MODULE 3: SPECIMEN COLLECTION AND PROCESSING

OUTLINE o analytical errors: errors made during the testing

I Introduction process,
▪ running the wrong test, reagent or instrument
II General Methods of Blood Collection
failure, or technologist error
A Proper Patient Identification o postanalytical errors: errors made in interpretation
i Proper Patient Identification of analytical results
ii Time of Collection ▪ wrong calculation or data entry errors when
B Specimen Collection results are manually entered into the laboratory
i Methods of Collection information system
ii Types of Blood Specimen • Minimizing specifically preanalytical errors through
careful adherence to the concepts discussed here and to
C Arterial Puncture
individual institutional policies will result in more reliable
D Venipuncture information for use by healthcare professionals in
i Complications of Venipuncture providing quality patient care.
E Skin puncture • Errors are considered controllable variables; however,
i Order of Draw uncontrollable variables are also present in the
F Specimen Rejections preanalytical phase of testing.
G Type of Sample o physiology of the particular patient (age, sex,
underlying disease, etc.) or variables associated with
i Variations on Serum Quality
different specimen types from the same patient.
III Specimen Preservation and Anticoagulants
• Laboratorians need to understand these issues as well.
A Clinical Specimen Handling
B Anticoagulants Used in Clinical Laboratory II. GENERAL METHODS OF BLOOD COLLECTION
C Order of Draw
i Common Tests affected by additive A. PATIENT IDENTIFICATION
contamination
ii Common Stopper Colors, Additives, And i. PROPER PATIENT IDENTIFICATION
Departments Involved o First step in sample collection
IV Other Body Fluids o Prime factor for accurate results in the laboratory
o Mismatch leads to inaccuracy of results
A Cerebrospinal Fluid
i Collection
• Conscious inpatients/hospitalized
ii Labeling o Ask for full name(verbally)
iii Specimen Handling and Transport o Don’t ask yes or no questions
B Urine
i Types of Urine Specimen • ID Bracelets
C Serous Fluid o First and last name match
i Transportation and processing o Room number match
ii Labeling o Unit number match
o Physician’s name match
D Pericardial Fluid
i Specimen Collection
• Sleeping patients
E Peritoneal Fluid o Wake up then proceed to normal procedure
i Specimen Collection
ii Chemical Examination • Unconscious / mentally-incompetent
F Synovial Fluid o Confirm with ID and
i Gross Examination o Ask the relatives
ii Chemical Analysis o If no relative, ask the nurse-on-duty
G Amniotic Fluid o Read the wrist tag; info should be the same with
V Specimen Variable requisition form
A Pre-analytical
• Infants & children
B Analytical
o Confirm with ID
C Post-analytical o Ask the relatives
o If no relative, ask the nurse-on-duty
I. INTRODUCTION
• Critical factors involved in collecting a valid specimen or • Outpatient / ambulatory patients
analysis in the clinical laboratory include: o Ask for full name, address and/or birth date (verbally)
o appropriate policies, procedures, and techniques
o collection, identification, processing, storage, and • ID bracelets
transport. o First & last name match
• Many errors have been known to occur when a specimen o Room number match
is collected: o Unit number match
o preanalytical errors o Physician’s name match

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• Emergency room patients C. ARTERIAL PUNCTURE

o Conscious, then ask name • Bright red color, oxygenated blood; uniform in
o If unconscious, look through wallet for I.D. cards or composition throughout the body
ask relative or fellow accident victim • Heparin is always the anticoagulant
• Withdrawn from the patient’s artery
• Labelling • Sample is collected without tourniquet
o matches requisition form • Used in BGA & pH determination:
o Take note of time of collection • Sites:
o Radial artery:
ii. TIME OF COLLECTION ▪ painful, difficult to puncture but less complication
• ASAP: as soon as possible ▪ 45 degrees
• STAT: short turnaround time (derived from latin ▪ Most common AP site for adults
word statim = collected and analyzed immediately) ▪ Allen’s test - Test whether ulnar artery can
o Highest priority provide collateral circulation to the hand after
o Critical units, emergency units the radial artery puncture
• TIMED: monitor changes in px condition; determine o Brachial artery:
level of medication or how well medicine is ▪ Gauge: 18-20 gauge
metabolized ▪ Angle: 45-60 degrees
o 2 hr post prandial: specimen drawn 2 hrs ▪ constitutes the main arterial supply of the arm
after px ate; results are compared with o Femoral artery:
fasting level ▪ Provides oxygenated blood to lower extremity
structures
▪ 90 degrees
B. SPECIMEN COLLECTION ▪ relatively large, easy to puncture,
• Process of extraction to transportation to the laboratory ▪ bleeds more bleeding may not be notice unless
• Arterial Puncture massive (site is covered with bed covers)
o medtechs are not allowed to perform o Umbilical artery:
• Skin puncture ▪ Arteries that passed through umbilical cord to
o Frequently done on pediatrics or geriatrics the placenta carrying deoxygenated blood from
• Venipuncture the fetus
o Most common method for collection by medtechs ▪ Most common puncture site for newborns
▪ Another draw site: scalp artery
i. METHODS OF COLLECTION
• Syringe method • Modified Allen Test:
o Materials: o Don’t draw: Irritated, edematous
▪ Needle o Not advisable to draw: wound, arterial fistula
▪ Syringe • HEPARIN
▪ Transfer device o Preferred anticoagulant
▪ Additive tubes
o Blood Gas Analysis/pH analysis
o Needles
▪ Single-sample needle o Too much heparin = common in preanalytical error
▪ Sterile and disposable in blood gas measurement
▪ Larger the gauge number, the smaller the o Transportation (example):
needle bore ▪ BGA (Blood Gas Analysis): preservative should
▪ Color coded for gauges. Gauge 23 and 21 are be ice water bath/coolant (1-5 degrees Celsius
the most commonly used to minimize leukocyte consumption of oxygen)
▪ 1 to 1.5 inch of needle length
• Butterfly infusion set: not recommended
• Butterfly method
o Used for infants / elderly
o Short needle with thin tube and plastic wings D. VENIPUNCTURE
o Connected to syringe or evacuated tubes through • Dark red color due to deoxygenation
long flexible plastic tube • Most common blood extraction method
o ½ or ¾ inch needle • Blood is obtained from a patient’s vein
• Evacuated tube system • Sites for venipuncture:
o Materials: o Antecubital fossa region (preferred site)
▪ Multisample needle or single sample needle 1. Median cubital
▪ Tube holder / needle adapter ▪ Preferred vein
▪ Evacuated tubes ▪ Median cubital vein
▪ Largest and best anchored vein in the
ii. TYPES OF BLOOD SPECIMEN antecubital fossa region
▪ Most suitable for venipuncture
1. Serum ▪ If not felt/seen, proceed to cephalic then basilic
o for chemistry
2. Cephalic
2. Plasma
▪ 2nd preferred vein
o for hematology and can be used for chemistry in ▪ Bruise less
absence of serum ▪ tougher to puncture
3. Whole blood
▪ rolls easily than median
o for hematology and chemistry
3. Basilic
▪ Only used in HbA1C or glycated hemoglobin ▪ Tends to roll
test ▪ Greater chance to break brachial artery
▪ Requires whole blood
4. Last resort vein
▪ Measure of glucose in blood for 3 months
▪ Veins on the wrist or dorsal aspect of the hands
▪ Usually for DM patients ▪ Veins on the ankle
▪ Veins on the dorsal parts of the foot:

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→ double check if patient have other

ailments such as diabetes.
→ Ask permission with physician to draw
blood in this area
• Sites to be avoided for venipuncture:
o IV lines in both arms
▪ 2 minutes is needed to avoid hemodilution
▪ Collect below the site if there are two IV sites
• Initial draw 5 mL of blood to be
discarded (diluted blood)
o Areas with hematoma
▪ Collect if no other choice
o Burned or scarred areas
▪ Use skin puncture
o Thrombosed veins
o Edematous arms
o Mastectomy
▪ Collect from the arm that still has breast
▪ If both breasts are removed, try to collect from
the ankle
o Casts on arm
o AV shunt or fistula
• Connection of artery and vein in dialysis

ARTERIAL BLOOD VENOUS BLOOD

Carry blood from the heart,
carry oxygenated blood
Normally bright red in color
Elastic wall that expands with
surge of blood
Can feel a pulse
Carry blood to the heart, carry
deoxygenated blood
Normally dark red in color
Thin walls/ less elastic
No pulse

• Most common used needle gauges:

o 19, 20, 21, 22
o Note: the larger the gauge number, the smaller the
bore
• Most common used needle length
o 1 to 1 ½ inches (2.5 to 3.7cm)
o Butterfly needle: ½ - ¾ inch
• Tourniquet applied 3-4 inches above the site
• Blood pressure cuff used as a tourniquet
• Tourniquet application should NOT exceed 1 minute
• Benzalkonium chloride solution
o Zephiranchloride, 1:750
o Traces of alcohol = hemolysis
• Bevel up at 15-30 degree angle
o Dry and sterile syringe = avoids hemolysis NOTE: FOR THE ORDER OF DRAW, PLEASE REFER TO
CC LAB M2

i. COMPLICATIONS OF VENIPUNCTURE
• Immediate Local
o Hemoconcentration
▪ Increase in the number of formed elements in
the blood
▪ Plasma volume
• Decrease: polycythemia
• Increase: Anemia
o Failure of blood to enter the syringe/vacutainer tube
▪ Excessive pull of plunger
▪ Piercing the other hole of the vein
▪ Transfixation of vein
▪ Incorrect bevel position
▪ Absence of vacuum
o Hematoma

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▪ Failure to remove the tourniquet before • Indwelling umbilical artery catheter: best method for
withdrawing the needle Blood Gas Collection
▪ Failure to have the needle completely in the • best to warm site to dilate the vessels and increase blood
vein flow
▪ Repeat puncture of the vein o Warming: should not exceed 10 mins or it may
▪ Failure to apply pressure to the wound in alter results
sufficient amt. of time • Incision depth:
▪ Excess probing to obtain blood o Infant: < 2mm
o Circulatory Failure o Adults: < 2.5 mm
o Syncope (fainting) • Sites not recommended:
▪ Increases anxiety o Central arch of infant’s heel
• Late Local o Fingers of newborn or infant (one year old or below)
o Thrombosis (clot) o Thumb, index and 5th finger
▪ Abnormal vascular condition in which a o Fingers on side with mastectomy
thrombus develops within the blood vessel of o Scarred sites
the body
o Thrombophlebitis i. ORDER OF DRAW
▪ inflammation of a vein often accompanied by a
clot as a result of trauma to the vessel wall
• Late General Order of Draw Additives Inversion/mixing
o Blood borne infections Capillary Blood Gas Heparin Rotate between
palms
o Hepatitis
Blood Smears N/A 10
o AIDS
Lavender top EDTA 10
• Nerve Injury Heparinized Lithium Heparin 10
o The factors associated with nerve injury in blood Plasma Separator Lithium Heparin with 10
collection are preventable and include Tubes gel separator
▪ Improper vein selection Oxalate/ Fluoride Sodium fluoride with 10
▪ Using jerky movements Tubes Potassium oxalate
▪ Inserting the needle too far Serum tube with Clot activator 5
▪ Movement by the patient while the needle is in additives
the vein Serum tube without N/A 0
▪ Lateral redirection of the needle additives
Newborn Screening Use spot/filter cards 0
▪ Blind probing (blind chat)
o maybe temporary or permanent • Order of Draw important: platelets accumulate at the site
▪ Symptoms: of puncture
→ tingling or burning or electric shock • Last specimen
→ Pain felt up and down the arm and
• Phlebotomy Complications (Turgeon) ii. BLOOD SPOT COLLECTION
o Vascular complications • Blood should be collected
▪ most common o 1 to 3 days after birth (at least 24hrs after birth)
o Infection • Collection is done by heel puncture
▪ second most common • Neonatal screening program: PKU, galactosemia,
o Anemia hyperthyroidism, hemoglobinopathies
▪ iatrogenic (nosocomial) anemia • Lancet: no longer than 2.4 mm to avoid injury to the
o Neurological complications calcaneus or heelbone
▪ seizure or pain
o Cardiovascular
▪ orthostatic hypotension
▪ syncope shock
▪ cardiac arrest
o Dermatological
▪ allergic reaction to iodine

E. CAPILLARY/SKIN PUNCTURE
• Rarely done in chemistry
• Also known as Capillary puncture or microsampling
• Used when only a small amount of blood sample is
needed
• Cut must be made across or perpendicular to the
fingerprint ridges to facilitate good blood flow
• First drop should be wiped off
• Milking process is not allowed
• Preferred sites:
o Lateral plantar heel surface
▪ Common in infants
▪ Avoid hitting calcaneus bone/heelbone
o Plantar surface of the big toe, lateral side of the finger
adjacent to the nail, earlobe (least)
▪ Common in children
o Palmar surfaces of fingers 3rd and 4th
▪ Common in adults
o Earlobes
▪ Least preffered site

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F. SPECIMEN REJECTION o To prevent hemolysis

• According to Henry’s Clinical Diagnosis and Management • Physical Preservation
o Hemolysis/Lipemia including TAGs, pink/red blood o Placing sample at different temperature
o Clots (anticoagulated tubes) → Refrigerator tempt: 4°C
o Non-fasting specimen → Freezing tempt: -5 to -20°C
o Short draws → Liquid Nitrogen: -142°C
o Improper transport → Room Tempt: 18-30°C
o Errors between labeling and test request • Chemical Preservation
o Unlabeled/Mislabeled o Interferes, prevent microbial group
o Contaminated specimen o Collection and storage = sterile condition
• Common Preservatives
G. TYPE OF SAMPLE o Concentrated HCl:
• Whole Blood ▪ Catecholamines
• Serum ▪ Vanillylmandelic acid analysis
o Used most commonly in CC o Thymol, toluene, CHCl3:
o Clot formation: 15-20 mins before centrifugation ▪ Urine fluoride analysis
• Plasma o Sodium carbonate
▪ porphyrins
o Petroleum ether
▪ Retired oxidation by formation of protective layer
o Antibiotics
▪ In addition to blood for urea determination and
hemoglobin
▪ EXAMPLE: 1 mg streptomycin base/10 mL of
blood
o Boric acid
i. VARIATION ON SERUM QUALITY ▪ Adrenocorticotropic hormone (ACTH)
• Icterus/Icteric determination
o serum bilirubin increases 430 mmol/L or 25 mg/L • Processing of Blood Sample After Collection
o Lead to yellow discoloration o Whole blood
• Lipemia/Lactasense ▪ 4-5 °C (refrigerated): if test is not done within an
o Occurs after blood obtained 1-2 hrs after eating fatty hour after collection
meal o PFF (Protein Free Filtrate)
o Serum triglyceride level: exceeds 4.6 mmol/L or 400 ▪ Prepared at once
mg/dL ▪ 30 mins after collection and refrigerated
o Due to chylomicrons: large triglyceride-rich o Separate serum and plasma
lipoprotein ▪ after standing and refrigerated at 4-6°C
o Milky appearance ▪ Or freeze at -20°C if analysis is delayed for more
• Hemolysis than 4 hrs
o Breaking of RBCs o Specimen for blood ammonia, gases, or other
o Rejected for testing unstable substance should be processed ASAP
o Orange-red serum/plasma: REJECTED
o Significantly alter results A. CLINICAL SPECIMEN HANDLING

Analyte Specimen Handling

Glucose (blood Refrigerated for a few hours if not
sugar) performed within 2 hours
PFF stored overnight in a refrigerator
NPN Substance
(ex. creatinine, BUN, Uric Acid)
Serum stored in refrigerator for few
Cholesterol (esters)
hours
HDL cholesterol Store at ROOM temperature
Separate serum from clot within 30
Calcium
mins
Phosphorous Very unstable: test immediately
Cephalin cholesterol Serum cannot be preserved; tets much
flocculation be started within 4 hours collection
Decrease after blood withdrawal; may
Amylase
be refrigerated for 3 hours ONLY
Lipase Must be run within 2 hours of collection
Place sample at 5°C; analyze within 30
Ammonia
mins

III. SPECIMEN PRESERVATION AND
ANTICOAGULANTS
• Tube additives
o Preserve a specific blood constituent
o Aid in the separation of serum from cell
• Reasons for rapid separation of serum:
o To prevent glycolysis
o To prevent lipolysis
o Certain substance are very unstable
o To prevent shift of electrolytes
B. ANTICOAGULANTS
1. Oxalate
• Mechanism of Action: combines with calcium to form an
insoluble salt
• Types: Na, K, ammonium, lithium, or dioxalate
o Lithium oxalate: best type; used for plasma uric
acid
o Na oxalate: prothrombin tests (routine)
o K oxalate: caused variable dilution of plasma due
to H2O transports
▪ Shrinks RBC = not use to measure hematocrit
• Interferes with Na, K, BUN tests

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• Inhibits: lactate dehydrogenase (LDH), acid citrate o prevents glycolysis for 24 hours
phosphatase, amylase
• Used as dried: 6. Heparin
o Should be dried as a thin film on the wall of the vial • Mechanisms of action: antithrombin (accelerates) and
= minimize hemolysis antithromboplastin (neutralizes thrombin, prevent fibrin
o Tempt of drying: should not exceed 100°C formation)
▪ otherwise, oxalate CONVERTS TO • Total calcium determination in lack of serum or plasma
carbonate = no anticoagulant property • Advantages:
• Concentration: o Ideal universal anticoagulant; least interference
o 1-2 mg/mL of blood (K oxalate) with analysis
o 0.01 mL of aq. 20% solution per mLof blood o Minimal chelating properties
o 1 gt per mL of blood o Minimal effects on H2O shifts
o Low cation concentration
2. Citrate • Disadvantages:
• Mechanism of action: combines with calcium in a non- o Interferences: some immunoassays
ionized soluble form ▪ Not used for coagulation and hematology
• Citrate: inhibits amylase activity testing
• Coagulation studies; ESR determination (black top) • Uses:
• Na Citrate o pH or blood gas analysis
o Black Top o ammonia determination
▪ Buffered citrate: stabilizes plasma pH o carboxy, methemoglobin determination
▪ Used for Westergren ESR o ionized calcium
o Light Blue Top: o cytogenic studies
▪ Coagulation testing: preserves the labile • Cytogenetic studies
coagulation factors • Types: Na, K, Lithium, and ammonium salts
• Concentration: • Concentration:
o 3.2-3.8 g/dL o 0.2 mg/mL of blood
▪ Light blue top – 0.105M (3,2%) or 0.129M ,1:9 • Heparinized plasma
(ratio of anticoagulant to blood) o Used for Potassium measurements: avoid an
▪ Black top –1:4, 0.129 M (3.8%) elevation due to the release of potassium from
platelets as blood clots
3. Acid Citrate Dextrose (ACD) • Lithium heparin
• Dextrose o For chem tests EXCEPT lithium and folic levels
• Used for blood transfusion; non-toxic • Sodium heparin
• Rapidly utilized by the body; easily excreted by the o Can’t use for sodium tests, assays
kidneys o Recommended: trace elements (lead, toxicology)
• Dextrose o Injectable form: anticoagulant therapy
o Added as a source of energy to prolong the
lifespan of RBC during storage 7. Sodium Polyanethol Sulfonate (SPS)
o Concentration: 5 mg/mL of blood • Concentration:
o 1 to 2.5 mg/mL of blood
4. EDTA (ethylenediaminetetraaceticacid)
• Mechanism of action: combines with calcium (chelation) 8. Glass Beads
• Uses • Mechanical means of preventing coagulation
o Primary: Hematology
o Blood Banking, CEA (carcinoembryonic antigen), 9. Red Top Tubes
lead testing • No additives
o Hb1Ac • Most Chemistry, Blood Bank, and Immunology assays
• Two forms: • Serum samples
o Versene: disodium (Na2EDTA)
o Sequestrene: dipotassium (K2EDTA)
10. Red/Gray and Gold tubes
• Concentration:
• Contain a clot activator and separation gel
o 1-2 mg/mL of blood
• Referred to as SST
• Inappropriate: enzyme analysis
o Binding of metal cofactor necessary for enzyme • Advantages
action o Ease to use
o Shorter processing time to clot activation
5. Sodium Fluoride o Higher serum yield compared to the ordinary RED
TOP
• Mechanism of action: forms weakly dissociated calcium
o Minimal liberation of potentially hazardous
components
aerosols upon separation of serum
• Glucose measurement
o Only one centrifugation step is required
• For Glucose Testing o Use of the same tube/mother tube px sample
• Bacterial septicemia: originally drawn with the case of single labelling
o Fluoride inhibition is neither adequate nor effective in
preserving glucose formation
• Concentration:
o 10 mg/mL of blood
• Sodium fluoride
o prevents glycolysis for 3 days
o Inhibits: glycolytic enzyme, enolase, glucose oxidase
o ↑ amylase activity, ↓ ACP activity
o Interferes to: Na, K, BUN testing
• Lithium iodoacetate

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C. ORDER OF DRAW

ORDER OF DRAW TUBE STOPPER COLOR RATIONALE FOR COLLECTION ORDER

Blood Cultures (sterile Yellow SPS
Minimizes chance of microbial contamination
collections) Sterile media bottle
Coagulation Tubes Light Blue 1st additive tube; all other additives affect coagulation tubes
Glass nonadditive tubes Red Prevents contamination by additives in other tubes
Plastic clot activator tubes Red Filled after coagulation tests
Red and gray rubber o Silica particles: activate clotting and affect coagulation tests
Serum Separator Tubes (SSTs) ▪ Carry over of silica into subsequent tubes = overridden by anticoagulant in them
Gold Plastic
Green and gray rubber Heparin
Plasma Separator Tubes (PSTs)
Light-green plastic o Affects coagulation tests
o Interferes in collection of serum specimens
Heparin Tubes Green
o Causes least interference other than coagulation tests
EDTA:
Lavender o Responsible for more carry-over problems than any other additive
EDTA Tubes o Elevates Na+ & K+ levels; chelates and decreases calcium and iron levels
o Elevates PT and PTT results
Pink
Gray Top:
Plasma Preparation Tubes (PPTs) Pearl Top o Sodium fluoride & potassium oxalate = affect sodium and potassium levels, respectively
after hematology tubes because:
Oxalate/Fluoride tubes Gray ▪ oxalate damages cell membranes; causes abnormal RBC morphology
o Oxalate: interferes in enzyme reactions

i. COMMON TESTS AFFECTED BY ADDITIVE CONTAMINATION

CONTAMINATING ADDITIVE TESTS POTENTIALLY AFFECTED

Alkaline phosphatase
Citrate Calcium
Phosphorous
Alkaline phosphatase Potassium
Calcium Protine
EDTA
Creatine Kinase Serum iron
Partial Thromboplastin time Sodium
Activated clotting time Protime
Acid phosphatase Sodium (sodium formulation)
Heparin (all formulations)
Calcium (some test methods) Lithium (lithium formulation)
Partial thromboplastin
Acid phosphatase Partial thromboplastin time
Alkaline phosphatase Potassium
Oxalates Amylase Protime
Calcium Red cell morphology
Lactate dehydrogenase
Partial thromboplastin time
Silica (clot activator)
Protime
Sodium
Sodium Fluoride
Urea nitrogen

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ii. COMMON STOPPER COLORS, ADDITIVES, AND DEPARTMENTS INVOLVED

STOPPER COLOR ADDITIVE DEPARTMENT(S)

Light blue Sodium citrate Coagulation
Red (glass) None Chemistry, blood bank, serology/immunology
Red (plastic) Clot activator Chemistry
Red/light gray (plastic) Nonadditive NA (discard tube only)
Red/black tiger Clot activator and gel separator Chemistry
Gold
Red/Gold
Green/gray Lithium heparin and gel separator Chemistry
Light green
Lithium heparin Chemistry
Green
Sodium heparin
Lavender EDTA Hematology
Pink Blood Bank
Sodium fluoride and potassium oxalate Chemistry
Gray Sodium fluoride and EDTA
Sodium fluoride
Orange Thrombin Chemistry
Gray/Yellow
None (red label) Chemistry
Royal Blue EDTA (lavender label)
Sodium heparin (green label)
Tan (glass tube) Sodium heparin Chemistry
Tan (plastic) EDTA
Yellow Sodium polyanethol sulfonate (SPS) Microbiology
Yellow Acid citrate dextrose (ACD) Blood bank/Immunohematology

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IV. OTHER BODY FLUIDS • Obtained by inserting a catheter or sterile

flexible tube into the bladder via the urethra to
A. CEREBROSPINAL FLUID withdraw urine.
• Collected using lumbar puncture • Done only by specially trained personnel.
i. COLLECTION • Specimens must be labeled with patient’s
• Collect appropriate volumes of CSF in sequential order name, date of birth, date and time of collection,
into 4 sterile, screw capped tubes consecutively ordering physician.
numbered 1 to 4; three tubes are sufficient for pediatric
testing C. SEROUS FLUID
• Lumbar puncture samples: use tubes provided in the AKA: PLEURAL, PERICARDIAL, PERITONEAL
standard pre-packaged lumbar puncture kits or CSF
collection kits i. SPECIMEN COLLECTION
• If numbered tubes are not available, number each tube
as per collection order (1, 2, 3, or 4) • Diagnostic thoracentesis
• Specimen Labelling Requirements • Between 20 to 40 mL of pleural fluid is needed for a
o Patient’s first and last name complete analysis
o Date of Birth • Tests: biochemical, cytological microbiological
o Personal Health Number (PHN) or Regional studies (infection detected)
Health Record Number (RHRN) • Tubes: EDTA or heparin
o Date and time of collection
o Specimen source (CSF and i.e. lumbar, shunt, i. TRANSPORATION AND PROCESSING
EVD/external ventricular drains)
o Tube identification number (1, 2, 3, 4) indicating • Fresh fluid: promptly transported to the laboratory
order of collection at ambient temperature.
• maximum acceptable time delay before the
processing of the specimen: 2 hours.
ii. LABELLING
o longer delay is expected: stored in the
1. for chemistry and serology refrigerator at 4ºC, except for microbiological
2. for microbiology cultures.
3. for hematology o Refrigerated 48 hours = no significant effect
4. cytology analysis on the total leukocyte count/differential,
biochemical parameters
iii. SPECIMEN HANDLING AND TRANSPORT ▪ except Lactate dehydrogenase [LDH]:
• Take CSF specimens immediately to the laboratory may experience a reduction in
after collection; the pneumatic tube system may be concentrations from day 2 onward or
used for transport to the laboratory cytomorphology
o Refrigeration inhibits the viability of certain
• Do not refrigerate
microorganisms
• Do not leave specimen on the reception counter; give ▪ discouraged for specimens sent for
directly to laboratory staff microbial studies
• Two most common reasons for hemoglobin pigments ▪ Over 48 hours are unacceptable
1. Traumatic tap • Future research studies: recommended that the
2. Subarachnoid hemorrhage fluid sample be centrifuged and the supernatant
and/ or pellet be stored at -80ºC
B. URINE
i. TYPES OF URINE SPECIMENS: D. PERICARDIAL FLUID
1. Random sample i. SPECIMEN COLLECTION
• Collected anytime during the day • Sent to the lab ASAP
• Used only for routine screening • Collected via pericardiocentesis or open surgical
2. First voided specimen drainage
• Also referred to as a first morning specimen. • Cytopathology study: specimen sent to the
• Preferred for pregnancy testing, bacterial laboratory as soon as possible in a fresh state or
cultures and microscopic examinations. refrigerated at 2-8º C
3. Timed specimens • Volume: 2 mL for each lab test
• Used when the physician requires urine • Cytologic study of pericardial fluid helps identify
samples to be taken at specific intervals during malignancy as the cause of pericardial effusion by
the day. detecting neoplastic cells within the fluid.
• 24 hour urine specimens are required for
creatinine clearance tests and many other
E. PERITONEAL FLUID
hormone studies.
i. SPECIMEN COLLECTION
• The patient is told to empty their bladder and
discard the urine in the toilet and record the • Paracentesis- most common
time on the label of the urine container. • Peritoneal lavage- detects intra-abdominal bleeding
• For the next 24 hours, all urine must be • Peritoneal dialysis
collected in the container. • Peritoneal washings
4. Clean-catch midstream specimen • Gross examination
• Used for culture and bacterial growth.
• For cytology Normal Clear and pale yellow
• Used for routine screening
Cloudy/turbid Infection
5. Catheterized specimen
• Catheter inserted inside urethra Green Bile, pancreatitis, cholecystitis

CANDAZA, DELA CRUZ, DUBLOIS, GRANADA, LAGUD, MACATUGGAL, MALANA, MELOSANTOS, PANGILINAN, SUELILA, TORRES, ZUÑIGA 18
 MODULE 3: SPECIMEN COLLECTION AND PROCESSING

Bloody Malignancy, traumatic tap, tuberculosis o Provides a protective cushion for the fetus
o Allows the movement of the fetus
Milky Lymphatic trauma and blockage o Exchange of nutrients between mother and
fetus
ii. CHEMICAL EXAMINATION o Regulates the temperature of the fetal
environment
1. Glucose
o Decreased in tuberculosis and malignancy • Amniocentesis
2. Enzymes • Also known as amniotic sac puncture
o LDH – malignancy • Method of amniotic fluid collection
o AMS – pancreatitis, GIT perforation, • Can be transabdominal or transplacental
intestinal necrosis • Maximum of 30 mL
o ALP – intestinal perforation • Centrifugation should be done at low speed
3. Lactate
o Elevated in spontaneous bacterial peritonitis, • 500-1000g for 5 minutes to get supernatant and
sediment
malignancy and tuberculosis
4. BUN and Creatinine • Preservation depends on tests to be performed
o Ruptured bladder • Fetal lung maturity: ice or refrigerated
5. Ammonia • Cytogenetic analysis: room temperature or 37
o Perforated peptic ulcer, ruptured appendix, degrees
bowel strangulation, ruptured bladder • Hemolytic Disease of the Newborn: protect from
6. Serum ascites-albumin gradient(SAAG) light
o Transudate: >1.1
o Exudate: <1.1 COLOR AND APPEARANCE
7. Tumor markers
o CEA and CA125 Normal Colorless
Traumatic tap or
F. SYNOVIAL FLUID Blood-streaked
hemorrhage
• Viscous fluid in the cavities of movable joints
Hemolytic Disease of the
• Ultrafiltrate of plasma combined with hyaluronic acid Yellow
Newborn
produced by the synovial cells
• Specimen Collection and Handling Dark Green Meconium
o Arthrocentesis- collection procedure Dark Red Brown
o Collected in three tubes like CSF Fetal Death
1. Sterile heparinized: for microbiology Brown
2. Liquid EDTA and Na heparin: microscopic
cell count NORMAL
3. Sodium fluoride: glucose analysis TESTS DISEASES
VALUES
4. Plain tube: for other extra tests
AFP (alpha-
Neural tube defect
i. GROSS EXAMINATION fetoprotein) < 2.0 MoM
• Total volume: <3mL AchE Neural tube defect
• Color: colorless to pale yellow ABO-Rh
• Clarity: clear compatibility
HDN
• Consistency: Viscous and non-clotting OD at 365 nm
Bilirubin
Bilirubin
Assay
ii. CHEMICAL ANALYSIS
1. Glucose L/S Ratio FLM > 2.0 L/S
o Normal value: 0-10 mg/dL lower than serum Foam Ring of bubbles
levels FLM
Stability at > 0.47 mL
o Ratio of synovial fluid to serum glucose: 0.9:1
o Decreased glucose is seen in septic arthritis Fluorescence
FLM > 55 mg/g
2. Protein Polarization
o Normal value: <3 g/dL
o Elevated in inflammatory and hemorrhagic Lamellar > 32,000
FLM
disorders Bodies particles/uL
3. Lactate/ Lactic acid
o Normal value: <25 mg/dL V. SPECIMEN VARIABLES
o Septic arthritis: >250 mg/dL up to 1000 mg/dL Specimen Variables
4. Uric acid • Includes:
o Normal value: 6-mg/dL o physiologic considerations, proper patient
o Used for diagnosis of gout, in cases wherein preparation, and problems in collection,
crystal examination is not available transportation, processing, and storage.
5. Lactate dehydrogenase • Physiologic variation:
o Increased in cases of rheumatoid arthritis, o refers to changes that occur within the body,
infectious arthritis and gout. o cyclic changes (diurnal or circadian variation)
o In case of RA: LDH is abnormal in synovial o those resulting from exercise, diet, stress, gender,
fluid but normal in serum age, underlying medical conditions (e.g., fever,
asthma, obesity), drugs, or posture.
G. AMNIOTIC FLUID • Drugs can affect various analytes.
• Fluid present in the amniotic sac surrounding the • High amounts or chronic consumption of alcohol causes
fetus hypoglycemia
• Functions:
CANDAZA, DELA CRUZ, DUBLOIS, GRANADA, LAGUD, MACATUGGAL, MALANA, MELOSANTOS, PANGILINAN, SUELILA, TORRES, ZUÑIGA 19
 MODULE 3: SPECIMEN COLLECTION AND PROCESSING

A. PRE-ANALYTICAL
• Personnel Professionalism
• Patient consent
• Patient preparation
• Infection control
• Standard precautions
• Patient identification
• Preparation for venipuncture
• Venipuncture Procedure and other specimen collection
• Proper use of anticoagulant and preservatives
• Specimen Handling and Processing
• Transporting Specimens
• Delivery time limits

B. ANALYTICAL
• Analytic techniques and instrumentation
• Quality Control
• Interferences with the methods
• Specific reagents
• knowledge of the analyte, analytic parameters,
methodology, and instrumentation and management of
all study variables

C. POST ANALYTICAL
• LIS (lab integrated system) and HIS (hospital integrated
system)
• Report should include:
o Unique patient identifier and test name
o the test value with the unit of measure
o date and time of collection
o sample information
o reference ranges
o other pertinent information for proper test
interpretation.

REFERENCES
Notes from the discussion by Ms. Aurea P. Manzon, RMT,
MSMT (c)

Ms. Aurea P. Manzon PowerPoint presentation: Specimen

Collection and Processing

CANDAZA, DELA CRUZ, DUBLOIS, GRANADA, LAGUD, MACATUGGAL, MALANA, MELOSANTOS, PANGILINAN, SUELILA, TORRES, ZUÑIGA 20