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Umemura H, Takahashi H, Fukuda Y, Soma H, Aoki R, Takei N, Nakayama T. Use of finer needles for venipuncture increases in vitro haemolysis despite reducing persistent pain and nerve injury: A retrospective study. Ann Clin Biochem 2024; 61:107-114. [PMID: 37542363 DOI: 10.1177/00045632231196045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
BACKGROUND Although venipuncture is minimally invasive, and is the most frequently performed medical procedure, it carries the small risk of causing persistent pain, including nerve damage. Recently, our hospital stopped using 22-gauge needles for venipuncture in outpatients and switched to using only 23- and 25-gauge needles. We investigated the impact of using only the finer needles on the incidence of persistent or neuropathic pain and the prevalence of haemolysis, as well as the impact of haemolysis associated with the needle change on other laboratory data. METHODS We retrospectively collected and analysed data on venipuncture-associated pain complaints made during the 1-year period prior and 1-year period after the change in needles, as well as the frequency of haemolysis before and after the change. We also focused on 90 cases that showed significant haemolysis after the needle change and compared the serum aspartate aminotransferase, lactate dehydrogenase, and potassium levels before and after the needle change. RESULTS The incidence of persistent pain was significantly reduced from 1 in 10,825 venipunctures before the change to 1 in 29,747 venipunctures after the change. Notably, no patients experienced neuropathic pain after the change. However, the prevalence of haemolysis was significantly increased. Additionally, the serum aspartate aminotransferase, lactate dehydrogenase, and potassium levels were significantly elevated in the cases that showed moderate to gross haemolysis after the needle change. CONCLUSION Using finer needles involves both advantages and disadvantages, and careful consideration is needed to determine which type of needle is in the best interests of the patient.
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Affiliation(s)
- Hiroshi Umemura
- Division of Laboratory Medicine, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiromichi Takahashi
- Division of Laboratory Medicine, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshiaki Fukuda
- Department of Clinical Laboratory, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Hitoshi Soma
- Department of Clinical Laboratory, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Rumiko Aoki
- Department of Clinical Laboratory, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Norihisa Takei
- Department of Clinical Laboratory, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Tomohiro Nakayama
- Division of Laboratory Medicine, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
- Department of Clinical Laboratory, Nihon University Itabashi Hospital, Tokyo, Japan
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2
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Monaghan JF, Cullen D, Wynne C, Lyng FM, Meade AD. Effect of pre-analytical variables on Raman and FTIR spectral content of lymphocytes. Analyst 2023; 148:5422-5434. [PMID: 37750362 DOI: 10.1039/d3an00686g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
The use of Fourier transform infrared (FTIR) and Raman spectroscopy (RS) for the analysis of lymphocytes in clinical applications is increasing in the field of biomedicine. The pre-analytical phase, which is the most vulnerable stage of the testing process, is where most errors and sample variance occur; however, it is unclear how pre-analytical variables affect the FTIR and Raman spectra of lymphocytes. In this study, we evaluated how pre-analytical procedures undertaken before spectroscopic analysis influence the spectral integrity of lymphocytes purified from the peripheral blood of male volunteers (n = 3). Pre-analytical variables investigated were associated with (i) sample preparation, (blood collection systems, anticoagulant, needle gauges), (ii) sample storage (fresh or frozen), and (iii) sample processing (inter-operator variability, time to lymphocyte isolation). Although many of these procedural pre-analytical variables did not alter the spectral signature of the lymphocytes, evidence of spectral effects due to the freeze-thaw cycle, in vitro culture inter-operator variability and the time to lymphocyte isolation was observed. Although FTIR and RS possess clinical potential, their translation into a clinical environment is impeded by a lack of standardisation and harmonisation of protocols related to the preparation, storage, and processing of samples, which hinders uniform, accurate, and reproducible analysis. Therefore, further development of protocols is required to successfully integrate these techniques into current clinical workflows.
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Affiliation(s)
- Jade F Monaghan
- School of Physics, Clinical and Optometric Sciences, Technological University Dublin, Central Quad, City Campus, Grangegorman, D07 XT95, Ireland.
- Radiation and Environmental Science Centre, Focas Research Institute, Technological University Dublin, Aungier Street, D02 HW71, Ireland
| | - Daniel Cullen
- School of Physics, Clinical and Optometric Sciences, Technological University Dublin, Central Quad, City Campus, Grangegorman, D07 XT95, Ireland.
- Radiation and Environmental Science Centre, Focas Research Institute, Technological University Dublin, Aungier Street, D02 HW71, Ireland
| | - Claire Wynne
- School of Biological, Health and Sports Sciences, Technological University Dublin, Central Quad, City Campus, Grangegorman, D07 XT95, Ireland
| | - Fiona M Lyng
- School of Physics, Clinical and Optometric Sciences, Technological University Dublin, Central Quad, City Campus, Grangegorman, D07 XT95, Ireland.
- Radiation and Environmental Science Centre, Focas Research Institute, Technological University Dublin, Aungier Street, D02 HW71, Ireland
| | - Aidan D Meade
- School of Physics, Clinical and Optometric Sciences, Technological University Dublin, Central Quad, City Campus, Grangegorman, D07 XT95, Ireland.
- Radiation and Environmental Science Centre, Focas Research Institute, Technological University Dublin, Aungier Street, D02 HW71, Ireland
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Schlüter K, Cadamuro J. Erroneous potassium results: preanalytical causes, detection, and corrective actions. Crit Rev Clin Lab Sci 2023; 60:442-465. [PMID: 37042478 DOI: 10.1080/10408363.2023.2195936] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023]
Abstract
Potassium is one of the most requested laboratory tests. Its level is carefully monitored and maintained in a narrow physiological range. Even slightly altered potassium values may severely impact the patient's health, which is why an accurate and reliable result is of such importance. Even if high-quality analytics are available, there are still numerous ways in which potassium measurements may be biased, all of which occur in the preanalytical phase of the total laboratory testing process. As these results do not reflect the patient's in-vivo status, such results are referred to as pseudo-hyper/hypokalemia or indeed pseudo-normokalemia, depending on the true potassium result. Our goal in this review is to present an in-depth analysis of preanalytical errors that may result in inaccurate potassium results. After reviewing existing evidence on this topic, we classified preanalytical errors impacting potassium results into 4 categories: 1) patient factors like high platelet, leukocytes, or erythrocyte counts; 2) the sample type 3) the blood collection procedure, including inappropriate equipment, patient preparation, sample contamination and others and 4) the tube processing. The latter two include sample transport and storage conditions of whole blood, plasma, or serum as well as sample separation and subsequent preanalytical processes. In particular, we discuss the contribution of hemolysis, as one of the most frequent preanalytical errors, to pseudo-hyperkalemia. We provide a practical flow chart and a tabular overview of all the discussed preanalytical errors including possible underlying mechanisms, indicators for detection, suggestions for corrective actions, and references to the according evidence. We thereby hope that this manuscript will serve as a resource in the prevention and investigation of potentially biased potassium results.
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Affiliation(s)
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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4
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Kirchhoff D, Baser R, Hall S, Kwong D, Ramanathan L, McCash S. Comparison of a Novel Thin-Walled 25-gauge Needle Push Button Blood Collection Set to a Standard 23-gauge Needle in a Cancer Patient Population. J Appl Lab Med 2023; 8:264-271. [PMID: 36680315 PMCID: PMC11066949 DOI: 10.1093/jalm/jfac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/13/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Phlebotomy can be an uncomfortable and even painful experience that increases in likelihood in patients who require frequent blood draws, such as those with cancer. The 25-gauge BD Vacutainer® UltraTouch™ Push Button Blood Collection Set has a smaller outer bore needle size and unique bevel configuration, which in theory should reduce pain associated with phlebotomy. Smaller needles typically cause less pain, however, they have a higher incidence of compromising the specimen integrity. Innovative engineering allows this particular needle to maintain a larger inner bore size similar to a standard 23-gauge needle. This study compares pain and specimen integrity between this novel device and a standard 23-gauge needle. METHODS Two cohorts of 190 patients each had phlebotomy performed with either needle. Pain experienced was assessed by patient surveys, rating pain from 0 (low) to 10 (high). Sample integrity was assessed by determining the hemolysis index (Abbott Architect c8000). RESULTS No statistically significant difference in median pain scores was observed between the 2 cohorts, P-value: 0.068. The 23-gauge cohort more frequently reported 3+ pain than the 25-gauge cohort, 14/190 vs 5/190. Pain scoring 1 and 2 was more frequent in the 25-gauge cohort, 84/190 vs 54/190. Pain scores of 0 were more frequent in the 23-gauge cohort, 122/190 vs 101/190. This stratification is statistically significant, P-value: 0.003. The 25-gauge needle showed no increase in hemolysis rates, P-value: 0.5. CONCLUSIONS Sample integrity was identical between both needles. The 25-gauge needle resulted in less 3+ pain, while pain scoring 1 and 2 was more frequent in the 25-gauge cohort.
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Affiliation(s)
- Daniel Kirchhoff
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raymond Baser
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shannon Hall
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Kwong
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lakshmi Ramanathan
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sam McCash
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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5
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Wauthier L, Favresse J, Hardy M, Douxfils J, Le Gal G, Roy P, van Es N, Ay C, ten Cate H, Lecompte T, Lippi G, Mullier F. D-dimer testing: A narrative review. Adv Clin Chem 2023. [DOI: 10.1016/bs.acc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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6
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D-dimer Testing in Pulmonary Embolism with a Focus on Potential Pitfalls: A Narrative Review. Diagnostics (Basel) 2022; 12:diagnostics12112770. [PMID: 36428830 PMCID: PMC9689068 DOI: 10.3390/diagnostics12112770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
D-dimer is a multifaceted biomarker of concomitant activation of coagulation and fibrinolysis, which is routinely used for ruling out pulmonary embolism (PE) and/or deep vein thrombosis (DVT) combined with a clinical pretest probability assessment. The intended use of the tests depends largely on the assay used, and local guidance should be applied. D-dimer testing may suffer from diagnostic errors occurring throughout the pre-analytical, analytical, and post-analytical phases of the testing process. This review aims to provide an overview of D-dimer testing and its value in diagnosing PE and discusses the variables that may impact the quality of its laboratory assessment.
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7
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Kadwa AR, Grace JF, Zeiler GE. Sources of error in acid-base analysis from a blood gas analyser result: a narrative review. J S Afr Vet Assoc 2022; 93:89-98. [DOI: 10.36303/jsava.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Affiliation(s)
- AR Kadwa
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria,
South Africa
- Section of Anaesthesia and Critical Care, Valley Farm Animal Hospital,
South Africa
| | - JF Grace
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria,
South Africa
- Section of Anaesthesia and Critical Care, Valley Farm Animal Hospital,
South Africa
| | - GE Zeiler
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria,
South Africa
- Section of Anaesthesia and Critical Care, Valley Farm Animal Hospital,
South Africa
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8
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Deng Y, Lv Z, Cheng Y, Liu A, Huang Z. Clinical Application of a Safe Blood Sampling Device with an Indwelling Needle. Appl Bionics Biomech 2022; 2022:6362905. [PMID: 36091628 PMCID: PMC9458410 DOI: 10.1155/2022/6362905] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/27/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
Background The traditional indwelling needle catheter is hard and can only complete one puncture at a time. The safety and indwelling needle catheter is soft, with a large lumen, with high success rate of blood collection, and one puncture completes two operations, so it is of important value and significance to study the new safety and indwelling needle. To explore the clinical utility of a novel blood collection device with indwelling needle for blood collection among pediatric patients. Methods A total of 300 children who were admitted to the children's hospital from March to June 2020 were selected and randomly divided into the control group (148) and the observation group (152). The control group received venipuncture using regular needles for infusion and blood collection. For the observation group, a modified indwelling needle device was used for the procedures. Comparisons were made between the two devices in five aspects: blood sample quality, operation time, needlestick incidence, related complications, and patient satisfaction. Results There was no significant difference in coagulation rate between the two groups, but slightly lower overall hemolysis incidence in the observation group. The unqualified rate of blood specimens collected in the observation group was 10.0% lower than that in the control group (P < 0.05). Shorter operation time, lower incidence of needlestick injuries, and improved satisfaction were observed in the group using the novel blood collection device. Conclusions This modified blood collection device is superior to the regular venipuncture needle, in terms of safety, efficiency, and patient satisfaction; thus, it has potential for broad clinical applications for infusion and blood collection.
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Affiliation(s)
- Yeqin Deng
- Anhui Maternal and Child Health Hospital, Anhui Medical University, Hefei, Anhui, China
| | - Zhengbing Lv
- Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Yue Cheng
- Anhui Maternal and Child Health Hospital, Anhui Medical University, Hefei, Anhui, China
| | - Annuo Liu
- School of Nursing, Anhui Medical University, Hefei, Anhui, China
| | - Zhengling Huang
- Anhui Maternal and Child Health Hospital, Anhui Medical University, Hefei, Anhui, China
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9
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Lucas F, Mata DA, Greenblatt MB, Means J, Jarolim P. A Potassium-Based Quality-of-Service Metric Reduces Phlebotomy Errors, Resulting in Improved Patient Safety and Decreased Cost. Am J Clin Pathol 2022; 157:789-798. [PMID: 34932068 DOI: 10.1093/ajcp/aqab194] [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: 09/02/2021] [Accepted: 12/08/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Poor phlebotomy technique can introduce pseudohyperkalemia without hemolysis, requiring additional workup and placing a significant burden on patients, clinical teams, and laboratories. Such preanalytical biases can be detected through systematic evaluation of potassium concentrations on a per-phlebotomist basis. We report our long-term experience with a potassium-based quality-of-service phlebotomy metric and its effects on resource utilization. METHODS Potassium monitoring and retraining of 26 full-time phlebotomists were piloted as a quality-of-service intervention. Changes in potassium concentrations and impact on resource utilization were assessed. An algorithm for data monitoring and phlebotomist feedback was developed, followed by institution-wide implementation. RESULTS Systematic intervention and retraining normalized K+ concentrations and lowered the percentage of venipunctures with K+ above 5.2 mmol/L, leading to a marked increase in phlebotomist compliance. This change resulted in resources savings of 13% to 100% for individual phlebotomists, reducing the total extra laboratory time required for repeat phlebotomies to determine hyperkalemia, mostly in the high-volume phlebotomist group. CONCLUSIONS A quality-of-service algorithm that involved monitoring potassium concentrations on a per-phlebotomist basis with feedback and retraining contributed to a concrete, data-based quality improvement plan. The institution-wide implementation of this metric allowed for significant cost savings and a reduction in critical value alerts, directly affecting the quality of patient care.
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Affiliation(s)
- Fabienne Lucas
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Matthew B Greenblatt
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
- Research Division, Hospital for Special Surgery, New York, NY, USA
| | - Janet Means
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
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10
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Nikolac Gabaj N, Miler M, Vrtaric A, Celap I, Bocan M, Filipi P, Radisic Biljak V, Simundic AM, Supak Smolcic V, Kocijancic M. Comparison of three different protocols for obtaining hemolysis. Clin Chem Lab Med 2022; 60:714-725. [PMID: 35212494 DOI: 10.1515/cclm-2021-1227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Hemolysis is associated with erroneous or delayed results. Objectives of the study were to compare four different methods for obtaining hemolysis in vitro on three different analyzers. METHODS Hemolysis was prepared with addition of pure hemoglobin into serum pool, osmotic shock, aspiration through blood collection needle, freezing/thawing of whole blood. Biochemistry parameters were measured in duplicate at Architect c8000 (Abbott, Abbott Park, USA), Beckman Coulter AU680 (Beckman Coulter, Brea, USA) and Cobas 6000 c501 (Roche, Mannheim, Germany), according to manufacturers' declarations. Cut-off value was defined as the highest value of H index with corresponding bias lower than acceptance criteria. RESULTS We were not able to obtain results with freezing protocol. On all three platforms, lowest number of analytes were sensitive to hemolysis at H=0.5 using method of adding free hemoglobin. When osmotic shock was used, cut-off values for the most analytes were generally met at lower values. Hemolysis significantly interfered with measurement of potassium and lactate dehydrogenase (LD) at H=0.5 on all platforms. The most of the tested analytes had the lowest acceptable H index when aspiration method was used. At the low level of hemolysis (H=0.8) glucose, sodium, potassium, chloride, phosphate, and LD were affected on all analyzers, with some additional analytes depending on the manufacturer. CONCLUSIONS Hemolysis interference differs on different analyzers and according to protocol for obtaining hemolysis. Aspiration method was generally the most sensitive to hemolysis interference, while addition of free Hb was the most resistant.
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Affiliation(s)
- Nora Nikolac Gabaj
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Marijana Miler
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Alen Vrtaric
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ivana Celap
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Marina Bocan
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Medical Biochemistry Laboratory, Polyclinic Salzer, Zagreb, Croatia
| | - Petra Filipi
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Department of Medical Laboratory Diagnostics, University Hospital Centre Split, Split, Croatia
| | - Vanja Radisic Biljak
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Department of Medical Laboratory Diagnostics, University Hospital "Sveti Duh", Zagreb, Croatia
| | - Ana-Maria Simundic
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
- Department of Medical Laboratory Diagnostics, University Hospital "Sveti Duh", Zagreb, Croatia
| | - Vesna Supak Smolcic
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Clinical Department of Laboratory Diagnostics, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Medical Informatics, Rijeka University School of Medicine, Rijeka, Croatia
| | - Marija Kocijancic
- Working Group for Preanalytical Phase of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia
- Department of Laboratory Medicine, Central Laboratory, University Clinic Halle, Halle, Germany
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11
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Lappas NT, Lappas CM. Analytical Samples. Forensic Toxicol 2022. [DOI: 10.1016/b978-0-12-819286-3.00012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Merrill VD, Ward MD, Diaz-McNair J, Pickett EA, Duh SH, Christenson RH. Assessing Phlebotomy Device Preference and Specimen Quality in an Oncology Outpatient Clinic. J Appl Lab Med 2021; 7:532-540. [PMID: 34632493 DOI: 10.1093/jalm/jfab109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/17/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Oncology patients have frequent venipunctures, which causes scarring, making subsequent draws difficult and painful. Novel blood collection systems may decrease discomfort in patients experiencing repeat blood draws. METHODS Oncology outpatients (n = 101; criteria excluded 12) were recruited to determine their preference for either of two blood collection systems, the 23-gauge standard BD Vacutainer Push Button Blood Collection Set (Standard Push Button system) or the 25-gauge BD Vacutainer UltraTouch Push Button Blood Collection Set (UltraTouch Push Button system). Subjects received two blinded, randomized blood draws, one with each device and just one device for each arm. Subjects subsequently rated their blinded preference for blood collection system. Specimen quality was assessed for each device with measurements for plasma hemoglobin (Shimadzu UV-1800 spectrophotometer, Shimadzu), lactate dehydrogenase, and potassium (Vitros 4600/5600 analyzer, Ortho Diagnostics). RESULTS Preference for the 25-gauge UltraTouch Push Button system over the 23-gauge Standard Push Button system was significant (UltraTouch, n = 51; Standard n = 30; no preference, n = 8; P = 0.0196). Regarding sample quality, the 25-gauge UltraTouch Push Button system had significantly lower plasma hemoglobin (average 5.34 mg/dL) vs the 23-gauge Standard Push Button system (9.37 mg/dL; P < 0.0001); serum lactate dehydrogenase and potassium differences were not statistically significant. CONCLUSION Subjects in an oncology clinic preferred phlebotomy with the 25-gauge UltraTouch Push Button system, and samples using this device had less hemolysis as assessed by plasma hemoglobin.
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Affiliation(s)
- VeRonika D Merrill
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew D Ward
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jovita Diaz-McNair
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth A Pickett
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Show-Hong Duh
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
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Piskunov DP, Danilova LA, Pushkin AS, Rukavishnikova SA. Influence of exogenous and endogenous factors on the quality of the preanalytical stage of laboratory tests (review of literature). Klin Lab Diagn 2020; 65:778-784. [PMID: 33373510 DOI: 10.18821/0869-2084-2020-65-12-778-784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A literature review in the article presents an analysis of the influence of endogenous and exogenous factors on quality of preanalytical phase of laboratory testing. The review shows significance of external and internal factors influencing blood samples at preanalytical phase of laboratory testing. Among the exogenous factors considered: phlebotomy, test tubes for samples, transportation and storage. A number of factors exist at this phase that significantly affect test results. We examined these aspects of phlebotomy process: staff training, disinfectant contamination, needle diameter, needle material contamination. The review considers possible contamination with tube components and the importance of choosing the right anticoagulants and excipients. Transportation and storage of biological samples can be a source of errors at the preanalytical phase of laboratory testing. We analyzed the problem of determining the stability of analytes during storage and aspects of transportation samples by modern means. Among the endogenous factors considered: hemolysis, lipemia, icterricity, cell metabolism.. Hemolysis is one of the most frequent consequences of errors at the preanalytical phase. We analyzed importance of choosing a method for identifying hemolized tubes and the heterogeneity of bias results on different analytical systems. The review shows contribution of various classes of lipoproteins to turbidity of sample, possible preanalytical errors and impact on analytical tests. We examined possible effects of high bilirubin concentrations on analyte measurements. In the review, we also examined metabolism of some cells and its effect on samples.
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Affiliation(s)
- D P Piskunov
- Saint-Petersburg State Pediatric Medical University.,«City Multiprofile Hospital № 2»
| | - L A Danilova
- Saint-Petersburg State Pediatric Medical University
| | - A S Pushkin
- Pavlov First Saint-Petersburg State Medical University.,«City Multiprofile Hospital № 2»
| | - S A Rukavishnikova
- Pavlov First Saint-Petersburg State Medical University.,«City Multiprofile Hospital № 2»
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14
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Ungerer V, Bronkhorst AJ, Holdenrieder S. Preanalytical variables that affect the outcome of cell-free DNA measurements. Crit Rev Clin Lab Sci 2020; 57:484-507. [DOI: 10.1080/10408363.2020.1750558] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Vida Ungerer
- Institute for Laboratory Medicine, German Heart Centre, Technical University Munich, Munich, Germany
| | - Abel J. Bronkhorst
- Institute for Laboratory Medicine, German Heart Centre, Technical University Munich, Munich, Germany
| | - Stefan Holdenrieder
- Institute for Laboratory Medicine, German Heart Centre, Technical University Munich, Munich, Germany
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15
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Hu J, Zhang QX, Xiao TT, Pan MC, Cai YM. Residual Negative Pressure in Vacuum Blood-Collection Tube and Hemolysis in Pediatric Blood Specimens. Lab Med 2020; 51:41-46. [PMID: 31185079 DOI: 10.1093/labmed/lmz026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To determine a method to reduce specimen hemolysis rates in pediatric blood specimens. METHODS A total of 290 blood specimens from pediatric patients were classified into the capped group or uncapped group. The hemolysis index and levels of lactate dehydrogenase (LDH) were measured using an automated biochemical analyzer. Also, we performed a paired test to measure the concentration of free hemoglobin in specimens from 25 randomly selected healthy adult volunteers, using a direct spectrophotometric technique. RESULTS The hemolytic rate of capped specimens was 2-fold higher than that of uncapped specimens. We found significant differences for LDH. Also, there was a significant difference in the concentration of free hemoglobin in the random-volunteers test. CONCLUSIONS Eliminating the residual negative pressure of vacuum blood-collection tubes was effective at reducing the macrohemolysis and/or microhemolysis rate.
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Affiliation(s)
- Jing Hu
- Department of Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, China
| | - Qiao-Xin Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, China
| | - Tong-Tong Xiao
- Department of Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, China
| | - Mei-Chen Pan
- Department of Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, China
| | - Ying-Mu Cai
- Department of Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, China
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Evaluation of an improved small gauge needle for venipuncture in children with difficult venous access: Impact on sample quality, phlebotomist satisfaction and patient pain perception. Clin Chim Acta 2019; 500:213-219. [PMID: 31678576 DOI: 10.1016/j.cca.2019.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Smaller needles gauge (G) may reduce pain and improve vein access in difficult venous access (DVA). Aims were to compare the performances of two Beckton-Dickinson (BD) Vacutainer® Blood Collection Sets in a pediatric setting: UltraTouch™ Push Button (UT-PBBCS) and Safety-Lok™ (SLBCS). MATERIALS AND METHODS Questionnaires were used to record venipuncture features, patient pain perception and phlebotomist difficulty score. Specimen quality was evaluated by hemolysis index (HI) on Roche Cobas® 6000. RESULTS SLBCS (21/23G) or UT-PBBCS (23/25G) were used in 211 (50.2%) and 209 (49.8%) subjects. Pain was associated with age (p < 0.0001) and was lower in UT-PBBCS (p = 0.0339). Difficulty was significantly associated with age (p = 0.002), not with needle gauge (p = 0.461) and it was 0.42 points lower in UT-PBBCS. HI was not associated with blood collection set (p = 0.385). CONCLUSIONS UT-PBBCS globally performed better than SLBCS and could enhance phlebotomy and patient comfort, without affecting sample quality in pediatric patients with DVA.
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Simundic AM, Baird G, Cadamuro J, Costelloe SJ, Lippi G. Managing hemolyzed samples in clinical laboratories. Crit Rev Clin Lab Sci 2019; 57:1-21. [PMID: 31603708 DOI: 10.1080/10408363.2019.1664391] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hemolysis is conventionally defined as membrane disruption of red blood cells and other blood cells that is accompanied by subsequent release of intracellular components into the serum or plasma. It accounts for over 60% of blood sample rejections in the laboratory and is the most common preanalytical error in laboratory medicine. Hemolysis can occur both in vivo and in vitro. Intravascular hemolysis (in vivo) is always associated with an underlying pathological condition or disease, and thus careful steps should always be taken by the laboratory to exclude in vivo hemolysis with confidence. In vitro hemolysis, on the other hand, is highly preventable. It may occur at all stages of the preanalytical phase (i.e. sample collection, transport, handling and storage), and may lead to clinically relevant, yet spurious, changes in patient results by interfering with laboratory measurements. Hemolysis interference is exerted through several mechanisms: (1) spectrophotometric interference, (2) release of intracellular components, (3) sample dilution and (4) chemical interference. The degree of interference observed depends on the level of hemolysis and also on the assay methodology. Recent evidence shows that preanalytical practices related to detection and management of hemolyzed samples are highly heterogeneous and need to be standardized. The Working Group for Preanalytical Phase (WG-PRE) of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has published many recommendations for facilitating standardization and improvement of this important preanalytical issue. Some key EFLM WG-PRE publications related to hemolysis involve: (i) a call for more transparency and some practical recommendations for improving the harmonization of the automatic assessment of serum indices and their clinical usefulness, specifically the hemolysis index (H-index), (ii) recommendations on how to manage local quality assurance of serum or plasma hemolysis/icterus/lipemia-indices (HIL-indices) and (iii) recommendations on how to detect and manage hemolyzed samples in clinical chemistry testing. In this review we provide a comprehensive overview of hemolysis, including its causes and effects on clinical laboratory assays. Furthermore, we list and discuss the most recent recommendations aimed at managing hemolyzed samples in everyday practice. Given the high prevalence of hemolyzed blood samples, the associated costs, the great heterogeneity in how hemolysis is handled across healthcare settings, countries and continents, and increasing patient cross-border mobility, standardization and quality improvement processes aimed at combatting this important preanalytical problem are clearly warranted.
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Affiliation(s)
- Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, University Hospital "Sveti Duh", University of Zagreb, Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Geoffrey Baird
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Seán J Costelloe
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Favresse J, Lippi G, Roy PM, Chatelain B, Jacqmin H, Ten Cate H, Mullier F. D-dimer: Preanalytical, analytical, postanalytical variables, and clinical applications. Crit Rev Clin Lab Sci 2019; 55:548-577. [PMID: 30694079 DOI: 10.1080/10408363.2018.1529734] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
D-dimer is a soluble fibrin degradation product deriving from the plasmin-mediated degradation of cross-linked fibrin. D-dimer can hence be considered a biomarker of activation of coagulation and fibrinolysis, and it is routinely used for ruling out venous thromboembolism (VTE). D-dimer is increasingly used to assess the risk of VTE recurrence and to help define the optimal duration of anticoagulation treatment in patients with VTE, for diagnosing disseminated intravascular coagulation, and for screening medical patients at increased risk of VTE. This review is aimed at (1) revising the definition of D-dimer; (2) discussing preanalytical variables affecting the measurement of D-dimer; (3) reviewing and comparing assay performance and some postanalytical variables (e.g. different units and age-adjusted cutoffs); and (4) discussing the use of D-dimer measurement across different clinical settings.
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Affiliation(s)
- Julien Favresse
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Giuseppe Lippi
- b Section of Clinical Biochemistry , University Hospital of Verona , Verona , Italy
| | - Pierre-Marie Roy
- c Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC , Université d'Angers , Angers , France
| | - Bernard Chatelain
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Hugues Jacqmin
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Hugo Ten Cate
- d Department of Internal Medicine, Cardiovascular Institute , Maastricht University Medical Center , Maastricht , the Netherlands
| | - François Mullier
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
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Ustundağ Y, Huysal K, Ozgunay ŞE, Turkoğlu AR. Interchangeability of Sodium and Potassium Result Values of Arterial Blood Gas with Laboratory Analyzer: Narrative Review. Indian J Crit Care Med 2019; 23:35-42. [PMID: 31065207 PMCID: PMC6481262 DOI: 10.5005/jp-journals-10071-23110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The major extracellular electrolytes, sodium, and potassium are often requested together and form a large percentage of the requested tests in routine clinical chemistry laboratories. Two types of devices that use direct and indirect ion-selective electrode (ISE) methods are used in hospitals for electrolyte measurements: blood gas analyzers (BGA), which use direct ISE technology, and the indirect ISE method, which is often used in a central-laboratory autoanalyzer (AA). We aimed to summarize the current scientific knowledge based on whether the electrolyte test results, using Na and K test results obtained with BGA and an AA, can be used interchangeably. We searched Medline (PubMed), Google Scholar, and Web of Science up to 31st March 2018. In addition, references of the included studies were also examined. Fourteen studies with a risk of bias were included in the analysis. Limits of agreement differences were variable among BGA and AA sodium and potassium test results in clinical practice. The results of both BGA and AA measures should not be used interchangeably under the assumption that they are equivalent to each other.
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Affiliation(s)
- Yasemin Ustundağ
- Department of Clinical Biochemistry, University of Health Sciences, Bursa YuksekIhtisas Training and Research Hospital, Bursa, Turkey
| | - Kağan Huysal
- Department of Clinical Biochemistry, University of Health Sciences, Bursa YuksekIhtisas Training and Research Hospital, Bursa, Turkey
| | - Şeyda E Ozgunay
- Department of Anestesiology and Reanimation, University of Health Sciences, Bursa YuksekIhtisas Training and Research Hospital, Bursa, Turkey
| | - Ali R Turkoğlu
- Department of Urology, University of Health Sciences, Bursa YuksekIhtisas Training and Research Hospital, Bursa, Turkey
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Ialongo C, Bernardini S. Preanalytical investigations of phlebotomy: methodological aspects, pitfalls and recommendations. Biochem Med (Zagreb) 2017; 27:177-191. [PMID: 28392739 PMCID: PMC5382842 DOI: 10.11613/bm.2017.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 11/25/2016] [Indexed: 11/12/2022] Open
Abstract
Phlebotomy is often addressed as a crucial process in the pre-analytical phase, in which a large part of laboratory errors take place, but to date there is not yet a consolidated methodological paradigm. Seeking literature, we found 36 suitable investigations issued between 1996 and 2016 (April) dealing with the investigation of pre-analytical factors related to phlebotomy. We found that the largest part of studies had a cohort of healthy volunteers (22/36) or outpatients (11/36), with the former group showing a significantly smaller median sample size (N = 20, IQR: 17.5-30 and N = 88, IQR: 54.5-220.5 respectively, P < 0.001). Moreover, the largest part investigated one pre-analytical factor (26/36) and regarded more than one laboratory test (29/36), and authors preferably used paired Student’s t-test (17/36) or Wilcoxon’s test (11/36), but calibration (i.e. sample size calculation for a detectable effect) was addressed only in one manuscript. The Bland-Altman plot was often the preferred method used to estimate bias (12/36), as well as the Passing-Bablok regression for agreement (8/36). However, often papers did assess neither bias (12/36) nor agreement (24/36). Clinical significance of bias was preferably assessed comparing to a database value (16/36), and it resulted uncorrelated with the size of the effect produced by the factor (P = 0.142). However, the median effect size (ES) resulted significantly larger if the associated factor was clinically significant instead of non-significant (ES = 1.140, IQR: 0.815-1.700 and ES = 0.349, IQR: 0.228-0.531 respectively, P < 0.001). On these evidences, we discussed some recommendations for improving methodological consistency, delivering reliable results, as well as ensuring accessibility to practical evidences.
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Affiliation(s)
- Cristiano Ialongo
- Department of Human Physiology and Pharmacology, University of Rome Sapienza, Rome, Italy; Laboratory Medicine Department, "Tor Vergata" University Hospital, Rome, Italy
| | - Sergio Bernardini
- Laboratory Medicine Department, "Tor Vergata" University Hospital, Rome, Italy; Experimental Medicine and Surgery Department, "Tor Vergata" University, Rome, Italy
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Mouser A, Uettwiller-Geiger D, Plokhoy E, Berube J, Ahuja AJ, Stankovic AK. Evaluation of Pain and Specimen Quality by Use of a Novel 25-Gauge Blood Collection Set With Ultra-Thin Wall Cannula and 5-Bevel Tip Design. J Appl Lab Med 2017; 2:201-210. [PMID: 32630975 DOI: 10.1373/jalm.2017.023564] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/05/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Phlebotomy has significant impact on overall patient satisfaction. Smaller gauge needles, such as a 25 gauge, may lessen patient discomfort but increase hemolysis and tube-filling times. Our studies evaluated the effect of a 5-bevel, 25-gauge blood collection set (BCS) with ultra-thin wall cannula [BD Vacutainer® UltraTouch™ Push Button BCS (UltraTouch)] on patient pain and anxiety compared with two 3-bevel, thin-wall, 23-gauge BCSs [BD Vacutainer® Safety-Lok™ (Safety-Lok) and Greiner Bio-One Vacuette® (Vacuette)]. Our studies also evaluated the 25-gauge UltraTouch for sample quality and tube filling compared with the 3-bevel, thin-wall, 23-gauge BD Vacutainer Push Button BCS. METHODS We conducted 2 studies with 214 subjects to compare pain and anxiety regarding future phlebotomy with the 3 aforementioned devices. Another study with 52 subjects assessed hemolysis in specimens collected with the UltraTouch and Push Button BCS; bench testing evaluated tube-filling times with these devices. A questionnaire captured pain upon needle insertion, overall pain, and anxiety regarding future phlebotomy. Hemolysis was evaluated visually, by Hemolysis Index and hemolysis-sensitive indicators potassium (K) and lactate dehydrogenase (LDH). RESULTS A statistically significant decrease was noted for overall pain with UltraTouch compared with Vacuette and with insertion pain compared with Safety-Lok. There was no significant difference in anxiety regarding future phlebotomy. No increase was observed in Hemolysis Index, K or LDH. Tube-filling times were comparable for each device. CONCLUSIONS The 25-gauge UltraTouch provided less overall pain compared with the 23-gauge Vacuette, less pain upon needle insertion than the 23-gauge Safety-Lok, and no compromise in specimen quality or flow rate.
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Affiliation(s)
- Amy Mouser
- BD Life Sciences-Preanalytical Systems, Franklin Lakes, NJ
| | | | | | - Julie Berube
- BD Life Sciences-Preanalytical Systems, Franklin Lakes, NJ
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Lima-Oliveira G, Volanski W, Lippi G, Picheth G, Guidi GC. Pre-analytical phase management: a review of the procedures from patient preparation to laboratory analysis. Scand J Clin Lab Invest 2017; 77:153-163. [PMID: 28266238 DOI: 10.1080/00365513.2017.1295317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The pre-analytical phase encompasses all the procedures before the start of laboratory testing. This phase of the testing process is responsible for the majority of the laboratory errors, since the related procedures involve many sorts of non-laboratory professionals working outside the laboratory setting, thus without direct supervision by the laboratory staff. Therefore, either correct organization or management of both personnel and procedures that regard blood specimen collection by venipuncture are of fundamental importance, since the various steps for performing blood collection represent per se sources of laboratory variability. The aim of this (non-systematic) review addressed to healthcare professionals is to highlight the importance of blood specimen management (from patient preparation to laboratory analyses), as a tool to prevent laboratory errors, with the concept that laboratory results from inappropriate blood specimens are inconsistent and do not allow proper treatment nor monitoring of the patient.
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Affiliation(s)
- Gabriel Lima-Oliveira
- a Post-Graduate Program of Pharmaceutical Sciences, Department of Clinical Analyses , Federal University of Parana , Curitiba , Parana , Brazil
- b Laboratory of Clinical Biochemistry, Department of Neurosciences, Biomedicine and Movement Sciences , University of Verona , Italy
| | - Waldemar Volanski
- a Post-Graduate Program of Pharmaceutical Sciences, Department of Clinical Analyses , Federal University of Parana , Curitiba , Parana , Brazil
| | - Giuseppe Lippi
- b Laboratory of Clinical Biochemistry, Department of Neurosciences, Biomedicine and Movement Sciences , University of Verona , Italy
| | - Geraldo Picheth
- a Post-Graduate Program of Pharmaceutical Sciences, Department of Clinical Analyses , Federal University of Parana , Curitiba , Parana , Brazil
| | - Gian Cesare Guidi
- a Post-Graduate Program of Pharmaceutical Sciences, Department of Clinical Analyses , Federal University of Parana , Curitiba , Parana , Brazil
- b Laboratory of Clinical Biochemistry, Department of Neurosciences, Biomedicine and Movement Sciences , University of Verona , Italy
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Yeung RSM, Albani S, Feldman BM, Mellins E, Prakken B, Wedderburn LR. Enhancing translational research in paediatric rheumatology through standardization. Nat Rev Rheumatol 2016; 12:684-690. [PMID: 27652504 DOI: 10.1038/nrrheum.2016.156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The past decade has seen many successes in translational rheumatology, from dramatic improvements in outcomes brought about by novel biologic therapies, to the discovery of new monogenic inflammatory disorders. Advances in molecular medicine, combined with progress towards precision care, provide an excellent opportunity to accelerate the translation of biological understanding to the bedside. However, although the field of rheumatology is a leader in the standardization of data collection and measures of disease activity, it lags behind in standardization of biological sample collection and assay performance. Uniform approaches are necessary for robust collaborative research, particularly in rare diseases. Standardization is also critical to increase reproducibility between centres, a prerequisite for clinical implementation of translational research. This Perspectives article emphasizes the need for standardization and implementation of best practices, presented in the context of lessons learned from international biorepository networks.
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Affiliation(s)
- Rae S M Yeung
- Department of Paediatrics, Division of Rheumatology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; and at the Department of Immunology and the Institute of Medical Science, University of Toronto Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Salvatore Albani
- Duke-National University of Singapore Graduate Medical School, 8 College Road, 169857, Singapore
| | - Brian M Feldman
- Department of Paediatrics and Institute of Medical Science, University of Toronto Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada; the Division of Rheumatology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; and at the Institute of Health Policy Management and Evaluation, The Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada
| | - Elizabeth Mellins
- Department of Pediatrics and the Stanford Program in Immunology, Stanford University, 300 Pasteur Drive, Stanford, California 94305, USA
| | - Berent Prakken
- Department of Immunology, University Medical Centre, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Lucy R Wedderburn
- Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
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Ialongo C, Bernardini S. Phlebotomy, a bridge between laboratory and patient. Biochem Med (Zagreb) 2016; 26:17-33. [PMID: 26981016 PMCID: PMC4783087 DOI: 10.11613/bm.2016.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/06/2015] [Indexed: 12/28/2022] Open
Abstract
The evidence-based paradigm has changed and evolved medical practice. Phlebotomy, which dates back to the age of ancient Greece, has gained experience through the evolution of medicine becoming a fundamental diagnostic tool. Nowadays it connects the patient with the clinical laboratory dimension building up a bridge. However, more often there is a gap between laboratory and phlebotomist that causes misunderstandings and burdens on patient safety. Therefore, the scope of this review is delivering a view of modern phlebotomy to "bridge" patient and laboratory. In this regard the paper describes devices, tools and procedures in the light of the most recent scientific findings, also discussing their impact on both quality of blood testing and patient safety. It also addresses the issues concerning medical aspect of venipuncture, like the practical approach to the superficial veins anatomy, as well as the management of the patient's compliance with the blood draw. Thereby, the clinical, technical and practical issues are treated with the same relevance throughout the entire paper.
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Affiliation(s)
- Cristiano Ialongo
- Laboratory Medicine Department, "Tor Vergata" University Hospital, Rome, Italy
| | - Sergio Bernardini
- Laboratory Medicine Department, "Tor Vergata" University Hospital, Rome, Italy; Experimental Medicine and Surgery Department, "Tor Vergata" University, Rome, Italy
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Herpel E, Schmitt S, Kiehntopf M. Qualität von Biomaterialien im Biobanking von Flüssig- und Gewebeproben. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 59:325-35. [PMID: 26753866 DOI: 10.1007/s00103-015-2294-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Esther Herpel
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Gewebebank des Nationalen Centrums für Tumorerkrankungen (NCT), Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Sabrina Schmitt
- Gewebebank des Nationalen Centrums für Tumorerkrankungen (NCT), Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Michael Kiehntopf
- Institut für Klinische Chemie und Laboratoriumsdiagnostik, Universitätsklinikum Jena, Jena, Deutschland.
- Integrierte Biobank Jena (IBBJ), Universitätsklinikum Jena, Jena, Deutschland.
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Penn AM, Lu L, Chambers AG, Balshaw RF, Morrison JL, Votova K, Wood E, Smith DS, Lesperance M, del Zoppo GJ, Borchers CH. Exploring phlebotomy technique as a pre-analytical factor in proteomic analyses by mass spectrometry. Genome 2015; 58:569-76. [PMID: 26484650 DOI: 10.1139/gen-2015-0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Multiple reaction monitoring mass spectrometry (MRM-MS) is an emerging technology for blood biomarker verification and validation; however, the results may be influenced by pre-analytical factors. This exploratory study was designed to determine if differences in phlebotomy techniques would significantly affect the abundance of plasma proteins in an upcoming biomarker development study. Blood was drawn from 10 healthy participants using four techniques: (1) a 20-gauge IV with vacutainer, (2) a 21-gauge direct vacutainer, (3) an 18-gauge butterfly with vacutainer, and (4) an 18-gauge butterfly with syringe draw. The abundances of a panel of 122 proteins (117 proteins, plus 5 matrix metalloproteinase (MMP) proteins) were targeted by LC/MRM-MS. In addition, complete blood count (CBC) data were also compared across the four techniques. Phlebotomy technique significantly affected 2 of the 11 CBC parameters (red blood cell count, p = 0.010; hemoglobin concentration, p = 0.035) and only 12 of the targeted 117 proteins (p < 0.05). Of the five MMP proteins, only MMP7 was detectable and its concentration was not significantly affected by different techniques. Overall, most proteins in this exploratory study were not significantly influenced by phlebotomy technique; however, a larger study with additional patients will be required for confirmation.
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Affiliation(s)
- Andrew M Penn
- a Department of Neurosciences, Stroke Rapid Assessment Unit (SRAU), Island Health, 1 Hospital Way, Victoria, BC V8Z 6R5, Canada
| | - Linghong Lu
- b Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada
| | - Andrew G Chambers
- c University of Victoria, Genome British Columbia Proteomics Centre, Vancouver Island Technology Park, #3101 - 4464 Markham St., Victoria, BC V8Z 7X8, Canada
| | - Robert F Balshaw
- d BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada
| | - Jaclyn L Morrison
- b Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada
| | - Kristine Votova
- b Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada
| | - Eileen Wood
- e Department of Laboratory Medicine, Pathology and Medical Genetics, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada
| | - Derek S Smith
- c University of Victoria, Genome British Columbia Proteomics Centre, Vancouver Island Technology Park, #3101 - 4464 Markham St., Victoria, BC V8Z 7X8, Canada
| | - Maria Lesperance
- b Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada
| | - Gregory J del Zoppo
- f Division of Hematology/Department of Medicine, Department of Neurology, University of Washington School of Medicine, 1959 N.E. Pacific Street, Seattle, WA 98195, USA
| | - Christoph H Borchers
- b Department of Research and Capacity Building, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada.,c University of Victoria, Genome British Columbia Proteomics Centre, Vancouver Island Technology Park, #3101 - 4464 Markham St., Victoria, BC V8Z 7X8, Canada.,g Department of Biochemistry and Microbiology, University of Victoria, Petch Building Room 207, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada
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Ellervik C, Vaught J. Preanalytical Variables Affecting the Integrity of Human Biospecimens in Biobanking. Clin Chem 2015; 61:914-34. [DOI: 10.1373/clinchem.2014.228783] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 04/13/2015] [Indexed: 12/20/2022]
Abstract
Abstract
BACKGROUND
Most errors in a clinical chemistry laboratory are due to preanalytical errors. Preanalytical variability of biospecimens can have significant effects on downstream analyses, and controlling such variables is therefore fundamental for the future use of biospecimens in personalized medicine for diagnostic or prognostic purposes.
CONTENT
The focus of this review is to examine the preanalytical variables that affect human biospecimen integrity in biobanking, with a special focus on blood, saliva, and urine. Cost efficiency is discussed in relation to these issues.
SUMMARY
The quality of a study will depend on the integrity of the biospecimens. Preanalytical preparations should be planned with consideration of the effect on downstream analyses. Currently such preanalytical variables are not routinely documented in the biospecimen research literature. Future studies using biobanked biospecimens should describe in detail the preanalytical handling of biospecimens and analyze and interpret the results with regard to the effects of these variables.
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Affiliation(s)
- Christina Ellervik
- Department of Research, Nykoebing Falster Hospital, Nykoebing Falster, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, MA
| | - Jim Vaught
- International Society for Biological and Environmental Repositories, Vancouver, Canada
- Editor-in-Chief, Biopreservation and Biobanking, Vancouver, Canada
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Gillio-Meina C, Cepinskas G, Cecchini EL, Fraser DD. Translational research in pediatrics II: blood collection, processing, shipping, and storage. Pediatrics 2013; 131:754-66. [PMID: 23509173 DOI: 10.1542/peds.2012-1181] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Translational research often involves tissue sampling and analysis. Blood is by far the most common tissue collected. Due to the many difficulties encountered with blood procurement from children, it is imperative to maximize the quality and stability of the collected samples to optimize research results. Collected blood can remain whole or be fractionated into serum, plasma, or cell concentrates such as red blood cells, leukocytes, or platelets. Serum and plasma can be used for analyte studies, including proteins, lipids, and small molecules, and as a source of cell-free nucleic acids. Cell concentrates are used in functional studies, flow cytometry, culture experiments, or as a source for cellular nucleic acids. Before initiating studies on blood, a thorough evaluation of practices that may influence analyte and/or cellular integrity is required. Thus, it is imperative that child health researchers working with human blood are aware of how experimental results can be altered by blood sampling methods, times to processing, container tubes, presence or absence of additives, shipping and storage variables, and freeze-thaw cycles. The authors of this review, in an effort to encourage and optimize translational research using blood from pediatric patients, outline best practices for blood collection, processing, shipment, and storage.
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Random variation and systematic error caused by various preanalytical variables, estimated by linear mixed-effects models. Clin Chim Acta 2012; 415:196-201. [PMID: 23117035 DOI: 10.1016/j.cca.2012.10.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 10/16/2012] [Accepted: 10/17/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND We wanted to determine whether specific, preanalytical sample handling increases preanalytical variation and bias test results compared with optimal handling. METHODS Blood was collected into 4 serum-separation tubes from each arm of 60 outpatients. In 30 of the patients, half of the tubes were transported in the pneumatic tube system, while the other half were manually delivered. In the remaining patients, the blood samples were collected using 21-gauge straight needles (green needles) and 23-gauge butterfly needles. Half of the tubes were mixed by inverting 5-6 times, and the other half by one inversion. Linear mixed-effects models were used as statistical method. RESULTS Transporting samples in the pneumatic tube system caused a significant bias to the results for LD (4.5 U/L, p<0.001) and magnesium (0.0021 mmol/L, p=0.003). For CK and glucose, the preanalytical variation was significantly higher for samples transported in the pneumatic tube system vs manual delivery. Using butterfly needles resulted in lower values (p<0.05) for calcium (-0.0072 mmol/L), CK (-0.75 U/L) and LD (-1.6 U/L) compared with 21-gauge needles. The preanalytical variation for ALP was significantly higher with butterfly needles. CONCLUSIONS The specific sample handling had significant but small random and systematic effects on results for some analytes.
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31
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Herring J, McMichael M. Diagnostic Approach to Small Animal Bleeding Disorders. Top Companion Anim Med 2012; 27:73-80. [DOI: 10.1053/j.tcam.2012.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 07/18/2012] [Indexed: 11/11/2022]
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Lim MD, Dickherber A, Compton CC. Before you analyze a human specimen, think quality, variability, and bias. Anal Chem 2010; 83:8-13. [PMID: 21114268 DOI: 10.1021/ac1018974] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Personalized medicine requires capabilities to detect and measure health-associated biomarkers with increasingly specific and sensitive methods, putting analytical chemists at the front lines of translational research. Analytical scientists must be upstream in the experimental design process because the analysis of a biospecimen (tissue, blood, etc.) presents technical and experimental design complexities. (To listen to a podcast about this feature, please go to the Analytical Chemistry multimedia page at pubs.acs.org/page/ancham/audio/index.html.).
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Affiliation(s)
- Mark David Lim
- AAAS Science and Technology Policy Fellowship Program and National Cancer Institute, National Institutes of Health, USA
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33
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Delobel J, Rubin O, Prudent M, Crettaz D, Tissot JD, Lion N. Biomarker analysis of stored blood products: emphasis on pre-analytical issues. Int J Mol Sci 2010; 11:4601-17. [PMID: 21151459 PMCID: PMC3000103 DOI: 10.3390/ijms11114601] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 11/10/2010] [Accepted: 11/14/2010] [Indexed: 12/28/2022] Open
Abstract
Millions of blood products are transfused every year; many lives are thus directly concerned by transfusion. The three main labile blood products used in transfusion are erythrocyte concentrates, platelet concentrates and fresh frozen plasma. Each of these products has to be stored according to its particular components. However, during storage, modifications or degradation of those components may occur, and are known as storage lesions. Thus, biomarker discovery of in vivo blood aging as well as in vitro labile blood products storage lesions is of high interest for the transfusion medicine community. Pre-analytical issues are of major importance in analyzing the various blood products during storage conditions as well as according to various protocols that are currently used in blood banks for their preparations. This paper will review key elements that have to be taken into account in the context of proteomic-based biomarker discovery applied to blood banking.
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Affiliation(s)
- Julien Delobel
- Service Régional Vaudois de Transfusion Sanguine, route de la Corniche 2, CH-1066 Epalinges, Switzerland; E-Mails: (J.D.); (O.R.); (M.P.); (D.C.); (N.L.)
- Faculté de Biologie et Médecine, Université de Lausanne, rue du Bugnon 21, CH-1011 Lausanne, Switzerland
| | - Olivier Rubin
- Service Régional Vaudois de Transfusion Sanguine, route de la Corniche 2, CH-1066 Epalinges, Switzerland; E-Mails: (J.D.); (O.R.); (M.P.); (D.C.); (N.L.)
- Faculté de Biologie et Médecine, Université de Lausanne, rue du Bugnon 21, CH-1011 Lausanne, Switzerland
| | - Michel Prudent
- Service Régional Vaudois de Transfusion Sanguine, route de la Corniche 2, CH-1066 Epalinges, Switzerland; E-Mails: (J.D.); (O.R.); (M.P.); (D.C.); (N.L.)
| | - David Crettaz
- Service Régional Vaudois de Transfusion Sanguine, route de la Corniche 2, CH-1066 Epalinges, Switzerland; E-Mails: (J.D.); (O.R.); (M.P.); (D.C.); (N.L.)
| | - Jean-Daniel Tissot
- Service Régional Vaudois de Transfusion Sanguine, route de la Corniche 2, CH-1066 Epalinges, Switzerland; E-Mails: (J.D.); (O.R.); (M.P.); (D.C.); (N.L.)
| | - Niels Lion
- Service Régional Vaudois de Transfusion Sanguine, route de la Corniche 2, CH-1066 Epalinges, Switzerland; E-Mails: (J.D.); (O.R.); (M.P.); (D.C.); (N.L.)
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Seimiya M, Yoshida T, Sawabe Y, Sogawa K, Umemura H, Matsushita K, Nomura F. Reducing the Incidence of Pseudohyperkalemia by Avoiding Making a Fist During Phlebotomy: A Quality Improvement Report. Am J Kidney Dis 2010; 56:686-92. [DOI: 10.1053/j.ajkd.2010.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2009] [Accepted: 06/18/2010] [Indexed: 02/07/2023]
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Sylte MS, Wentzel-Larsen T, Bolann BJ. Estimation of the Minimal Preanalytical Uncertainty for 15 Clinical Chemistry Serum Analytes. Clin Chem 2010; 56:1329-35. [DOI: 10.1373/clinchem.2010.146050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND
We sought a model to estimate preanalytical uncertainty of blood samples collected and processed by using optimal procedures.
METHODS
Optimal preanalytical handling of blood samples included use of a loosely fastened tourniquet, wide bore needles, recommended clotting time and centrifugation speed, and minimal storage before analysis. Blood was collected from each arm of 20 volunteers into 2 rapid-serum tubes and 2 serum-separation tubes. Linear mixed-effects models were used to estimate the between-venipuncture SD, the preanalytical SD (excluding venipuncture), the measurement repeatability SD, and systematic differences between the tubes and between venipunctures.
RESULTS
No significant systematic differences were found between successive venipunctures. However, statistically significant mean differences were seen between serum-separation tubes and rapid-serum tubes for 7 of the 15 analytes. The preanalytical SD (excluding venipuncture) for lactate dehydrogenase (3.2 U/L, 95% CI 2.8–3.7) was significantly higher than the SD for measurement repeatability (1.9 U/L, 95% CI 1.7–2.1). For potassium both the preanalytical SD (excluding venipuncture) (0.092 mmol/L, 95% CI 0.080–0.11) and the between-venipuncture SD (0.075 mmol/L, 95% CI 0.048–0.12) were significantly higher than the measurement-repeatability SD (0.031 mmol/L, 95% CI 0.028–0.035). For glucose the between-venipuncture SD (0.20 mmol/L, 95% CI 0.14–0.27) was significantly higher than the preanalytical SD (excluding venipuncture) (0.07 mmol/L, 95% CI 0.06–0.08), and the measurement repeatability SD (0.057 mmol/L, 95% CI 0.051–0.064).
CONCLUSIONS
By applying linear mixed-effects models we have estimated the minimal preanalytical uncertainty that will influence all patient results.
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Affiliation(s)
| | - Tore Wentzel-Larsen
- Centre for Clinical Research, Haukeland University Hospital, Helse Bergen HF, Bergen, Norway
| | - Bjørn J Bolann
- Laboratory of Clinical Biochemistry and
- Institute of Medicine, University of Bergen, Bergen, Norway
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Bowen RAR, Hortin GL, Csako G, Otañez OH, Remaley AT. Impact of blood collection devices on clinical chemistry assays. Clin Biochem 2009; 43:4-25. [PMID: 19822139 DOI: 10.1016/j.clinbiochem.2009.10.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Revised: 09/30/2009] [Accepted: 10/02/2009] [Indexed: 11/29/2022]
Abstract
Blood collection devices interact with blood to alter blood composition, serum, or plasma fractions and in some cases adversely affect laboratory tests. Vascular access devices may release coating substances and exert shear forces that lyse cells. Blood-dissolving tube additives can affect blood constituent stability and analytical systems. Blood tube stoppers, stopper lubricants, tube walls, surfactants, clot activators, and separator gels may add materials, adsorb blood components, or interact with protein and cellular components. Thus, collection devices can be a major source of preanalytical error in laboratory testing. Device manufacturers, laboratory test vendors, and clinical laboratory personnel must understand these interactions as potential sources of error during preanalytical laboratory testing. Although the effects of endogenous blood substances have received attention, the effects of exogenous substances on assay results have not been well described. This review will identify sources of exogenous substances in blood specimens and propose methods to minimize their impact on clinical chemistry assays.
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Affiliation(s)
- Raffick A R Bowen
- Department of Pathology, Stanford University, 300 Pasteur Drive, Room H1507 B, Stanford, CA 94305, USA.
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