MODULE 1

Introduction to Clinical Chemistry and Laboratory Mathematics

Week 1 to 2
Objectives:
1. Define briefly terms in Clinical Chemistry
2. Identify properly the duties of Medical Technologist in Clinical Chemistry
3. Compute accurately for Normality, Molarity and Percent Solution
4. Carry out correctly the Unit Conversion
5. Prepare properly various dilutions of samples and chemicals.

A. Introduction to Clinical Chemistry

What is Clinical Chemistry?

CLINICAL comes from the greek
- is an applied science when analyses are
word
performed on body fluids or tissue
kline “BED”
specimens to provide important
information for the diagnosis or
treatment of disease.

NOTES TO REMEMBER:
ANALYTE- a chemical substance that is the subject of chemical analysis.

REAGENT- is a compound or a mixture added to a system to cause chemical reaction

or test if a reaction occurs.

STANDARD- a material of known concentration. (FOR CALIBRATING INSTRUMENT)

CONTROL- sample of known quantity with several analytes present.

Fundamental Concepts in Analytical Procedures

Units of Measurement
a. Meter (m)= length
b. Kilogram (kg)= mass
 c. Seconds (s) = time
d. Mole (mol) = quantity of substance
e. Ampere (A) = electric current
f. Kelvin (K) = thermodynamic temperature
g. Candela (cd) = luminous intensity

Preparation and Standardization of Slolutions

1. FILTRATION – removes particulate matter for municipal water supplies before additional
treatments.

2. DISTILLATION- water is boiled and the resulting steam is cooled; condensed steam
is distilled water. Many minerals are found in natural water, most often iron, magnesium
and calcium. Water from which these and other minerals have been removed by
distillation is known as distilled water.

3. DEIONIZATION (ION EXCHANGE) – in these process water is passed through a resin

column containing positively (+) and negatively (-) charged particles. These particles
combine with ions present in the water to remove them; this water is known as deionized
water.

TAKE NOTE:

• Occupational Safety and Health Act (OSHA) requires manufacturers to clearly

indicate the lot number, physical or biological health hazard of the chemical
reagents, and precautions for safe use and storage.

• College of American Pathologist (CAP) recommends that a laboratory

document culture growth, ph and specific water resistance on reagent grade water.

Three Grades of Reagent Water

- Water should be classified in terms of type instead of the method of preparation, according
to Clinical and Laboratory Standards Institute (CLSI).
 - FILTRATION is the first steps before the process are performed in reagent grade water
preparation.
- CLSI and CAP have identified three grades of water purity.

Type I Reagent Water

- PREPARATION OF STANDARD SOLUTIONS (highest purity)

- Used for test methods requiring minimum interference
- For procedures that requires maximum purity for accuracy and precision.
- Used immediately after production

Type II Reagent Water

- Acceptable for preparation of reagents and quality control materials.

- For HEMATOLOGY, MICROBIOLOGY, IMMUNOLOGY AND CHEMISTRY
(Just remember the major subjects )

Type III Reagent Water

- For washing of glasswares

- For URINALYSIS, PARASITOLOGY AND HISTOLOGY.

Chemical Reagents used for Reagent Preparation

a. Analytical Reagent Grade
- It is important for qualitative analyses, essential for accuracy.
- Use for trace metal analysis and preparation of standard solutions.

b. Ultrapure Reagents
- Used for chromatography, atamic absorption and immunoassays.

c. Chemically Pure or Pure Grade

- It is recommended for research and analytical chemistry unless further purification or a
reagent blank is included.
 d. Technical or Commercial Grade
- Used primarily in manufacturing
- It should never be used in clinical laboratory testing.

e. United Sates Pharmocopoeia (USP) and National Formulary (NF)

- For drug manufacturing

Types of Solution in Clinical Laboratory

1. Dilution Solution- it has the presence of relatively little solute.

2. Concentrated Solution- it has a large quantity of solute in solution
3. Saturated Solution- is a solution in which there is an excess of undissolved solute
particles
4. Super saturated Solution- it has a greater concentration of undissolved solute
particles than does a saturated solution of the same substance.

Reference Materials:
- Calibration materials should meet the identity, labeling and performance requirement of
CLSI.

1. Primary Standard
Is a highly purified chemical that can be measured directly to produce a substance of
exact known concentration.

2. Secondary Standard Is a substance of lower purity whose concentration is

determined by comparison with a primary standard.

B. LABORATORY SAFETY IN CLINICAL CHEMISTRY

TYPES OF HAZARD

✓ Biological Hazards

✓ Sharp Hazards

✓ Chemical Hazards

✓ Radioactive Hazards

✓ Electrical Hazards

✓ Fire/ Explosive
 ✓ Physical Hazards

BIOLOGICAL HAZARDS
SIX COMPONENTS OF CHAIN OF
INFECTIONS
Potentially harmful microorganisms
“IREMES”
CHAIN OF INFECTION 1. Infectious Agent
- Essential in preventing infection
- It requires a continuous link between: 2. Reservoir
- “SMS”
3. Exit Portal
Source
4. Means of Transmission
Method/ mode of Transmission
Susceptible Host 5. Entry Portal

6. Susceptible Host
Note: In the clinical laboratory, the most direct contact with a source of infection is
through contact with patient specimens.
PREVENTION:
WEAR PERSONAL PROTECTIVE EQUIPMENT (PPE)
- Gloves, fluid resistant gowns, eye and face shields
and Plexiglas countertop shields.

HANDWASHING - best way to break the chain of infection.

Note:

When hands are visibly soiled wash hands with soap and
water.

When hands are NOT visibly soiledapply alcohol based.

Handwashing Procedure “HAPPY BIRTHDAY SONG 2X”

1. Wet hands with warm water
 2. Apply antimicrobial soap
3. Rub to form a lather, create friction and loosen debris
4. Thoroughly clean between fingers, including thumbs, under fingernails, and rings and up
to the wrist for at least 15 seconds
5. Rinse hands in a downward position
6. Dry with a paper towel
7. Turn off faucets with a clean paper towel to prevent recontamination.

Disposal of Biological Waste

-all biological waste EXCEPT URINE must be placed in appropriate containers labeled with the
biohazard symbol.

- Disinfection using a 1:10 dilution of sodium hypochlorite should be perform daily.

- 10% bleach inactivates hepatitis B virus in 10 minutes

- 10% bleach inactivates HIV in 2 minutes

- Bleach should be in contact with the area for at least 20 minutes.

SHARP HAZARDS

- Needles, lancets, and broken glass

- Must be placed in a PUNCTURE- RESISTANT CONTAINERS

CHEMICAL HAZARDS

- In cases of CHEMICAL SPILLS

o When skin contact occurs, the best first aid is to flush the area with large amount
of water for at least 15 minutes and then seek medical attention.
NOTES TO REMEMBER: hazardous chemicals must be labeled as poisonous,
corrosive, or carcinogenic.
 NOTE:
Yellow Quadrant “SUV SM”
Blue Quadrant “ NSHED”
RED quadrant= Flammability Hazard
BLUE quadrant= Health Hazard

DEGREE OF HAZARDS “No SMS ex ”

0= NO /Minimal Hazard

1= Slight Hazard

2= Moderate Hazard

3= Serious Hazard

4= Extreme /Severe

RADIOACTIVE HAZARDS

- exposure to radiation during pregnancy presents a danger to the fetus

ELECTRICAL HAZARDS

- All electrical equipment is grounded in a three-pronged plug to avoid electric shock.

FIRE/ EXPLOSIVE

- flammable chemicals should be stored in explosion-proof refrigerators.

 Extinguisher :

Water (A)

Dry chemicals (ABC)

Carbon dioxide
(BC)Halon (BC)

TYPE OF TYPE OF HAZARD TYPE OF

FIRE EXTINGUISHER

A Ordinary combustibles: paper, cloth, Water, dry chemical,

rubbish, plastic, wood loaded steam

B Flammable liquids: grease, gasoline, Dry chemical, carbon

paints, oil dioxide, halon foam

C Electrical equipment and motor Dry chemical, carbon

switches dioxide, halon

D Flammable metals: mercury, Metal X, sand; fought by

magnesium, sodium, lithium fire fighters only

E Detonation (Arsenal Fire) Allowed to burn out and

nearby materials
protected

K Cooking media; grease, oils, fats Liquid designed to

prevent splashing and
cool the fire

When a fire is discovered “RACE”

 Rescue anyone in immediate
danger

Alarm activate the

institutional fire alarm
system

Contain Close all doors to

potentially affected
areas

Extinguish/ evacuate
To operate a fire
Attempt to extinguish
extinguisher “PASS”
the fire, if possible,
exit the area

Pull the pin

Aim At the base of the fire

Squeeze Handles

Sweep Nozzle side to side

PHYSICAL HAZARDS
General Precautions:
Ergonomic Hazards
1. Avoid running in rooms and hallways - Physical actions that may over time, contribute
2. Watch wet floors to repetitive strain disorders such as
3. Bend knees when lifting heavy objects tenosynovitis, bursitis, and ganglion cysts.
4. Keep long hair pulled back
5. Avoid dangling jewelry
6. Maintain clean, organized work are
7. Wear closed-toe shoe

BSC: BIOSAFETY CABINETS

BCS Class I BSC Class II BSC Class III

Filters exhausted air only
Product contamination is
possible
A;k,a. Vertical Laminar Flow Entirely sealed Accessible
BSC thru glove ports
Filters exhausted Filters supplied & exhausted
&recirculated air air

COMPARISON OF BIOSAFETY CABINET CHARACTERISTICS

BSC Face Airflow Pattern
Class Velocity

I 75 In at front through HEPA to the outside or into the room through HEPA
II, A1 75 70% recirculatedto the cabinet work area through HEPA; 30% balance
can be exhausted through HEPA back into the room or to outside
through a canopy unit
II, B1 100 30% recirculated, 70% exhausted. Exhaust cabinet air must pass
through a dedicated duct to the outside through a HEPA filter
I, B2 100 No recirculation; total exhaust to the outside through a HEPA filter
II, A2 100 Similar to II, A1 but has 100 Ifm intake air velocity and plenums are
under negative pressure to room; exhaust air can be ducted to the
outside through a canopy unit
BSC (biological safety cabinet) | HEPA (high-efficiency particulate air) | Ifm (linear feet per minute)

C. Laboratory Mathematics

UNITS OF CONVERSION

ANALYTES CU TO SI CONVERSION FACTOR

Albumin g/dl to g/L 10

Ammonia ug/dl to umol/L 0.587

Bicarbonate mEq/L to mmol/L 1.0
Bilirubin mg/dl to umol/L 17.1
BUN mg/dl to mmol/L 0.357
Calcium mg/dl to mmol/L 0.25

Chloride mEq/L to mmol/L 1.0

Cholesterol mg/dl to mmol/L 0.026
Creatinine mg/dl to umol/L 88.4
Glucose mg/dl to mmol/L 0.0555
Iron mg/dl to umol/L 0.179
Thyroxine ug/dl to nmol/L 12.9
Uric acid mg/dl to mmol/L 0.0595
Triglyceride g/dl to mmol/L 0.0113
Total Protein g/dl to g/L 10
Na, K mEq/dl to mmol/L 1.0
Temperature Conversions:

• Centigrade (O C) to Kelvin (oK) = O

C+ 273

37+273= 310

• Centigrade (O C) to Fahrenheit (oF) = (OC X 9/5) +32 OR (OC X 1.8) +32

37*1.8= 66.6 +32= 98.6

• Fahrenheit (oF) to Centigrade (oC)= (OF -32) X 5/9 OR (OF -32) X 0.556

98.6 -32 = 66.6 *0.556= 3

PERCENT SOLUTION
- Is equal parts per 100 or the amount of solute per 100 total units of solution

- It is determined in the same manner regardless of whether it is w/w, v/v, or w/v units are
used

- CONCENTRATION – is expressed as “percent solution”

1. Weight/ volume (w/v) % solution

- it is the most common type of solution prepared in the clinical laboratory

- it refers to the number of grams of solute per 100 ml of solution

Grams of solute= %solution desired x total volume desired

100

Or
% = X .
100 Volume or weight given or required

EXAMPLE:
a. Make 100g of 5% aqueous solution of HCl acid (12 M HCl)

SOLUTION:
Grams of solute= %solution desired x total volume desired
100
 100g = 5 x vol = = 0.05 *100 =5
100 100

% = X .
100 Volume or weight given or required
Note:
5% = x = 500 = 5
We were able to get the answer 5
100 100g 100
2. Volume/Volume (v/v) % solutions by cross multiplication.

- It is used when both solute and solvent are liquid

- It refers to the amount of solute in ml in 100ml of solvent

ml of solute= %solution desired x total volume desired

100

Example: Make up 50ml of 2% (v/v) concentrate hydrolic acid solution

SOLUTION: ml of solute= %solution desired x total volume desired

100

ml of solute = 2% x 50 = 100 = 1
100 100

3. Weight / weight (w/w) %solutions

- It refers to the number of grams of solute per 100 grams of solution

Grams of solute= %solution desired x grams of the total solution

100

TAKE NOTE: When preparing concentrated acid solutions, ALWAYS ADD Acid to Water (AW)
MOLARITY (mol/L)
- Is the number of moles of solute per liter of solution.
- 1 mole of substance equals its gram molecular weight (gmw)
- Gram Molecular Weight (GMW) – is obtained by adding the atomic weights of the
component elements

Molarity of solution (M) = grams of solute

GMW X Volume of sol’n (L)

Moles = weight (grams)

GMW

Example: What is the molarity of NaOH given the following:

Mass: 100g volume: 800ml
Molecular weight: 80

(M) = grams of solute

GMW X Volume of sol’n(L)
Take note: the given volume is in ml, you need to convert it to L.

CONVERSION: 1L = 0.001X 800= 0.8L

1000ML

M= 100g = 1.6
80 (0.8L)

• How to prepare a molar solution: Molarity x GMW of the solute x Volume (L) desired

• To convert %w/v to Molarity:

M= %W/V X 10
GMW
NORMALITY

- Is the number of equivalent weight of solute per liter of solution

- It has often been used in acid-base balance calculations.

Normality (N) = grams of solute

EW X Volume (L)

Equivalent Weight = MW
Valence
 Example:

a. What is the normality of 5g of H2SO4 given the following

Mole weight= 98
Volume= 200ml

Normality (N) = grams of solute

EW X Volume (L)

Equivalent Weight =MW

Valence

EW= 98 = 49
2

Solution:
N = 5g = 5 = 5 = 0.51N
(98/2) x 0.2 49 X 0.2 9.8

• How to prepare a normal solution of solids:

Grams of solute= EW X Normalityx Volume (L)

• To convert %w/v to Normality:

N= %W/ V X 10
EW

Relationship between Molarity and Normality

Normality: Molraity x Valence
Molarity: Normality
Valence
DILUTIONS
- It is the relative concentration of a solution

Dilution = Volume of solute

Example: Volume of solute + volume of solvent
 a. What is the dilution if 5ml of sample is mixed with 12 ml of diluent

Dilution = Volume of solute

Volume of solute + volume of solvent
Volume of solute = 5ml

Volume of solvent= 12 ml

D= 5 = 5
5+12 17

b. What is the dilution in tube #5 if undiluted sample from tube #1 is subjected into 2 fold?

X2 Since it is subjected into 2 fold.

1/1 1/2 1/4 1/8 1/16 1/32

1 23 4 5 6

The answer is 1/16 since it is the dilution for tube #5

CLINICAL CHEMISTRY I
Module 2: III. PATIENT PREPARATION AND SPECIMEN COLLECTION

Week 3-4
Objectives:

1. Apply properly guidelines on acceptability of blood samples submitted to clinical lab.

2. Discuss briefly the duties of Medical Technologist with regards to proper specimen
collection, processing, and handling.
3. Practice properly the steps to be undertaken in patient preparation and specimen
collection, processing and handling.
4. Perform correctly venipuncture and finger prick methods of blood collection.
5. Enumerate the precautions to be considered in proper specimen collection.

PATIENT PREPARATION

- Prior to blood collection, patients must be given correct instructions on how to prepare
for each laboratory test.

FACTORS CONTRIBUTING TO THE VARIATION OF RESULTS:

1. Exercise

- Transient increased in Lactate, fatty acid, ammonia

-Increased in Prolactin, testosterone and leutenizing hormone

-Elevated levels in proteins in urine (proteinuria)

-Vigorous hand exercise (FIST CLENCHING) INCREASES POTASSIUM (every 1 minute of

fist clenching 1 mmol/L of K), lactate and phosphate

- Physical activity can have different effects on analyte concentrations.

2. Fasting

- 8-14 hours: glucose, lipids and lipoproteins

- 48 hours: may increase serum bilirubin

- 72 hours of fasting may increase plasma TAG while glucose decreases in healthy women
45mg/dl.

- Basal state collection (early blood collection, 12 hours after the last ingestion of food):
glucose, cholesterol, TAG and electrolytes.

3. Diet

- High protein diet- increases urea, uric acid and ammonia

- Fat-rich food may increase K, ALP, TAG and 5-hydroxyindole acetic acid(5-HIAA)

-Serotonin-rich food (banana, pineapple, tomato and avocado) increases urinary excretion of
5-HIAA

-Argentaffinoma patient preparation (serotonin rich)

- increases turbidity or LACTESCENCE (> 400mg/dl)

-Caffeine increases concentration of glucose; it promotes the release of catecholamines from

adrenal medulla and brain tissue

-Obese persons: LD, cortisol and glucose

4. Posture or Position

- Preferred position in phlebo- upright of supine(lying) at least 15-20mins before blood

collection to prevent hemodilution (fluid content of blood) or hemoconcentration (formed
elements of blood)

-Prolonged bed rest results to decreased plasma albumin due to fluid retention

5. Tourniquet application

- NOT MORE THAN 1 MINUTE APPLICATION IS RECOMMENDED

-Prolonged use of a tourniquet with fist exercise- increase serum potassium level by as
much a 1 mmol/L

-Tourniquet application and or muscular activity decrease venous pO2 and pH

6. Tobacco Smoking “Nicotine”

- Increase risk to DM type 2 and increase hemoglobin A1c

7. Alcohol Ingestion

-Increased level of urate, TAG and GGT (gamma glutamyl transferase)

-it causes hypoglycemia (Chronic alcoholism)

8. Anxiety

-Total cholesterol has been reported to increase with mild stress, HDL cholesterol to
decrease by as much as 15%
-results hyperventilate which affects acid-base balance

9. Diuretics

– decreased plasma sodium and potassium levels

- Vitamin C – interferes almost all analytes

-hepatotoxic drugs can elevate liver function enzymes

Tests affected by Diurnal Variation

TESTS VARIATION

CORTISOL Peaks 4-6am; Lowest 8pm-12am; 50% lower at 8pm than

8am; increased with stress

ADRENOCORTICOTROPIC Lower at night; increased with stress

HORMONE(ACTH)

PLASMA RENIN ACTIVITY Lower at night; higher standing than supine

ALDOSTERONE Lower at night

INSULIN Lower at night

GROWTH HORMONE Higher in afternoon and evening

ACID PHOSPHATASE(ACP) Higher in afternoon and evening

THYROXINE Increases with exercise

PROLACTIN Higher with stress; higher levels at 4 and 8am and at 8

and 10pm

IRON Peaks early to late morning; decrease up to 30% during

the day
 CALCIUM 4% decrease supine

SPECIMEN COLLECTION AND HANDLING

Reasons for Specimen Rejection

1. Hemolysis/ Lipemia
2. Clots in anticoagulated tube
3. Non-fasting specimen (if required)
4. Wrong blood collection tube
5. Short draws
6. Improper transport (temp)
7. Discrepancies between requisition and specimen label
8. Unlabeled or mislabeled specimen
9. Contaminated specimen/ leaking container

PATIENT IDENTIFICATION

✓ First step in sample collection

✓ “PROPER PATIENT IDENTIFICATION IS THE FIRST STEP IN SAMPLE
COLLECTION”- this is the prime factor in order to attain accurate results in the
clinical laboratory.
✓ MISLABELING =mortal sin of phlebotomist

NOTES: DO NOT PRE-LABEL THE TUBES.

Label the tubes AFTER Blood collection

Patient Identification Procedures

1. Conscious Inpatients/ Hospitalized Patient

• verbally ask their full names

• verify the name by identification bracelet:
First and Last Names, Hospital/Unit number, Room/ Bed Number and Physician’s
Name
 2. Sleeping Patients

• Identified in the same manner as conscious in-patients

• Must be awakened before blood collection

3. Unconscious, Mentally Incompetent Patients

• Identified by asking the attending nurse or relative; Identification bracelet

4. Infants and Children

• A nurse or relative may identify the patient, or by means of an identification bracelet

5. Outpatient/ Ambulatory Patient

• Ask their full names, address or birthdate (double check the ID with photo)
➢ 3-Way ID
To avoid misidentification, a phlebotomist may required what is referred to as 3-Way
ID, in which the patient is identified by:
• Patient’s verbal ID statement
• A check of ID band
• A visual comparison of the labeled specimen with the patient’s ID band before leaving
the bedside

General Methods of Blood Collection:

• Average human body = 5 quarts (4.73 L of whole blood)

• Male Adult = 5-6 liters of whole blood
• Female Adult = 4-5 liters of whole blood
• Whole blood is composed of approximately:
a.) 60% of plasma
b.) 40% of cells

ARTERIAL PUNCTURE

• A process by which blood is obtained from a patient’s artery

• Arterial blood is the oxygenated blood with a bright red color
• Use: for blood gas analysis and pH measurement
 • Sites: radial artery, brachial artery, femoral artery, scalp artery
and umbilical artery

1. Have the patient make a fist and occlude both the ulnar (opposite of the thumb
side) and the radial arteries (closest to the thumb) by compressing with two fingers
over each artery.

2. Have the patient open his or her fist, and observe if the patient’s palm
has become bleached of blood.

3. Release the pressure on the ulnar artery (farthest from the thumb) only, and not
if blood return is present. The palm should become perfused with blood. Adequate
perfusion is a positive test indicating that arterial blood may be drawn from the
radial artery. Blood should not be taken if the test is negative. Serious
consequences may occur of this procedure is not followed, which may result in loss
of the hand of its function.
• Blood sample is collected without a tourniquet
• Before blood is collected from the radial artery, modified Allen test should be done to
determine whether the ulnar artery can provide collateral circulation to the hand after
the radial artery puncture
• Arterial bleeding is the hardest to control and usually requires special attention
• Major complications: thrombosis, hemorrhage, and possible infection
• Unacceptable sites: irritated, edematous, near a wound, or in an area an
arteriovenous (AV) shunt or fistula
Modified Allen Test

II. VENIPUNCTURE

• A process by which blood is obtained from a patient’s vein.

• Venous blood (deoxygenated blood) = dark red color.

VEINS FOR ROUTINE VENIPUNCTURE: superficial veins of the antecubital fossa region (
most common veins for venipuncture)

• veins on the wrist and at the back of hands, veins on the ankle

Take note: Veins on the back of the hand and wrist may be used for
venipuncture. However, veins on the underside of the wrist should never be
used. Leg, ankle and foot veins may be used but not without the permission
of a physician.
• Median cubital vein is the best site for venipuncture (most preferred) because
it is the largest and the best anchored vein.
• According to CLSI Standards, an attempt must have been made to locate the
median cubital vein on both arms before considering an alternative vein.
 • Cephalic vein is the second choice if the median cubital vein is unsuitable;
basilic vein is the third choice.
• Basilic vein should not be chosen unless no other vein is more prominent due
to its close proximity to the branchial artery.
• Ankle vein should be used only if arm vein have been determined to be
unsuitable.
• If petechiae appear after venipuncture, it indicates that minute amounts of
blood have escaped into skin epithelium.
• For blood gases measurement, venous blood is not the specimen of choice
because it usually reflects the acid-base status of an extremity not the body as
a whole.

• In venipuncture, if a phlebotomist accidentally punctures an artery instead of a

vein, he should;

1. STOP the procedure

2. immediately apply pressure
3. Call and report the case to the
supervisor.

Two Anatomical Patterns:

“H” Pattern “M” Pattern

Veins to be used: Veins to be used:
Median Cubital vein Median vein
Cephalic Vein Accessory cephalic vein
Basilic Vein Basilic vein

PROCEDURE FOR VENIPUNCTURE:

1. Greet the patient politely and with gladness.

2. Determine the identity of the patient (according to the required procedure). Compare the
verbal identity stated by the patient with the information in the laboratory test requisition.
3. Decontaminate hands, put gloves and prepare the materials, preferably in the presence of
the patient.

4. Position the patient’s arm in a downward and comfortable manner.

5. Apply the tourniquet 3 to 4 inches above the site, and instruct the patient to make a fist.
Check for potential sites by gently palpating the vein. Never leave the tourniquet longer than
one minute.

6. If a suitable vein is not felt on the first arm, remove the tourniquet and try the other arm or
other sites.

7. If a vein has already been chosen, release the tourniquet and decontaminate the patient’s
skin with an alcohol pad starting at the point where you expect to enter the needle, and
moving outward in even-widening concentric circles.

8. Allow the site to dry by allowing the alcohol to evaporate to achieve maximum sterility, or
remove excess alcohol with sterile gauze pad. Do not blow on it. Do not touch the site after
cleansing.

9. Re-apply the tourniquet and instruct the patient to make a fist. Avoid fist clenching or
vigorous hand exercise.

10. Pull the skin gently with the thumb (if needed, hold the patient’s arm below the site), and
position the needle parallel or running in the same direction as the vein.

11. Insert the needle quickly, with the bevel side up at a 15-30 degree angle with the skin. A
slight ‘pop’ should be felt as the needle enters the vein.

12. For evacuated tube, push the tube and as the blood begins to flow, instruct the patient to
open his fist and release the tourniquet. The tourniquet can be left on until after the tubes
have been filled if it appears that blood flow is slow. But always remove the tourniquet first
before withdrawing the needle.

• For multidraw, carefully remove each tube from the holder with a gentle twist-and-pull
motion. Follow the order of draw.
• For syringe, gently pull the plunger and as the blood begins to flow, instruct the patient
to open his fist, and release the tourniquet.
13. When blood collection is done or all tubes have been filled and removed from the holder,
withdraw the needle with a quick motion and hold a dry sterile gauze pad (2-by 2-inch gauze
pad) over the site. Apply pressure to the site for a minimum of 2 minutes.

14. Label the tubes with patient’s full name, date and time of collection, and initials of the
phlebotomist. Check the condition of the patient before leaving (as part of their protocol,
some phlebotomists are also showing the labeled specimen to the patient to ensure accurate
labelling of the tubes).

15. Dispose all materials in the designated waste bins.

PRECAUTION:

- In conditions were both arms are involved in therapy and the IV cannot be
discontinued for a short time, a site below the IV line should be sought; the initial
sample (5ml) drawn should be discarded.
- NOTE: collection of blood below the IV line must be written on the laboratory request
form to inform the staff in the chemistry section.
- IV CONTAMINATION: INCREASE of infused substances such as: glucose
chloride potassium and sodium, with a DECREASE in urea and creatinine
- AS LITTLE AS 10% contamination with 5% dextrose will INCREASE GLUCOSE IN
A BLOOD SAMPLE BY 500mg/dl or more.

ORDER OF DRAW (EVACUATED TUBE AND SYRINGE) “BCSHES”

Blood collection tubes Anticoagulant Uses

1. YELLOW -SPS- Sodium Polyanethol Sulfonate -Blood culture

-ACD – Acid Citrate Dextrose -DNA test

-Blood bank test
-HLA test
 2. LIGHT BLUE -3.2% Sodium Citrate -Coagulation tests (PT,
(Trisodium APTT)
citrate)
-Special Function
Assays:
Light blue CTAD- Citrate theophylline
Adenosine Dipyridamole

3. RED (Serum -non-additive tube - Serum/

top) Chemistry,
-Glass Serology

-Plastic

4. Green -Heparin (Sodium Heparin, Lithium -Plasma chemistry

Heparin, Ammonium Heparin) - OFT
- Blood gas analysis
Take note: Lithium Heparin – most
widely used anticoagulant for plasma NOTE: Cardiopulmonary
and whole blood chemistry tests. bypass

5. Lavander/Purple - Ethylenediaminetetraacetic - Complete blood

acid (EDTA) count
(most commonly
used in
hematology)
 6. Gray Top -Potassium oxalate - Blood glucose
and alcohol levels
ADDITIVES:
-Antiglycolytic agent:

1. Sodium Flouride (NaF)

2. Lithium Iodoacetate

OTHER COLLECTION TUBES

COLLECTION TUBES ADDITIVE/ USES

ANTICOAGULANT
1. Tan top - K2 EDTA -Lead testing/
- certified to contain - Sodium Heparin determination
less than 0.01 (glass tube)
ug/ml of lead
2. Royal Blue top - K2 EDTA - Trace elements
- Contains only low - None tests
levels of trace - TDM, Toxicology
elements - Nutritional studies
3. Pink top - K2 EDTA - General chemistry
- None and Serology
- Special for
crossmatching of
patient approved by
AABB
 4. Black top (3.8% - Buffered sodium - ESR (westergreen)
Sodium Citrate) citrate (4:1 ratio of
blood to
Anticoagulant)
5. White top -EDTA and contains gel - Molecular Diagnostic

6. Gold -Polymer barrier -General chemistry

Note:

- Underfilling blood collection tubes can affect RBC morphology and lipids in EDTA
tubes and binding of electrolytes and troponin to heparin in some plasma tubes.

NOTES TO REMEMBER:

• TOURNIQUET APPLICATION:
- Alternative = Blood pressure cuff (inflated 60mmHg)
- Prior collection= ask patient for latex sensitivity
- Length of time = less than 1 minute
- Angle between skin and needle= 30 0
- Distance of tourniquet to the intended venipuncture site: 3-4 inches
- According to CLSI, when a tourniquet is used during preliminary vein selection, it
should be released and reapplied after 2 minutes.
- Studies have shown that reusable tourniquet have the potential to transmit bacteria:
METHICILIN -RESISTANT Staphylococcus aureus (MRSA)

• DISINFECTION OF THE SITE FOR VENIPUNCTURE

- No traces of alcohol should remain on the skin because it may cause HEMOLYSIS
AND CONTAMINATE GLUCOSE TESTING.

- For ETHANOL TESTING- BENZALKONIUM CHLORIDE SOLUTION (Zephiran

chloride 1:750) should be used for cleansing. (Non alcoholic)
 - 70% isopropyl alcohol= most common antiseptic/ skin cleanser

- According to CLSI, Chlorhexidine gluconate is the recommended blood culture site

disinfectant for INFANTS 2 MONTHS OLD and OLDER PATIENTS WITH IODINE
SENSITIVITY.

• NEEDLE SPECIFICATIONS
- The gauge of the needle is inversely related to the size of the needle.
- The larger the gauge number, the smaller the needle bore and length.
- GAUGE 21 standard for venipuncture.
- GAUGE 23 used for children
- Gauge 23-25 is for winged infusion set (butterfly needle)
- 25 Gauge- used by trained personnel to collect from scalp and other tiny veins for
premature infants and other neonate.
- Needle length: 1 inch or 1.5 inches
- A phlebotomist must never puncture a patient more than twice.

SITES TO BE AVOIDED (VENIPUNCTURE)

1. Intravenous lines in both arms

2. Burned or scarred areas

3. Areas with hematoma

4. Veins in the inner wrist and feet

5. Edmatous arms/ sites

6. Partial/radical mastectomy on one or both arms
7. Arms with arteriovenous (AV) shunt or fistula
8. Casts on arms and inflamed sites

COMPLICATIONS OF VENIPUNCTURE:
1. Immediate Local Complication
a. Hemoconcentration- is an increase in the number formed elements in blood resulting either
from a decrease or increase in plasma volume.
b. Failure of blood to enter the syringe/ vacutainer tube

• Excessive pull of the plunger

• Piercing the other pole of the vein
• Incorrect bevel position (bevel down)
• c.Syncope (fainting)
• Is the transient loss of consciousness due to lack of oxygen in the brain and results in
an inability to stay in an upright position.
• If a seated patient feels faint, the needle should be removed immediately, the patient’s
head should be lowered between the legs and the patient should be instructed to
breathe deeply.

2. Late Local Complication

a. Thrombosis- is an abnormal vascular condition in which thrombus develops within a
blood vessel of the body.
b. Thrombophlebitis- is inflammation of a vein often accompanied by a clot which occurs
as result of trauma to the vessel wall.

3. Late General Complications- serum hepatitis and AIDS

Causes of Hemolysis ( Hemolyzed Speciemn):

• Using a needle that is too small

• Pulling a syringe plunger back too fast
• Forcing the blood from a syringe into an evacuated tube
• Shaking or mixing the tubes vigorously
• Performing the blood collection before the alcohol has dried at the collection site.

Causes of Hematoma:

1. The vein is fragile or too small for the needle size

2. The needle penetrates all the way through the vein
3. The needle is partly inserted to the vein
4. The needle is removed while the tourniquet is on

SKIN PUNCTURE
 • Used only when small quantities of blood are required
• Avoid applying pressure/ squeezing/ milking the site

EFFECTS OF SQUEEZING:

1. CAN CAUSE HEMOLYSIS

2. CAN INTRODUCE EXCESS TISSUE FLUID

• A fingerstick to obtain blood for routine laboratory analysis is usually preferred for
children older than one year old.
• Length of the lancet: 1.75mm (preferred; to avoid penetrating the bone)
• The depth of the incision should be < 2.0 mm for infants and children;
• < 2.5 mm for adults, to avoid contact with the bone.
• The distance from the skin surface to bone or cartilage in the middle finger is 1.5-
2.4mm.
• The cut should be oriented across the fingerprints to generate a large drop of blood
using a single deliberate motion.

Preferred Sites:

1.Lateral Plantar heel surface – newborn

2.Palmar surfaces of the fingers (3rd and 4th fingers)
3.Plantar surface of the big toe
4.Earlobes – least site

Why do we need to discard the first drop of blood?

- To discard excess fluid

- To discard dead epidermal cells
- To facilitate free flow of blood

ORDER OF FILLING MICROCOLLECTION TUBES:

1. EDTA
2. OTHER TUBES WITH ADDITIVES
3. NONADDITIVE TUBES
NICE TO KNOW: (In Hematology)

The order of draw for skin puncture is the following: “TSEOS”

1. Tube for blood gas analysis

2. Slides
3. EDTA
4. Other microcollection tubes with anticoagulants
5. Serum microcollection tubes

ADVANTAGE OF SKIN PUNCTURE

1. For premature infants because large amount of blood required for repeated
venipunctures may cause iatrogenic anemia.
2. For sick infants which require parenteral therapy – accessible veins in sick infants
must be reserved exclusively for parenteral therapy.
3. Skin puncture is often preferred in geriatric patients because the skin is thinner and
less elastic.

Skin puncture is useful in adults with: extreme obesity, severe burns, and thrombotic
tendencies

Sites not generally recommended for skin puncture: central arch area of an infant’s
heel; fingers of a newborn or infant less than one year old; thumb, index and fifth
fingers and fingers on the side of a mastectomy.

REASONS FOR RAPID SEPARATION OF BLOOD (AFTER CENTRIFUGATION)

• Ideally, all measurements should be performed within45 minutes to 1 hour after

collection.
• Serum and plasma should be separated from cells as soon as possible, preferably
within 1 hour.
• Adequate time for clotting must be allowed to prevent latent fibrin formation, which
may cause undesirable clogging of automated chemistry analyzers.
• Plasma should not remain in contact with the cells overnight. Even in the presence if
anticoagulant, protein aggregation can occur in plasma that is stored in the refrigerator
for a few days or frozen for longer periods.
• 3000 relative centrifugal force (RCF) for 10 minutes is the centrifugation requirement
(required RCF may vary depending on the manufacturer’s recommendation).

1. To prevent glycolysis.
• 2mg NaF/ ml of blood – prevents glycolytic enzyme (enolase-Mg+2 -dependent
enzyme) or glycolysis for up to 48-72 hours.
• The use of fluoride-containing tube is not necessary if plasma is separated from
cells or glucose measured is measured immediately.
• Glucose concentration in unseparated serum and plasma decreases rapidly in the
first 24 hours and more slowly thereafter.
• Glycolysis occurs faster in newborns because their metabolism is increased, and
in patients with leukemia because of high metabolic activity of WBC’s

2. Certain substances are very unstable.

• Unseparated serum and plasma yield clinically significant increases in total

bilirubin, sodium, urea, nitrogen, albumin, calcium, magnesium, and total protein-
due to movement of water into cells after 24 hours, resulting in
hemoconcentration.
• Least stable in serum if not removed from the clot within 30 minutes: potassium,
phosphoru and glucose
• Unstable after 6 hours when the serum was not separated from the clot: albumin,
bicarbonate, chloride, C-peptide, HDL-cholesterol, iron, LDL-cholesterol, and total
protein

3.To prevent shift of electrolytes.

• This will result to false increase of potassium and subsequent decrease of sodium
in serum and plasma.
4.To prevent hemolysis.
Effects of hemolysis:
a. Increased levels of the following analytes: enzymes (LD, ACP, ALT, AST);
electrolytes (magnesium, phosphorus, and potassium); total protein; albumin;
 cholesterol and iron.
b. Interferes with the color reactions.
c. It increases bilirubin levels.
• When serum bilirubin approaches 430 mmol/L (25mg/L), Interference may be
observed in assays for albumin (4-hydroxyazobenzene-2-carboxylic acid [HABA]
procedure), cholesterol (using ferric chloride reagents), and total protein (Bluret
procedure).
d. It inhibits lipase enzyme.

Interfering Conditions in the Measurements of Analytes:

• Most common interfering conditions: hemolysis, icterus, and lipemia

• Hemolysis and icterus strongly absorb specific wavelengths of light.
1.Hemolysis
• Severe hemolysis causes a slight dilutional effect on the analytes present in serum
or plasma.

2.Bilirubin
Serum bilirubin of 25.2 mg/L (430 mmol/L) which means icteric specimen,
interferes with the measurement of total protein, albumin, cholesterol and glucose.
• Bilirubin in a specimen is not readily removed and so may cause spectral
interference through its high absorbance at wavelengths between 340 and 500
nm.

3.Lipemia
• It occurs when serum triglyceride exceeds 4.6 mmol/L (400mg/dL).
• It scatters light and eventually blocks transmission of light.
• It can potentially be cleared from a serum or plasma specimen by
ultracentrifugation.
• Lipemia inhibits amylase, urate, urea, CK, bilirubin, and total protein.
• Protective measures for artifactual absorbance (lipemia): blanking technique and
dual-wavelength reading.
COLLECTION OF OTHER BODY FLUIDS:

1.Cerebrospinal Fluid (CSF)

• Most common method of collection: Lumbar puncture (between the third and
fourth lumbar vertebrae, or between the fourth and fifth lumbar vertebrae)
• Other methods of collection: cisternal puncture and lateral cervical puncture
• Purpose of collection: to establish a diagnosis of infection (bacterial, fungal,
mycobacterial, or amebic meningitis), malignancy, subarachnoid, hemorrhage,
multiple sclerosis, demyelinating disorders
• Required pressure before collection: between 90 and 180 mm Hg
• Volume that can be collected: 20ml of CSF (not more than 2ml can be removed
when the pressure is greater than 200 mm Hg)
• Purpose of the CSF Vials/Tubes:
Tube #1=chemistry for glucose and protein analysis, or
immunology/serology;
Tube #2 = microbiology for culture and Gram stain; Tube #3=
hematology for cell counts
Tube #3 is the least likely to be contaminated by a bloody tap at
collection)

• Complications of Lumbar Tap: cerebellar tonsillar herniation in patients with

elevated intracranial pressure; asphyxiation in infants; paresthesia; headache;
and, rarely, hematoma.

2.Urine

• Random specimens may be collected at any time, but a first-morning-voided

aliquot is optimal for constituent concentration, as it is usually the most
concentrated and has a lower pH caused by decreased respiration during sleep.

• For 24-hour urine collection, the first morning specimen should be discarded,
record the time, and collect the succeeding voiding for the next 24 hours –
overcollection occurs if the first morning specimen is included in this routine.
• 24-hour urine creatinine- to assess the completeness of the specimen
 • Sodium fluoride can be added to 24-hour urine for glucose determinations to
inhibit bacterial growth and cell glycolysis
• Pediatric collections require special attention to avoid stool contamination.

3.Synovial fluid, Pleural fluid, Pericardial Fluid, and Peritoneal Fluid

• Synovial fluid is collected by arthrocentesis, an aspiration of the joint using a

syringe, moistened by an anticoagulant, usually 25 units of sodium heparin per mL
of synovial fluid.
• Synovial fluid differs from the other serous fluids in that it contains hyaluronic acid
(mucin) and may contain crystals.
• Sodium heparin is the preferred anticoagulant for synovial fluid
• Some hospitals transfer synovial fluid to aerobic and anaerobic blood culture
bottles for microbiologic culture.
• Thoracentesis is a surgical procedure to drain fluid (effusions) from the thoracic
cavity and is helpful in diagnosing inflammation or neoplastic disease in the lung
or pleura.
• Pericardiocentesis and peritoneocentesis refer to the collection of fluid from the
pericardium (effusion) and the peritoneal cavities (ascites), respectively. These
cavities usually contain less than 50ml of fluid.
• Pleural fluid is an ultrafiltrate of the blood plasma. It is formed continuously in the
pleural cavity.

Note to remember:

• Commonly encountered pre-analytical errors: Improper filling of sample tubes, wrong

choice of tubes or containers and selecting the incorrect test.

Ten Common Errors in Specimen Collection

 CLINICAL CHEMISTRY I
Module 3 : Quality Control and Analytical Method
Objectives:

1. Misidentification of patient

2. Mislabeling of specimen

3. Short draws/wrong anticoagulant/blood ratio

4. Mixing problems/clots

5. Wrong tubes/wrong anticoagulant

6. Hemolysis/lipemia

7. Hemoconcentration from prolonged tourniquet time

8. Exposure to light/extreme temperature

9. Improperly timed specimens/ delayed delivery to the laboratory

10. Processing errors: Incomplete centrifugation Incorrect log-in, improper storage

➢ Compute and establish the values of central tendencies, dispersions (X, SD, CV, etc)

➢ Prepare guidelines on how to prevent the interference of pre-analytic variables on test

result

➢ Explain the concepts of internal and external Quality Control.

QUALITY CONTROL

• is a system that:

✓ Ensures accuracy and precision including QC reagents in every series of

measurements

✓ Ensures analytical results are correct by testing know samples that resemble patient

samples

✓ Involves process of monitoring the characteristics of the analytical processes and

detects analytical errors during testing

✓ Prevents the reporting of inaccurate patient test results

QUALITY CONTROL- is one component of the quality assurance system and is part of the

performance monitoring that occurs after a test has been established.

PARAMETERS OF QUALITY CONTROL

• SENSITIVITY “smallest concentration”

- the ability of the analytical method to measure the smallest concentration of the
analyte of interest

• SPECIFICITY “only the analyte of interest”

- the ability of the analytical method to measure only the analyte of interest

• ACCURACY “closeness/ nearness” TAM

- closeness or nearness of the assayed value to the target or true value

Three types of studies: RIP (Recovery, Interference and Patient Sample Comparison)

> RECOVERY- “how much-sample identified”

> INTERFERENCE- “affects laboratory test= hemolysis, icteric”
 > PATIENT- “assess presence of error”

• PRECISION/ REPRODUCIBILITY “repeated results” SPF

- the ability of the analytical method to give repeated results on the same sample
that agree with one another

• PRACTICABILITY “method easily repealed”

- is the degree by which a method is easily repeated

• RELIABILITY
-ability of the analytical method to maintain accuracy and precision over an
extended period of time

• DIAGNOSTIC SENSITIVITY “with the disease ” “TRUE POSITIVE”

- ability of the analytical method to detect proportion of individuals WITH THE
DISEASE.
-indicates the ability of the test to generate more TRUE-POSITIVE results and
few false-negative.
-Screening test: High sensitivity (no case missed)

100 X the no. of individuals with POSITIVE TEST

SENSITIVY (%)=
Total number of DISEASED individuals tested

TP
Diagnostic Sensitivity= x100
TP + FN

• DIAGNOSTIC SPECIFICITY “WITHOUT the disease ” “TRUE NEGATIVE”

- ability of the analytical method to detect proportion of individuals WITHOUT
THE DISEASE.
-reflects the ability of the method to detect TRUE-NEGATIVE with very few false-
positives
 - Confirmatory: High specificity to be certain of the diagnosis

100 X the no. of individuals without the disease with NEGATIVE TEST
Specificity (%)=
Total number of individuals tested without the disease

TN
Diagnostic Specificity= x100
TN + FP

KINDS OF QUALITY CONTROL

INTRALAB QUALITY CONTROL (INTERNAL QC)

• DAILY MONITORING OF ACCURACY & PRECISION

• Detects random and systematic errors in a daily basis
• It allows identification of analytical errors within a 1 week cycle

INTERLAB QUALITY CONTROL (EXTERNAL QC)

• Important in maintaining LONG TERM ACCURACY

• Use to determine state-of-the-art inetrlab performance

OBJECTIVE OF QUALITY CONTROL “QTS”

TO CHECK:
✓ Stability of machine

✓ Quality of reagents

✓ Technical errors

Control Solutions (QC Materials)

• General chemistry assays used 2 levels of control solutions

• Immunoassays used 3 levels of control solutions

Control Limits (Control Values)

 • Control limits are calculated from the mean (x) and standard deviation (SD)

• Ideal reference limit = [ 2SD +/- ]

• Quality control sample= human sample

Characteristics of an Ideal QC Material

✓ Resembles human sample
✓ Inexpensive, stable for long periods
✓ No Communicable diseases
✓ No known matrix effects
✓ With known analytic concentration (assayed control)
✓ Convenient packaging and easy dispensing/ storage
✓ Quality Control sample availability “1 year” with same lot number

VARIATIONS

- errors encountered in collection, preparation, measurement of samples, including transcription

and releasing of laboratory results.

TYPES OF ERRORS

RANDOM ERROR

“due to chance”

-present in all measurements

-error that varies from sample to sample

-basis for varying differences between repeated measurements (PRECISION)

Error occurs due to: Instrument, operator, environmental condition

“PM si TIM”

1. Pipetting errors
2. Mislabeling of samples

3. Temperature fluctuation

4. Improper mixing of sample and reagents

SYSTEMATIC ERROR

“errors consistently in one direction”

-detected either as positive or negative bias

“CoCo CaIn Lang Po”

1. deterioration of Control materials and reagents

2. Contaminated solutions, unstable and inadequate reagent blanks

3. Calibration problems

4. Improperly made standard solutions

5. Leaky Ion selective electrode (ISE) , falling instrumentation

6. Poorly written procedures

a. Constant Error

-difference between the target value and the assayed value

-“independent” of sample concentration

-there is a continual difference between the comparative method and the test method regardless
of concentration

b. Proportional/ Slope/ Percent Error

- difference between the test method and the comparative method values is proportional to the
analyte concentration

- Increase SD= Decrease Precision (vice versa)

CLERICAL ERROR

• The highest frequency of clerical errors occurs with the use of hand written labels
and request
PRE-ANALYTICAL ERRORS:

1. Improper patient preparation

2. Mislabeled specimen

3. Incorrect order of draw and incorrect patient identification

4. Wrong specimen container

5. Incorrect anticoagulant to blood ratio

6. Improper mixing of samples and additives

7. Incorrect specimen preservation and incorrect used of tubes for blood collection

8. Mishandled specimen (transport and storage)

9. Missed or incorrectly interpreted lab requests

POST-ANALYTICAL ERRORS:

1. Unavailable or delayed results

2. Incomplete laboratory results

3. Wrong transcription of the patients data and lab results and Interpretation

ALLOWABLE ERROR (Ea)

• Is determined for each test method and is expressed either in measurement units of
analyte (mmol/L or %)

STATISTTICS:

• Is the science of gathering, analyzing, interpreting and presenting data.

1. MEAN- is a measure of central tendency. It is associated with symmetrical or normal

distribution

Mean= ∑x
n
2. STANDARD DEVIATION- is a measure of dispersion of values from the mean

- a measure of distribution range

- it is the most frequently used measure of variation

-1

3. COEFFICIENT OF VARIATION (CV)- is a percentile expresiion of the mean

- an index of precision

CV= SD x 100
Mean

4. VARIANCE- called the standard deviation squared; a measure of variability.

V= SD2
TERMINOLOGIES:

o Inferential Statistics- are used to compare the means or standard deviations of two

groups of data

o F-Test – used to determine whether there is statistically significant difference between

the Standard deviations of two groups of data. SPF

o T-test- used to determine whether there is statistically significant difference between the

Means of two groups of data.TAM

 o Median – value of the observation that divides the observations into two groups, each

containing equal number of observations. It is the midpoint of a distribution; 50th centile.

o Mode – is the most frequent observation; used to describe data with two centers

(bimodal)

o Range – simplest expression of spread or distribution; difference between the highest

and lowest score in data

QUALITY CONTROL CHART

• Used to observe values of control materials over time to determine reliability of the

analytical method.

• Utilized to observed and detect analytic errors such as inaccuracy and imprecision

1. GAUSSIAN CURVE (Bell-Shaped Curve)

- data elements are centered around the mean

- The total area under the curve is 1.0 or 100%

2. CUMULATIVE SUM GRAPH (CUSUM)

-it calculates the difference between QC results and the target means

- this plot will give the earliest indication of systematic errors (trend)-Common method: V- mask

3. YOUDEN / TWIN PLOT

-used to compare results obtained on a high and low control serum from different lab

- displays the results of the analysis by plotting the mean values for one specimen on the
ordinate (y-axis) and the other specimen on the abscissa (x-axis) “HAXI VOYD”

4. SHEWHART LEVEY-JENNINGS CHART

- it is the most widely used QC chart and easily identifies random and systematic errors

- it allows the technicians to apply multiple rules without the aid of a computer
- graphic representation of the acceptable limits of variation in the results of an analytical
method

ERRORS OBSERVED ON LJ CHART

a. TREND – formed by control values that either increase or decrease for six consecutive days.

-“gradual”
Main cause: DETERIORATION OF REAGENTS

b.SHIFT – formed by control values that distribute themselves on one side of the mean for six
consecutive days.

- shift in the reference range is due to transient instrument differences

- “abrupt change”

Main cause: IMPROPER CALIBRATION OF THE INSTRUMENT

c. OUTLIERS – are control values that are far from the main set of values

-are highly deviating values

WESTGARD CONTROL RULES

• 12S – it is used as a “rejection or warning” rule when one control result exceeds
the mean [ 2SD +/- ]; for screening purposes
• 13s – one control result exceeds the mean 3SD +/-; it is effective in random error
• 22s – the last 2 control results (or 2 results from the same run) exceed either the
mean 2SD; respond most often to systematic errors
• 41s – the last 4 (or any 4) consecutive control results exceed either mean +/-
1SD; respond to systematic errors
• R4S – the range or difference between the highest and the lowest control result
within an analytical run exceeds 4SD; respond to random errors or increase
precision
• 10x – ten consecutive results are on the same side of the target mean;
systematic errors.
General Interpretation of QC results

• The acceptable reference limit is set at +/- 2SD

• The upper and lower reference limits define a specified percentage, usually 95% of the
values for a certain group of population, hence 5% of the population will fall outside the
reference
• A control value between 2s and 3s is a sign of a potential problem
• A control value outside the 3s would require corrective action
• Some laboratories use the 2s as a warning limit and 3s as an error limit

TERMINOLOGIES:
1. Analytical Run – is a set of control and patient specimens assayed, evaluated and
reported together

2. Delta check – is the commonly used patient based –QC technique

• It requires computerization of test data so that current results can be

compared with the past results
• Is the difference between two consecutive measurements of the same
analytes on the same individual

3. Interference experiments – are used to measure systematic errors or inaccuracy caused

by substances other than the analyte

Interferences: Hemoglobin, lipids, bilirubin, anticoagulants and preservatives

4. Linear Range/ Dynamic Range – is the concentration range over which measured
concentration is equal to the actual concentration without modification of the method
5. Physiologic Limit – is sometimes referred to as absurd value
• It helps detects the sample contamination or dilution, inadequate
sample volume, sudden major problems with the method or incorrect
recording or transmission of the result.
6. Point of Care Testing (POCT) – is the type of the analytical testing performed outside the
confines of the central laboratory, usually by nonlaboratorian personnel (nurses,
respiratory therapists etc)
• Most commonly used POCT: use of portable whole blood glucometers
for the management of patients with diabetes mellitus
• Other name: near-patient testing, decentralized testing, bedside testing
and alternate site testing
7. Quality Assurance – it can be envisioned as a tripod with program development,
assessment and monitoring
• Is a systemic action necessary to provide adequate confidence that
laboratory services will satisfy the given medical needs for patient care.
 8. Quality Patient Care – it includes effective test request forms, clear instruction for patient
preparation and specimen handling, appropriate turn-around time for specimen
processing testing and result reporting appropriate reference ranges and intelligent
result reports.
9. Recovery experiment – is shows whether a method measures all analytes or only part of
it
10. Predictive Value – it depends on sensitivity, specificity and prevalence of the disease
being test
1. Positive Predictive Value – is the probability that a positive test indicates
disease; it is the proportion of persons with a positive test who truly have the
disease
2. Negative Predictive Value – is the probability that a negative test indicates
absence of disease. It is the proportion of persons with a negative test who
are truly without the disease
11. Reference Limit/ Reference Interval/ Reference Value – is a value obtained by
observation or measurement of a particular type of quantity on a reference individual

ANALYTICAL METHODS

Light energy, wavelength and radiant energy spectrum:

ENERGY – is transmitted via electromagnetic waves that are characterized by their frequency
and wavelength.

WAVELENGTH – is the distance between two successive peaks and it is expressed in terms of
nanometer (nm)

400 – 700 nm = visible light

< 400 nm = ultraviolet region (UV)

>400 nm = infrared region (IR)

NOTES:

Visible to Ultraviolet Region = XENON LAMP

Visible to Infrared Region = TUNGSTEN

Ultraviolet Region = Hydrogen lamp, Deuterium lamp

Infrared Region = Merst glower and Globar (silicone carbide)

The relationship between wavelength and energy (E) is described by “PLANCK’S FROMULA”

E = hv

E = is the energy of a photon in Joules or eV

 h = constant (6.626x 10-34 erg sec)

v = frequency

FREQUENCY – is the number of vibrations of wave motion per second

• The lower the wave frequency, the longer the wavelength

• The wavelength is inversely related to frequency and energy; the
shorter the wavelength, the higher the frequency and energy and vice
versa

Notes to Remember:

6. Didymium or holium oxide filter is used to check wavelength accuracy (wavelength

calibration)

7. Neutral Density Filters and Dichromate solution verify absorbance accuracy on linearity

COLORIMETRY

A. SPECTROPHOTOMETRY
• Measurement of light transmitted by a solution
(to determine the concentration of the light-absorbing substances in the
solution)

Single Beam Spectrophotometer

• It is the simplest type of absorption spectrometer

• It is designed to make one measurement at a time at one specified
wavelength

Double Beam Spectrophotometer

• It is an instrument that splits the monochromatic light into two

components – one beam passes through the sample and the other
through a reference solution or blank

2 types of Double-Beam Spectrophotometer:

o Double-beam in space – uses 2 photodetectors ( for the sample and

reference beams)

o Double-beam in time – uses one photodetecor and alternately passes the

monochromatic light through the sample cuvet and then reference cuvet
using a chopper or rotating sector mirror
6 basic components of Single or Double-beam spectrophotometer:

Stable source of radiant energy, Filter that isolates a specific region of electromagnetic
spectrum, Sample holder, Radiant Detector, Signal Processor and Readout device

PARTS OF SPECTROPHOTOMETER: “LEt ME CPR”

1. LIGHT/ RADIANT SOURCE – provides POLYCHROMATIC light

2 types:

a. Continuum source – emits radiation that changes in intensity; widely used in the
laboratory
• Examples: Tungsten, Deuterium and Xenon lamps
• TUNGSTEN BULB is the commonly used light source in the visible and
near infrared region
• DEUTERIUM LAMP is routinely used to provide UV radiation in analytic
spectrometers
• Xenon discharge lamp produces a continuous source of radiation, which
covers both the UV and visible range

b. Line source - emits limited radiation and wavelength

• Examples: Mercury and Sodium Vapor lamps (UV and visible region)
• Hollow Cathode Lamp (AAS)
• Light Amplification by Stimulated Emission of Radiation (LASER) – also
used as light source

Factors for choosing a light source:

Range, spectral distribution within the range, the source of radiant production , stability of the
radiant energy and temperature

2. ENTANCE SLIT – minimizes unwanted or STRAY LIGHT and prevents the entrance of
scattered light into the monochromator system

STRAY LIGHT – most common cause of loss of linearity at high analyte

concentration
• Refers to any wavelength outside the band transmitted by the
monochromator
 • Neutral Density Filter and Dichromate Solution – very fine absorbance
accuracy and linearity

•
3. MONOCHROMATORS – isolates specific or individual wavelength of light

Kinds of Monochromators:

• PRISMS – are wedge-shaped pieces of glass, quartz or sodium chloride

• It can be rotated, allowing only the desired wavelength to pass through
an exit slit
• A narrow light focused on prism is refracted as it enters the more dense
glass

• DIFFRACTION GRATINGS – are the most commonly used; better resolution than
prism
• Are made by cutting grooves (parallel grooves) or slits into aluminized
surface of a flat piece of crown glass – wavelengths are bent as they
pass a sharp corner

• FILTERS – are simple, least expensive not precise but useful

4. EXIT SLIT – controls the width of light beam (bandpass)

BANDPASS – Is the total range of wavelengths transmitted

5. CUVET – It is also called as absorption cell/ analytical cell/ sample cell

• it holds the solution whose concentration is to be measured

Kinds of Cuvets:

a. Alumina Silica glass – most commonly used

b. Quartz / plastic – used for measurement of solution requiring visible and ultraviolet
spectra
c. Borosilicate glass
d. Soft glass

6. Cuvets with scratches on their optical surface scatter light and should be
discarded
 7. Silica cuvets transmit light effectively at wavelength >/= 220 nm
6. PHOTODETECTOR – it detects and converts transmitted light into photoelectric energy
• it detects the amount of light that passes through the sample in the
cuvet

Kinds of Detectors:

a. Barrier Layer Cell / Photocell / Photovoltaic cell

• It is the simpliest detector; least expensive; temperature- sensitive

• It is used in filter photometers with a wide bandpass

b. Phototube
• It contains cathode and anode enclosed in a glass case
• It has a photosensitive material that gives off electron when light energy
strikes it

c. Photomultiplier Tube (PMT)

• It is the most commonly used detector - measures visible and UV

regions
• It has excellence sensitivity and has rapid response – detects very low
levels of light
• It should NEVER BEEN EXPOSED TO ROOM LIGHT because it will
BURN OUT.
d. Photodiode
• It is not as sensitive as PMT but with excellent linearity
• It measures light at a multitude of wavelengths – detects less amount of
light
• It has a lower dynamic range and higher noise compared to PMT
• It is most useful as a simultaneous multichannel detector

7. METER OR READ-OUT DEVICE – it displays output of the detection system

• Examples: Galvanometer/ ammeter / light- emitting diode (LED)

BEER’S LAW

• It states that the concentration of the unknown substance is directly

proportional to the absorbed light (absorbance or optical density) and
inversely proportional to the amount of transmitted light

ABSORBANCE
Is the amount of light absorbed

• Is proportional to the inverse log of transmittance

A = abc = 2 – log%T

Where:

• A = ABSORBANCE
• a = molar absorptivity
• b= length of light through the solution
• c= concentration of absorbing molecules

BLANKING TECHNIQUE

• means the blank contains serum but without the reagent to complete
the assay
• REAGENT BLANK – corrects absorbance caused by the color of the
reagents – the absorbance of the reagents is automatically subtracted
from each of unknown reading
• SAMPLE BLANK – measures absorbance of the sample and reagent in
the absence of the endproduct and corrects measurement for optical
interference (like HEMOGLOBIN)

B. FLAME EMISSION PHOTOMETRY (FEP)

• It measures light emitted by a single atom BURNED in a flame
• Principle: EXCITATION of electrons from lower to higher energy state
• Light source: Flame (also serves as cuvet)
• Method: Indirect Internal Standard Method
• Internal Standard : Lithium / Cesium ( corrects variation in flame and
atomizer characteristics)
• It is used for the measurement of excited ions (Sodium and Potassium)

C. ATOMIC ABSORPTION SPECTROPHOTOMETRY (AAS)

• It measures the light absorbed by atoms dissociated by heat
• Principle: Element IS NOT EXCITED by merely dissociated from its
chemical bond and place in an unionized, unexcited, ground state
• Light source: Hollow-Cathode Lamp
• It is used for measurement of unexcited trace metals (Calcium and
Magnesium)
• More sensitive than FEP; it is accurate, precise and more specific.
• Internal standard is not needed
 • An atomizer (nebulizer/ graphite furnace) is used to convert ions to
atoms; a chopper is used to modulate the light source.

• VOLUMETRIC (Titrimetric)
• Principle: the unknown sample is made to react with known solution in
the presence of an indicator
• Examples: Schales and Schales method (Chloride test)
• EDTA Titration Method (Calcium test)
• TURBIDIMETRY
• For measuring abundant large particles (proteins) and bacterial
suspensions
• Principle: it determines the amount of light blocked (reduction of
light) by a particulate matter in a turbid solution
• Use: protein measurements (CSF and Urine) to detect bacterial growth
in broth cultures: antimicrobial test (broth method) and to detect clot
formation

• NEPHELOMETRY
• For measuring the amount of antigen- antibody complexes (proteins)
• Principle: it determines the amount of scattered light by a particulate
matter suspended in a turbid solution
• Light scattering depends on wavelength and particle size
• Components of nephelometer: light source (mercury-arc lamp, a
tungsten-filament lamp, light emitting diode and a laser)
• Collimator, monochromator, sample cuvet, stray light trap, and
photodetector

• ELECTROPHORESIS
• Is the migration of charged particles in an electric field
• It separates proteins on the basis of their electric charge densities
• The acidic and basic amino acids determine the net charge on a protein
hence its electrophoretic mobility
• DURING ELECTROPHORESIS proteins are NEGATIVELY CHARGED
(anions) and they move towards the anode.

Components of Electrophoresis: electrical power, support medium, buffer, sample and

detecting system

Buffer: BARBITAL (8.6 pH)

Terminologies:

• AMPHOTERIC: has a net charge that can be either positive or negative

depending on PH conditions
 • ELECTROENDOSMOSIS: Is the movement of buffer ions and solvent
• IONTOPHORESIS: Is the migration of the small charged ions
• ZONE ELECTROPHORESIS: is the migration of charged
macromolecules

Factors affecting rate of migration:

• Net electric charge of the molecule

• Size and shape of the molecule
• Electric field strength
• Nature of the supporting medium
• Temperature of operation

Supporting Media:

• CELLULOSE ACETATE: separates by molecular size

• AGAROSE GEL: by electrical charges does not bind protein
• POLYACRYLAMIDE GEL: separates on the basis of charge and
molecular size ; separates proteins into 20 fractions; used to study
enzymes

Stains for Visualization of Fractions:

Serum Proteins“CAP” Lipoproteins “FOS”

Coomasie Brillant Blue Fat Red 7B

Amido Black B Oil Red O

Ponceaus S Sudan Black

DENSINOMETRY

• It measures the absorbance of stain – concentration of the dye and

protein fraction
• It scans and quantitates electrophoretic pattern

ISOELECTRIC FOCUSING

• It separates molecules by migration through a ph gradient

• It is ideal for separating proteins of identical sizes but with different net
charges

Advantages:

• The ability to resolve mixture of proteins

 • To detect isoenzymes of ACP, CK, ALP in serum
• To identify genetic variants of proteins such as alpha-1-antitrypsin
• To detect CSF oligoclonal banding

• CHROMATOGRAPHY
• It involves separation of soluble components in a solution by specific
differences in physical-chemical characteristics of the different
constituents.

Bases of separation

✓ Rate of diffusion
✓ Solubility of solute
✓ Nature of the solvent
✓ Sample volatility/solubility
✓ Distribution between 2 liquid phases
✓ Molecular Size (molecular sieving)
✓ Hydrophobicity of the module
✓ Ionic attraction
✓ Differential distribution between two immiscible liquids
✓ Selective separation of substances
✓ Differences in adsorption and desorption of solutes

2 Forms of Chromatography

• Planar

• Paper Chromatography
- It is used for fractionation of sugar and amino acid
- Sorbent (stationary phase)- Whatman paper

• Thin Layer Chromatography (TLC)

• It is a semiquantitative (drug screening test)
• Biological samples suc as blood, urine and gastric fluid can be used for
the test
• Sorbent: thin plastic plates impregnated with a layer od silica gel or
alumina

Retention factor (Rf) value - is the relative distance of migration from the point application

Rf= distance leading edge of components moves

Total distance solvent front moves
 • Column

• Gas Chromatography (GS)

• It is used in separation of steroids, barbiturates, blood, alcohol and
lipids
• It is useful for compounds that are naturally volatile or can easily
converted into a volatile form
• Mobile phase: Nitrogen, Helium, hydrogen and argon (inert gases)

2 TYPES:

a. Gas Solid Chromatography – separation occurs based on differences in absorption at

the solid phase surfaces
b. Gas Liquid Chromatography – separation occurs by differences in solute partitioning
between gaseous mobile phase and liquid stationary phase

MASS SPECTROSCOPY

• It is based on the fragmentation and ionization of molecules using a

suitable source of energy.

GAS CHROMATOGRAPHY- MASS SPECTROSCOPY (GC-MS)

• Gold standard for drug testing

TANDEM MASS SPECTROSCOPY (MS/MS)

• Can detect 20 inborn errors of metabolism from a single blood spot

• Liquid Chromatography
• It is based in the distribution of solutes between the mobile phase and
stationary phase
• HPLC is the most widely used liquid chromatography

High Performance Liquid Chromatography (HPLC)

• USE: fractionation of drugs, hormones, lipids, carbohydrates and

proteins; separation and quantitation of various hemoglobins associated
with specific disease (thalassemia) rapid HbA1c test (within 5 minutes)
• In reverse phase HPLC, the mobile phase is more polar than stationary
phase.

Liquid Chromatography-Mass Spectroscopy (LC—MS)

 • Is for detecting nonvolatile substances in the fluids
- It is utilized to confirm positive results from screening of illicited drugs- it is
complementary method to GC-MS.

FLUOROMETRY/ MOLECULAR LUMINISCENCE SPECTROPHOTOMETRY

• It measures the amount of light intensity present over a zero

background
• PRINCIPLE: it determines the amount of light emitted by a molecule
after excitation by electromagnetic radiation
• USE: Porphyrins, Mg, Ca, Catecholamines
• Light source: Mercury arc or Xenon lamp
• IT USES 2 MONOCHROMATORS (either filters, prisms or grating)
• Is about 1000x sensitive than spectrophotometer
• AFFCETED BY “QUENCHING” – ph and temperature changes,
chemical contaminants, UV light
CHEMILUMINISCENCE

• It differs from fluorescence and phosphorescence in that the emission of

light is created from a chemical or electrochemical reaction
• PRINCIPLE: The chemical reaction yields an electronically excited
compound that emits light as it then returns to its ground state, or that
transfers its energy to another compound which then produces
emission.
• NO EXCITATION RADIATION IS REQUIRED
• NO MONOCHROMATORS ARE NEEDED
• It involves the oxidation of an organic compound
OSMOMETRY

• It is the measurement of the osmolality of an aqueous solution such as

serum, plasma, or urine
• PRINCIPLE: it is based on measuring changes in the colligative
properties of solutions that occur owing to variations in particle
concentration
• COLLIGATIVE PROPERTIES: Osmotic pressure, boiling point, freezing
point and vapor pressure (FaVOr Bo”)

NOTE: As the OSMOLALITY of a solution INCREASES the following reactions occur:

• Freezing point and Vapor pressure are depressed (FaVor)

• Boiling point is elevated and Osmotic pressure is increased (BOBO)
Freezing point depression Osmometry
 • Most commonly used method for measuring the changes in colligative
properties of a solution
ELECTROCHEMISTRY TECHNIQUES

• The measurement of current or voltage generated by the activity of a

specific ion
1. Potentiometry
• Is the measurement of electrical potential due to the activity of free ions
• It is also the measurement of differences in voltage at a constant
current
• REFERENCE ELECTRODE: CALOMEL AND SILVER-SILVER
CHLORIDE
• USE: ph and PCO2 (SEVERINGHAUS ELECTRODE)

ION SELECTIVE ELECTRODE

• It is an electrochemical transducer capable of responding to one given

ion
• It is a sensitive method but not specific

ISE MEMBRANE

• Glass aluminum silicate (sodium) valinomycin gel (potassium) organic

liquid membrane ion exchangers (Ca and Lithium) gas and enzymes
electrodes
2. Coulometry
• Is the measurement of the amount of electricity at a fixed potential
• USE: CHLORIDE TEST (CSF, Serum and sweat)
• Interference: bromide, cyanide and cysteine
3. Amperometry
• Is the measurement of the current flow produced by an oxidation –
reaction
• USE: pO2 , glucose, chloride and peroxidase determinations
• CLARKE ELECTRODE (pO2)
4. Voltammetry
• Anodic-stripping voltammetry- for lead and iron testing
 Clinical Chemistry I

MODULE 4 : INSTRUMENTATION
TYPES OF GLASSWARES
1. Borosillicate glass (pyrex and kimax)

- It is used for heating and sterilization purposes; most commonly used

- It is characterized by a high degree of thermal resistance, has low alkali content
and is free from the magnesiumlime – zinc group of elements, heavy metals,
arsenic, and antimony
2. Boron-Free Glassware/ Soft Glass
- It has resistance to alkali
- Its thermal-resistance is less as compared to borosilicate glass
3. Corex (Corning)
- Is a special alumina-silicate glass that has been strengthened chemically than
thermally; six times stronger than borosilicate
4. Vycor (Corning)
- It is utilized for high thermal, drastic heat shock and extreme chemical treatment
with acids (except hydrofluoric) and dilute alkali it can be heated to 900 degree
celcius
5. Flint glass
- It is made up of soda-lime glass and a mixture of Calcium, silicon and sodium
oxides
- It has poor resistance to high temperature – easy to melt and used to make
disposable glasswares

PIPET CLASSIFICATION
I. Calibration Marks/ Design:

1. To Deliver (TD) – it delivers the exact amount it holds into a container

2. To Contain (TC) – it holds a particular volume but does not dispense the exact
volume

II. Drainage Characteristics:

1. Blowout – it has continuous etched rings on top of the pipet; exact volume is
obtained when the last drop is blown out
 2. Self-draining – absence of etched rings; liquid is allowed to drain by gravity

III. Types:

1. Transfer Pipets

▪ Volumetric pipet – for nonviscous fluid; self-draining; small amount left in

the tip should not be blown out
▪ Ostwald Folin – for viscous fluid ; with etched ring
▪ Pasteur Pipet – transfers fluid without consideration of a specific volume
▪ Automatic macro/micropipets

2. Graduated or Measuring Pipets

▪ Serological Pipet – with graduation to the tip; blowout pipet

▪ Mohr Pipet – without graduations to the tip; calibrated between 2 marks;
self- draining
▪ Bacteriologic pipet
▪ Ball, Kolmer and Kahn Pipet

Micropipets (<1ml) –TC Pipets

1. Sahli- Hellige pipet
2. Lang-Levy pipet
3. RBC and WBC pipet
4. Kirk and Overflow Pipet

MECHANICAL OR AUTOMATIC PIPETS

1. Air Displacement Pipet
- It relies on piston for suction creation to draw the sample into a disposable tip
- The piston does not come in contact with the liquid
2. Positive Displacement Pipet
- It operates by moving the piston in the pipet tip or barrel, much like a hypodermic
syringe
- It does not require a different tip for each use
3. Dispenser/ Dilutor Pipet
- It obtains liquid from a common reservoir and dispensed it repeatedly
- It combines sampling and dispensing functions
For Calibration of Pipets:
- 0.1% phenol red solution in distilled water – used to compare the reproducibility
of brands of pipet tips

CALIBRATION OF ANALYTICAL BALANCE AND THERMOMETER

Analytical Balance
- Laboratory balances require calibration at regular intervals – calibration intervals
should coincide with the requirements of the laboratory’s licensing and
accrediting organizations

Thermometer
- 2 types of thermometers: Total immersion (freezers and refrigerators)
- Partial immersion (water baths and heating blocks)

THREE BASIC APPROACHES TO AUTOMATION

Advantages:
1. Increase the number of tests to be performed in a given period
2. Minimizes variation of result from one laboratorian to another
3. Eliminates the potential error in manual analyses such as pipetting, calculation and
transcription of results
1. Continuous Flow Analyzer

- Liquid are pumped through a system of continuous tubing

- Samples flow through a common reaction vessel or pathway

- Air bubbles at regular intervals serve as separating and cleaning media

- A heating bath maintains the required temperature of the reaction to allow

complete color development – reaction rate is controlled by a temperature

- MIXING OF SAMPLE AND REAGENTS : by using a glass coil inserted into the

flow path

- Disadvantage: all tests are performed in parallel ( measurement of every analyte

configured on the system for every sample)

2. Centrifugal Analyzer

- It uses the force generated by centrifugation to transfer specimen and reagents

 - Mixing: centrifugal force (rotor) is utilized or bubbling of air

- Examples : Cobas-Bio

- Major advantage: Batch analysis

3. Discrete Analyzer

- It is the most popular and versatile analyser – measures only the tests requested

on a sample

- It is capable of running multiple tests one sample at a time

- Examples: Vitros,

- Major Advantage: Random access capability, allows STAT samples to be easily

tested

CENTRIFUGES:
Horizontal Head Centrifuge
- Also known as SWINGING- BUCKET CENTRIFUGE
- High air friction and air resistance
- When not spinning – VERTICAL
- When spinning – HORIZONTAL
- Speed – 1650g

Angle-Head Centrifuge
- Fixed angle
- Lesser air friction and air resistance
- Speed – 9000g

TERMINOLOGIES:

▪ Batch Testing – all samples are loaded at the same time and a single test is conducted

one each sample

▪ Parallel testing – more than one test is analysed concurrently on a given clinical

specimen

▪ Random Access Testing – any test can be performed on any sample in any sequence

▪ Sequential Testing – multiple tests analysed one after another on a given specimen
▪ Open Reagent System – a system other than manufacturer’s reagents can be utilized for

measurement

▪ Closed Reagent System – a system where the operator can only used the

manufacturer’s reagents

▪ Pneumatic tube delivery system – it provides point to point delivery of specimens to the

lab and offered several advantages over specimen transport by humans