Mike Cornes Preanalytical Cases

Preanalytical cases
Mike Cornes
Worcestershire Acute Hospitals NHS Trust
What is the pre-analytical phase?
Errors within the total laboratory
process
Error rate within the total laboratory process:
0.05% - 20 % of all samples
At what stage in the total laboratory process do these
errors occur?
POSTANALYTIC PREANALYTIC
23 %
15 % 62 %
ANALYTIC
Lippi G,et al Clin Chem Lab Med 2009; 47:143-153; Carraro P, Plebani M. Clin Chem 2007; 53:1338-
What is the pre-analytical phase?
Plebani M. Exploring the iceberg of errors in laboratory medicine. Clin Chimica Acta (2009) 16-23
Case #1
• 84-year-old woman
• Therapy with warfarin for atrial fibrillation
• Admitted to the ED or severe gluteal hemorrhage
• First blood sample drawn and transported <20 min to the laboratory
• Test results:
• PT, 8.8 INR
• Hb, 75 g/L
• Serum sodium, 60 mmol/L
• Serum potassium, 1.4 mmol/L
• Intravenous injection of 10 mg vitamin K
• Second blood sample drawn 2 h after admission
• Test results:
• PT, 3.5 INR
• Hb, 78 g/L
• Serum sodium, 145 mmol/L
What is… your guess?
1. Fibrin gel in serum
2. Contrast media interference
3. Pneumatic tube transport induced
interference
4. EDTA contamination
5. Change from seated to suppine
6. Patient ID error
7. Contamination from drip arm
8. Sodium citrate contamination
An accurate analysis of
the serum specimen
collected upon patient
admission in the ED
revealed the presence of a
transparent fibrin gel in
serum, which could only
be detected after serum
was pipetted into another
tube.
• Serum is subject to fibrin formation when clotting is inadequate
– Plasma is not
• This can be in the form of clots or strands
• Causes
– Anticoagulants
– Inadequate mixing
– Delayed clotting
– Insufficient time to clot
• Can cause analytical errors which can be very subtle
• Can block probes
How to prevent this?
• Plasma
• Ensure sample is well mixed and clotted
– Education
• Delta checks
• Duty biochemist
Case #2
• 50-year-old man
• Admitted to the ED for acute myocardial infarction
• Subjected to percutaneous coronary intervention (PCI)
• First blood sample drawn from femoral artery and transported to the laboratory
• Apperance of sample after standard centrifugation:
interference
6. Patient ID error
• Specific gravity of serum and
plasma is 1.026-1.031 g/cm3,
and that of the clot is 1.092-
1.095.
• Specific gravity of separator
gels should be between 1.03-
and 1.09 g/cm3 to permit its
suitable positioning after
centrifugation.
• The potential interfering
substance was a tri-iodinated
nonionic water-soluble
contrast dye, 140 ml of which
were administered to the
patient before coronary
revascularization
• Education
• Observation
Case #3
• 72-year-old man
• Admitted to the ED for fatigue and dizziness lasting for days
• First blood sample drawn and transported to the laboratory by PTS
• Test results:
• WBC, 75x109/L
• Hb, 81 g/L
• Plasma potassium, 5.7 mmol/L
• No signs or symtoms of hyperkalemia
• Second blood sample drawn 45 after admission and manully trasnported to the Lab
• Test results:
• WBC, 78x109/L
• Hb, 80 g/L
• Plasma potassium, 3.9 mmol/L
interference
6. Patient ID error
• The patient is diagnosed with
acute myeloid leukemia.
• Fragile neoplastic
leukocytes are injuried or
destroyed during PTS
transportation, so releasing
potassium in the surrouding
plasma.
Video
• Paired serum/plasma sample

• Samples to the laboratory quickly
– Beware clotting time!!
• Samples hand delivered
Case #4
• 66-year-old man
• Hospitalized for colorectal cancer
• Routine (morning) blood sample drawn and transported to the laboratory
• Test results:
• Creatinine, 82 μmol/L
• Hb, 121 g/L
• Serum calcium, non measurable
• Second blood sample drawn after 1 h admission
• Test results:
• Creatinine, 81 μmol/L
• Hb, 122 g/L
• Serum calcium, 2.5 mmol/L
interference
6. Patient ID error
• Four blood samples were
planned to be collected:
• 1 EDTA blood tube
• 1 Sodium citrate blood tube
• 2 Serum blood tubes
• Blood stopped during collection
of the fourth blood tube, leaving
the tube almost empty.
• The nurse poured some EDTA
blood into the serum blood tube.
• Education
• Laboratory checks via algorithmns
• Delta checks
• Duty biochemist observations
Algorithms – High
Potassium
Clin Chim Acta. 2011 Jan 14;412(1-2):1-6

Case #5
• 55-year-old women
• Admitted to the ED at 1 AM for acute gastrointestinal pain lasting for 5 hours
• Blood sample immediately drawn upon arrival and transported to the laboratory
• Test results:
• CRP, 1.2 mg/L
• Hb, 118 g/L
• WBC, 3.5x109/L
• Patient managed with “watch-and-wait” approach, waiting for echography
• Second blood sample drawn after 2 h, in the ED observation unit
• Test results:
• CRP, 1.0 mg/L
• Hb, 107 g/L
• WBC, 3.0 x109/L
• Echography negative, no clinical signs of bleeding, no other signs or symptoms
interference
6. Patient ID error
1 min
• First blood sample drawn with
only 1 min of stay in seated
position;
• Second blood samples drawn in
supine position;
• Plasma volume changes up to
20% shifting from standing to 2 hours
supine position
Change from supine to upright position
Blood collection preferably

after 15 minutes rest in one
position
Guder WG, Narayanan S. Pre-Examination Procedures in Laboratory Diagnostics. 1st ed. DeGruyter, Berlin 2015
• Patient should remain in one position for 15 minutes

Case #6
• A 71-year-old man
• Admitted with left anterior cerebral artery hemorrhagic stroke
• Blood tests were never ordered
• Test results:
• Procalcitonin, 4.4 ng/mL
• CRP, 13.3 mg/L
• WBC, 13.5x109/L
• Clinicians refuse to take action and order lab tests on this patient
• Blood sample drawn and transported to the laboratory
• Test results:
• Procalcitonin, Not requested
• CRP, 0.3 mg/L
• WBC, 9.4x109/L
interference
6. Patient ID error
• First blood sample drawn from
another 75-year-old same
gender patient with right middle
cerebral artery ischemic stroke,
with a similar family name, who
was transferred the same day to
the intensive care unit due to a
nosocomial infection
• Identification errors must be met with zero tolerance
– High risk to patient if not
• Identification MUST be in the presence of the patient
• At least two independent identifiers:
– Patient full name (the first and the last name )
– Date of birth
• Preferably one additional identifier
– Address
– Health insurance number
– ID card
• Use open ended questions: “What is your name?” and “What is your
date of birth?”
Tube labelling must be done in presence of the
patient. Labelling before or after blood collection
should be based on a prospective risk analysis of
the phlebotomy process in each institution.
Tube label should at least contain:
• Patient first and last name
• ID number
• Date
• Time (if necessary, like for TDM)
• ID of the phlebotomist
(or there should be a mechanism to identify a phlebotomist)
Case #7
• A 56-year-old man
• Admitted to the ED with alcohol-induced severe acute pancreatitis
• Blood tests ordered:
• Test results:
• Blood glucose, 15.4 mmol/L (277 mg/dL)
• Clinicians refuse to take action since there were no signs of hyperglicaemia

• Second blood sample drawn and transported to the laboratory
• Test results:
• Blood glucose, 4.9 mmol/L (88 mg/dL)
interference
6. Patient ID error
• First blood sample was collected
from drawn from glucose-
contaminated arterial blood line,
without appropriate flushing.
• Encourage clinical colleagues to question results that don’t fit

clinicaly
• Delta checks
• Duty biochemist
• Pattern of results
Case #8
• 61-year old man with chronic kidney disease
• Undergoing maintenance haemodialysis
• Blood tests ordered:
• Test results:
• Sodium, 182 mmol/L
• Potassium, 4.8 mmol/L
• Chloride, 87 mmol/L
• Second blood sample immediately drawn and transported to the laboratory
• Test results:
• Sodium, 139 mmol/L
• Potassium, 4.6 mmol/L
• Chloride, 88 mmol/L
interference
6. Patient ID error
• First blood sample
contaminated during collection
with trisodium citrate, a
catheter-lock solution,
commonly used in dialysis units
to maintain patency of dialysis
catheters.
• Education
• Laboratory checks via algorithmns
• Delta checks
• Duty biochemist observations
Algorithms – High
Sodium
“I've seen things you people wouldn't believe...”
Replicant Roy Batty; Ridley Scott’s Blade Runner (1982)

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Preanalytical cases

• Paired serum/plasma sample

Clin Chim Acta. 2011 Jan 14;412(1-2):1-6

Blood collection preferably

• Patient should remain in one position for 15 minutes

• Clinicians refuse to take action since there were no signs of hyperglicaemia

• Encourage clinical colleagues to question results that don’t fit

Replicant Roy Batty; Ridley Scott’s Blade Runner (1982)

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