PREANALYSIS

IN THE LABORATORY

LECTURER: Rolaine Ann Añoza-Polo, RMT, MPH

COVERAGE

I. Pre-collection Variables
II. Specimen Consideration
III.Specimen Collection
Overview & Techniques
IV.Precentrifugation &
Centrifugation Phases

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WHAT IS
PREANALYSIS?

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**RECALL**: TESTING PHASES

❑ PREANALYTIC PHASE

❑ ANALYTIC PHASE

❑ POSTANALYTIC PHASE

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PREANALYSIS
• All the complex steps that MUST take place
BEFORE a sample can be analyzed
• 32-75% of testing errors happens here
• Careful attention is necessary in this phase to
ensure meaningful results
• Errors = extra work; diagnosis delayed; extra cost
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PREANALYSIS
PRE-ANALYTIC FACTORS
• Patient-related variables
(diet, age, sex, etc.)
• Patient Preparation
• Collection & Labeling
• Preservatives & Anticoagulants
• Transport
• Processing & Storage
POTENTIAL ERRORS
• Improperly ordered tests,
sample misidentification
• Improper timing, improper fasting
• Improper anticoagulant:blood
ratio
• improper mixing
• incorrect order of draw
• Hemolyzed/lipemic specimens.
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PREANALYSIS

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PATIENT-RELATED
VARIABLES

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PATIENT-RELATED VARIABLES: PHYSIOLOGY

• DIURNAL VARIATION
• EXERCISE
• FASTING
• DIET
• AGE/GENDER/RACE
• POSTURE

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PATIENT-RELATED VARIABLES: PHYSIOLOGY

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PATIENT-RELATED VARIABLES: COLLECTION
Reasons for Hemolysis • IN VIVO
1. Needle too small
▪ TOBACCO SMOKING
2. pulling back plunger
too fast ▪ ALCOHOL & DRUG INGESTION
3. Transferring blood
too vigorously • IN VITRO
4. shaking tubes ▪ HEMOLYZED
vigorously
▪ ICTERIC
5. Collecting blood
before alcohol has ▪ LIPEMIC
completely dried ▪ HEMODILUTED/CONCENTRATED
▪ ANTICOAGULANT USE
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PATIENT
PREPARATION

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THE TEST ORDER
• Laboratory tests are usually
ordered electronically or in
writing
• Online computer input is the
most error-free
• Verbal requests are made
only in emergency situations
and should be documented
on a standard form
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THE TEST ORDER
PATIENT DEMOGRAPHICS LAB INFO SYSTEM (LIS)
• Patient’s name Provides quick access to:
• Age/Sex • List of available tests
• Date of birth (DOB) • Types of specimens required,
• Date of admission (for inpatients) • Collection Methods
• • Blood collection tubes
Date of test order
• Amounts of blood/body fluid
• Location
required
• Attending Physician • Turnaround time
• Costs
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PATIENT ID AND CONSENT
MORTAL SIN:
MISIDENTIFICATION!
In collection, ensure:
• ID of the patient
• Labeling of the specimen
• Patient consent and privacy
• Chain of custody
TESTS REQUIRING COC
• HIV Testing
• Drug Testing
• Nucleic Acid Test
• Networking Tests/
Send-Out Tests
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PATIENT ID AND CONSENT
ISSUES ARISING IN PX ID:
Policies should describe what to do
when:
• A patient refuses blood collection
• A patient was unable to be drawn
• A patient is unavailable
• A patient is combative (i.e.
geriatrics and pediatrics)

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TIME OF COLLECTION
• most common tests are the ASAP and the stat
– ASAP🡪“as soon as possible”
– Stat 🡪 “immediately” and is highest priority
• Timed specimens are ordered usually to:
– monitor changes in a patient’s condition
– determine the level of a medication
– measure how well a substance is metabolized
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SPECIMEN ACCEPTABILITY
• Failure to follow can result
in specimen rejection
• Rejected specimen means
more cost and more delay
• IPSG#1: IDENTIFY
PATIENTS CORRECTLY

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SPECIMEN ACCEPTABILITY

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SPECIMEN COLLECTION
OVERVIEW

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**RECALL**: TYPE OF SPECIMEN
SPECIMEN COLLECTION TECHNIQUES
BLOOD Phlebotomy/Venipuncture
URINE MSCC-Technique
CSF Lumbar Puncture
Pleural Fluid Thoracentesis
Pericardial Fluid Pericardiocentesis
Ascites/Ascitic Fluid Peritoneocentesis
Synovial Fluid Arthrocentesis
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BLOOD (WB, SERUM/PLASMA)
• Most common specimen
• performed using a
needle/adapter assembly
attached to a syringe/
evacuated glass
• transferred to the
appropriate specimen
container

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BLOOD (WB, SERUM/PLASMA)
PROBLEMATIC SITES
• Burns, Scars, Tattoos
• Damaged Veins
– Sclerosed
– Thrombosed
• Edema
• Hematoma
• Mastectomy
• IV sites
• Fistula
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INNOVATIONS IN PHLEBOTOMY
TOURNIQUET/VEIN PALPATION SAFETY DEVICES

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BLOOD COLLECTION TUBES
• color-coded
• pre-determined internal
vacuum
• converted from glass to
plastic collection tubes to
minimize exposure to
biohazards and broken glass

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TUBE ADDITIVES
• Contains additives which • ANTICOAGULANTS
– Prevents blood from clotting
serve specific functions – EDTA, citrate, heparin, oxalate
• ANTIGLYCOLYTIC AGENTS
• Functions optimally only – Prevents glycolysis
when tube is completely – Sodium fluoride
• CLOT ACTIVATORS
filled and gently – Speeds up clotting
inverted/mixed – Thrombin, silica particles, diatomite
• THIXOTROPIC GEL
• Categorized as: – Separates serum/plasma from cells
• OTHERS
– SPS (anticoagulant, anticomplement)
– ARD (antibiotic removal device)

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EDTA (Ethylenediaminetetraacetic acid)
• Anticoagulant of choice
for hematologic counts
and morphology
• Chelates/binds calcium
• Has two salts:
K2EDTA and K3EDTA
• Spray-dried or liquid form

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CITRATES
• Commonly used for
coagulation studies and
sedimentation rates
• Chelates/binds calcium
• Very sensitive about
anticoagulant:blood ratio
• 1:4 (black), 1:9(blue)
• 0.105 M or 0.129 M (3.2%
or 3.8%)
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HEPARIN
• effective anticoagulant in
small quantities without
significant effect on many
determinations
• Inhibits thrombin
• Has 2 forms:
– Lithium Hep (LiHep)
– Sodium Hep (NaHep)
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SODIUM FLUORIDE-OXALATE
• generally used for glucose
measurements because
they contain a
antiglycolytic agent which
prevents glycolysis for 3
days

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SEPARATOR TUBES
• Either contains clot activators and/or
thixotropic gels
• During centrifugation, the gel undergoes
a change in viscosity lodges between the
cells and the top layer
• Advantages:
– ease of use
– shorter processing time
– higher serum yield
– minimal liberation of potentially hazardous
aerosols
– only one centrifugation step
– use of single tube
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BLOOD COLLECTION TUBES

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BLOOD COLLECTION TUBES

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BLOOD COLLECTION TUBES

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SAFETY IN BLOOD COLLECTION
• Best practice for prevention of
needlestick injuries is the use of a
sharp with engineered sharps injury
protection (SESIP) and immediate
disposal of the entire unit after.
• Closable, puncture-resistant, leak-proof
sharps containers that are labeled and
color-coded, must have a large enough
opening, and easily accessible
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URINE
• Next most common
specimen
• Usually requires a timed
specimen and/or complete
collection
• Creatinine is often used to
assess completeness of a
collection

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MID-STREAM, CLEAN-CATCH
1. Clean the external genitalia with
an antiseptic wipe
2. Begin urination, stop midstream
and discard this first portion of
urine
3. Collects the remaining urine in a
sterile container.
4. Tightly seal vessel and label
correctly
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CEREBROSPINAL FLUID
• Lumbar punctures are performed
to collect CSF
• most common site for an LP is
between the 3rd and 4th lumbar
vertebrae or between the 4th and
5th lumbar vertebrae
• Distribution
– Tube #1: Chemistry or Immuserology
– Tube #2: Microbiology
– Tube #3: Hematology

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SYNOVIAL FLUID
• Ultrafiltrate of plasma found in the
joints
• collected by arthrocentesis, an
aspiration of the joint using a syringe,
moistened with an anticoagulant
• Distribution
– Sterile Tube: Microbiology
– EDTA Tube: Hematology
– Red Tube: Chemistry

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SPECIMEN
TRANSPORT & PROCESSING

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SPECIMEN TRANSPORT
• accounts for approx. 1/3 of the
total TAT
• specimen must always be
transported carefully to prevent
breakage and protect specimen
integrity
• STAT: transport immediately
• Routine: delivered <45mins after
collection & centrifuged <1hr

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SPECIMEN PROCESSING
• Labs typically have a specific
area where specimens are
received, accessioned and
prepped for testing
• This area evaluates
specimen sustainability and
sorts the samples, ready for
processing
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FINITE.
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REFERENCES
McPherson, R. A. & Pincus, M. R. (2017). Henry’s Clinical
Diagnosis and Management by Laboratory Methods.
23rd ed. St. Louis, Missourri: Elsevier Inc.
Bishop, M. L., Fody, E. P. & Schoeff, L. E. (2010). Clinical
Chemistry: Techniques, Principles, Correlations. 6th ed.
Philadelphia, PA: Lippicott Williams & Wilkins.

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