Extra-analytical phase of laboratory

process
Practical problems

Jozefina Palić, MMedBiochem

Department of Medical Chemistry, Biochemistry and Clinical Chemistry
University of Zagreb, School of Medicine
Brain-to-brain cycle.
George D Lundberg
Downloaded from: Cadamuro, Janne and Simundic, Ana-Maria. "The preanalytical phase – from an instrument-centred to a patient-centred laboratory medicine" Clinical
Chemistry and Laboratory Medicine (CCLM), vol. 61, no. 5, 2023, pp. 732-740.
Preanalytical phase

1. Test selection
2. Preparation of individuals before sample collection
3. The sample collection and transport
4. Handling of the sample before analysis
 PREANALYTICAL
VARIABLES
(factors)

UNCONTROLABLE CONTROLABLE

• Age • Collection
• Gender • Identification
• Processing
• Circadian rhythm
• Storage
• Underlying diseases • Transport
• Diet
 PREANALYTICAL
VARIABLES
(factors)

INFLUENCING
(biological)
• Changable or unchangable
• Gender, circadian rhythm,
underlying diseases, ethnicity,
diet, stress, physical effort, etc.
• Effect reduced with
standardization
INTERFERENCE
(methodological)
• Mechanisms and factors that
lead to falsely increased or
decreased results
• Differ dependent on the
intended anaylte and analytical
method
SOURCE: Sciacovelli, L, Panteghini, M, Lippi, G, Sumarac, Z, Cadamuro, J, Galoro, CAO, et al.. Defining a roadmap for harmonizing quality indicators in Laboratory Medicine: a consensus
statement on behalf of the IFCC Working Group “Laboratory Error and Patient Safety” and EFLM Task and Finish Group “Performance specifications for the extra-analytical phases”. Clin
Chem Lab Med 2017;55:1478–88.
The goal is to avoid errors in preanalytical phase!

1. Preparation of individuals before sample collection

2. The sample collection and transportation
3. Handling of the sample before analysis

Problems in any step (preanalytical error) lead

to

BIAS
(inaccurate result)
 PATIENT
SAFETY

…premature patienth deaths associated with preventable medical errors ~ 210,000 per year, USA…
A New, Evidence-based Estimate of Patient Harms Associated w... : Journal of Patient Safety (lww.com)

…laboratory test related errors ~ 70% of medical errors…

15% of hospital activity in OECD (Organisation for Economic Co-operation and Development ) countries
can be attributed to treating safety failures

…annual costs for haemolyitic samples ranging from $100,000 to $1.2 million…
The preanalytical phase – from an instrument-centred to a patient-centred laboratory medicine (degruyter.com)
Biological factors

Diet
• Importance of fasting time before blood extraction:
• Lipids measurements, glucose and iron levels, ALP (alkaline phosphatase)
• Urate levels – purine rich food and alcohol should be avoided
• Influence on hormonal and metabolic changes – glucose absorption triggers insulin release which leads to potassium and
phosphate entrance into the cells (falsely lower level)
• Alcohol - short effect: decreased plasma glucose, increased lactate levels anf GGT activity
- long term effect: increased TG, AST, ALT, GGT, MCV

Stress
• Glucose level rising
• Influence on hormonal test results (e.g. falsely higher levels of prolactin – 20 min rest before sampling)

Patient position
• Fast change from siting to lying causes change in the plasma volume and distribution – leads to higher
concentration of analytes, 15 min to achieve normal distribution

High physical activity

• higher lactate levels
• Lower estrogen levels
• Higher activity: AST, LD, CK, aldolase
Biological factors

Circadian rythm
Biological factors
Test selection – decision about sample type

• Best benefit for the patient, but also cost effective

• Clinical guidelines!
• Regular monitoring of the changes in clinical guidelines and
communication with laboratory professionals!
• Right sample choosing (differences between plasma, serum and whole
blood)

Example: no more CK level testing in emergency laboratory department

at UHC Zagreb (unnecessary expense and time consuming), only
TROPONINE levels – clinical guidelines!
Preparation of individuals before sample collection

• Fasting time
• Therapy (anticoagulation, hormonal therapy…)
• Time of the day
• Menstrual cycle
• Therapeutic and diagnostic procedures (biopsy, operative
procedures)
• Therapeutic drug monitoring (TDM) – time of the last intake!
The sample collection and transport
Sample collection errors
• Body position
• Ethanol contamination
• Air in the capillary or arterial blood
• Anticoagulant contamination (wrong order of test tubes)
• Wrong anticoagulant
• Diluted sample (sample collection from the infusion catheter)
The sample collection and transport
The sample collection and transport

Transport errors
• Sample shaking → cell content release
• Special conditions:
• Sample on ice – for homocysteine levels and other metabolites
• Protected from the light – bilirubin levels
Handling of the sample before analysis

• Postponed time from collecting to the separation of the cells from

serum/plasma → change in glucose, phosfate levels due to cell
metabolism
• Compounds degradation
HAEMOLYSIS LIPEMIA ICTERUS
Haemolysis
• In vivo or in vitro
• Spectrophotometric influence (haemoglobin absorption 415, 450
and 570 nm)
• Release of the cell components into the sample
• Chemical interference (pseudo-peroxidase activity of haemoglobin)
• Sample dilution
Haemolysis
Postanalytical phase
• Result reporting errors
• Result interpretation errors
• Miscommunication/lack of communication between laboratory
professional (medical biochemist) and clinician
• Lack of harmonization:
• Immunochemistry methods – measurement units differ between
laboratories and methods → results between different labs are not
comparable!

Laboratory accreditation: ISO 15189

Thank you for the attention!