a) For analysis in platelet-poor plasma For analysis in PPP, which is the standard material required for PT, aPTT, fibrinogen, single coagulation factor assays, functional protein S and C assays, activated protein C resistance, lupus anticoagulant (LA) assays, antiphospholipid antibody testing, thrombin generation, microparticles measurements, homocysteine, VWF assays, tPA, PAI, plasminogen and antiplasmin, or monitoring of unfractioned heparin therapy, and many other tests, sample tubes require a second centrifugation and should be centrifuged in capped tubes within 4h after drawing blood [2, 36, 37, 79]. Specimens collected in 3.8% buffered sodium citrate may prolong the PT and aPTT and underestimate fibrinogen if the normal range is based on 3.2% citrated samples [4, 47]. During this phase, aside from the ability to draw blood from the patient, the phlebotomist should also possess the skill of being able to identify factors that affect the process and address the same as needed. Huang H, Yin H, Xu W, Wang Q, Xiao M, Zhao Q. fibrinogen, D-dimer, factors II, V, VII, VIII, IX, X, XI, proteins C and S and AT, ) and suggested that discard tubes are not necessary when drawing samples for specialized coagulation testing [2, 5, 54, 55]. ODonnell J, Laffan MA. Test immediately. The pH of the anticoagulated plasma should be comprised between 7.3 and 7.45. It is also advisable not to eat dark chocolate [39]. Explain the phlebotomist's role in minimizing pre-analytical variability associated with venipuncture and urine sample collection. In particular, the vacuum aspiration of blood into primary collection tubes could have an influence on platelet function testing. It is important to take samples so as to reduce platelet activation in-vitro and to restrict the use of the tourniquet [15, 36, 49]. The BS is proposed as a predictor of clinical outcomes of inherited VWD, and may also help to identify cases at higher risk of frequent and severe bleeds requiring more intensive prophylactic regimens [30]. For these samples, due to the variable heparin neutralization by platelet factor 4 (PF4), the delay before centrifugation should not exceed 1h for a sample collected in citrate and 4h in CTAD. Chen YW, Chen JK, Wang JS. This review is a summary of the most important recommendations regarding the importance of pre-analytical factors for coagulation testing and should be a tool to increase awareness about the importance of pre-analytical factors for coagulation testing. Problems may arise during the collection of blood specimens such as misidentification of the sample, use of inadequate devices or needles, incorrect order of draw, prolonged tourniquet placing, unsuccessful attempts to locate the vein, incorrect use of additive tubes, collection of unsuitable samples for quality or quantity, inappropriate mixing of a sample, etc. Laboratory Evaluation of Hemostasis. PMC insufficient amount of blood or inappropriate blood-to-anticoagulant ratio), inappropriate mixing of a sample, etc. Raps M, Helmerhorst FM, Fleischer K, Dahm AE, Rosendaal FR, Rosing J, Reitsma P, Sandset PM, van Vliet HA. Cold storage of citrated whole blood prior to centrifugation, by placing samples either in an ice bath or in refrigerated (28C) storage, is no longer recommended. However, the pre-analytical phase, in which human factors are mainly involved, is clearly a vulnerable part of the laboratory process. The first one is devoted to the clinical history, bleeding score and physical examination to demonstrate the importance of the patients history regarding various diseases such as thrombotic diseases in case of haemorrhagic diathesis or preoperative assessment. Boudaoud L, Divaret G, Marie P, Bezeaud A. Discard tube may be considered to ensure correct filling of sample tubes for coagulation tests. 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]. Transport samples at ambient temperature (1525C) in as short a time as possible. eCollection 2017 Apr. 2017 Feb 15;27(1):177-191. doi: 10.11613/BM.2017.020. Other BS have been developed for the large population of patients with atrial fibrillation (AF) that require oral anticoagulant therapy (e.g. Centrifuge samples that cannot be tested within 4h and frozen the plasma aliquot. The direct transfer of blood specimens from syringes to blood collection tubes by piercing of the rubber stopper of the tube is a practice that should be avoided. How do you treat bleeding disorders with desmopressin? It seems that higher plasma levels of fibrinogen and viscosity are the main contributors to higher coagulability found in smokers, whereas the lower fibrinolytic potential is mainly attributed to an increase in PAI-1 activity and possibly also a decrease in tPA activity and lower plasminogen levels [41, 42]. Hence, the tourniquet should be placed tightly but less than one minute in order to prevent haemoconcentration, increased fibrinogen and factors VII, VIII, XII as well as activation of endothelial cells and therefore fibrinolysis [47, 48]. Labelling blood tubes in the absence of the patient is a potentially life threatening error. Only the Italian SISET recommendations (Societ Italiana per lo Studio dellEmostasi et della Trombosi) suggest performing systematic haemostasis testing with aPTT, PT and platelet count prior to any intervention, even in patients with no bleeding diathesis history [9]. 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. Click the card to flip . Sodium citrated tubes must be filled up to 90% of the nominal volume or to the mark noted on the tube if provided [41, 47]. 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). Nelson S, Pritt A, Marlar RA. If tubes need to be transported this should be done with care in order to avoid unnecessary agitation. (WHO Best Practices in Phlebotomy, CLSI GP42-A6 and CLSI C46-A2), which have been modified based on local logistical, cultural, legal and regulatory requirements. Patient and Sample Identification. A temperature-controlled centrifuge is required for processing routine coagulation assays. Quality in Laboratory Hemostasis and Thrombosis. sharing sensitive information, make sure youre on a federal Summary of key pre-analytical recommendations about transportation of samples. National Library of Medicine Lippi G, Rossi R, Ippolito L, Zobbi V, Azzi D, Pipitone S, Favaloro EJ, Funk DM. Clin Chem Lab Med. The PRP should then be transferred to a capped polypropylene tube and a platelet count performed. It has been demonstrated that a high platelet count (>200109/L) does not affect results of PT, D-dimer, fibrinogen and aPTT assays, when samples are tested fresh and analyzed immediately after centrifugation [36, 79]. Federal government websites often end in .gov or .mil. The diameter of the needle should preferably be comprised between 19 and 22 gauge [34, 49]. Idarucizumab for dabigatran reversal. New Solutions for the Sample Transport and Results Delivery: A Digital Lab. In order to prevent disturbing pre-analytical influences, any interfering drugs should be administered after collecting a blood sample. Vigorous shaking, vortexing or agitation of blood samples should be avoided in order to prevent inducing haemolysis or spurious platelet and factor activation that may result in shortened clotting times or false elevation of clotting factor activity in specimen tests (e.g. Objective To evaluate the major causes of preanalytical errors in medical laboratory of a tertiary care hospital. The shortest stability is observed for factors V and VIII. Moreover, it is very important that the clinician and the laboratory exchange all relevant information as much as possible [25]. DOI: 10.11613/BM.2017.020 Abstract Phlebotomy is often addressed as a crucial process in the pre-analytical phase, in which a large part of laboratory errors take place, but to date there is not yet a consolidated methodological paradigm. b) For analysis in platelet-rich plasma The preparation of platelet-rich plasma (PRP) for platelet function analysis requires that centrifugation is performed at 200250g for 10min without application of a rotor brake [8, 15]. 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]. A standardized sequence of blood sampling must be respected in order to avoid carry-over between tubes [3]. HHS Vulnerability Disclosure, Help van Vliet HA, Bertina RM, Dahm AE, Rosendaal FR, Rosing J, Sandset PM, Helmerhorst FM. External influences (like temperature, light ) may be of major impact (Table6). Check the absence of vibration (during acceleration/deceleration processes) due to lack of centrifuge maintenance. Haemolysed samples may lead to early flow obstruction in the PFA, presumably due to platelet activation, fragmentation of platelet and red blood cells and the presence of micro-thrombi [4]. 3). Neurotherapeutics. PDF Pre-analytical Errors in The Clinical Laboratory and How to Minimize Them This review aimed at summarizing recommendations with regard to the pre-analytical phase and provides some guidance to reduce the effects of biological factors that can have a significant impact on patient care. Types and Frequencies of Pre-Analytical Errors in the Clinical - PubMed Samples can be stored as whole blood or stored following centrifugation [81]. Pre-analytical phase: Automated ProTube device supports quality Patients should not be studied after meals associated with a high fat content, so as to avoid the formation of chylomicrons in plasma, which will interfere with light transmission aggregometry [15, 37]. Microparticles derived from maternal endothelial cells and platelets, and from placental trophoblasts may contribute to the procoagulant effect [19]. Methods: Sultan A. Five-minute preparation of platelet-poor plasma for routine coagulation testing. Clin Chim Acta. Vol. Mechanisms of hormonal therapy related thrombosis. VWF appears to be stable at room temperature for 48h [4]. The discriminant power of bleeding history for the diagnosis of type 1 von Willebrand disease: an international, multicenter study. If an IV line is present, the sample site selected is distant from the line. Plasma samples frozen at minus 20C remain stable for 2weeks. Bethesda, MD 20894, Web Policies Before transport, samples should be tested regarding identification, safety conditions and stability. IVTEAM offers its visitors a premier service that has no financial or subscriber based restrictions. Guder WG. In order to minimize misinterpretation of laboratory results, blood samples should be collected from fasting subjects in the morning between 7 and 9a.m. and from subjects who have refrained from smoking for at least 30min [4, 8, 15, 36, 37]. Do not vortex or shake. Ialongo, C. and Bernardini, S. (2017) Preanalytical investigations of phlebotomy: methodological aspects, pitfalls and recommendations. J Thromb Haemost. However, the results of LTA studies could be inaccurate when the platelet count in the PRP samples is lower than 150x109/L [8, 15]. Store samples at 70C (or below) rather than 20C. If the phlebotomist is a member of the laboratory staff, he/she will be aware of the impact of the quality of sampling on the quality of results. We hope that these recommendations will be a useful contribution to the . Out of the Maze. It is important to know if the patient is pregnant. Bonhomme F, Ajzenberg N, Schved JF, Molliex S, Samama CM, French A. Rapid preparation of plasma for coagulation testing. Lipets EN, Ataullakhanov FI. Bethesda, MD 20894, Web Policies Stability of prothrombin time and activated partial thromboplastin time tests under different storage conditions. Store samples at room temperature (1525C) until analysis. 2nd EFLM-BD European Conference on Preanalytical Phase - Zagreb, 1-2 March 2013 contaminated, haemolysed) or quantity (e.g. Thromb Haemost. Ozgonenel B, Rajpurkar M, Lusher JM. The centrifuge should be validated before use, every 6months or after modifications, in order to assure that platelet-poor plasma (PPP) is achieved [47]. Pregnancy is associated with increase in fibrinogen, factors VII, VIII, X, VWF, D-dimer concentration and with increase in levels of prothrombin fragments 1+2 and thrombin-antithrombin III complexes. Each day 6K users have access thousands of pages of easy to access relevant intravenous news and updates. The pre-and post-analytical phases of the process account for 93% of errors. 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). 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]. dependence on clinician interpretation regarding patient recall, inability to distinguish among bleeding events occurring at different anatomical sites, etc.) Patients with blood group O are known to have lower levels of VWF. The pre-analytical phase involves specimen collection, acquisition by the laboratory, labeling and coding, and preparation for analysis. Most errors in laboratory medicine occur in the pre-analytical phase of the total testing process. The site is secure. aspirin, thienopyridines) should be stopped at least 10days before sampling, if possible [8, 15]. After thawing, mix the sample gently to resuspend any cryoprecipitate. Stress should be avoided. Use rapid freezing technique (liquid nitrogen). Results: Temperatures higher than room temperature can lead to degradation of factor V and factor VIII [64]. However, due to lack of sufficient evidence, the practice of drawing a discard tube should still be recommended [5]. F. Bamforth, in Comprehensive Sampling and Sample Preparation, 2012 3.09.8.3 Sample Preparation for MS/MS. The diameter of the needle should preferably be comprised between 19 and 22 gauge. Cornes M, van Dongen-Lases E, Grankvist K, Ibarz M, Kristensen G, Lippi G, Nybo M, Simundic AM, Working Group for Preanalytical Phase EFoCC, Laboratory M. Order of blood draw: Opinion Paper by the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE). Lippi G, Becan-McBride K, Behulova D, Bowen RA, Church S, Delanghe J, Grankvist K, Kitchen S, Nybo M, Nauck M, Nikolac N, Palicka V, Plebani M, Sandberg S, Simundic AM. The combination of the standardized bleeding questionnaire and an interpretation grid has been referred to as a Bleeding Assessment Tool (BAT) [7]. Right or wrong sample received for coagulation testing? b) pre-operative assessment: For preoperative investigations, some guidelines are available. 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]. 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. their use is strongly encouraged, as BATs have proven validity in assessment of symptom severity and help identify patients needing further investigations [10, 32, 33]. Elements usually seen in haemorrhagic syndrome are bruising, purpura, or haemarthrosis. Phlebotomy issues and quality improvement in results of laboratory testing. This is largely due to placental derived plasminogen activator inhibitor type 2 (PAI-2), which is present in substantial quantities during pregnancy [19]. Conclusions: For platelet function assays and coagulation factors, we suggest numbering each tube according to the sample collection order. Hemostasis & Thrombosis Center, University of California, Davis Health System, Sacramento, CA, USA. FOIA 2017 Apr 22;36(2):107-112. doi: 10.1515/jomb-2017-0003. Preanalytic variables of thrombin generation: towards a standard procedure and validation of the method. Error in patient identification or lack of identification. The findings of our search have been grouped into different subtopics. Preanalytical investigations of phlebotomy: methodological aspects, pitfalls and recommendations. This may cause haemolysis when cells under pressure from the plunger collide with the tube wall [4]. The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation. 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.
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