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Nordin N, Ab Rahim SN, Wan Omar WFA, Zulkarnain S, Sinha S, Kumar S, Haque M. Preanalytical Errors in Clinical Laboratory Testing at a Glance: Source and Control Measures. Cureus 2024; 16:e57243. [PMID: 38559530 PMCID: PMC10981510 DOI: 10.7759/cureus.57243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 04/04/2024] Open
Abstract
The accuracy of diagnostic results in clinical laboratory testing is paramount for informed healthcare decisions and effective patient care. While the focus has traditionally been on the analytical phase, attention has shifted towards optimizing the preanalytical phase due to its significant contribution to total laboratory errors. This review highlights preanalytical errors, their sources, and control measures to improve the quality of laboratory testing. Blood sample quality is a critical concern, with factors such as hemolysis, lipemia, and icterus leading to erroneous results. Sources of preanalytical errors encompass inappropriate test requests, patient preparation lapses, and errors during sample collection, handling, and transportation. Mitigating these errors includes harmonization efforts, education and training programs, automated methods for sample quality assessment, and quality monitoring. Collaboration between laboratory personnel and healthcare professionals is crucial for implementing and sustaining these measures to enhance the accuracy and reliability of diagnostic results, ultimately improving patient care.
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Affiliation(s)
- Nani Nordin
- Pathology, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, MYS
| | - Siti Nadirah Ab Rahim
- Pathology, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, MYS
| | | | - Sarah Zulkarnain
- Pathology, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, MYS
| | - Susmita Sinha
- Physiology, Khulna City Medical College and Hospital, Khulna, BGD
| | - Santosh Kumar
- Periodontology and Implantology, Karnavati School of Dentistry, Karnavati University, Gandhinagar, IND
| | - Mainul Haque
- Karnavati Scientific Research Center (KSRC), Karnavati School of Dentistry, Karnavati University, Gandhinagar, IND
- Pharmacology and Therapeutics, National Defence University of Malaysia, Kuala Lumpur, MYS
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2
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Hu WT, Nayyar A, Kaluzova M. Charting the Next Road Map for CSF Biomarkers in Alzheimer's Disease and Related Dementias. Neurotherapeutics 2023; 20:955-974. [PMID: 37378862 PMCID: PMC10457281 DOI: 10.1007/s13311-023-01370-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 06/29/2023] Open
Abstract
Clinical prediction of underlying pathologic substrates in people with Alzheimer's disease (AD) dementia or related dementia syndromes (ADRD) has limited accuracy. Etiologic biomarkers - including cerebrospinal fluid (CSF) levels of AD proteins and cerebral amyloid PET imaging - have greatly modernized disease-modifying clinical trials in AD, but their integration into medical practice has been slow. Beyond core CSF AD biomarkers (including beta-amyloid 1-42, total tau, and tau phosphorylated at threonine 181), novel biomarkers have been interrogated in single- and multi-centered studies with uneven rigor. Here, we review early expectations for ideal AD/ADRD biomarkers, assess these goals' future applicability, and propose study designs and performance thresholds for meeting these ideals with a focus on CSF biomarkers. We further propose three new characteristics: equity (oversampling of diverse populations in the design and testing of biomarkers), access (reasonable availability to 80% of people at risk for disease, along with pre- and post-biomarker processes), and reliability (thorough evaluation of pre-analytical and analytical factors influencing measurements and performance). Finally, we urge biomarker scientists to balance the desire and evidence for a biomarker to reflect its namesake function, indulge data- as well as theory-driven associations, re-visit the subset of rigorously measured CSF biomarkers in large datasets (such as Alzheimer's disease neuroimaging initiative), and resist the temptation to favor ease over fail-safe in the development phase. This shift from discovery to application, and from suspended disbelief to cogent ingenuity, should allow the AD/ADRD biomarker field to live up to its billing during the next phase of neurodegenerative disease research.
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Affiliation(s)
- William T Hu
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA.
- Center for Innovation in Health and Aging Research, Institute for Health, Health Care Policy, and Aging Research, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, 08901, USA.
| | - Ashima Nayyar
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA
| | - Milota Kaluzova
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA
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Fernández Prendes C, Castro Castro MJ, Sánchez Navarro L, Rapún Mas L, Morales Indiano C, Arrobas Velilla T. Handling of lipemic samples in the clinical laboratory. ADVANCES IN LABORATORY MEDICINE 2023; 4:5-27. [PMID: 37359904 PMCID: PMC10197190 DOI: 10.1515/almed-2023-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/11/2022] [Indexed: 06/28/2023]
Abstract
Interferences in the clinical laboratory may lead physicians misinterpret results for some biological analytes. The most common analytical interferences in the clinical laboratory include hemolysis, icterus and lipemia. Lipemia is defined as turbidity in a sample caused by the accumulation of lipoproteins, mainly very-low density lipoproteins (VLDL) and chylomicrons. Several methods are available for the detection of lipemic samples, including the lipemic index, or triglyceride quantification in serum or plasma samples, or mean corpuscular hemoglobin (MCHC) concentration in blood samples. According to the European Directive 98/79/CE, it is the responsibility of clinical laboratories to monitor the presence of interfering substances that may affect the measurement of an analyte. There is an urgent need to standardize interference studies and the way interferences are reported by manufacturers. Several methods are currently available to remove interference from lipemia and enable accurate measurement of biological quantities. The clinical laboratory should establish a protocol for the handling of lipemic samples according to the biological quantity to be tested.
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Affiliation(s)
- Carla Fernández Prendes
- Laboratory Medicine Department, Laboratori Clínic Metropolitana Nord, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
- Workgroup of Lipoproteins and Cardiovascular Diseases, Spanish Society of Laboratory Medicine, Barcelona, Spain
| | - María José Castro Castro
- Workgroup of Lipoproteins and Cardiovascular Diseases, Spanish Society of Laboratory Medicine, Barcelona, Spain
- Biochemistry Core, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain
| | - Lourdes Sánchez Navarro
- Haematological Core, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain
| | - Loreto Rapún Mas
- Haematological Core, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain
| | - Cristian Morales Indiano
- Laboratory Medicine Department, Laboratori Clínic Metropolitana Nord, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
- Workgroup of Lipoproteins and Cardiovascular Diseases, Spanish Society of Laboratory Medicine, Barcelona, Spain
| | - Teresa Arrobas Velilla
- Laboratory of Nutrition and Cardiovascular Risk, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Workgroup of Lipoproteins and Cardiovascular Diseases, Spanish Society of Laboratory Medicine, Barcelona, Spain
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Garcia-Castrillo Riesgo L, Lauwaert D, Cadamuro J, von Meyer A, Dodt C. The preanalytical process in the emergency department, a European survey. Clin Chem Lab Med 2023; 61:93-103. [PMID: 36302372 DOI: 10.1515/cclm-2022-0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 09/30/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Clinical decision-making in emergency medicine is under constant pressure from demand and performance requirements, with blood tests being a fundamental part of this. However, the preanalytical process has received little attention. Therefore, this study aimed to investigate the quality of preanalytical phase processes in European emergency departments (EDs) from the perspectives of the three main providers: clinicians, nurses, and laboratory specialists. METHODS This online survey, distributed among European EDs and laboratories, was supported by the European Society for Emergency Nursing (EUSEN), European Society for Emergency Medicine (EuSEM), and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM). The size of the centres, the European region, the responder's profession and the country's economic condition were used as co-variables. RESULTS We included 376 responses from all ED-related professions from 306 European centres. In 66.9% of all ED visits, at least one blood test was performed. Tests were requested mostly by nurses (44.6%) using electronic Order/Entry systems (65.4%). Only a minority (19%) reported not using laboratory quality indicators (QIs). Most responders defined the TAT starting point "when the laboratory receives the sample" (66.1%), defining the goal to be "less than 60 min" (69.9%), but only 42.4% of the centres estimated achieving this goal. CONCLUSIONS Our survey illustrates the current situation on preanalytical blood sample processing in European EDs from the clinical and laboratory perspectives. The results emphasise the importance of the IT infrastructure and QI usage in this process and highlight some differences between European regions.
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Affiliation(s)
| | | | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alexander von Meyer
- Institute for Laboratory Medicine and Medical Microbiology, München-Klinik, Munich, Germany
| | - Christoph Dodt
- Emergency Department, München-Klinik Bogenhausen, Munich, Germany
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5
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Cadamuro J, Simundic AM. The preanalytical phase – from an instrument-centred to a patient-centred laboratory medicine. Clin Chem Lab Med 2022; 61:732-740. [PMID: 36330758 DOI: 10.1515/cclm-2022-1036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
Abstract
In order to guarantee patient safety, medical laboratories around the world strive to provide highest quality in the shortest amount of time. A major leap in quality improvement was achieved by aiming to avoid preanalytical errors within the total testing process. Although these errors were first described in the 1970s, it took additional years/decades for large-scale efforts, aiming to improve preanalytical quality by standardisation and/or harmonisation. Initially these initiatives were mostly on the local or national level. Aiming to fill this void, in 2011 the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) working group “Preanalytical Phase” (WG-PRE) was founded. In the 11 years of its existence this group was able to provide several recommendations on various preanalytical topics. One major achievement of the WG-PRE was the development of an European consensus guideline on venous blood collection. In recent years the definition of the preanalytical phase has been extended, including laboratory test selection, thereby opening a huge field for improvement, by implementing strategies to overcome misuse of laboratory testing, ideally with the support of artificial intelligence models. In this narrative review, we discuss important aspects and milestones in the endeavour of preanalytical process improvement, which would not have been possible without the support of the Clinical Chemistry and Laboratory Medicine (CCLM) journal, which was one of the first scientific journals recognising the importance of the preanalytical phase and its impact on laboratory testing quality and ultimately patient safety.
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Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine , Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics , University Hospital “Sveti Duh”, University of Zagreb, Faculty of Pharmacy and Biochemistry , Zagreb , Croatia
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Cadamuro J, Baird G, Baumann G, Bolenius K, Cornes M, Ibarz M, Lewis T, Oliveira GL, Lippi G, Plebani M, Simundic AM, von Meyer A. Preanalytical quality improvement - an interdisciplinary journey, on behalf of the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE). Clin Chem Lab Med 2022; 60:cclm-2022-0117. [PMID: 35258235 DOI: 10.1515/cclm-2022-0117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/15/2022]
Abstract
Since the beginning of laboratory medicine, the main focus was to provide high quality analytics. Over time the importance of the extra-analytical phases and their contribution to the overall quality became evident. However, as the initial preanalytical processes take place outside of the laboratory and mostly without its supervision, all professions participating in these process steps, from test selection to sample collection and transport, need to engage accordingly. Focusing solely on intra-laboratory processes will not be sufficient to achieve the best possible preanalytical quality. The Working Group for the Preanalytical Phase (WG-PRE) of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has provided several recommendations, opinion papers and scientific evidence over the past years, aiming to standardize the preanalytical phase across Europe. One of its strategies to reach this goal are educational efforts. As such, the WG-PRE has organized five conferences in the past decade with the sole focus on preanalytical quality. This year's conference mainly aims to depict the views of different professions on preanalytical processes in order to acquire common ground as basis for further improvements. This article summarizes the content of this 6th preanalytical conference.
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Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Geoffrey Baird
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Gabriele Baumann
- Department of Laboratory Medicine, Pyhrn-Eisenwurzen Klinikum, General Hospital Steyr, Steyr, Austria
| | - Karin Bolenius
- Department of Nursing, Umeå University, The Unit of Research and Education, The County Council of Västerbotten, Umeå, Sweden
| | - Michael Cornes
- Clinical Chemistry Department, Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - Mercedes Ibarz
- Laboratory Medicine Department, University Hospital Arnau de Vilanova, IRBLleida, Lleida, Spain
| | - Tom Lewis
- North Devon District Hospital, Devon, UK
| | - Gabriel Lima Oliveira
- Clinical Laboratory, Carlo Poma Hospital, Mantua, Italy
- Latin American Working Group for Preanalytical Phase (WG-PRE-LATAM), Latin America Confederation of Clinical Biochemistry (COLABIOCLI), Montevideo, Uruguay
| | - Giuseppe Lippi
- Section of Clinical Biochemistry and School of Medicine, University of Verona, Verona, Italy
| | - Mario Plebani
- Honorary Professor of Clinical Biochemistry and Clinical Molecular Biology, School of Medicine, University of Padova, Padova, Italy
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, University Hospital "Sveti Duh", Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Alexander von Meyer
- Institute for Laboratory Medicine and Medical Microbiology, Munich Clinics, Munich, Germany
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7
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Letter to the Editor. REV ROMANA MED LAB 2022. [DOI: 10.2478/rrlm-2021-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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8
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Gómez Rioja R, Ventura M, Llopis MA, Bauça JM, Caballero Garralda A, Ibarz M, Martinez D, Gómez C, Salas Gómez-Pablos P, García Del Pino I, Delgado J, Puente JJ, Marzana I. External quality assessment of serum indices: Spanish SEQC-ML program. Clin Chem Lab Med 2022; 60:66-73. [PMID: 34670030 DOI: 10.1515/cclm-2021-0786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/24/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Serum indices included in clinical chemistry instruments are widely used by laboratories to assess the quality of samples. Instruments that report quantitative results allow an evaluation of their diagnostic performance in a similar way to other biochemical tests. The Spanish Society of Laboratory Medicine (SEQC-ML) launched a monthly External Quality program of serum indices in 2018 using three lyophilized materials of simultaneous annual distribution. We present the results of the first three years of the program. METHODS The use of four different quality control materials with different concentrations in three alternate months allows an annual evaluation of the participant's accuracy. Assigned values are established by consensus among homogeneous groups, considering necessary at least 10 participants for a comparison at instrument level. The average percentage difference results per instrument allow the assessment of bias among groups. RESULTS The imprecision of the three indices ranges between 3 and 9%, with no major differences among instruments. Significant differences were observed in all indices among instruments with more than 10 participants (Roche Cobas, Abbott Architect, Abbott Alinity and Siemens Advia). The 90th percentile of the distribution of percentage differences was used as the analytical performance specification (APS). An improvement in performance was observed in the first three years of the program, probably due to the learning curve effect. In 2020, APS of 7.8, 12.2 and 9.7% were proposed for hemolytic, icteric and lipemic indices, respectively. CONCLUSIONS Serum indices have a great impact on the quality and the reliability of laboratory test results. Participation in proficiency testing programs for serum indices is helpful to encourage harmonization among providers and laboratories.
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Affiliation(s)
- Rubén Gómez Rioja
- Laboratory Medicine, La Paz - Cantoblanco - Carlos III University Hospital, Madrid, Spain
| | | | - María Antonia Llopis
- Laboratory Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Josep Miquel Bauça
- Servei d'Anàlisis Clíniques, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, Spain
| | | | - Mercedes Ibarz
- Labortory Medicine, Hospital Universitari Arnau de Vilanova, Lleida, Catalunya, Spain
| | | | - Carolina Gómez
- Laboratory Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | | | - Jose Delgado
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Mallorca, Spain
| | - Juan Jose Puente
- Servicio Bioquímica, Hospital Clinico Universitario Lozano Blesa, Zaragoza, Spain
| | - Iciar Marzana
- Unidad Extraanalítica, Laboratorios Hospital Universitario Cruces, Baracaldo (Vizcaya), Spain
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9
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OUP accepted manuscript. Am J Clin Pathol 2022; 158:494-498. [DOI: 10.1093/ajcp/aqac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
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10
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Soh SX, Loh TP, Sethi SK, Ong L. Methods to reduce lipemic interference in clinical chemistry tests: a systematic review and recommendations. Clin Chem Lab Med 2021; 60:152-161. [PMID: 34773729 DOI: 10.1515/cclm-2021-0979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/21/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Lipemia is the presence of abnormally high lipoprotein concentrations in serum or plasma samples that can interfere with laboratory testing. There is little guidance available from manufacturers or professional bodies on processing lipemic samples to produce clinically acceptable results. This systematic review summarizes existing literature on the effectiveness of lipid removal techniques in reducing interference in clinical chemistry tests. METHODS A PubMed search using terms relating to lipid removal from human samples for clinical chemistry tests produced 1,558 studies published between January 2010 and July 2021. 15 articles met the criteria for further analyses. RESULTS A total of 66 analytes were investigated amongst the 15 studies, which showed highly heterogenous study designs. High-speed centrifugation was consistently effective for 13 analytes: albumin, alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, creatine kinase (CK), creatinine (Jaffe method), gamma-glutamyl transferase (GGT), glucose (hexokinase-based method), lactate dehydrogenase (LDH), phosphate, potassium, and urea. Lipid-clearing agents were uniformly effective for seven analytes: ALT, AST, total bilirubin, CK, creatinine (Jaffe method), lipase, and urea. Mixed results were reported for the remaining analytes. CONCLUSIONS For some analytes, high-speed centrifugation and/or lipid-clearing agents can be used in place of ultracentrifugation. Harmonized protocols and acceptability criteria are required to allow pooled data analysis and interpretation of different lipemic interference studies.
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Affiliation(s)
- Sheila X Soh
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Tze Ping Loh
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Sunil K Sethi
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Lizhen Ong
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
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11
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Mainali S, Merrill AE, Krasowski MD. Frequency of icteric interference in clinical chemistry laboratory tests and causes of severe icterus. Pract Lab Med 2021; 27:e00259. [PMID: 34761095 PMCID: PMC8567001 DOI: 10.1016/j.plabm.2021.e00259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/06/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives The aims of this study were to identify the causes of severe icterus in an academic medical center patient population and to assess the impact of icterus on clinical chemistry testing using assay package insert thresholds. Design and Methods: In this retrospective study at an academic medical center core clinical laboratory, icteric, hemolysis, and lipemia indices were available for all serum and plasma chemistry specimens analyzed on Roche Diagnostics cobas 8000 analyzers over a 12-month period, encompassing 414,502 specimens from 94,081 unique patients (51,851 females; 42,230 males) including children, inpatient, outpatient, and emergency department patients. Extensive chart review was done for all 57 patients (4 pediatric, 53 adult; 534 total specimens) who had one or more samples with an icteric index of 40 or higher (defined as severe icterus). Results Specimen icteric index exceeded package insert icteric index thresholds in 0.14% of clinical chemistry assays, with the highest number of instances for creatinine (1358 samples, 0.6% of total tests), total protein (1194 samples, 2.2%), and ammonia (161 samples, 3.9%). The 57 patients with an icteric index of 40 or higher accounted for 49.7% of all instances where the icteric index exceeded the specific assay package insert limit. The most common etiologies of this group of 57 patients were alcohol-related liver disease (34 patients), biliary tract disease (7 patients), and neoplasms (6 patients). Conclusions Approximately half of all instances where specimen icteric index exceeded assay package insert thresholds occurred in a small cohort of patients with severe liver/biliary tract disease. Specimen icteric indices exceeded package insert icteric index thresholds for 0.14% of clinical chemistry tests ordered at an academic medical center. Icteric interference exceeding package insert thresholds had the most overall occurrences for enzymatic creatinine, total protein, and ammonia. Only 57 of 94,081 unique patients (0.06%) with severe icterus accounted for nearly half of instances where the icteric index exceeded the package insert limit for a specific assay. The small cohort of patients with severe icterus had high mortality generally associated with cirrhosis, biliary disease, or aggressive metastatic cancer. Icteric indices exceeding 20 were mostly comprised of patients with predominantly conjugated hyperbilirubinemia.
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Affiliation(s)
- Sandhya Mainali
- Carver College of Medicine, University of Iowa, 451 Newton Road, Iowa City, IA, 52242, USA.,Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS, 67214, USA
| | - Anna E Merrill
- Department of Pathology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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12
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Krintus M, Panteghini M. Laboratory-related issues in the measurement of cardiac troponins with highly sensitive assays. Clin Chem Lab Med 2021; 58:1773-1783. [PMID: 32134723 DOI: 10.1515/cclm-2020-0017] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/24/2020] [Indexed: 12/13/2022]
Abstract
A number of assay-related issues can affect the performance of cardiac troponin (cTn) measurement in everyday practice. In this respect, it is vital that all information on cTn assays is known and that the performance characteristics of assays are objectively assessed and adequately described. The advent of the latest generation of more sensitive cTn assays has heralded a new wave of information about low concentrations of cTn in blood. These recent generation assays have improved analytical sensitivity and corresponding performance at low cTn concentrations when compared to their predecessors, providing a convincing goal for laboratory medicine in helping clinicians in the diagnosis of acute myocardial infarction. Crucial to the clinical utility of highly sensitive cTn assays is the laboratorians' role in closely scrutinizing proposed assays and defining their value in relation to available evidence. Analytical, as well as pre-analytical and post-analytical, aspects must be documented. In this review, we describe what laboratory professionals should know about their cTn assay performance characteristics and the pre-analytical prerequisites for robustness to ensure optimal post-analytical reporting.
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Affiliation(s)
- Magdalena Krintus
- Department of Laboratory Medicine, Nicolaus Copernicus University, Collegium Medicum, 9 Sklodowskiej-Curie Street, 85-094 Bydgoszcz, Poland, Phone: +48 52 585 44 90, Fax: +48 52 585 36 03
| | - Mauro Panteghini
- Department of Biomedical and Clinical Sciences 'Luigi Sacco', University of Milan, Milan, Italy
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13
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Can Çubukçu H, Vanstapel F, Thelen M, Bernabeu-Andreu FA, van Schrojenstein Lantman M, Brugnoni D, Mesko Brguljan P, Milinkovic N, Linko S, Vaubourdolle M, O'Kelly R, Kroupis C, Lohmander M, Šprongl L, Panteghini M, Boursier G. Improving the laboratory result release process in the light of ISO 15189:2012 standard. Clin Chim Acta 2021; 522:167-173. [PMID: 34418364 DOI: 10.1016/j.cca.2021.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 11/18/2022]
Abstract
The ISO 15189:2012 standard section 5.9.1 requires laboratories to review results before release, considering quality control, previous results, and clinical information, if any, and to issue documented procedures about it. While laboratory result reporting is generally regarded as part of the post-analytical phase, the result release process requires a general view of the total examination process. Reviewing test results may follow with troubleshooting and test repetition, including reanalyzing an individual sample or resampling. A systematic understanding of the result release may help laboratory professionals carry out appropriate test repetition and ensure the plausibility of laboratory results. In this paper, we addressed the crucial steps in the result release process, including evaluation of sample quality, critical result notification, result reporting, and recommendations for the management of the result release, considering quality control alerts, instrument flags, warning messages, and interference indexes. Error detection tools and plausibility checks mentioned in the present paper can support the daily practice of results release.
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Affiliation(s)
- Hikmet Can Çubukçu
- Ankara University Stem Cell Institute, Interdisciplinary Stem Cells and Regenerative Medicine, Ankara, Turkey.
| | - Florent Vanstapel
- Laboratory Medicine, Department of Public Health, Biomedical Sciences Group, University Hospital Leuven, Belgium, KU Leuven, Leuven, Belgium
| | - Marc Thelen
- Result Laboratory for Clinical Chemistry, Amphia Hospital Breda, the Netherlands,; Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Marith van Schrojenstein Lantman
- Result Laboratory for Clinical Chemistry, Amphia Hospital Breda, the Netherlands,; Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Duilio Brugnoni
- Clinical Chemistry Laboratory, Spedali Civili, Brescia, Italy
| | - Pika Mesko Brguljan
- Department of Clinical Chemistry, University Clinic for Respiratory and Allergic Deseases, Golnik, Slovenia
| | - Neda Milinkovic
- Department of Medical Biochemistry, Pharmaceutical Faculty, University of Belgrade, Belgrade, Serbia
| | | | | | - Ruth O'Kelly
- Association of Clinical Biochemists in Ireland, Ireland
| | - Christos Kroupis
- Department of Clinical Biochemistry, Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, Haidari, Greece
| | - Maria Lohmander
- Regional Laboratoriemedicin, Sahlgrenska Universitetssjukhuset, Trollhättan/Göteborg, Sweden
| | - Luděk Šprongl
- Clinical Laboratory, Hospital Kladno, Kladno, Czech Republic
| | - Mauro Panteghini
- Department of Biomedical and Clinical Sciences "Luigi Sacco", and Research Centre for Metrological Traceability in Laboratory Medicine (CIRME), University of Milan, Milano, Italy
| | - Guilaine Boursier
- Dept of Genetics, Rare Diseases and Personalized Medicine Rare Diseases and Autoinflammatory Unit, CHU Montpellier, Montpellier, France
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14
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Tan TXZ, Lim SHC, Khoo J. Strawberry pink blood: hypertriglyceridaemia and diabetic ketoacidosis secondary to poorly controlled type 2 diabetes mellitus. BMJ Case Rep 2021; 14:14/8/e243696. [PMID: 34417241 PMCID: PMC8381315 DOI: 10.1136/bcr-2021-243696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A 54-year-old woman with insulin-requiring type 2 diabetes mellitus presented with acute shortness of breath and drowsiness on a background of polydipsia, weakness and significant weight loss. One year ago, she had decided to stop her insulin and other medications and adopt lifestyle modifications instead. Initial emergency department (ED) blood samples were highly lipaemic and appeared strawberry pink. She was eventually diagnosed with diabetic ketoacidosis (DKA) with severe hypertriglyceridaemia, intubated for airway protection, and managed with fluid resuscitation and intravenous insulin to good effect. We share an uncommon DKA presentation at the ED. History was limited as the patient was drowsy and minimally communicative. Physical examination was unremarkable. Blood investigations were also delayed in view of the need for additional centrifugation. These contributed to a paucity of information in the acute setting and resulted in a diagnostic challenge.
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Affiliation(s)
| | | | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore
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15
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von Meyer A, Lippi G, Simundic AM, Cadamuro J. Exact time of venous blood sample collection - an unresolved issue, on behalf of the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE). Clin Chem Lab Med 2021; 58:1655-1662. [PMID: 32549131 DOI: 10.1515/cclm-2020-0273] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Objectives An accurate knowledge of blood collection times is crucial for verifying the stability of laboratory analytes. We therefore aimed to (i) assess if and how this information is collected throughout Europe and (ii) provide a list of potentially available solutions. Methods A survey was issued by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group on Preanalytical Phase (WG-PRE) in 2017, aiming to collect data on preanalytical process management, including sampling time documentation, in European laboratories. A preceding pilot survey was disseminated in Austria in 2016. Additionally, preanalytical experts were surveyed on their local setting on this topic. Finally, the current scientific literature was reviewed on established possibilities of sampling time collection. Results A total number of 85 responses was collected from the pilot survey, whilst 1347 responses from 37 European countries were obtained from the final survey. A minority (i.e. ~13%) of responders to the latter declared they are unaware of the exact sampling time. The corresponding rate in Austria was ~70% in the pilot and ~30% in the final survey, respectively. Answers from 17 preanalytical experts from 16 countries revealed that sampling time collection seems to be better documented for out- than for in-patients. Eight different solutions for sample time documentation are presented. Conclusions The sample collection time seems to be documented very heterogeneously across Europe, or not at all. Here we provide some solutions to this issue and believe that laboratories should urgently aim to implement one of these.
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Affiliation(s)
- Alexander von Meyer
- Institute for Laboratory Medicine and Microbiology, Munich Municipal Clinic Group, Munich, Germany, Phone: +49-179-2940459
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Ana-Maria Simundic
- Department for Medical Laboratory Diagnostics, Clinical Hospital "Sveti Duh", Zagreb, Croatia.,Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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16
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Uçar KT, Çat A, Gümüş A, Nurlu N. Interferograms plotted with reference change value (RCV) may facilitate the management of hemolyzed samples. J Med Biochem 2021; 41:53-61. [PMID: 35291494 PMCID: PMC8882018 DOI: 10.5937/jomb0-31250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background The European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE) have recommended an algorithm based on the reference change value (RCV) to evaluate hemolysis. We utilized this algorithm to analyze hemolysis-sensitive parameters. Methods Two tubes of blood were collected from each of the 10 participants, one of which was subjected to mechanical trauma while the other was centrifuged directly. Subsequently, the samples were diluted with the participant's hemolyzed sample to obtain the desired hemoglobin concentrations (0, 1, 2, 4, 6, 8, and 10 g/L). ALT, AST, K, LDH, T. Bil tests were performed using Beckman Coulter AU680 analyzer. The analytical and clinical cut-offs were based on the biological variation for the allowable imprecision and RCV. The algorithms could report the values directly below the analytical cut-off or those between the analytical and clinical cut-offs with comments. If the change was above the clinical cut-off, the test was rejected. The linear regression was used for interferograms, and the hemoglobin concentrations corresponding to cut-offs were calculated via the interferograms. Results The RCV was calculated as 29.6% for ALT. Therefore, ALT should be rejected in samples containing >5.9 g/L hemoglobin. The RCVs for AST, K, LDH, and T. Bil were calculated as 27.9%, 12.1%, 19.2%, and 61.2%, while the samples' hemoglobin concentrations for test rejection were 0.8, 1.6, 0.5, and 2.2 g/L, respectively. Conclusions Algorithms prepared with RCV could provide evidence-based results and objectively manage hemolyzed samples.
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Affiliation(s)
| | - Abdulkadir Çat
- Istanbul Gaziosmanpasa Training and Research Hospital, Istanbul, Turkey
| | | | - Nilhan Nurlu
- Istanbul Gaziosmanpasa Training and Research Hospital, Istanbul, Turkey
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17
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Ho CKM, Chen C, Setoh JWS, Yap WWT, Hawkins RCW. Optimization of hemolysis, icterus and lipemia interference thresholds for 35 clinical chemistry assays. Pract Lab Med 2021; 25:e00232. [PMID: 34095417 PMCID: PMC8145753 DOI: 10.1016/j.plabm.2021.e00232] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/21/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives Interference of chemistry assays by hemolysis, icterus and lipemia (HIL) was investigated on the Abbott Alinity c system. We sought to empirically establish optimized HIL index thresholds for the purposes of reporting HIL interference in a hospital laboratory and advising clinicians on the interpretation of laboratory results in the presence of hemolysis, icterus or lipemia. Methods HIL index values measured by spectrophotometry were compared with concentrations of hemoglobin, bilirubin and Intralipid. HIL interference of 35 Abbott Alinity chemistry assays was subsequently investigated by pairwise comparison of test results in pooled serum or plasma with those in test preparations spiked with hemolysate, bilirubin or Intralipid. Data generated from the interference experiments were critically assessed according to assay-specific acceptance criteria adapted from multiple sources, and optimized thresholds for HIL indices were established. Results Correlations between HIL index values and their corresponding concentrations of hemoglobin, bilirubin and Intralipid were, in general, very good within the ranges of interferent concentrations tested. Hemolysis significantly affected 12 of 35 assays, whereas bilirubin and Intralipid interfered with four and three assays, respectively. Both the direction and magnitude of Intralipid interference with the direct bilirubin assay were dependent on the concentrations of the analyte. Conclusions HIL interference of the Abbott Alinity clinical chemistry assays investigated in this study was not uncommon. At present, there are no universally accepted criteria for defining significant assay interference for clinical practice. In establishing acceptance criteria for defining assay interference, each assay should be assessed according to both analytical criteria and clinical relevance.
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Affiliation(s)
- Clement K M Ho
- Department of Pathology and Laboratory Medicine, KK Women's & Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | | | - Johnson W S Setoh
- Department of Pathology and Laboratory Medicine, KK Women's & Children's Hospital, Singapore
| | | | - Robert C W Hawkins
- Department of Pathology and Laboratory Medicine, KK Women's & Children's Hospital, Singapore.,Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore
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18
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Van Elslande J, Hijjit S, De Vusser K, Langlois M, Meijers B, Mertens A, Van der Schueren B, Frans G, Vermeersch P. Delayed diagnosis and treatment of extreme hypertriglyceridemia due to rejection of a lipemic sample. Biochem Med (Zagreb) 2021; 31:021002. [PMID: 33927560 PMCID: PMC8047784 DOI: 10.11613/bm.2021.021002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction Most laboratories routinely determine haemolysis, icterus and lipemia indices to identify lipemic samples and reject potentially affected results. Hypertriglyceridemia is the most common cause of lipemia and severe hypertriglyceridemia (≥ 11.3 mmol/L) is a major risk factor of acute pancreatitis. Laboratory analysis A 56-year-old woman attended the outpatient clinic for a follow-up visit 1 month after a kidney transplantation. Her immunosuppressive therapy consisted of corticosteroids, cyclosporine, and mycophenolic acid. The routine clinical chemistry sample was rejected due to extreme lipemia. The comment "extreme lipemic sample" was added on the report, but the requesting physician could not be reached. The Cobas 8000 gave a technical error (absorption > 3.3) for the HIL-indices (L-index: 38.6 mmol/L) which persisted after high-speed centrifugation. The patient was given a new appointment 2 days later. The new sample was also grossly lipemic and gave the same technical error (L-index: 35.9 mmol/L). What happened The second sample was manually diluted 20-fold after centrifugation to obtain a result for triglycerides within the measuring range (0.10-50.0 mmol/L). Triglycerides were 169.1 mmol/L, corresponding to very severe hypertriglyceridemia. This result was communicated to the nephrologist and the patient immediately recalled to the hospital. She received therapeutic plasma exchange the next day and did not develop acute pancreatitis. Main lesson This case illustrates the delicate balance between avoiding the release of unreliable results due to lipemia and the risk of delayed diagnosis when results are rejected. Providing an estimate of the degree of hypertriglyceridemia might be preferable to rejecting the result.
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Affiliation(s)
- Jan Van Elslande
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Samira Hijjit
- Clinical department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Katrien De Vusser
- Clinical department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Michel Langlois
- Department of Laboratory Medicine, AZ Sint-Jan Brugge, Belgium
| | - Björn Meijers
- Clinical department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ann Mertens
- Clinical Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Department of Laboratory Medicine, AZ Sint-Jan Brugge, Belgium.,Nutrition & Obesity Unit, Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Leuven, Belgium
| | - Glynis Frans
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Vermeersch
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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19
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Mondejar R, Mayor Reyes M, Melguizo Madrid E, Cañavate Solano C, Pérez Ramos S. Utility of icteric index in clinical laboratories: more than a preanalytical indicator. Biochem Med (Zagreb) 2021; 31:020703. [PMID: 33927553 PMCID: PMC8047785 DOI: 10.11613/bm.2021.020703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 01/31/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Total bilirubin tests are highly demanded in clinical laboratories. Since icteric index (I-index) has zero cost, we aimed to evaluate its clinical utility and cost-effectiveness to determine if total bilirubin is necessary to be tested. We took into account if haemolysis could interfere to icteric index determination. Material and methods Retrospectively we reviewed I-index results in two cohorts (43,372 and 8507 non-haemolysed and haemolysed samples, respectively). All determinations were done using Alinity c chemistry analysers (Abbott Diagnostics). Receiver operating characteristic (ROC) curve was used to determine the optimal index cut-off to discriminate between normal and abnormal bilirubin concentration (20.5 µmol/L). Results The ROC curve analysis suggested 21.4 µmol/L as the optimal I-index cut-off but differences in sensitivity and specificity were detected between patient derivation. For rejecting purpose, 15.4 µmol/L and 17.1 µmol/L I-index thresholds were selected based on patient derivation (inpatients and emergency room; and primary care and outpatients, respectively) with 97% sensitivity and 0.25% false negative results. Sensitivity was much lower in haemolysed samples. We selected 34.2 µmol/L I-index as threshold to detect hyperbilirubinemia with 99.7% specificity and 0.26% false positive results, independent of haemolysis. With the icteric index cut-offs proposed, we would save 66% of total bilirubin requested and analyse total bilirubin in around 2% of samples without total bilirubin requested. Conclusions This study supports the use of I-index to avoid bilirubin determination and to identify patients with hyperbilirubinemia. This work considers that the economic and test savings could help to increase the efficiency in clinical laboratories.
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Affiliation(s)
- Rufino Mondejar
- UGC Laboratory, Puerto Real University Hospital, Cádiz, Spain.,Committee of Personalised Medicine, Spanish Association of Medical Biopathology - Laboratory Medicine (AEBM-ML), Madrid, Spain
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20
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Mrazek C, Lippi G, Keppel MH, Felder TK, Oberkofler H, Haschke-Becher E, Cadamuro J. Errors within the total laboratory testing process, from test selection to medical decision-making - A review of causes, consequences, surveillance and solutions. Biochem Med (Zagreb) 2021; 30:020502. [PMID: 32550813 PMCID: PMC7271754 DOI: 10.11613/bm.2020.020502] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/18/2022] Open
Abstract
Laboratory analyses are crucial for diagnosis, follow-up and treatment decisions. Since mistakes in every step of the total testing process may potentially affect patient safety, a broad knowledge and systematic assessment of laboratory errors is essential for future improvement. In this review, we aim to discuss the types and frequencies of potential errors in the total testing process, quality management options, as well as tentative solutions for improvement. Unlike most currently available reviews on this topic, we also include errors in test-selection, reporting and interpretation/action of test results. We believe that laboratory specialists will need to refocus on many process steps belonging to the extra-analytical phases, intensifying collaborations with clinicians and supporting test selection and interpretation. This would hopefully lead to substantial improvements in these activities, but may also bring more value to the role of laboratory specialists within the health care setting.
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Affiliation(s)
- Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Giuseppe Lippi
- Section of Clinical Chemistry, University of Verona, Verona, Italy
| | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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21
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Çat A, Uçar KT, Gümüş A. Effect of haemolysis on an enzymatic measurement of ethanol. Biochem Med (Zagreb) 2020; 31:010704. [PMID: 33380891 PMCID: PMC7745161 DOI: 10.11613/bm.2021.010704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/22/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction We investigated the interference of haemolysis on ethanol testing carried out with the Synchron assay kit using an AU680 autoanalyser (Beckman Coulter, Brea, USA). Materials and methods Two tubes of plasma samples were collected from 20 volunteers. Mechanical haemolysis was performed in one tube, and no other intervention was performed in the other tube. After centrifugation, haemolysed and non-haemolysed samples were diluted to obtain samples with the desired free haemoglobin (Hb) values (0, 1, 2, 5, 10 g/L). A portion of these samples was then separated, and ethanol was added to the separated sample to obtain a concentration of 86.8 mmol/L ethanol. After that, these samples were diluted with ethanol-free samples with the same Hb concentration to obtain samples containing 43.4, 21.7, and 10.9 mmol/L. Each group was divided into 20 equal parts, and an ethanol test was carried out. The coefficient of variation (CV), bias, and total error (TE) values were calculated. Results The TE values of haemolysis-free samples were approximately 2-5%, and the TE values of haemolysed samples were approximately 10-18%. The bias values of haemolysed samples ranged from nearly - 6.2 to - 15.7%. Conclusions Haemolysis led to negative interference in all samples. However, based on the 25% allowable total error value specified for ethanol in the Clinical Laboratory Improvement Amendments (CLIA 88) criteria, the TE values did not exceed 25%. Consequently, ethanol concentration can be measured in samples containing free Hb up to 10 g/L.
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Affiliation(s)
- Abdulkadir Çat
- Istanbul Gaziosmanpasa Training and Research Hospital, Medical Biochemistry, Istanbul, Turkey
| | - Kamil Taha Uçar
- Istanbul Gaziosmanpasa Training and Research Hospital, Medical Biochemistry, Istanbul, Turkey
| | - Alper Gümüş
- Istanbul Gaziosmanpasa Training and Research Hospital, Medical Biochemistry, Istanbul, Turkey
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22
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Gils C, Sandberg MB, Nybo M. Verification of the hemolysis index measurement: imprecision, accuracy, measuring range, reference interval and impact of implementing analytically and clinically derived sample rejection criteria. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:580-589. [DOI: 10.1080/00365513.2020.1818281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Charlotte Gils
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Maria Boysen Sandberg
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
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23
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Dupuy AM, Bargnoux AS, Kuster N, Cristol JP, Badiou S. Determination of hemolysis cut-offs for biochemical and immunochemical analytes according to their value. ACTA ACUST UNITED AC 2020; 58:1232-1241. [DOI: 10.1515/cclm-2019-1228] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/18/2020] [Indexed: 11/15/2022]
Abstract
Abstract
Background
All general biochemistry instruments allow the measure of hemolysis index (HI), and suppliers provide an acceptable HI for each assay without consideration of the analyte value or its clinical application. Our first objective was to measure the impact of hemolysis degree on plasma biochemical and immunochemical analytes to determine the maximum allowable HI for each of them using four calculation methods as significant bias in comparison to manufacturer’s data. The second objective was to assess whether the maximum allowable HI varied according to the analyte values.
Methods
Twenty analytes were measured in hemolyzate-treated plasma to determine the HI leading to a significant change compared to baseline value. Analytes were assessed at one (3 analytes), two (5 analytes) and three (12 analytes) values according to their sensitivity to hemolysis and their clinical impact. We used four calculation methods as significant limit from baseline value: the total change limit (TCL), the 10% change (10%Δ), the analytical change limit and the reference change value.
Results
Allowable HI was significantly different according to the threshold chosen for most analytes and was also dependent on the analyte value for alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, creatine kinase, iron, haptoglobin and high sensitivity troponin T. No hemolysis interference was observed for albumin, creatinine, C-reactive protein, and procalcitonin even at an HI value of 11 g/L.
Conclusions
This study highlights that TCL is the most appropriate calculation method to determine allowable HI in practice for biochemical and immunochemical parameters using Cobas 8000© from Roche Diagnostics. In addition, different allowable HI were found according to analyte value leading to optimization of resampling to save time in patient care.
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Affiliation(s)
- Anne Marie Dupuy
- Department of Biochemistry , Lapeyronie University Hospital , Montpellier , France
| | - Anne Sophie Bargnoux
- Department of Biochemistry , Lapeyronie University Hospital , Montpellier , France
- PhyMedExp, INSERM, CNRS , University of Montpellier , Montpellier , France
| | - Nils Kuster
- Department of Biochemistry , Lapeyronie University Hospital , Montpellier , France
- PhyMedExp, INSERM, CNRS , University of Montpellier , Montpellier , France
| | - Jean Paul Cristol
- Department of Biochemistry , Lapeyronie University Hospital , 191 Avenue du Doyen Gaston Giraud , 34295 Montpellier Cedex 5 , France
- PhyMedExp, INSERM, CNRS , University of Montpellier , Montpellier , France , Fax: +33 4 67 33 83 93
| | - Stéphanie Badiou
- Department of Biochemistry , Lapeyronie University Hospital , Montpellier , France
- PhyMedExp, INSERM, CNRS , University of Montpellier , Montpellier , France
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24
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Barbato L, Campelo MD, Pigozzo S, Realdon N, Gandini A, Barbazza R, Coêlho ML, Bovo C, Marini P, Lima-Oliveira G. Rejection of hemolyzed samples can jeopardize patient safety. EJIFCC 2020; 31:15-20. [PMID: 32256285 PMCID: PMC7109497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION In vitro hemolysis is the primary cause of sample/test rejection by the laboratory. CASE REPORT A 10-year-old, admitted with an asthma attack in the emergency-room, medicated with albuterol sulphate (intravenous bronchodilator that could induce hypokalemia), needed laboratory test monitoring. The physician prescribed the technical-nurse to perform blood sampling for: complete blood count, electrolytes, glucose, and blood gas analysis-within 30min after therapy. Samples were delivered to laboratory with a note "I had difficult to locate an appropriate access to perform the blood collection". LABORATORY RESULTS Glucose: 4.77 mmol/L. Complete blood count revealed discreet eosinophilia 0.13x109/L, and thrombocytopenia 18x109/L. However, platelet clumps were observed in peripheral blood smear. Blood gas analysis was unreported, laboratory informed that sample had micro clots.Electrolytes: laboratory did not report the results; sample hemolyzed. 0.9 g/L of free hemoglobin is the cut-off defined by the laboratory; the sample presented 2.3 g/L of free hemoglobin. 3.9 mmol/L of potassium was the unreported result vs 2.1 mmol/L in the new sample.Briefly, the laboratory technician was trained to hide potassium results on hemolyzed sample due to the potential overestimation. Even if the hemolyzed sample presented a potassium value close to the lower reference range value (3.5-5.1 mmol/L), reporting the potassium result could allow the physician starting proper therapy to revert the hypokalemia by albuterol sulfate. CONCLUSION The laboratory should be aware of the clinical patient conditions and of the related physician needs, before hiding results. Therefore, both the laboratory and the clinic personnel should communicate in order to guarantee the patient safety.
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Affiliation(s)
| | - Marise Danielle Campelo
- Clinical Laboratory Bioanalise, Teresina, Piaui, Brazil,Faculdade Integral Diferencial Facid-Wyden, Teresina, Piaui, Brazil
| | - Sara Pigozzo
- Pharmacy, University Hospital of Verona, Italy, Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Italy
| | - Nicola Realdon
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Italy
| | | | | | | | - Chiara Bovo
- Health Management, University Hospital of Verona, Italy
| | | | - Gabriel Lima-Oliveira
- Faculdade Integral Diferencial Facid-Wyden, Teresina, Piaui, Brazil, Section of Clinical Biochemistry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy,Latin American Working Group for Preanalytical Phase (WG-PRE-LATAM) of the Latin America Confederation of Clinical Biochemistry (COLABIOCLI), Montevideo, Uruguay,Corresponding author: Gabriel Lima-Oliveira Section of Clinical Biochemistry Department of Neurosciences Biomedicine and Movement Sciences University of Verona Italy E-mail:
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25
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Cadamuro J, Lippi G, von Meyer A, Ibarz M, van Dongen E, Cornes M, Nybo M, Vermeersch P, Grankvist K, Guimaraes JT, Kristensen GBB, de la Salle B, Simundic AM. European survey on preanalytical sample handling - Part 1: How do European laboratories monitor the preanalytical phase? On behalf of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE). Biochem Med (Zagreb) 2019; 29:020704. [PMID: 31223258 PMCID: PMC6559617 DOI: 10.11613/bm.2019.020704] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/12/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction Compared to other activities of the testing process, the preanalytical phase is plagued by a lower degree of standardization, which makes it more vulnerable to errors. With the aim of providing guidelines and recommendations, the EFLM WG-PRE issued a survey across European medical laboratories, to gather information on local preanalytical practices. This is part one of two coherent articles, which covers all practices on monitoring preanalytical quality except haemolysis, icterus and lipemia (HIL). Materials and methods An online survey, containing 39 questions dealing with a broad spectrum of preanalytical issues, was disseminated to EFLM member countries. The survey included questions on willingness of laboratories to engage in preanalytical issues. Results Overall, 1405 valid responses were received from 37 countries. 1265 (94%) responders declared to monitor preanalytical errors. Assessment, documentation and further use of this information varied widely among respondents and partially among countries. Many responders were interested in a preanalytical online platform, holding information on various aspects of the preanalytical phase (N = 1177; 87%), in a guideline for measurement and evaluation of preanalytical variables (N = 1235; 92%), and in preanalytical e-learning programs or webinars (N = 1125; 84%). Fewer responders were interested in, or already participating in, preanalytical EQA programs (N = 951; 71%). Conclusion Although substantial heterogeneity was found across European laboratories on preanalytical phase monitoring, the interest in preanalytical issues was high. A large majority of participants indicated an interest in new guidelines regarding preanalytical variables and learning activities. This important data will be used by the WG-PRE for providing recommendations on the most critical issues.
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Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Giuseppe Lippi
- Section of Clinical Chemistry, University of Verona, Verona, Italy
| | - Alexander von Meyer
- Institute of Laboratory Medicine, Kliniken Nordoberpfalz AG and Klinikum St. Marien, Weiden and Amberg, Germany
| | - Mercedes Ibarz
- Department of Laboratory Medicine, University Hospital Arnau de Vilanova, IRBLleida, Lleida, Spain
| | - Edmee van Dongen
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria.,Section of Clinical Chemistry, University of Verona, Verona, Italy.,Institute of Laboratory Medicine, Kliniken Nordoberpfalz AG and Klinikum St. Marien, Weiden and Amberg, Germany.,Department of Laboratory Medicine, University Hospital Arnau de Vilanova, IRBLleida, Lleida, Spain.,Department of Clinical Chemistry, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Clinical Chemistry Department, Worcestershire Acute Hospitals NHS Trust, Worcester, UK.,Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Medical Biosciences, Clinical Chemistry, Umea University, Umea, Sweden.,Department of Clinical Pathology, São João Hospital Center, Department of Biomedicine, Faculty of Medicine, and EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal.,Norwegian Quality Improvement of laboratory examinations (Noklus), Bergen, Norway.,UK NEQAS Haematology, West Hertfordshire Hospitals NHS Trust, operating UK NEQAS for Haematology and Transfusion, Watford, UK.,Department of Medical Laboratory Diagnostics, University Hospital Sveti Duh, Zagreb, Croatia
| | | | - Michael Cornes
- Clinical Chemistry Department, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Pieter Vermeersch
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Kjell Grankvist
- Department of Medical Biosciences, Clinical Chemistry, Umea University, Umea, Sweden
| | - Joao Tiago Guimaraes
- Department of Clinical Pathology, São João Hospital Center, Department of Biomedicine, Faculty of Medicine, and EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Gunn B B Kristensen
- Norwegian Quality Improvement of laboratory examinations (Noklus), Bergen, Norway
| | - Barbara de la Salle
- UK NEQAS Haematology, West Hertfordshire Hospitals NHS Trust, operating UK NEQAS for Haematology and Transfusion, Watford, UK
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, University Hospital Sveti Duh, Zagreb, Croatia
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