PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2

College of Allied Health Sciences

Bachelor of Science in Medical Laboratory Science
Second Semester, A.Y. 2022-2023

[TRANS] PMLS UNIT 2: SPECIAL COLLECTIONS AND POINT-OF-CARE TESTING

 The unit is normally filled by weight but typically contains
OUTLINE around 450 ml of blood when full. Only one needle
puncture can be used to fill a unit. If the unit only partially
I Blood Bank Specimens fills and the procedure must be repeated, an entire new
II Blood Cultures unit must be used.
III Coagulation Specimens LOOKBACK PROGRAM
IV 2-Hour Postprandial Glucose
V Glucose Tolerance Test  A unit of blood can be separated into several components:
VI Lactose Tolerance Test RBCs, plasma, and platelets
VII Parental/Paternity Testing  A lookback program requires notification to all blood
VIII Therapeutic Drug Monitoring recipients when a donor for a blood product they have
IX Therapeutic Phlebotomy received has turned positive for a transmissible
X Toxicology Specimens disease.
XI Trace Elements
XII Point-of-care testing
AUTOLOGOUS DONATION
XIII Coagulation monitoring by POCT  It is the process by which a person donates blood for his
XIV Other tests performed by POCT or her own use.
 This is done for elective surgeries when it is anticipated
that a transfusion will be needed.
BLOOD BANK SPECIMENS  Requirements:
 Specimen requirements: Use of lavender or pink-top o (1) a written order from a physician;
EDTA tubes o (2) Hb - at least 11 g/dL;
 Labelling requirements: o (3) Hct - ≥ 33%
o Patient’s full name (including middle initial) CELL SALVAGING
o Patient’s hospital ID no. (or other unique identifier)  It is the process by which blood from the surgical field is
o Patient’s DOB collected, filtered, and washed to produce autologous
o Date and time of collection blood for transfusion back to the patient.
o Phlebotomist’s ID no or full name  Salvaged blood should be tested for residual-free
o Room no. and bed no (optional) hemoglobin prior to reinfusion.
BLOOD TYPE AND SCREEN o High free hemoglobin level - too many red cells
 Determines a patient’s blood type (ABO) and Rh factor were destroyed during the salvage process;
(positive or negative) o Renal dysfunction could result if the blood is
CROSS MATCHING reinfused
 Determines the compatibility between the donor’s and the BLOOD CULTURES
recipient’s blood  Blood cultures help determine the presence and extent
 Patient’s serum or plasma and the donor’s RBCs of infection, the type of organism responsible, and the
BLOOD DONOR COLLECTION antibiotic to which it is most susceptible.
 Involves screening and collecting blood to be used for  Specimen collection:
transfusion purposes rather than for diagnostic testing o Specimens are collected in special bottles
 Blood is collected from volunteers in amounts referred to containing nutrient broth
as units o ASM – 2 to 4 blood cultures
o CLSI - Specimens are collected in sets of two: one
 Facilities that provide blood products for transfusion
aerobic and one anaerobic
purposes are called Blood Donor Centers
o Blood centers follow guidelines set by the RECOMMENDATIONS FOR THE NUMBER OF
American Association of Blood Banks (AABB) BLOOD CULTURES TO COLLECT INCLUDE THE
and are also regulated by U.S. FDA FOLLOWING
 CPD (citrate-phosphate dextrose) or CPDA1 (CPD plus  Critical situations (rapid administration of antibiotics) –
adenine) 2 to 3 cultures; one right after another from different sites
PRINCIPLES OF DONOR UNIT COLLECTION  For FUO - 2 to 3 cultures; one right after another from
 Donor units are normally collected from a large antecubital different sites
vein o If negative after 24-48 hours, 2 more cultures
 The vein is selected in a manner similar to routine from different sites
venipuncture and cleaned in a manner similar to blood  Bacteremia or fungemia is suspected (blood cultures
culture collection are negative), use alternative media to recover
 The collection unit is sterile, closed system consisting of mycobacteria and fungi
a bag to contain the blood connected by a length of tubing BLOOD CULTURES
to a sterile 16 to 18 gauge needle  Skin antisepsis:
 The bag fills by gravity and must be placed lower than o 10% povidone or 1% to 2% tincture of iodine
the patient’s arm (swab sticks) or special cleaning-pad kits such as
 The collection bag contains an anticoagulant and benzalkonium chloride
preservative solution and is placed on a mixing unit o Iodine sensitivities – chlorhexidine gluconate or
while the blood is being drawn 70% isopropyl alcohol

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 TRANS: PMLS 2 Unit 8
 KEYPOINT: According to the CLSI, chlorhexidine  The patient is instructed to eat a high-carbohydrate
gluconate is the recommended blood culture site breakfast (typically one containing the equivalent of 75 to
disinfectant for infants 2 months and older and patients 100 g of glucose) or given a measured dose of glucose
with iodine sensitivity. beverage on the day of the test.
MEDIA INOCULATION METHODS  After the meal, nothing else should be consumed before
 Media Inoculation Methods the test. The patient should rest during the 2-hour waiting
o Direct inoculation period; no exercise.
o Syringe inoculation  A blood glucose specimen is collected 2 hours after the
o Intermediate collection tube patient finishes eating.
 Intermediate collection tube GLUCOSE TOLERANCE TEST
o Yellow-top sodium polyanethol sulfonate (SPS)  It is used to diagnose problems of carbohydrate
tube metabolism.
o Use of an intermediate tube is discouraged for  ORAL GLUCOSE TOLERANCE TEST (OGTT)
these reasons:  It evaluates the body’s ability to metabolize glucose by
 SPS in the collection tube when added to the monitoring the patient’s tolerance to high levels of
blood culture bottle increases the final glucose without adverse effects.
concentration of SPS.  2 major disorders:
 Transfer of blood from the intermediate tube to o HYPERGLYCEMIA
the blood culture bottles presents another o HYPOGLYCEMIA
opportunity for contamination.  Preparation:
 Transfer of blood to the culture bottles presents o 150 grams of CHO for 3 days before the test
an exposure risk to laboratory staff. o Fast for 8-16 hours
 KEY PONT: Blood culture specimens are always o Adult dose – 75 g;
collected first in the order of draw to prevent o Children – 1 g /kg body weight
contamination from other tubes.  The GTT Length is 1 hour for gestational diabetes while
BLOOD CULTURES it is 3 hours for other evaluations
 ANTIMICROBIAL NEUTRALIZATION PRODUCTS LACTOSE TOLERANCE TEST
o Presence of the antimicrobial agent in the patient’s  It is used to determine if a patient lacks the enzyme
blood can inhibit the growth of the (mucosal lactase) that is necessary to convert lactose, or
microorganisms in the blood culture bottle milk sugar, into glucose and galactose.
 Fastidious Antimicrobial Neutralization (FAN) or  Absence of the enzyme:
Antimicrobial Removal Device (ARD) bottles. o Gastrointestinal distress and diarrhea
o ARD bottles - resin  Can be performed on breath samples
o FAN bottles - activated charcoal o Hydrogen breath test
COAGULATION SPECIMENS PARENTAL/PATERNITY TESTING
 At one time it was customary to draw a “clear” or discard  Uses DNA profiling (also called genetic fingerprinting)
tube prior to collection of a blue-top tube. to determine the probability that two specific individuals
o New studies have shown that a clear tube is not have a genetic parent–child relationship
necessary when collecting for a PT or APTT.  If the result does not include alleged parent, further test
o A clear tube is required for all other coagulation is performed which involves
tests (e.g., factor VIII). o Extended red cell antigens
 Sodium citrate tubes ; blood to anticoagulant ratio – 9:1 o Red cell enzymes
 Use a discard tube when using butterfly method o Serum proteins testing
 Never pour two partially filled tubes together to create o White cell enzymes
a full tube. o Human Leukocyte Antigen
 Coagulation factors V and VIII  Other two methods used:
o If the testing is delayed, the specimen must be o Polymerase Chain Reaction (PCR)
centrifuged and the plasma frozen. o Restriction Fragment Length Polymorphism
 If a coagulation specimen must be drawn from VADs, the (RFLP)
CLSI recommends drawing and discarding 5 mL of blood  Blood samples are preferred for testing; however, buccal
or six times the dead-space volume of the tubing before (cheek) swabs are increasingly being used.
collecting the specimen. o Blood sample testing includes ABO and Rh typing.
2-HOUR POSTPRANDIAL GLUCOSE PATERNITY TEST VS MATERNITY TEST
 Postprandial (PP) means after a meal.
 It is rarely elevated in normal persons but may be Paternity Test Maternity Test
increased in diabetic patients. Determines the likelihood Determines the likelihood
 It is an excellent screening test for diabetes and other of a man being the of a woman being the
metabolic problems and is also used to monitor insulin biological father of a biological mother of a
therapy. child. child.
PRINCIPLES OF 2-HOUR POSTPRANDIAL Compares the DNA of the Compares the DNA of the
SPECIMEN COLLECTION alleged father with that alleged mother with that
 The patients fast prior to the test. This means no eating, of the child. of the child.
smoking, or drinking other than water for at least 10 to 12
hours before the test. THERAPEUTIC DRUG MONITORING
 A fasting glucose specimen may be collected before the  A quantitative evaluation of circulating concentrations of
start of the test drugs

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 TRANS: PMLS 2 Unit 8
 Ensures that a given drug dosage produces maximal THERAPEUTIC PHLEBOTOMY
therapeutic benefit and minimal toxic effects  It involves the withdrawal of large volumes of blood
 For a drug to be beneficial, the peak level must not usually measured by the unit or approximately 500 mL.
exceed toxic levels, and the trough level must remain  It is used as a treatment for certain medical conditions such
within the therapeutic range as polycythemia and hemochromatosis.
 Peak levels screen for drug toxicity. o Polycythemia is a disease involving the body’s
o Peak times occur approximately 30 minutes after IV overproduction of RBCs.
administration, 60 minutes after IM administration, o Hemochromatosis is a disease characterized by
and 1 to 2 hours after oral intake. excess iron deposits in the tissues.
 Trough levels are monitored to ensure that levels of the  Causes: genetic defect in iron metabolism,
drug stay within the therapeutic range. due to multiple blood transfusions,
o Trough-level specimens are collected prior to hemolytic disorders, iron supplements,
administration of the next scheduled dose. excess iron intake from foods
EXAMPLES OF CATEGORIES OF DRUGS THAT TOXICOLOGY SPECIMENS
TYPICALLY REQUIRE THERAPEUTIC MONITORING  Clinical toxicology
o Concerned with the detection of toxins and
Drug Category Examples Use treatment for the effects they produce.
Antibiotics Aminoglycosides Treat infections  Forensic toxicology
(Gentamicin, caused by o Concerned with the legal consequences of toxin
Tobramycin, bacteria that exposure, both intentional and accidental.
Amikacin), are resistant to  Specimen used:
chloramphenicol, other antibiotics o Blood, Hair and Urine
vancomycin o Other body substances
Anticancer Drugs Methotrexate Psoriasis,  Forensic specimens:
rheumatoid o Breath or blood for alcohol
arthritis (RA), o Urine drug screens and blood specimens for
non-Hodgkin's drugs and DNA analysis
lymphoma, o Chain of custody must be strictly followed
osteosarcoma BLOOD ALCOHOL (ETHANOL) SPECIMENS
Antiepileptics Carbamazepine Epilepsy,  Blood alcohol test (Ethanol)
(Tegretol), seizure o Used for medical reasons related to treatment or
ethosuximide, prevention, other clinical purposes.
gabapentin, mood  Blood Alcohol Concentration (BAC) on an individual who
lamotrigine, stabilization has been involved in a traffic accident
phenobarbital,  Antiseptics: benzalkonium chloride (BZK) and sometimes
phenoytoin, povidone–iodine
valproic acid o Alternative: Regular soap and water
Bronchodilators Theophylline, Asthma,  Specimen requirement: glass gray-top sodium fluoride
caffeine chronic tube
obstructive DRUG SCREENING
pulmonary  Preemployment drug screening; random screening
disease
 Specimen: Urine
(COPD),
 There are legal implications to drug screening, and a
neonatal apnea
chain-of-custody protocol is required whether or not the
Cardiac Drugs Digitoxin, Congestive
test is being performed for legal reasons.
digoxin, Heart Failure
 Follow the National Institute on Drug Abuse (NIDA)
procainamide, (CHF), angina,
protocol for patient preparation and specimen collection
quinidine arrhytmia
Immunosuppresants Azathioprine, Autoimmune
DRUGS COMMONLY DETECTABLE AT DRUG
cyclosporine, disorders, SCREENING
sirolimus, prevent organ
tacrolimus transplant Drug or Common Detecta Comment
rejection Drug Names ble
Protease Inhibators Atazanavir, HIV/AIDS Families (Time)
inidnavir, Alcohol 2-12
lopinavir, hours
nelfinavir, Amphetami Methamphetami 1-3 days Single/light
ritonavir s ne, speed, 2-7 days use
Psychiatric Drugs Antidepressants Bipolar disorder crystal, crank, Frequent/chr
(such as (Manic ice onic use
imipramine, Depression), Barbiturate "Downers,: 2 days to Varies
amitriptyline, depression s Seconal, 4 weeks considerably
nortriptyline, Florinal, Tuinal, with drugs in
doxepin, Phenobarbital this class
desipramine), Benzodiaze Valium, Librium, 1 week Varies
lithium, valproic pines Xanax, to > 30 considerably
acid Dalmane, Serax days with drugs in
this class

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 TRANS: PMLS 2 Unit 8
Cocaine (as Crack 1-3 days Single/light o Used to determine a patient’s response to
Metabolite) 3-14 use Frequent medication before open heart surgery or cardiac
days use/free base catheterization
Cannabinoi Marijuana, 1-7 days Single/light o Can help prevent excessive bleeding or blood
ds Grass, Hash >30 use clots
days Frequent/chr  Bleeding Time
onic use o The time required for blood to stop flowing from
Methadone Dolophine 1-4 days Single/light a standardized puncture on the inner surface of the
use forearm
Opiates Heroin, 2-4 days Single/light o Used in diagnosing problems with hemostasis and
Morphine, >7 days use as a presurgical screening test
Codeine, Frequent/chr ARTERIAL BLOOD GASES AND ELECTROLYTES
Dilaudid, onic use  Arterial blood gases (ABGs)
Hydrocodone o pH
Phencylidin PCP, angel dust 2-7 days Single/light o Partial Pressure of Carbon Dioxide
e >30 use o Oxygen Saturation
days Frequent/chr o Partial Pressure of Oxygen
onic use  Electrolytes
Propoxyphe Darvon, 1-2 days Single/light o Sodium
ne Darvocet >7 days use o Potassium
Frequent/chr o Chloride
onic use o Bicarbonate Ion
o Ionized Calcium
TRACE ELEMENTS MULTIPLE-TEST PANEL MONITORING BY POCT
 Include aluminum, arsenic, copper, lead, iron, and zinc  Examples of instruments that have a menu of several
 Specimens for these tests must be collected in special different tests are:
trace element–free tubes o ABL80 Flex
o These tubes are typically royal blue o AVOXimeter
o Contain EDTA, heparin, or no additive. o GEM Premier
o The type of additive is indicated on the label (e.g., o i-STAT
red for no additive, lavender for EDTA, and green for o STAT PROFILE® Prime
heparin).  Sodium
POINT-OF-CARE TESTING  Potassium
 AKA: alternate site testing (AST) or ancillary, bedside,  Chloride
or near-patient testing  Bicarbonate
 Brings laboratory testing to the location of the patient  Blood Gases
 Benefits:  Glucose
o Convenience to the patient  BUN
o A short turnaround time (TAT)  Hgb
 Electronic quality controls (ECQs)  Hct
 Disinfect POC instrument: 1:10 bleach solution; EPA-  Lactate
registered bleach wipes  Troponin
COAGULATION MONITORING BY POCT OTHER TESTS PERFORMED BY POCT
 Prothrombin time (PT)  Cardiac troponin T (TnT) and troponin I (TnI)
 International Normalized Ratio (INR) o Are proteins specific to heart muscle
 Activated partial thromboplastin time (APTT or PTT) o Measurement of these proteins is a valuable tool in
 Activated clotting time (ACT) the diagnosis of acute myocardial infarction
 Platelet function (AMI) or heart attack
 POC instruments available to perform various coagulation  Blood levels of cardiac TnT begin to rise within
tests are: 4 hours of the onset of myocardial damage
o CoaguChek XS Plus—PT/INR and may stay elevated for up to 14 days.
o Hemochron Signature Elite—ACT  Cardiac TnI levels rise within 3 to 6 hours and
o i-STAT—ACT, PT/INR return to normal in 5 to 10 days.
o VerifyNow—Platelet function  Bilirubin Testing
 ACT  B-Type Natriuretic Peptide
o Test analyzes activity of the intrinsic coagulation  C-reactive protein
factors and is used to monitor heparin therapy  Complete Blood Count
 PT/INR  Glucose
o Used to monitor warfarin (e.g., Coumadin) therapy  Glycosylated Hemoglobin
 APTT  Hematocrit or Packed Cell Volume
o Used to screen for bleeding disorders prior to  Hemoglobin
surgery, investigate bleeding or clotting  Lactate
disorders, detect clotting factor deficiencies, and  Lipid/Cholesterol Testing
monitor low-dose heparin therapy  Pregnancy Testing
 Platelet Function  Rapid Syphilis Test
 Urinalysis

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