David Plaut is a chemist and statistician in Plano, TX. The patients blood group provides relevant information related to haemostatic activity (e.g. 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]. The phlebotomy procedure provided by the CLSI requires wearing gloves, cleansing the venipuncture site and drying of skin before applying the tourniquet and selecting the venipuncture site and vein [47]. obstruction in the needle or too narrow needle size may lead to hemolyzation [9,10]. For analyses that can be performed on frozen plasma, freezing should be fast (using rapid freezing technique like liquid nitrogen), and samples should be preferably stored at 70C (or below) rather than 20C. Below you will find detailed lists of preanalytical issues affecting each of the four electrolyte parameters. The tube volume between the catheter and the sampling port is called the dead space. In case of contamination, the results will be erroneous and a re-collection will be necessary, leading to a delay in subsequent medical decisions. As more laboratories use electronic readers for orders and patient identification, one of the major sources of error will decrease. 1. Before hemolysis. 2012;103:7982. 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 (e.g. OBrien EC, Simon DN, Thomas LE, Hylek EM, Gersh BJ, Ansell JE, Kowey PR, Mahaffey KW, Chang P, Fonarow GC, Pencina MJ, Piccini JP, Peterson ED. CAS for factor assays, fibrinogen). 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. Google Scholar. Lacroix R, Judicone C, Poncelet P, Robert S, Arnaud L, Sampol J, Dignat-George F. Impact of pre-analytical parameters on the measurement of circulating microparticles: towards standardization of protocol. With an increasing amount of testing occurring at the point of care, it is even more important to ensure the continuous competence of staff. 2010;16 Suppl 5:748. 1. 2012;38:57685. This article (1) illustrates several different types of analytical errors and situations within laboratories that may result in increased variability in data, (2) provides The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation. Patient identification - Orders with errors in patient ID. Next, it provides lists with useful tips on how to avoid preanalytical errors when measuring electrolyte parameters on blood gas analyzers. Methodology and clinical applications of ion-selective electrodes. Regarding the surgical and obstetrical history, it is important to note the number of interventions that resulted in bleeding complications (new intervention due to complication, transfusion, admission to intensive care, etc. Laboratory hematology practice. 2001;11:34351. Samples can be stored as whole blood or stored following centrifugation [81]. Vol. Blood samples should be collected after the subject has rested for a short period (at least 5min) [15]. Quad Sclavo Diagn 1984; 20, 1: 110-21. Narayanan S. The preanalytical phase - an important component of laboratory medicine. Our experience shows it is important to check the absence of vibration (during acceleration/deceleration processes) due to lack of centrifuge maintenance. Published studies have demonstrated that for routine coagulation testing, the use of a discard tube is not necessary because there was no significant difference in the aPTT and PT results between the first and second tubes drawn [2, 4, 5, 36, 44, 54]. 3 shows the effect of different degrees of hemolysis on cNa+, cK+ and cCa2+. About dark chocolate, platelet aggregation is modulated by a flavanol-independent mechanism that is likely due to theobromine which is containing by cocoa products [39]. 9. Ensuring Specimen Integrity: Proper Processing and Handling of Specimens for Coagulation Testing. 2011 Jul;44(10-11):944-5. doi: 10.1016/j.clinbiochem.2011.05.003. Arch Pathol Lab Med. Adcock Funk DM, Lippi G, Favaloro EJ. Median ED throughput time was 17 minutes less for the EMS group (163 minutes) than for ED group (180 minutes). If an IV line is present, the sample site selected is distant from the line. Salvagno GL, Lippi G, Montagnana M, Franchini M, Poli G, Guidi GC. 2007;83:15963. Bermes EW, Young DS. By establishing a standardized system to recognize pre 3min at 1000g) used before performing dilute thrombin time and ecarin clotting time, was not validated [78]. Provided by the Springer Nature SharedIt content-sharing initiative. The lists can be used as checklists when a specific problem is encountered, or as a tool to supplement or expand the knowledge of the staff involved in laboratory medicine, e.g. Lock, R. The whole-blood sampling handbook. Vol. The presence of the H-antigen (O group) promotes the cleavage of VWF by ADAMTS13 metalloprotease, and, moreover, a higher hepatic clearance of VWF [13, 14]. The database was searched for studies, clinical practice recommendations and literature reviews. An example: Plebani M, Carraro P. Mistakes in a stat laboratory: types and frequency. Disclaimer. FIG. This guide provides key facts and practical tips on women's health. Ozgonenel B, Rajpurkar M, Lusher JM. GFHT. Following initial centrifugation, the plasma is carefully transferred to a nonactivating plastic centrifuge tube using an automatic pipette, and then centrifuged again for about 15min. Privacy Please enable it to take advantage of the complete set of features! Heparin also binds all positive ions in blood, especially calcium ions.. Olayemi and Asiamah-Broni pointed out that the implementation of advanced information technology and robotics in the pre-analytical phase have improved accuracy and clinical efficiency of the laboratory process, and created a process that minimizes errors.5. In case of high haematocrit, the citrate volume may be adjusted because this may also impact the citrate-calcium ratio. Copenhagen: Private Press, 1981: 163-90. 28 No. Lack of standardized procedures for sample collection accounts for most of the errors encountered within the total testing process. 2010 Jan;36(1):16-20, Favaloro EJ. Evaluation of the prethrombotic state in pregnancy and in women using oral contraceptives. 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]. 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]. In case of reception of an aliquot without information about the anticoagulant used, this one must be rejected because serum and all types of plasma have virtually identical visual appearance. Another common way to obtain blood samples from critically ill patients for analysis of the electrolyte status is to use a venous catheter. The phlebotomist should label each drawn tube with the patients full name, patients date of birth, identification number [6, 38]. Int J Lab Hematol. Aliquoted plasma is stable for 4h when refrigerated, except for plasma for PT-INR and PT-sec, which should not be refrigerated [2, 5, 47]. Sommer SR, Warekois RS. 1. Care must be taken to follow manufacturers expiry dates. 2a. Here are some recommended strategies. The measurement of the parameters pH, pCO2, and pO2 is vulnerable to a number of pre- analytical errors. External influences (like temperature, light ) may be of major impact (Table6). Women using combined oral contraceptives with the highest risk of venous thrombosis (e.g. It is also advisable not to eat dark chocolate [39]. 2008;99:41626. It is not suggested to recentrifuge the aliquots coming from external laboratories. AM drafted the manuscript. A systematic review was conducted following the recommendations of the French Study Group on Haemostasis and Thrombosis (GFHT), the World Health Organization (WHO), the Clinical and Laboratory Standards Institute (CLSI) guidelines, the International Society on Thrombosis and Haemostasis (ISTH), the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) and the British Committee for Standard in Haematology (BCSH) about the pre-analytical phase and the pre-analytic variables which can have an impact on the quality of medical laboratory results and about the procedures for sample collection, processing, transportation, and storage in haemostasis testing. Thode J, Holmegaard SN, Transbl I, Fogh-Andersen N, Siggaard-Andersen O. Article PubMed The glycolysis, which occurs mainly in the red blood cells [17], is a process where glucose is converted into lactic acid. Pre-analytical issues in the haemostasis laboratory: guidance for the clinical laboratories. Pre 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].. Errors in patient preparation, specimen collection, anticoagulant A discard tube (or a citrate tube if the sampling is difficult) must be drawn when citrated plasma is obtained using butterfly systems or other IV catheter devices because the air volume contained in the tubing partially fills the vacuum tube, leading to insufficient filling of the tube with citrate. Fig. 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]. Haemostasis. Even if the ISTH-BAT has not been evaluated sufficiently in inherited platelet function disorders to allow a firm recommendation of its use, it could also be potentially useful for the diagnosis of platelet function disorders [32, 33]. Before transport, samples should be tested regarding identification, safety conditions and stability. 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. Approved standard. However, the focus of the article is not restricted to this application only, as electrolyte values can also be measured on venous blood, capillary blood, plasma, and serum. 1.2, The syringe or sampling tube is not mixed too vigorously, The mixing of the capillary sample with magnet and mixing wire/flea is not done too vigorously, cK+is measured in plasma, as serum yield results 6.2 % higher due to lysis of the platelets during clotting [7], The sample tube is sealed during centrifugation prior to the measurement, The transportation in the pneumatic tube is not too turbulent, The syringe or sample tube is not stored directly on ice, The sample is not stored too long at 0-4 C, The sample material is stored in an anaerobic tube or syringe, Evaporation Bonini P, Plebani M, Ceriotti F et al. Mixing samples is an important way to prevent in-vitro clot formation. A Practical Guide to Laboratory Haemostasis: http://www.practical-haemostasis.com/index.html. Furthermore, it means that the laboratory must try to reach the goal of zero defects. The effects of pneumatic tube system transport on ROTEM analysis and contact activation assessed by thrombin generation test. Explain how the COVID-19 pandemic has renewed the urgency for automation. 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]. 2015;13:4. 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]. A New Method for the Prevention of Pre-Analytical Errors This may well be a reason for the much higher frequency of hemolysed samples and with the wrong order of collection the possibility of potassium-EDTA-contaminated samples.7, Lippi and his co-workers8 studied the effects of hemolysis (a major factor on pre-analytical errors), as well as elevated bilirubin and elevated triglycerides. 2023 BioMed Central Ltd unless otherwise stated. 2013;109:60613. Unauthorized use of these marks is strictly prohibited. Fincher R, Strong J, Jackson J. The maximum errors happen in the pre-analytical phase itself; thus, needless to say, that data capturing plays an important role to prevent these errors. Pre-Analytical Variation 2011 Oct;57(10):1349-50, Felder RA. Hemolysis. WebMost errors affecting laboratory test results occur in the pre - analytical phase (4668.2% of total errors) The traditional laboratory approach to correct pre analytical tasks has Platelet concentrate transport in pneumatic tube systems--does it work? Denmark, Your practical guide to critical parameters in acute care testing.. The expiry dates of the needle and the integrity of the sterile seal should be checked. 2005;93:8539. 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]. Ordering the Test. Background: Kitchen S, Olson JD, Preston FE. Blood Coagul Fibrinolysis. Ann Biol Clin (Paris). If this is done diligently, it can be considered as one of the best screening tests of the risk of bleeding [7, 9, 10]. contraceptives containing levonorgestrel) [22, 23]. Mixing or shaking the sample too hard may lead to hemolyzation. 4. Dilution of 1 mL whole blood sample (Hct 45 %). Wayne, Pa.: NCCLS, 1999; 19, 8. 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. 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. Lab Med. Preanalytical quality improvement: from dream to reality.Clin Chem Lab Med. 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. 2001;59:72535. 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]. cCa2+. Another common way to obtain blood samples from critically ill patients for analysis of 3. However, when the sample is stored in plastic syringes and the gases evaporate, pH will decrease even more.. Moreover, it is very important that the clinician and the laboratory exchange all relevant information as much as possible [25]. 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. Standardization efforts are essential to control and prevent errors and to ensure the quality of exploration in haemostasis. 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]. A comprehensive plan to prevent pre-analytical errors has 5 interrelated steps: Developing clear written procedures. 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. Vascul Pharmacol. For many years, the clinical laboratorys focus on analytical quality has resulted in an error rate of 4 5 sigma, which surpasses most other areas in healthcare. 2. Standardization efforts are essential to control and prevent errors and to ensure the quality of exploration in haemostasis. Professor of Pathology, NYU School of Medicine. 1994;118:1756. After thawing they should be gently stirred [2, 36]. Pre-analytical errors. For thrombin generation, direct plasma preparation is preferred to whole blood storage. WebUseful tips to avoid preanalytical errors in blood gas testing: electrolytes 2.2 Peripheral venous catheter. Double centrifugation significantly reduces the residual amount of platelets in a sample and can be performed to produce PPP such that the post centrifugation plasma platelet count is less than or equal to 10x109/L. 3. Hemolysis is one of the most frequent preanalytical errors occurring during patient preparation, the sampling process or handling of the sample: 3.1 A discard tube is also recommended when samples are subject to platelet function analysis and for thrombin generation measurements [2, 4, 8, 47]. Of course, the use of prebarcode tubes may facilitate collecting this information. Stability of the vitamin K-dependant factors has been reported to be 24h at room temperature [4, 5, 83, 88]. 3.4 PRE Four different ways of taking blood were tested to see the effect on hemolysis: cannulation and a syringe (38%); cannula with evacuated tube and adaptor (42%); syringe and needle into vein (14%); and evacuated tube system used conventionally (6%).6 Where a syringe was used, two methods of transfer into the sample tube were observed needle kept on with cap piercing (77%) and needle and evacuated cap both removed (23%).
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how to avoid pre analytical errors
