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Blood Gas & POC Testing

Procedural Recommendations:
Collection, Sampling & Pitfalls
Critical Care Testing =
Whole Blood Analysis
■ Whole Blood Analysis =
Many ‘Variables’ need to be ‘controlled’:

Variables Include:
Include
■ Prolonged contact of serum/plasma with cells

■ ‘Collection-Induced’ Hemolysis

■ Effects of Exposure to Room Air

■ Effects of Evaporation

■ Incorrect Transport/Storage Conditions

(inc temperature)
■ Anticoagulants: Type/Amount/Mixing

■ Collection/Preparation/Analysis Issues
Prolonged Contact of
Serum/Plasma with Cells
• Most Affected Critical Care Tests:
(if cells left in contact with serum/plasma):
– Glucose
– Lactate
– K+
– Hb
• Blood Gases + Others Analysis (Lytes/Metabolites):
– Collect via Syringe; Cannot separate typically
– Analysis should be within 10-15 minutes ideally; no more
than 30 minutes maximum
– No refrigeration recommended
– Keep Sample Well-Mixed
Cell Contact with Plasma:
Parameter Problems
• Affected Parameters:
– Glucose: (Glycolysis)
• Cells use up Glucose while in tube; lowering Gluc values over time.
• Estimated 5 % Decrease/Hour ‘on cells’
– Lactate:
• Due to cellular use of Glucose over time, and with limited O2 present: Increase
Lactic Acid seen.
• Falsely overly high Lact can be seen on samples > 30 min old from collection.
– K+:
• Samples kept as WB: May miss any Hemolysis present.
• Should use BG analyzer that can detect hemolysis.
– Hb:
• WB is proper sample for correct Hb/Hct testing.
• However, proper mixing of WB sample is required to give accurate results.
• Samples sitting too long may require excessive time for proper mixing.
‘Collection-Induced’ Hemolysis

• Hemolysis:
– “The breaking of the Red Blood Cell membrane with the
cellular contents being expelled into the plasma”.
– May interfere with correct measurement several POC
Parameters including:
• Potassium, Hb, SO2%, LDH, Billirubin

– Effects on ‘Common Tests’ w/ Hemolysis:


• K+ = Increased (severely)
• Hb = Variable; Often Increased
• SO2% = Incorrect results for measured technology.
Hemolysis Causes & Detection
• Common Causes of Hemolysis Include:
– Moisture in the collection tube/syringe
– Mechanical destruction of cells by device
– Freezing of sample (ie: Icing during transport)
– Excessive tourniquet use/time
– Too vigorous mixing of sample container

• WB Samples vs Serum/Plasma:
– Difficult to detect Hemolysis on WB sample
• Need to rely on BG instrumentation flagging or excessive K+ value
without underlying symptoms
Hemolysis Causes & Detection
• Common Causes of Hemolysis Include:
– Moisture in the collection tube/syringe
– Mechanical destruction of cells by device
– Freezing of sample (ie: Icing during transport)
– Excessive tourniquet use/time
– Too vigorous mixing of sample container

• WB Samples vs Serum/Plasma:
– Difficult to detect Hemolysis on WB sample
• Need to rely on BG instrumentation flagging or excessive K+ value
without underlying symptoms
Exposure to Room Air

• Parameters Affected:
– pO2
• Room Air = Higher O2 levels than syringe sample for normal
range patients; Lower O2 levels in Room Air for patients
receiving O2
• Exposure to Room Air can either Increase or Decrease
measured pO2
– pCO2
• Room Air = Lower CO2 levels than syringe sample
• Generally exposure will LOWER measured pCO2 value
(although not as severe as O2-exposure)
– pH:
• Effected by pCO2 changes (will change inverse to CO2)
pO2 Exposure Effects

• pO2 Detailed Exposure Effects:

– Effects for Normal Range pO2:


• Example: If an air bubble is in syringe that is equal to only 10%
of total blood volume present = Typical 30 mm Hg O2 change.
– Effects for High pO2 Patients:
• Lowering of measured pO2 seen at rate of up to 2 mm Hg/min
exposed for pO2’s in range of 300-400 mm Hg.
– Plastic syringes not completely ‘gas-tight’:
• Up to 9 mm Hg shift pO2 seen if sample left in Plastic Syringe >
20 minutes.
Evaporation Details

• Evaporation vs. Air Exposure:

– Evaporation: Referring mainly to non-syringe


samples, either in tube or on-analyzer-- Prolonged
exposure to air resulting in evaporation of liquid from
sample.

– Exposure to Air: Referring mainly to syringe samples


for gases where sample is mixed/exposed with room
air affecting gas values.
Effects of Evaporation
• Parameters Most Affected (Evaporation):
– Electrolytes:
• Longer exposure will have greatest impact on ‘Lytes’ (Na, K, Cl, iCa,
HCO3-)
• Generally will tend to ‘concentrate’ sample more resulting in HIGHER
measured values
• Greatest effects on Na+ and Cl- (due to higher values that can be affected
more by exposure)
– Metabolites:
• Gluc/Lact: If sample separated from cells, effects limited to ‘concentration’
of sample and generally INCREASE in value.
• Less of an effect compared to Electrolytes.
– Hb/Hct:
• Generally if samples ‘sit’ with air exposure, they tend to ‘settle’ and this
results in “two-layer” (plasma & cells)
• Sampling from un-mixed sample in either ‘layer’ can result in either Lower
or Higher Hb/Hct values.
Transport/Storage
Conditions
• Samples for BG Analysis:
– Not recommended to be on ice
• Effects Other Parameters:
Negatives: Hb/Hct sampling/mixing & Hemolysis (K+ values)
• Icing does help reduce Glycolysis & O2 consumption by cells, but
overall the negatives of use out-weigh the positive (Lower Glycolysis
– Analysis within 15 minutes of collection
• To avoid air contamination & temperature effects
• Without Icing (and > 30 min analysis time):
pH, pO2, HCO3-, BE = Will DECREASE
pCO2 = Will INCREASE
– Plastic or Glass syringes acceptable (if run w/in 15 min.)
• Glass syringes recommended for longer than 30 min. analysis intervals
– Proper Anticoagulants & Proper concentrations must be used (see later
slides for details)
Transport/Storage
Conditions
• Electrolytes/Metabolites/COOx:
– If gases not needed: Can collect in Syringe or Evacuated Tube
– Can run WB, Serum or Plasma
• WB/Plasma acceptable for TAT Considerations
• Serum: Sample Handling Issues and Delays affect TAT

– WB/Plasma: Anticoagulant Type & Concentration very important for


accurate results (see later slides for details)
– Icing samples can reduce Glycolysis (Glucose utilization), but this should
only be done when not in ‘conflict’ w/ BG-analysis.
– Can refrigerate/freeze non-WB samples (air-tight) for re-analysis later
– Must avoid air-evaporation effects on main sample and samples on
analyzers
Anticoagulants Overview
Information
• Anticoagulants Overview:
– Sodium Heparin/Lithium Heparin:
Best for Blood Gases, Chemistries
• Non-Acceptable Anticoagulants (for Gases/Lytes):
– Oxalate (often used for Glucose plasma collection)=
Major Lytes Binding Problems
– Citrate (Coag Use) & Iodoacetate= Major ISE Binding Issues
– Na/NH3 Fluoride (Gluc Plamsa Collection) =
Problems with ‘ISE Interference’ typically
• Non-Anticoagulant Collection:
– Serum Tubes (w/ & w/out separator):
• Lytes & Chemistries OK; Anaerobic required for ICa/IMg.
• Unacceptable for Gases/pH
• Unacceptable TAT due to centrifugation required
• Separator Tubes: Problems w/ K+ measurements possible.
Issues with Different
Types of Heparin
■ Acceptable Heparin Types:
■ Sodium (difficult to find; possible interferences)
■ Lithium (most common)
■ NH3 (rare to find)
■ Dosage Recommendations:
■ Normal Na+ and Li Heparin concentration should be no more than 15-20 IU/mL
■ ‘Low-Dose’ Syringes Available w/ Heparin as low as 7 IU/ml.
■ Lower dose syringes more prone to Clotting (must MIX well)
■ “Balanced Li Hep” recommended for Creat testing
■ Use of Normal LiHep can cause decreased Creat Values

■ Use Dry-Heparin Pre-Coated Syringes if Possible:


■ If adding proper amount of blood will result in expected dilution
and IU final concentration
■ Liquid Heparin (added manually) is unreliable in determining
final IU concentration
Other Issues with Heparin Use

■ Under-filling can result in Heparin concentrations of


up to 100 IU/mL
■ Especially common with Liquid Heparin, but can also
occur with Dry Heparin
■ Use of Na+ Heparin Syringes:
■ Excess Na+ Heparin may elevate Na+ results
(dependent on final concentration; usually IU
concentrations up to 15 IU have little effect.)
■ Heparin can also bind iCa & iMg
■ Especially true for Na+ Heparin
■ Dilution Errors for ‘Other’ Tests:
■ Possible if excess Liquid Heparin is present
Heparin Use-
Glass & Plastic Syringes

• Glass containers require more heparin than plastic:


– Coag factors & platelets activate quicker on contact w/ glass versus plastic
(increased heparin compensates for this).
– Not ideal for measurements of iCa and iMg (plastic better).

• Specific IFCC Recommended Maximum Heparin Levels:


(Note: IU/ml denotes final ‘in-syringe’ concentration of heparin to blood).
– Glass: w/ Dry/Liquid Heparin = 40 - 60 IU/ml
– Plastic: w/ Dry/Liquid Heparin = 12 - 50 IU/ml

– For Samples for iCa/iMg Determinations: < 15 IU/ml (plastic)


• Best to use “Low-Dose’, “Ca-Titrated” or “Balanced-Hep” Tubes.

IFCC= International Federation of Clinical Chemists


Interferences By Heparin
• Effects on- Na+ & BUN/Urea:
– Na+ Heparin Type:
• Up to 15 IU/ml heparin shows no effect.
• > 1 mmol/L increase after 15 IU limit.
– Li-Heparin: Type:
• Little effects up to 70 IU/mL
• Dilution effects (esp. with Liquid Heparin)

• Effects on pH/HCo3-Bicarbonate/Base Excess:


– No effect up to 50 IU/ml
• Not usually a problem using dry-heparin
• Only major effects when using liquid heparin manually introduced
– Increments of 100 IU/ml show the following decreases:
• pH: 0 - 0.004 pH units
• HCO3-: 0 - 0.3 mmol/L
• BE: 0 - 0.3 mmol/L
Additional Interferences By Heparin
• Effects on iCa/iMg:
– Decreased Values Seen with Increased Heparin:
• Due to Binding to Heparin by ‘Chelation’.
– Up to 4 IU/ml heparin: effect is < 0.01 mmol/L
– For every 100 IU/ml heparin: effect is 0.13 mmol/L
decrease
– At about 20 IU/ml a 3.5 % decrease will be seen

– Additional Problem: “Dilution Effect”:


• With Heparin Concentrations > 100 IU/ml
• Most values will be lower....
Anticoagulants Dilution Effects
• Parameters Affected:

– Electrolytes, HCO3-, CO2, Hb/Hct, Gluc, Lact, BUN:


• Will Decrease due to dilution (> 100 IU/ml concentrations)
• pCO2 Details: - 0.27 kPa (- 2.0 mm Hg)

– PO2/SO2:
• Will increase because PO2 of heparin solution is about 20 kPa (150 mm Hg)
• pO2 Details: + 0.53 kPa (+4.0 mm Hg)

– pH: Little/No Effects Due to Dilution.


Preventing Dilution Effects

• To Keep Effects of Dilution Minimized:

– Dead space of syringe/tube should not exceed 5 % of


blood volume to be drawn.

– Use primarily DRY-Heparin if possible


• Use pre-coated syringes with minimum fixed heparin

– Effects of dilution primarily on plasma phase so


electrolytes will be most affected
• Esp. for tests with tight 'normal ranges': Na, iCa,iMg)
Sample Collection Review

■ Blood Gases:
■ Patient should be in steady state of ventilation
■ If on Ventilator – (if possible): Settings should
be unchanged for 30 min. prior to collection
■ Collection must be anaerobic
■ Indwelling catheters/A lines may be used for sampling
■ General Collection Notes:
■ In-line catheters must be thoroughly flushed before sampling
■ A volume equal to 3 x “dead space” must be withdrawn prior to
collection to guard against contamination
■ Heparin drips should be stopped at least 30 min prior to collection
and the line should also be flushed
Syringe Use/Collection

■ Immediately after collection, check for and expel any


air bubbles and replace needle cap
■ Also expel any air bubbles trapped in syringe prior to sample
analysis:
■ With syringe needle up onto gauze etc.
■ Collect a volume of blood that is 20 x dead space volum
■ Mix syringe by rolling in your hands a minimum of 10
times prior to analysis to suspend cells
■ Analyze BG syringe samples promptly (under 15 minutes)
■ Ideal collection device for ABG’s:
■ 1,3,or 5 ml self filling, plastic disposable syringe
■ Pre-filled with the appropriate type of lyophillized (dry)
heparin
Capillary Tube Use/Collection

Capillary Samples:
• Shows characteristics of both arterial and venous samples.
• Subject to room air contamination if not collected properly

■ Capillary Collection Information:
■ Prior to collection >>Warm skin at the site to 39 - 42 o C for 3 min (if possible)
■ After making a single deep puncture, remove the first drop of blood and allow the blood to flow rather than squeezing it out
■ Place the tip of the capillary into the blood drop
■ Fill capillary without introducing air bubble
■ Seal the end that was in the blood immediately (cap or wax)
■ Add a metal mixing bar/flea from the other end of the tube and seal this end also
Capillary Tube Prior to Analysis

■ Be sure to use a capillary with pre-coated (lyopholized)


Heparin
■ Same final IU/ml heparin concentrations apply

■ For capillaries immediately before analysis:


■ Mix by dragging a magnet across the length of the tube 4-5
times
■ Remove mixing flea
■ Pass a wire stylette through the sample (check for clots)
■ Use a Clot-Catcher on analyzer as final safety measure
Capillary vs. Syringe Samples

■ pH & pCO2 Results:


■ Generally correlate well Capillary-Arterial
■ Little differences seen; clinically insignificant
■ pO2 Results:
■ Capillary samples closer to venous values
■ Potassium Values:
■ May be higher in capillary values due to Hemolysis
■ Others:
■ Generally most other POC/critical tests correlate well
between capillary & syringe (arterial) samples.
Sampling Sites/Details
• Blood Gases:
– Arterial Preferred: (Radial, Brachial, Femoral,
Scalp, Umbilical)
– Capillary: (Scalp, Heel, Finger)
{Anaerobic concerns....}
– Mixed Venous: (best site = Pulmonary
Artery)
– Venous: Multiple sites; easiest collection;
poor O2

• Electrolytes/Chemistries:
– Arterial & capillary blood acceptable.
– Venous Blood usually chosen
(not acceptable for pO2/SO2)
– Use of tourniquet must be kept to
< 2 minutes (hemostasis).
– No muscular activity at site of collection.
Typical ‘Expected’ Values
(Main Gas Parameters)
■ Note: Values listed are for reference only in this presentation. Typically institutions will determine their own ‘Normal
Values’ based on their location and population.

Test Arterial Capillary Venous


pH 7.37 – 7.44 7.35 – 7.45 7.33 – 7.43

pO2 83 – 108 mm Hg 35 – 80 mm Hg 30 – 50 mm Hg

pCO2 35 – 45 mm Hg 35 – 50 mm Hg 38 – 50 mm Hg

SO2% 95-99 % 65 – 85 % 60 – 85 %

HCO3- 21– 28 mmol/L 22– 29 mmol/L 22– 29 mmol/L


Oxygenation:
Assessing Oxygen Binding

Oxygen Transport
Determination

•Definition - Oxygen Saturation (SO2 %):


Amount of Hb in the blood as a percentage
of the total amount of Hb bound with O2.
Used to determine the effectiveness of O2
therapy and transport.
Determining Oxygen Binding to Hb:
• Measurement Methods: (Direct Measurement):
• (Using the difference in the wavelengths of maximum absorbance for oxyhemoglobin and
de-oxyhemglobin; optical determination.)
– Trend: Pulse Oximeters:
• Best for TREND Monitoring Only
• Subject to many interferences- Patient Circulation; Thickness of Skin;
Movement; Sensor Contact with Skin;
• Follow-up to low values = Confirmation BG w/ SO2%
– Simple: Nova BG Analyzers: 3 Wavelength Reflectance:
• Accounts for O2Hb and HHB fractions in sample
• Not calculated; no problems with Pulse-Ox Interferances
• Done simply with regular BG sample in same flowpath
• No extra cost or consumable items to get result
– Complex: CO-Oximeters (Multi-Wavelength):
• Provide direct measurements of normal & abnormal Hb fractions.
• Reports variant of SO2%……..………FO2Hb
Determining Oxygen Binding to Hb:

• Calculated Methods (Indirect):


– Most BG Analyzers: Calculate O2-Sat:
– Utilize pO2, pH, HCO3-, and input/calculated Hb value.
– Problems with Calculated Results:
• Assumes "normal" O2 dissociation curve.
Factors Affecting O2 Curve: (all may be abnormal in ‘sick’
patients)
– Patient Temperature
– pCO2 Value; HCO3-
– THb of Patient
– pH Value
• Assumes all Hb is O2Hb (100% able to bind)
– In truth, abnormal hemoglobin fractions may be present
– Over-estimates SO2% with abnormal fractions possible
Fractional Oxyhemoglobin
• Fractional OxyHemoglobin (FO2Hb):
– Amount of Hb in blood expressed as a fraction of the total amount of
O2Hb available. Used to determine the effectiveness of O2 therapy.
– Measured on some Blood Gas Analyzers similarly to SO2 %.
– Usually must be determined using a full (multiple) wavelength
Spectrophotometer
– Comparing FO2Hb and Measured SO2% (Simple) :
– FO2Hb = [O2Hb] / ([O2Hb]+[HHb]+[COHb]+[MetHb])
– SO2 % = [O2Hb] / ([O2Hb]+[HHb]) x 100

Usually: FO2Hb (decimal fraction)
˜ SO % (integer percent)
2

• Dangers in Use of Calculated SO2 vs. FO2Hb or mSO2%:


– May overestimate true oxygen saturation in cases where abnormal hemoglobins (e.g.
COHb, MetHb, HHb, etc.) are present
mSO2% as a Stand-Alone Parameter
• mSO2% is frequently all that is needed for oxygen status
assessment…..
– It is EASY to run (run in same flowpath when doing ABG sample-Nova
Analyzer)
– No extra costs to run.
• Can rely on mSO2 (Reflectance Method)
– If….The presence of COHb/MetHb has been ruled out by:
• Clinical evaluation
– No history of smoking or smoke inhalation
– No evidence of metHb
• Direct measurement using CO-Oximeter
• The beginning & the end:
– If the sum of COHb and MetHb is less than 3-4% then SO2% gives
adequate information on O2-Hb relationship
COHb & MetHb Populations
In Most Parts of the World:
The “In-Health” (for Oxygenation) Population
Represents between 80 - 90 % of patients coming
into a typical Emergency Dept, and between
40 - 70 % of the patients admitted ‘in-house’.
(Except in areas with high industrial pollution, high risk workers,
or toxic heating practices.)
In health, where there is minimal COHb and MetHb,
SO2% and FO2Hb can be used interchangeably.
Therefore, routine COOx screening of all patients
is NOT medically necessary.
Quality Control Usage in POC-
ABG Testing

A Brief Overview-

Things to Consider….
“QC”: What Is It?
• QC = Quality Control Material:
– Aqueous, protein-based, or blood-based solutions.
– Usually pre-assayed for specific analyzers
• Mean and Range Limits usually provided
– Best materials to use are provided by analyzer
manufacturer
– Used to confirm proper system performance and accuracy
of results
– Designed to ‘mimic’ blood analysis
– System should NOT be used if QC is out of limits
– Proper system ‘calibration’ does NOT mean proper
accuracy of results….
“QC”:
When Should It Be Run?
• How Often?

– Local Markets Set Their Own Regulations


• General Rule: QC Analysis as often as necessary to
assure the user that his instrument is working….

– USA & European Markets…


• The ‘Regulations’ for Blood Gases: Each 8 Hours of
analyzer use with 3 levels within a 24 hour period.
• Chemistry & HH Tests: 2 Levels each 8 hours of
Analyzer Use.
“QC”:
What Types/Materials?
• What Materials To Use?: Blood Gas Units

– Usually an AQEUOUS Material.


• Most companies offer Ampoule Solutions (multiple levels)
– Nova Biomedical: Unique Offerings….
• Typical Ampoule Controls OR
• On-Board ‘Auto-QC’ Packs (multi-level packs)
– Bagged QC Solutions (tonometered controls)
– 35 Day Typical Use Life/Pack
– Available on CCX and pHOx Product Lines
Nova External & ‘Auto’-QC
Advantages/Disadvantages-
External Versus Auto-QC:
• Auto-QC: • External-QC:
Advantages: Advantages:
1. More economical for low QC analysis/day
1. Easier to Use 2 Limited Shipping effects
2 Unlimited ‘Analysis Times’ 3. ‘Blood Gas Standard’
3. No Operator Intervention
4. Less temperature sensitive Disadvantages:
5. Guaranteed QC Compliance 1. Requires Operator Intervention
6. Use all bag QC (no waste) 2. More staff time required
3. Single Use Only per Ampoule
4. Temp Sensitive to RT changes
Disadvantages: 5. No Guarantee for QC Analysis
1. Must run min 3 QC/Day for cost
2. Subject to more shipping effects
If You Do Not Run Controls…??
• You Run a Risk…..
– Calibrations alone do NOT completely assess analyzer
results
– Changes in sensor or system operations can occur
that can affect patient results
– QC samples can indicate drifts or trends in analyzer
results
– QC samples can indicate ‘hidden’ analyzer problems
not seen with calibration alone

• This is true for all Blood Gas & Critical Care


Testing Analyzers…. SO BEWARE!!
Nova Quality Assurance
Program - “QAP”

Allows Nova QC Users to Submit Their QC


Data & Be Compared to Other Users of
Similar Systems

Intra-Laboratory Comparison

A ‘free’ service to all active Nova analyzer users


Nova Quality Assurance Program - “QAP”
What Is It?
A Quality Assurance Program compares the performance
of similar instruments by having all users sample the exact
same material.

Each group using the same Control Material ( same lot no.)
submits data on a Monthly basis. Each member of the
group (Peer Group) receives a monthly report showing the
performance of their unit relative to the rest of the group.

Questionable performance is followed by contact from


the manufacturer’s support specialist with suggestions
on improving the performance of their unit.
Nova Quality Assurance Program - “QAP”
Why Consider It?
There is NO COST to be in this program.
(Customers only need to purchase a minimum # of Nova-Qc material/year).

QC-data easily collected & sent to Nova


(Customer only send ‘statistics’ from analyzer QC; can send by e-mail/fax/mail).

Customers get the ‘manufacturers validation of performance’.

Customers can see how their unit performs relative to others


using the same model(s).
(Comparison range limits may vary from original insert sheet limits; improve validation).

Additional support for any accreditation audit or inspection.


QAP Input Sheet: Summary Statistics

Easy Data Input from Analyzer


Print-out of QC Data
QAP Web Site
qap.novabio.com

Allows Nova QC Users to Submit and Review


Quality Control Data Online:
Intra-Laboratory Comparison

A ‘free’ service to all active Nova analyzer users


Data Entry
Summary Data Entry

Members who have data management systems or can


calculate their Mean and Standard Deviation may use a
Summary Data Entry Form. Using this form, data is
submitted only once a month.
In Summary….

• Consider Many Factors that Affect Sample Results:


– Sample Handling
– Anti-Coagulants
– Pre-Analysis Errors
– Room Air Exposure/Evaporation
– Temperature & Storage
– Mixing of Sample & Sample Separation
• Consider Using Measured Oxygen Saturation Assessment:
– More Accurate Results
– Not Affected by Patient Condition like Calculated Value
• Perform Proper Quality Control on Analyzers:
– Verify Sensors Performance
– Calibrations alone do NOT completely assess analyzer results
– Legal Requirement in many markets now.