CLINICAL CHEMISTRY 2 – LABORATORY

SPECIMEN COLLECTION AND PRE-ANALYTICAL CONSIDERATIONS

INTRODUCTION:

The preanalytic phase of the testing process begins when a test is ordered and ends when testing begins. Numerous factors associated with this
phase of the testing process, if not address properly, can lead to errors that can affect specimen quality, jeopardize the health and safety of the
patient, and ultimately increase the cost of medical care.

Basal state refers to the resting metabolic state of the body early in the morning after fasting for a minimum of 12 hours. A basal state specimen is
ideal for establishing reference ranges on inpatients, because the effects of diet, exercise, and other controllable factors on test results are
minimized or eliminated. Basal state is influenced by a number of physiologic patient variables such as age, gender, and conditions of the body that
cannot be eliminated.

1. Veins that feel hard and cordlike when palpated may be

A. Collapsed B. Fistulas C. Thrombosed D. Venule
2. When the arm of the patient is swollen with excess fluids, the condition is called?
A. Edema C. Icterus D. Syncope
B. Hemoconcentration
3. Tiny red spots that appear on a patient’s arm when the tourniquet is applied are a sign that the
A. Patient is allergic to latex B. Patient is anemic C. Site may bleed excessively D. Tourniquet is too tight
4. Which of the following situations can result in hemoconcentration?
A. Leaving the tourniquet on longer than a minute C. Partially filling a normal draw tube D. Using a needle that
B. Mixing the specimen too vigorously is too small for size of the tube
5. Which of these tests are most affected if the patient is not fasting?
A. Protime C. Liver enzymes D. Blood culture
B. Triglycerides

Venipuncture

⮚ Materials and Equipment

o Syringe
o Tourniquet
o Evacuated Tubes
▪ Color coded stopper = Anticoagulants
▪ Order of Draw
 o ETS Needle
o Vacutainer Adapter
o Cotton
o Micropore
o Alcohol swab

Physiologic Variables

⮚ Age
o Values for some blood components vary considerably depending upon the age of the patient ⮚ Altitude
o Decreased oxygen levels at higher altitudes cause the body to produce more red blood cells to meet the body’s oxygen
requirements
o The higher the altitude, the greater the increase
⮚ Dehydration
o Causes hemoconcentration
o Blood components affected include: RBCs, enzymes, iron, calcium, sodium and coagulation factors
⮚ Diet
o Glucose (blood sugar)
▪ Ingestion of carbohydrates or sugar-laden substances
o Lipids (fats) = Lipemia
▪ Increased lipid causes the serum or plasma to appear milky/cloudy or turbid (lipemic) o Meat and certain vegetables (in
 cases of fecal occult blood test)
o Fluid intake
▪ Decrease Hgb levels, alter electrolyte balance
▪ Caffeine – affects cortisol levels
▪ Chronic consumption/ recent ingestion of large amounts of alcohol = hypoglycemia and increased triglycerides
o Fasting requirements
⮚ Diurnal/Circadian Variations
o Diurnal – happening daily
▪ Posture, activity, daylight and darkness, being awake or sleeping
▪ Tests influences by diurnal variation are often ordered as timed tests
o Circadian – 24 hour cycle
⮚ Drug Therapy
o Some drugs alter physiologic functions, causing changes in the concentration of certain blood analytes
o Chemotherapy drugs, Opiates, Steroids, Diuretics, Thiazide diuretics
o Drugs can also interfere in actual testing procedure (CRUD)
⮚ Exercise
o Arterial pH and PCO2 = reduced
o Glucose, creatinine, insulin, lactic acid and protein = elevated by moderate muscular activity o Skeletal enzymes = increased
o *Vigorous exercise shortly before blood collection* Cholesterol = increased by 6% ⮚ Fever
o Affects the levels of a number of hormones
▪ Fever induces hypoglycemia, increases cortisol and may disrupt normal diurnal variation
⮚ Gender
o Separate normal values for males and females
⮚ Jaundice
o Also called Icterus
o Condition characterized by increased bilirubin
o Icteric means relating to or marked by jaundice and is used to describe serum, plasma, urine specimens that have an abnormal
deep yellow to yellow-brown color
o Can interfere in chemistry tests
⮚ Position
o Going from supine to an upright sitting or standing position causes blood fluids to filter into the tissues, decreasing plasma
volume in adult up to 10%
⮚ Pregnancy
o Body fluids increases = diluting effect on RBCs
⮚ Smoking
o Smoking prior collection = increased Cholesterol, cortisol, glucose, triglycerides and WBCs o Chronic smoking = increased
RBC and HGB, increased IgE
⮚ Stress
o Decreased Iron and Cortisol
o Increased WBCs
⮚ Temperature and Humidity
o Specimen integrity

Problem Sites

⮚ Burns, Scars, and Tattoos ⮚ Inadvertent Arterial Puncture

⮚ Damaged Veins ⮚ Infection
o Sclerosed ⮚ Edema
o Thrombosed ⮚ Hematoma
⮚ Mastectomy
Vascular Access Devices and Sites ⮚ Obesity

⮚ Arterial Line
⮚ Arteriovenous Shunt, Fistula or Graft *NEVER APPLY
TOURNIQUET* ⮚ Heparin or Saline Lock

Patient Complications and Conditions ⮚ Inttravenous Sites

⮚ Previously Active IV Sites
⮚ Central Vascular Access Devices/CVADs
⮚ Allergies to Equipment and Supplies o Adhesive
Allergy
o Antiseptic Allergy
o Latex Allergy
⮚ Excessive Bleeding
⮚ Fainting (syncope)
⮚ Nausea and Vomiting
Procedural Error Risks
⮚ Pain
⮚ Petechiae
⮚ Hematoma Formation
⮚ Seizures/Convulsion
⮚ Iatrogenic Anemia
 ⮚ Nerve Injury ⮚ Vein Damage
⮚ Reflux of Anticoagulant

Specimen Quality Concerns

⮚ Hemoconcentration from Venous Stasis

⮚ Hemolysis
⮚ Partially Filled Tubes
⮚ Specimen Contamination

Troubleshooting Failed Venipuncture

⮚ Tube Position
⮚ Tube Vacuum
⮚ Needle Position
o Bevel Against the vein wall
o Needle too deep
o Needle not deep enough
o Needle beside the vein
o Undetermined needle position
⮚ Collapsed vein

General Laboratory Samples

⮚ Urine
o Routine Urinalysis, Urine Culture and Sensitivity, Pregnancy Test ▪ Midstream Clean Catch
▪ First morning colletion
▪ Timed (eg: 24H)
▪ Catheterized
▪ Double voided (for sugar and acetone)
⮚ Stool
o Stool culture, Routine Fecalysis, Rotavirus
▪ Random collection
▪ Timed (24H, 48H or 72H collection)
⮚ Pleural, Peritonial and Pericardial Fluid
o EDTA Tube for hematology (cell count, differential)
o Plain sterile tube for Microbiology testing
o Heparinized Tube (green) for Chemistry Testing
⮚ Cerebrospinal Fluid
o TEMPERATURE = 37 deg C (or room temp)
o 4 sterile tubes, labelled tube 1, 2, 3 and 4 (in the order of collection) ▪ Tube 1 = Chemistry and
Serology
▪ Tube 2 = Microbiology
▪ Tube 3 = Cell Count
▪ Tube 4 = Miscellanous or referral test requests
⮚ Synovial Fluid
o Normal synovial fluid will NOT clot
o Collect both anticoagulant and non-anticoagulant specimens
o EDTA Tube for hematology cell counts, differential
o Heparinized Tube for chemistry and immunologic tests
⮚ Samples for Microbiological and Serological Testing