MODULE 10: SPECIAL COLLECTION AND POINT-

OF-CARE-TESTING Blood Cultures

 Skin antisepsis: Most important part of
Blood Bank Specimens collecting
Specimen requirements o Purpose:
 Lavender - or pink-top EDTA tubes - Destroy skin microorganisms (normal
 Non additive glass red-top maybe used flora)
- Prevent misinterpretation of
Identification & labeling requirements microorganism as pathogenic
 Patient’s full name o Acceptable antiseptics
 Patient’s hospital ID# or SS# - Patient’s date of - chlorhexidine gluconate
birth - Tincture of iodine or povidine
 Date & time of collection  Requires 30 to 60-seconds
 Phlebotomist’s initials friction scrub
 ID bracelet w. self-carbon adhesive label for
specimen Media inoculation (process of introducing bacteria to
 Blood ID-band with linear bar-coded BBID #’s our culture media) methods
 Siemens Patient Identification Check-Blood  Direct inoculation to prevent any
Administration contamination
 Collect specimen directly into blood culture
Laboratory Procedures medium
1. Type, Screen, and Cross-Match  Use butterfly & specially designed holder
 Blood type (ABO) & Rh factor (+ or -) & screen  Syringe inoculation for small veins, children,
 Cross-match to determine compatibility between etc.
patient & donor  Transfer blood to bottles after draw is
completed
2. Blood Donor Collection  Safety transfer device is required
General
 Collected for transfusions, not diagnostic Intermediate collection tube
testing  Sometimes used in place of blood culture
 Collected in “units” from volunteers bottle
 Requires special training & skills  Yellow-top SPS (sodium polyanethol
sulfonate) tube is acceptable – evacuated tube
Donor eligibility w/ anticoagulant
 Between ages 17 & 66 years  Use is discouraged, however, because:
 Weight at least 110 lbs o Final concentration of SPS is increased
 Physical exam & medical history required o Presents another opportunity for
 Written permission from donor required contamination (rule: less transfer, less
contamination)
Lookback program o Increased exposure risk to lab staff
 All blood components of unit must be
traceable to donor Antimicrobial Neutralization Products
 Requires notification to all blood recipients  Purpose
when a donor is shown to be positive for a o Removes or neutralizes
transmissible disease antimicrobials/antibiotics from blood
o Prevents antimicrobials from inhibiting
Autologous donation growth of microorganisms.
 Person donates blood for his/her own use (e.g.,
for elective surgeries) 4. Coagulation Specimens
 A “clear” or discard tube is required for
Cell salvaging coagulation tubes (PT/PTT) drawn with butterfly
 Patient’s blood can be salvaged, washed, & because of the tubing. Some places require a
reinfused discard tube each time a blue top is drawn.
 Salvaged blood must be tested for residual free  Sodium citrate (blue top) tubes must be filled until
hemoglobin vacuum is exhausted. If not filled completely they
will be rejected. Must be 9:1 ratio of blood to
3. Blood Cultures anticoagulant.
General  Never pour 2 partially filled tubes together
 Determine presence & extent of infection  Cooling on ice during transport may be required
 Identify type of organism responsible & best  When drawing from an indwelling catheter: A
antibiotic to use draw & discard 10 mL must be drawn by the
 Should be ordered on basis of patient having a Registered Nurse.
condition in which bloodstream invasion is
possible & presence of fever 5. 2-Hour Postprandial Glucose
 To determine the glucose level after a meal
Specimen requirements
 Glucose in diabetics is significantly increased 2 hrs
 2 blood culture sets (in Philippines – requires after meal
3 different sites w/ 2 blood culture sets =
 Excellent screening test for diabetes
aerobic and anaerobic growth)
 Drawn 30 to 60 min. apart (unless patient in 6. Glucose Tolerance Test (GTT)
critical condition) and should collect in the
 Used to diagnose problems of carbohydrate
height of fever (bacteria are circulating in the
metabolism
bloodstream)
 Monitors patient’s tolerance to high levels of
 Collected in special bottles, one aerobic & one
glucose
anaerobic
 Hyperglycemia: increased blood glucose level
  Hypoglycemia: decreased blood glucose level
 GTT preparation
o Patient Preparation
- Fast at least 12 hrs but not more than 16
hrs before test
- Drink water during fast & test
- Do not smoke or chew gum, trigger the
release of enzymes
- Normal glucose test: 6-8 hrs fast
Glucose Tolerance Test (GTT) – GTT procedure
a. Follow normal ID protocol & explain
collection procedure; advise of fasting
requirements
b. Draw fasting specimen & check for glucose
c. Ask patient to collect fasting urine specimen
(if needed)
d. Give patient determined dose of glucose
beverage
e. Remind patient to finish beverage within 5
min.
f. Note time patient finishes, start timing,
calculate collection times
g. Give a copy of collection times to patient (not
necessary, pt does not leave area)
h. Collect blood & urine specimens at computed
times
i. Label all specimens with collection times,
intervals, patient ID
j. Deliver or send specimens to lab ASAP
7. Lactose Tolerance Test
 Determines lack of enzyme that converts lactose
into glucose/galactose
 Performed in same manner as 2-hr GTT, only w.
lactose
8. Paternity/Parentage Testing
 More of exclusion rather than proving
 Excludes possibility of paternity rather than proves
it
 Requires a chain-of-custody protocol (written
document that will identify who the last person
handled the sample) & specific ID procedures
 Mother, child, & alleged father are all tested
 Blood samples are preferred, but cheek swabs are
increasing
 Blood sample testing includes ABO & Rh typing
to give more evidence
9. Therapeutic Drug Monitoring
 To know if the drug that is administered is really
working
 Establishes & maintains drug dosage at therapeutic
level
 Such as blood thinners, seizure meds etc.
 Avoids drug toxicity
Typically used for drugs with therapeutic ranges
a. Therapeutic Phlebotomy: Video
(Hemochromatosis)
 Withdrawal of large volume of blood to
treat (500ml)
b. Polycythemia: Body’s over production of
RBCs
c. Hemochromatosis: Excess iron deposits in
tissues
10. Toxicology Specimens
General
 Toxicology: scientific study of toxins
(poisons)
 Concerned with detection of toxins &
treatment of effects
Forensic Blood Alcohol (ethanol) specimens
 Often requested by law enforcement officials
 Used to determine levels in breath, urine, or
blood
 Specimen collection must follow chain of
custody
 Forensic toxicology is concerned with legal
consequences of toxin exposure.
Toxicology Specimen
a. Clinical blood alcohol (ethanol) specimens
 Normally ordered by physician for
treatment purposes
 Chain of custody not required, but follow
standard protocol
 Required in connection to on-the-job
injury, employee insurance programs, &
employee drug screening
 Skin preparation: don’t use alcohol-based
disinfectant (may interfere, add certain
concentration, false increase)
 Specimen requirements: gray-top sodium
fluoride tube;
 Fill tube until vacuum is exhausted &
don’t remove stopper
b. Drug screening
 Required by many healthcare
organizations, sports associations, &
major companies
 May be random, pre-employment, post-
accident
 May detect a specific drug or screen for
up to 30 drugs (methamphetamine
hydrochloride or shabu;
tetrahydrocannabinol or marijuana)
 Typically performed on urine rather than
blood (…hair sample)
 Chain of custody is required
c. Patient preparation requirements
 Explain test purpose & procedure
 Advise patient of his or her legal rights
 Obtain a witnessed, signed consent form
d. Specimen collection requirements
 Special area for urine collection
 Proctor present at time of collection
 Split sample may be required
 Specimen must be labeled, sealed, &
placed in a locked container
11. Trace Elements
 Tests for aluminum, arsenic, copper, lead, iron, &
zinc
 Measured in small amounts
 Traces of them in glass, plastic, or stopper material
can leach into specimen
 Special trace element–free tubes must be used
(royal blue & contain EDTA, heparin, or no
additive)
12. Point-of-Care Testing
 Test that could be performed in the bedside
 Brings lab testing to location of patient
 Made possible by development of small, portable
testing devices
 Offers convenience to patient & short turnaround
time
 Requires carrying out quality-control &
maintenance procedures necessary to ensure that
results are accurate
 May be performed by the patient himself
Quality and Safety in POCT
  Waived vs. non-waived quality control checks o NOVA Stat Profile Analyzer
 Electronic quality control (EQC) built into o ABL 80 Flex
POC instruments
 Specimen collection & handling not checked 17. Other Tests Performed by POCT
by EQC  Cardiac troponin T & I
 Daily external liquid QC for non-instrumented  Lipid testing
POCT  B-type natriuretic peptide
 POC instruments become possible fomites for  C-reactive protein
disease  Glucose: Most common
o Disinfect with 10% bleach  Glycosylated hemoglobin
o Reduce cross-contamination between  Hematocrit
patients  Hemoglobin A1C: Done in some physician’s
office
Coagulation Monitoring by POCT  Lactate
 Coagulation tests that are monitored: Done in  Occult blood: Microscopic blood in stool
physician’s office, to monitor patient blood  Pregnancy testing
thinner (warfarin)  Skin tests
o Prothrombin time (PT) & international
 Strep testing
normalized ratio (INR)  Urinalysis
o Activated partial thromboplastin time
(APTT or PTT)
o Activated clotting time (ACT)
o Platelet function

POCT instruments
 Cascade POC — ACT, APTT, PT/INR
 CoaguChek XS Plus — PT/INR
 GEM Premier 4000 — ACT, APTT, PT/INR
 i-STAT — ACT, PT/INR
 Verify Now — platelet function

13. Bleeding-Time Test Procedure

a. ID patient & sanitize hands
b. Determine patient use of aspirin (blood thinner) in
past 2 weeks & describe risks
c. Support patient’s arm on steady surface
d. Select area on inner lateral surface of forearm
e. Place blood pressure cuff around arm
f. Clean selected area with alcohol & allow to air-dry
g. Put on gloves & prepare equipment
h. Remove puncture device from package, keeping
blade sterile
i. Inflate blood pressure cuff to 40 mm Hg
j. Remove safety clip & place puncture device on
forearm
k. Depress trigger & start timer; discard in sharps
container
l. Blot blood flow at 30 seconds w. filter paper
m. Stop timer when blood no longer stains filter paper
n. Remove blood pressure cuff, clean & bandage arm
o. Record time to nearest 30 seconds
p. Dispose of used & contaminated supplies; thank
patient

14. Arterial Blood Gases and Chemistry Panels

 Arterial blood gases measured
o pH
o Partial pressure of carbon dioxide
o Oxygen saturation
o Partial pressure of oxygen

15. Arterial Blood Gases and Chemistry Panels

 Electrolytes measured
o Sodium
o Potassium
o Chloride
o Bicarbonate ion
o Ionized calcium

16. Multiple-Test-Panel Monitoring by POCT

 Commonly ordered stat tests such as blood gases,
electrolytes, & hemoglobin
 Instruments with a menu of several different tests:
o GEM Premier
o i-STAT