Health Care / methods* PubMed Central The development of the present literature review was carried out using the PubMed database records including analysis of references from selected articles from 1991 to 2016 based on the following key-words: pre-analytical phase, pre-analytic variables, pre-analytical quality, preoperative/pre-operative tests, order of draw, phlebotomy, screening tests, routine tests, screening testing, hemostasis/haemostasis, coagulation tests, bleeding history, preoperative bleeding questionnaire, preoperative evaluation, bleeding risk, haemorrhage/hemorrhage, surgery, von Willebrand disease, von Willebrand factor, inherited bleeding disorders, bleeding score, quality, standardization, collection of blood, sample collection, tourniquet, samples, transportation, preparation, storage, recommendations, discard tubes, activated partial thromboplastin time, PTT, aPTT, prothrombin time, PT, international normalized ratio, INR, bleeding time, platelet count, platelet function testing, PFA-100, blood sampling, sample tubes, anticoagulant, order of filling the tubes, sampling process, processing of samples, transportation of samples, centrifugation, storage conditions, freezing, thawing. One of the components is free hemoglobin, which will give the plasma or serum a visible red color when the concentration is above 0.02 g/dL [26].. In case of a factor defect observed on a frozen sample, it is suggested to repeat the analysis on a fresh sample. GFHT. Freezing has an inconstant and unpredictable effect on the results and may cause significant elevations of aPTT, but also PT [4, 8486]. These changes tend to me more pronounced in women taking third generation combined oral contraceptives than on second generation [21]. Alesci S, Borggrefe M, Dempfle CE. 2012;38:56575. The patients blood group provides relevant information related to haemostatic activity (e.g. J Thromb Haemost. Stress should be avoided under all circumstances (e.g. WebThe objective was to show how the numbers of preanalytical errors related to unsuitable samples in a hospital setting decrease following two improvement strategies related to new technology and educational actions and how their effects Only articles in English or French were analysed. An example: The interference observed in lipemic samples is most evident with readings using wavelengths lower than 500 nm and can be prevented with readings at 650 nm or above, and/or using higher dilutions of the test sample, or can be abated in high hypertriglyceridemic specimens (i.e., > 1,000 mg/dL) using high speed micro-centrifugation, lipid extraction with organic solvents such as fluorine-chlorinated hydrocarbon, or lipid-clearing agents such as LipoClear (StatSpin Inc., Norwood, MA) and n-hexane.9. O'Donnell J, Tuddenham EG, Manning R, Kemball-Cook G, Johnson D, Laffan M. High prevalence of elevated factor VIII levels in patients referred for thrombophilia screening: role of increased synthesis and relationship to the acute phase reaction. The lists can be used as checklists for training in the different steps of sampling, or whenever a specific problem is encountered during: Useful tips when measuring potassium (cK+), The patient has not received blood transfusion just prior to the sampling, The patient does not clench the fist several times before or during sampling since contracting the forearm cause the release of potassium ions [21], The skin is completely dry if it has been cleaned with alcohol prior to the sampling, An appropriate amount of flush solution is discarded prior to sampling from catheters, Sampling from catheters The Na+/K+-ATPase pump in the cell membrane. There is a decrease in physiological anticoagulants manifested by acquired activated protein C (APC) resistance. Young DS. 5.1 The term pre-analytical phase describes all actions and aspects of the medical laboratory diagnostic procedure that occurs prior to the analytical phase [1]. Results: By using this website, you agree to our V n5 du 20/10/10. WebCorrect patient identification, for example, seems to be the most important step taken to avoiding preanalytical testing errors. insufficient amount of blood or inappropriate blood-to-anticoagulant ratio), inappropriate mixing of a sample, etc. The change in pH affects numerous conditions in the sample, among others protein's capacity to bind calcium, since hydrogen ions compete with calcium for binding sites on albumin and other proteins. When sampling from catheters, an important aspect to consider is dilution or contamination by flush solution. Blonshine S, Alberti R, Olesinski RL. 2013;35:113. Use of combined oral contraceptives is associated with a three-to six-fold increased risk of venous thrombosis. History of the preanalytical phase: a personal view. Hemolysis causes the release of Appropriate Test Selection. Evaluation of request forms submitted to the haematology laboratory in a Ghanaian tertiary hospital, Ann Clin Biochem. Inappropriate investigations Incomplete laboratory request forms: the extent and impact on critical results at a tertiary hospital in South Africa. Useful tips to avoid preanalytical errors in blood gas testing: electrolytes. Google Scholar. 2.2, Dry electrolyte-balanced heparin is used as anticoagulant, The sample tube is sealed if it is centrifuged prior to the measurement [9], The sample is not stored too long at 0-4 C, The sample material is stored in an anaerobic tube or syringe [7], Useful tips when measuring calcium (cCa2+), The sample is not drawn from an arm where infusion solution is being given or has been given within the last hour [7], The tourniquet is released after maximum one minute to avoid venous stasis, which can lead to an anaerobic glycolysis with production of lactic acid and decreased pH [8], The manufacturer's recommendation on the heparin-to-blood ratio is followed, Hemolysis Intravascular hemolyzation may occur during blood transfusion, depending on the age of the transfused blood [8]. WebDiagnostic Errors / prevention & control* Humans Quality Assurance, Health Care / methods* When aliquoting the plasma, care must be taken so that the buffy coat (the layer of cells between the red cells and plasma) is not disturbed or that this cellular component is not introduced back into the plasma. 2011;155:3044. Phlebotomy. Mller-Plathe O. Preanalytical aspects in STAT analysis. The time frame for analysis depends upon the stability of the analysis, which depends on storage temperatures and conditions. PT, aPTT and factor VIII tests from frozen samples cannot be performed [4]. Because samples that are rejected must be recollected, which gives potential delay in patient management, phlebotomists must be fully aware of the common reasons why specimens are rejected (Table4). Quality and reliability of routine coagulation testing: can we trust that sample? A comprehensive plan to prevent pre-analytical errors has 5 interrelated steps: Developing clear written procedures. For platelet function assays and coagulation factors, we suggest numbering each tube according to the sample collection order. Guder WG, Narayanan S. Pre-Examination Procedures in Laboratory Diagnostics: Preanalytical Aspects and Their Impact on the Quality of Medical Laboratory Results. 2012;22(2):145-9, Simundic AM, Lippi G. 2. Recently the French Society of Anaesthesia and Intensive Care issued recommendations for the prescription of routine preoperative testing before a surgical or non-surgical procedure, requiring any type of anaesthesia [9]. Testing should be completed within 3 to 4h of collection [4, 5, 8, 15]. Bonini P, Plebani M, Ceriotti F et al. Preventing pre-analytical errors to reduce costs and ensure positive patient outcomes. 2013;11:11903. Vol. Understanding the different values in electrolyte measurements. PubMed Need to clot for 20 to 30 minutes. Rapid preparation of plasma for Stat coagulation testing. aspirin, thienopyridines) should be stopped at least 10days before sampling, if possible [8, 15]. 2009;31:4627. The passage of blood through butterfly tubing and IV catheters might cause increased haemostatic alterations in comparison to blood collection using a conventional straight needle, directly into the tube [2]. Radiometer Medical ApS To reduce pre-analytical error rates, all procedures should be standardized and automated whenever possible. Rapid preparation of plasma for coagulation testing. 918-193. Evaluation of the prethrombotic state in pregnancy and in women using oral contraceptives. contraceptives containing levonorgestrel) [22, 23]. Continuous monitoring and management of pre-analytical errors is crucial in order to improve the quality of the pre-analytical phase, which is essential for patient care. Intracellular proteins released into the plasma binds free calcium ions [15]. Heparin also binds all positive ions in blood, especially calcium ions.. Darmstadt: GIT Verlag GMBH, 2001. 2010;32:1328. Google Scholar. 3. Optimally, blood sampling is done in the laboratory performing the analyses, which allows for verifying many of the above mentioned steps including when needed getting additional data on medical history, medication, fasting state etcetera. Plebani M, Carraro P. Mistakes in a stat laboratory: types and frequency. 3 [8]. Rochester, MN: Davies Printing Company, 1986: 141-46. Clin Biochem. This one is useful for the identification of subjects requiring laboratory evaluation for VWD and for assessing the clinical severity of the disorder in patients with type 1 VWD [7, 2729].
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