Specimen collection, storage, transfer and Automation

1. Specimen collection, storage, transfer and Automation

2. Medical Ethics in specimen collection • Professional appearance- Lab coat • Professional attitude and Interpersonal skills- relieve patient’s anxiety • Patient’s confidentiality-patient’s personal information/medical history WHY INVESTIGATE? • To diagnose disease • To evaluate its severity • To assess the complications of disorder • To monitor treatment • To screen for disease • To confirm the diagnosis what are necessary investigations required should be ordered. • Over investigation may actually harm not help the patient by causing him unnecessary discomfort or danger and delaying treatment.

3. FACTORS FOR ACCURACY OF RESULTS • Accurately completed requested forms. • Correctly labeled specimens. • Collection of specimens by correct technique at the appropriate time. • Speedy delivery to the laboratory. • Treatment based on technically correct results from a wrongly labeled or collected specimen may be as lethal as a faulty surgical technique.

4. PRE-ANALYTICAL FACTORS: • The control of Biological variability begins with proper preparation of an individual, prior to specimen collection. REQUEST FORM: - Accurate information about the patient clearly written is essential to minimize the errors. Hospital number Surname and first name Date of birth (rather than age) Sex, Address and Provisional diagnosis Location of patient: Ward and bed number, Unit and Department Doctor signature with his/her Name & Designation IF ABOVE INFORMATION ARE NOT PROVIDED CORRECTLY IT MAY BE DANGEROUS PARTICULARLY DURING EMERGENCY.

6. COLLECTION OF SPECIMENS • Blood • Urine – R, 24 hours • CSF • Ascetic fluid • Pleural fluid • Pericardial fluid • Synovial fluid • Saliva • Gastric, Duodenal and Jejunal secretion • Sweat • Calculai • Sample of dietary intake

7. COLLECTION OF BLOODVeins, Arteries or Capillaries VENIPUNCTURE: - BEFORE COLLECTION: • Verify patient identity. • Give reassurance. • Make sure patient is fasting. • Patient should be comfortably seated or supine. SITE: • Median cubital vein in the cubital fossa. • Wrist, ankle and hand veins. • IF I/V Line: - PROCEDURE: • Clean with 70% Isopropanol. • Tourniquet is applied (10-15 cm). It should be 1 inch wide & 15 inches long of soft rubber. • Ask patient to make fist. • Well sharpened sterile disposable needle with syringes of appropriate size. • Insert the needle into vein, plunger withdraw  blood appear  release tourniquet.

9. TYPE OF BLOOD TO BE USED

10. ARTERIAL PUNCTURE • Blood gas analysis, O2, CO2 and pH. • For critical ill patient of respiratory or cardiovascular disease. • Major surgery. • SITE: • Radial, Brachial or Femoral Artery • Free flow of blood is essential. • Heparinized syringe. • Expel any air bubble from syringe. • Syringe should be sealed quickly. • Mix well by gentle inversion of syringe. • Syringe with blood kept on ice. SKIN PUNCTURE (Capillaries Blood) Method of choice: • Paediatric patient (Infants) • Adult with extreme obesity, severe burns. • Where very little quantity of blood is required.

11. SKIN PUNCTURE (Capillaries Blood) SITE: • Infants: - Lateral or medial planter heals surface. • Older Infants: - Palmer surface of last digit of 2, 3 or 4th fingure • Others: - Planter surface of big toe. Ear lobe. PROCEDURE: • Warm with warm and moist towel  Blood flow. • Skin is cleaned. • Punctured by sharp sterile lancet. • Hold the finger  gravity assist the collection of blood on fingertip. • Avoid massage of finger to stimulate blood flow.

12. FACTORS WHICH HAS INFLUENCE ON RESULTS BEFORE/ DURING COLLECTION OF SAMPLE EFFECT OF POSTURE: • Plasma protein and protein bound substances are  if patient is supine as compared to standing position. • Tourniquet: - Incorrect and prolonged application  lactate,  serum enzymes,  protein,  cholesterol, Ca and iron. Sample of blood closest to tourniquet is most representative of composition of circulating blood. First drawn samples – critical medical decision like Calcium test, later sample has more venous stasis. Venous stasis 3min - Increase in T Protein, Iron, T lipids, Chl, AST, Bilirubin. Pumping of fist – Increase in Patassium, Phosphate and Lactate, lactate lowers pH therby increase ionized Calcium conc. ORAL MEDICATION: • Immediate withdraws avoided. Exp: - Hypokalaemia after taking potassium losing diuretics. EXERCISE: • Transient effect:  AA, Lactate and FFA. • Long lasting effect:  activity of muscle enzyme like creatine kinase, aldolase, AST and lactate dehydrogenase.

13. PROLONGED FASTING: • > 24 hours fasting – unexpected lab results • Serum bilirubin  • Plasma triglyceride  • FFA  • Blood glucose  DIET: • Change depend upon type and quantity and timing of sample collection. • Diet rich in protein  urea, uric acid & NH3 ETHANOL: • Immediate changes  Plasma lactate, uric acid, acetaldehyde and acetate. • In chronic alcoholic:  plasma HDL, uric acid  glutamyl transferase. TOBACCO SMOKING: •  carboxy Hb. •  plasma catecholamine and cortisol. •  FFA. • Stress: - It affects adrenal hormones and growth hormone. • Anxiety: - Lead to hyperventilation lead to disturbance in acid base balance. • Pregnancy: - Plasma protein, enzymes and electrolyte.

14. Precaution: • Make patient comfortable. • Clean the area and let the spirit/alcohol dries. • Avoid prolonged venous stasis. • Avoid haemolysis. HAEMOLYSIS – Various reasons  Blood unsuitable for plasma K+, Mg++, Phosphate and enzyme activity measurement. How we can avoid haemolysis: • Allow to dry skin. • Specimen should be collected with moderate suction. • Needle should be removed. • Transfer blood very gently. • Avoid use of wet and dirty tubes. • Gentle mixing with anti-coagulant. ANTICOAGULANTS

15. PRESERVATION STORAGE & TRANSPORT OF BLOOD SAMPLE Passage of time affects concentration of many blood constituents by • Evaporation of H2O. • Loss of Co2  pH  enzyme activities. (also reverse: ALP activity in serum increases approx. 3%-10% upon standing at 25o or 4o C for several hours). • Glycolysis  blood glucose (5% / hour). • Proteolytic & hydrolytic process  NH3  erythrocyte permeability  serum K+, Mg++ & phosphorus. Daylight destroys bilirubin quickly. Serum Plasma should be separated after proper labeling. Store: at 4 C or make frozen after accurate labeling- assayed preferably within one hour. Ideal is -80o C but expensive; -20oC recommended for most analytes- upto for 6 weeks Transport: test performed locally or other centers/reference labs- Proper containers with temp maintained; glass containers avoided, polypropyelene or polethene containers, leak proof, unbreakable; Styrofoam containers for frozen/refrigerated samples with dry ice [solid CO2] Courier services

16. URINE COLLECTION Type: - • Random – Few chemical test – morn F sample, mid stream. • Timed – Specific time of day – GTT. • 24 hours total volume. 24 hours total volume collection: - • Difficult, require patient cooperation • Error  incomplete or over collection • 8 AM  8 AM • First morning urine to be discarded and next day morning till 8 AM so be collected • Collect in clean container with suitable preservation. If preservative-first urine should be collected with precaution and container keep away from children. • Measure total volume  record on request form • Mix entire 24 collection  send for analysis Preservatives: - • Refrigeration • Acidification below pH 3: - boric acid (15 gm), glacial acetic acid or HCL. • Thymol and chloroform • Toluene • Sodium bicarbonate – for porphyrin & urobilinogen • Light sensitive compound  Amber glass bottle or plastic bottle wrapped in aluminum foil.

17. AUTOMATION What is Automation? Process whereby an analytical instrument perform many tests with only minimal involvement of manpower. Why? Tackle the increase workload. More accurate and rapid results. To provide better coordination of the patient, laboratory and physicians. Component of Automation and Processing: • Serum/ Plasma separation • Reagent preparation • Placing sample and reagents • Proportioning reagent and sample • Mixing • Incubation • Sensing • Computation • Readout • Dispatching

18. Advantages of Automation • Elimination of task that are repetitive and monotonous  Errors. • Significant improvement in quality of laboratory tests. • Large number of samples in less time. • Cost effectiveness (reagent consumption/ manual labor). • Quality control. • Recording and book keeping Drawbacks • High initial cost • Instrument error • Instrument failure

19. Autoanalyser • Mechanized versions of basic manual laboratory techniques and procedures, using highly advanced sophisticated technology with highest precision and accuracy using robotics & computers • open system: the operator can modify assay parameters and purchase reagents from a variety of sources. • closed system: most assay parameters are set by the manufacturer, who also provides reagents in a unique container or format. • modular configuration: an automated analyzer is as­sembled from individual components either by the manufac­turer or the user: flexibility and expandability to meet changing customer needs and to increase operational efficiency • Batch analysis: a type of analysis in which many specimens are processed in the same analytical session, or "run." • Centralized testing: a mode of testing where specimens are transported to a central or "core" facility for analysis

20. Automation Steps: • Specimen identification- labeling: Bar coding-one dimentional or two dimentional bar codes • Specimen preparation-whole blood/plasma/serum (mc): use of Robotics • Specimen delivery-Courier, Pneumatic tube systems, Electrical track vehicles, Robotics • Specimen handling and transport-cup/tubes, loading zone-circular tray/racks • Specimen processing-removal of proteins/interferents-dialysis, column chromatography,filtration • Sample transport and delivery- continuous flow analyzers:peristaltic pumps;discrete pocesing systems: positive liquid displacement pipetes • Reagent handling and storage- liquid:plastic/glass containers; dry tablet forms; 4-10 o C compartment temp; immunoassay systems:refrigerated storage • Reagent delivery- dry/liquid; reagent identification by bar codes; open or closed systems; liquid reagent:pumps or positive displacement syringe devices for delivery and mixing. Accuracy and precision –by metering pump, stop valves and volumetric level sensors in the pipete probe tip. • Chemical reaction phase • Measurement approaches-Photometry using monochromators with movable gratings and slits [older- prisms];radient energy ource:tungston,quarts halogen, deuterium,mercury and xenone lamps as well as lasers; 300-700 nm; filters. Detectors-Photodiodes/Phtomultiplier tubes in immunoassay • Signal processing, data handling and process control-computers

21. “Success doesn't mean absence of failures, it means attainment of ultimate aim winning the war not every battle” Thank You