Laboratory

Handbook
4th Edition
2002

The Ulster, Community and Hospitals Trust

 PREFACE
This handbook is a guide to the use of laboratory services in
the Ulster Community and Hospitals Trust. It is hoped that it
will provide the laboratory user with a quick and easy
reference to the services available in the Trust Laboratory
and specialist services at other central laboratories.

Information is provided on types of sample required,

interpretation of results and common interferences in test
results. If you wish further advice on selection of tests or
interpretation of results, please contact a senior member of
laboratory staff.

The Laboratory endeavours to produce high quality results

in a timely manner. We welcome comments from our users
about the services currently available, which may lead to
future improvements of the service.

Clinical Diagnostics Directorate

2002
 CONTENTS

Page No.
General Information 4-10

Clinical chemistry

1. List of Tests and reference values 12-29

2. Age related reference ranges 29-30
3. Significant changes in serial results 31
4. Drug interferences in test results 32
5. Common specimen artefacts 33
6. Test Protocols 34-38
7. Toxicology / Therapeutic drug monitoring 39-50
8. Neonatal/paediatric 51-56

Microbiology 57

1.Specimen collection 58

1.1 Specimen collection - general 58

1.2 Specimen collection - infection control 59
1.3 The request form 59
1.4 Reporting 60
1.5 Reasons for rejecting specimens 60
1.6 Collection of specific specimen types (alphabetical order) 60-67

2. Antibiotic monitoring 68-69

3. Investigation of Infectious Diseases 70-75

(table, alphabetical order)

4. Virology

4.1 General Information 76

4.2 The request form 76
4.3 Collection and transport of specimens 76-77
4.4 Common clinical indications for viral testing 78-79
(table, alphabetical order)
4.5 HIV testing 80-81

2
 Page no.

Haematology & Blood Transfusion 82

1. General Haematology 83

1.1 Routinely available tests & reference values 83

1.2 Test by arrangement only 85
1.3 Bone Marrow examination 85

2. Coagulation 86

2.1 Routinely available tests & reference values 86

2.2 Tests by arrangement only 87
2.3 Recommended Target INRs for Warfarin therapy 88

3. Blood Transfusion 89

3.1 Special requesting information 89

3.2 Transfusion Samples 89
3.3 Emergency Blood 90
3.4 CREST guidelines on Blood Transfusion 90
3.5 Transfusion reactions 90
3.6 Surgical Blood Ordering Tariff 91
3.7 Blood products 93

4. Paediatric Haematology 95

Tissue Pathology 97-101

Reference Data 102-108

Guidelines for body weight

Conversion factors
Weight tables

Alphabetical index of biochemistry tests 109-116

3
 GENERAL INFORMATION

USEFUL TELEPHONE NUMBERS

The Ulster Hospital (028) 9048 4511

Clinical Director Dr R. Wright Ext: 2653

Laboratory Business Manager Mr Brian Shanks Ext: 2361

BIOCHEMISTRY

Consultant Chemical Dr T. Trinick Ext: 2360

Pathologist tom.trinick@ucht.n-i.nhs.uk

Consultant Biochemist Ms E. Duly Ext: 2168

ellie.duly@ucht.n-i.nhs.uk

Head Biomedical Scientist Mr P. Grimason Ext: 2358

Enquiries Ext: 2600

HAEMATOLOGY

Consultant Haematologist Dr M. El Agnaf Ext: 2105

mawloud.el-agnaf@ucht.n-i.nhs.uk

Consultant Haematologist Dr K. Bailie Ext: 2276

karen.bailie@ucht.n-i.nhs.uk

Head Biomedical Scientist Mr J. McClintock Ext: 3127

Chief Biomedical Scientist Mr K. McLoughlin Ext: 2356

(Blood Bank)

Enquiries General Haematology Ext: 3127

Coagulation Ext: 2939
Blood Bank Ext: 2356

Direct Line (028) 9056 1370

(Blood Bank)

4
Clinical Secretaries Kerry Gilmore Ext: 2119
Elaine Crothers Ext: 2428

MICROBIOLOGY

Consultant Microbiologist Dr Anne Loughrey Ext: 2362

anne.loughrey@ucht.n-i.nhs.uk
Bleep #6405

Secretary Lorraine Moreland Ext: 2437

Infection Control Nurses Mrs Jenny Watson Ext: 3138

jenny.watson@ucht.n-i.nhs.uk
Bleep #6308

Mrs Janine Norrie Ext: 2437

Bleep #6308

Main Laboratory Enquiries Ext: 2359

Head Biomedical Scientist Mr Barry Spence Ext 2359

Serology Enquiries Ext: 2357

Direct Line (main laboratory) 028 9056 1372

Urine Examination laboratory Ext: 2797

Enteric Pathogen laboratory Ext: 2977

Belfast Link Labs

Royal Victoria Hospital Tie Line 7222 followed by extension

number if known or 0 for operator

Histopathology Ext: 2170

Cytology Ext: 3019
Virology Ext: 2662/2562
Immunology Ext: 2669

5
Haematology Ext: 3619
Endocrinology Ext: 3230/3180

Belfast City Hospital Tie Line 7111 followed by extension

number if known or 0 for operator

Tissue Typing Ext: 2444/3246

Medical Genetics Ext: 2323/2423
Haematology Ext: 2369
Histopathology Ext: 2772
Cytology Ext: 2132

UC&HT LABORATORY HOURS OF OPENING

NORMAL LABORATORY HOURS

Weekdays 09.00 - 17.00 hrs

SERVICE ON PUBLIC HOLIDAYS AND WEEKENDS

Saturday 09.00 - 12.00 hrs
Sunday 09.00 - 13.00 hrs
Public Holidays 09.00 - 13.00 hrs

A restricted service operates at these times. It would be appreciated

if requests are confined to essential investigations only. Specimens
should reach the laboratory by 10.30 hrs at the latest on these days.

Requests for post-mortems should be directed to the mortuary technician

who can be contacted through the Ulster Hospital switchboard.

EMERGENCY SERVICE

All urgent requests MUST be arranged with a member of laboratory staff.

Haematology For results not required within 30 mins, leave

message on answer phone Ext 3127
For all others and blood transfusion requests
Bleep 262
Biochemistry Bleep 274
Microbiology Contact via Ulster Hospital switchboard
028 9048 4511
If you experience any difficulty in directly contacting a Biomedical
scientist on-call please contact switchboard.
6
The following tests are available as an emergency:

Microbiology Haematology and Blood Biochemistry

Transfusion
• CSF examination • FBC • Electrolytes/creatinine
• Gram film of pus, body • ESR (for temporal arteritis) • Blood gases
fluid etc. • Coagulation screen • Blood/CSF sugar
• Immediate plating and • INR •Amylase
processing of urgent • APTT • Calcium
specimens • D-Dimer • Magnesium
• Sickle cell screen • Bilirubin - neonatal
• Malaria parasites • Paracetamol
* Blood grouping, Cross •Paraquat
matching and Blood product • Salicylate
issue • Ammonia
• Osmolality
• Cardiac enzymes
• Liver function tests

Note: For emergency Biochemistry requests a yellow request form must be used.

The Consultant Microbiologist, Haematologists and Chemical Pathologist each

carry a BT bleep and provide a 24-hour consultation service. Out of hours
contact may be made via the Ulster Hospital switch board.

SPECIMEN COLLECTION TIMES

WEEKDAYS

Ulster Hospital:

Wards 09.15 - 10.15, 11.15 - 12.15,

13.30 - 15.00 h.

Outpatients 11.15, 16.00 - 16.30 h.

Ards and Bangor Hospitals: 10.15 - 11.15, 13.00 - 14.00,

16.00

SATURDAY Ulster Hospital - 09.00 - 13.00

SUNDAY No collection.

7
EMERGENCY SPECIMENS Bleep portering Service

Transport of specimens from Ulster 10.00, 12.30 h.

Hospital to Royal Victoria Hospital

Transport of specimens from Ulster 12.30 h.

Hospital to Belfast City Hospital

Transport can also be arranged by special request

SPECIMENS FROM INFECTIOUS PATIENTS

See Microbiology: Section 1.2

PHLEBOTOMY SERVICE

A Phlebotomy service is provided for certain Directorates at the Ulster

Hospital, Monday to Friday from 9 am - 12 noon.

REQUEST FORMS

Request forms must contain the following information:

Patient name
Sex
DOB
Hospital no.
Return address
Consultant or GP
Clinical details

Patient labels* should be used if available - the label must be placed

within the space provided on the form.

* The only exception is for BLOOD TRANSFUSION. Request forms

and blood samples must be hand written and signed. Labels must
not be used. (See Haematology Section 3 p89).

8
 LABORATORY REPORTS

For all specialities clinically significant abnormal results will be

telephoned to the point of request.
Urgent Clinical Chemistry results from the acute services of the
Trust are communicated via computerised ward recall or as an
interim printed report in wards equipped with a suitable printer. All
other urgent results will be telephoned to the point of request.

Porters will deliver reports at the following times:

Ulster Hospital 14.00 - 15.00 h. and 17.00 h.

Reports are available on the Hospital ethernet via the VDU as soon as
the result has been checked out from the Laboratory.

Reports to GP surgeries are posted or sent by an electronic mailing

system on the evening of reporting.

RECALL OF LABORATORY RESULTS FROM WARDS

Logging into the laboratory system

[1] Connect to the Laboratory-

(a) When the Laboratory Systems Login prompt appears.
(b) To recall results for a patient: type uhd
(c) The Password prompt will appear.
(d) Type the password.
[2] PRESS THE CAPS LOCK KEY TO PUT CAPS LOCK ON.
The system expects ALL entries to be in UPPER CASE (CAPITAL
LETTERS)
[3] ‘PF4’ The ‘PF4’ Key also takes you back a Step
PF4 on a computer keyboard usually equates to the ‘-’ (minus), or F4
Key

Recall protocol for uhd login.

Laboratory Result Recall

Hospital Number UH YY/NNNNNN

If the Hospital Number is not known the return takes you to the next
screen.
9
 Surname xxxxxxx
Forename Y
Year of Birth Sex F
Two Digit year

Filling in SURNAME etc. brings a list of all available matches.

XXXXX YABCYYYY 01/1/97 98A TEMPLEMORE AV

XXXXX YBCDYYY 01/1/97 EAST-SIDE SURGERY
XXXXX YGHJYYY 01/1/97 MITCHELL WARD
XXXXX YYYYYYY 01/01/97 WARD 10
XXXXX YYTYYY 01/01/97 WARD 9

When a match is chosen the following screen appears.

Surname XXXX Hosp. No. U9999999

Forename YYYYYYY Ward WARD 10
Year of Birth 01/01/97 Sex Female_ Consultant MR JM DUNLOP

Profile _

Pressing return at the profile prompt display a list of tests for that patient
from which one can be chosen

BLOOD GROUP & HOLD 22/03/94 Awaiting Results

DIRECT COOMBS TEST 22/03/94 Report Available
SERUM ELECTROLYTES O 18/03/94 Report Available
BLOOD COUNTS 18/03/94 Report Available

10
CLINICAL CHEMISTRY

11
 CLINICAL CHEMISTRY
TEST AND REFERENCE VALUES

Test Specimen Reference Range

Acid Base/ 2.5ml arterial blood PO2 12-15 kPa

Blood Gas use AVL dry heparin syringe PCO2 4.7-6.0KPa
Analysis provided. Alternatively use pH 7.35-7.45
Adult 2.5ml syringe. Rinse with Base excess -2 to +2
heparin, expel fully, take Std Bicarb 22-26
2.5ml blood sample, cap mmol/l
syringe and send to Lab. on Actual Bicarb
ice immediately. 22-30 mmol/1

ACTH 1 purple topped tube. Send <55 ng/L

to lab on ice immediately.

ADH 1 green topped tube on ice Contact RVH Ext

to Lab. 3180

ADMISSION PROFILE 1 yellow topped tube

Sodium 135 - 145 mmol/l
Potassium 3.5 - 5.2 mmol/l
Urea 2.5 - 7.5 mmol/l
Creatinine 55 - 125 umol/l
Total Protein 60 - 80 g/l
Albumin 35-60 g/l
Bilirubin 3 - 17 umol/l
ALP (Adults) 40 - 130 µ/L
AST 17 - 45 U/L
GGT 10 - 45 U/L
Cholesterol 3.6 - 6.0 mmol/l
Glucose 3.5 - 8.0 mmol/l
Calcium 2.15 - 2.60 mmol/l

ADRENAL see Synacthen test

STIMULATION TEST page 37

ADRENAL see Dexamathasone

SUPPRESSION TEST test page 34

ALCOHOL 1 yellow topped tube

12
ALDOLASE 1 red topped tube 0.5-3.1 UL

ALDOSTERONE Contact UHD lab Ext 2358 Supine<400 pmol/l

Upright<820 pmol/l
Serum 1 red topped tube Saline suppression test
2L in 4h:<120pmol/l
Urine 24h urine collection 14 - 55 nmol/ 24h

ALKALINE 1 yellow topped tube

PHOSPHATASE~
ISOENZYMES

ALPHA SUB UNIT 1 red topped tube <1 IU/L

(ASUI) menopause and
mid cycle peak <3
IU/L

ALPHA 1 ACID 1 yellow topped tube 0.47 - 1.28 g/L

GLYCOPROTEIN
(Orosomucoid)

ALPHA 1 1 yellow topped tube 0.30 - 0.69 g/l

ANTICHYMOTRYPSIN
ALPHA 1 ANTITRYPSIN 1 red topped tube 0.89 - 1.89 g/l

Paediatrics 2 green tubes

ALPHA-FETO 1 yellow topped tube Male: < 10 KU/L

PROTEINS Female: < 10 KU/L
Serum
Amniotic Fluid 1 ml amniotic fluid in red
topped tube

ALPHA 1 Random urine 0 - 12.5 mg/l

MICROGLOBULIN

ALPHA 2 1 red topped tube 1.09 - 2.83 g/l

MACROGLOBULIN

ALUMINIUM 5 ml clotted blood in special < 10 µg/l

plastic tube. Contact UHD
Lab. Ext. 2358
13
AMINOLAEVULINATE 24h collection of urine 11.4 - 57.2 µmol/ 24hr

AMMONIA Paediatrics: 1 green topped Male 10 - 47 µmol/L

tube on ice
Adults: 1 green topped Female 11 - 38 µmol/l
tube on ice

AMNIOTIC FLUID 5 ml amniotic fluid in universal container

INVESTIGATIONS Contact RVH Lab. Ext 2643/2593

AMYLASE 1 yellow topped tube 25 - 125 U/L

ANTI CARDIOLIPIN 1 yellow topped tube

ANDROSTENEDIONE 1 red topped tube Males 3.0 - 15.0 nmol/l

Females 3.0 - 12.0 nmol/l

ANGIOTENSIN- 1 red topped tube 27 - 100 U/L

CONVERTING
ENZYMES

ANAPHYLACTIC Contact UHD Ext 2358 Protocol available

REACTIONS

ANDROGEN PROFILE 1 red topped tube

Androstenedione must be filled to top Males 4.0 - 13.5 nmol/L
Females 4.5 - 11.5 nmol/L
Dehydroepiandrosterone Males 0.5 - 18.0 µmol/L
sulphate Females 3.0 - 9.0 µmol/L

17 hydroxyprogesterone Adult Male 2.0 - 10.5 nmol/L

Female 2.0 - 12.0 nmol/L
Newborn <20 nmol/L

Testosterone Male 10.5 - 30 nmol/L

Female 0.5 - 2.7 nmol/L

Sex Hormone Male 7 - 40 nmol/L

Binding Globulin Female 25 - 85 nmol/L

Free Androgen Index Female <7

14
ARGININE 1 green topped tube on ice
VASOPRESSIN (ADH) Send to Lab immediately.
APO E PHENOTYPING 1 purple topped tube

APOLIPROTEINS 1 yellow topped tube

1. Apo A1 1. 0.9 - 1.9 g/L
2. ApoB 2. 0.5 - 1.2 g/L

B2 MICROGLOBULIN 1 yellow topped tube 1.40 - 2.5 µg/l

BENCE JONES 1 yellow topped tube plus

PROTEIN 50ml random urine specimen
in special container.
Contact UHD Ext 2358

BILIRUBIN
Infants 1 green tube 5 - 17 µmol/l
Bilirubin (direct) 1 green tube < 15% total Bilirubin

BONE PROFILE 1 yellow topped tube

Albumin Paediatrics - 1 green tube 35 - 50 g/l
Alkaline Adults 40 - 130 U/L
Phosphatase Age related see
page 30
Calcium 2.15 - 2.60 mmol/l
Phosphate 0.80 - 1.55 mmol/l
BROMIDE 1 yellow topped tube

C PEPTIDE Fasting sample in red topped 1 - 3 µg/L

tube. Send to Lab immedaitely

C1 ESTERASE 1 red topped tube 0.15 - 0.35 g/l

INHIBITOR

C3 NEPHRITIC 1 yellow topped tube Not normally

FACTOR detected

CADMIUM 1 purple top

Urine Random urine in red top

15
CAERULOPLASMIN 1 yellow topped tube 0.21 - 0.58 g/l

CALCITONIN: 1 green topped tube on ice. <0.08 µg/l

Send to Lab immediately

CALCIUM
Blood 1 yellow top 2.15 - 2.60 mmol/l
24h collection in special bottle 2.5 - 7.5 mmol/24h
Adults (urine) Contact UHD Ext. 2358

CALCIUM/ Random urine in universal >6 years < 0.7

CREATININE RATIO container mmol:mmol
creatinine
Ref range age related
See Page 30
CALCULI Send to Lab. in sterile container.

CARBON MONOXIDE See Page 44

CARCINOEMBRYONIC 1 yellow topped tube <5 µg/L

ANTIGEN (CEA)
CA-125 1 yellow topped tube <35 U/mL
CA-19-9 1 yellow topped tube <37 U/L

CARDIAC PROFILE 1 yellow topped tube

Creatine Kinase 0-200 U/L
Creatine Kinase MB
isoenzyme (CK-MB) 0-20 U/L

CAROTENE 1 red topped tube 0.74 - 3.72 µmol/L

CATECHOLAMINES 24h collection of urine in a Adrenaline
bottle containing 40ml 5 - 120 nmol/24h
30% HC1 Noradrenaline
Contact UHD Lab Ext 2358 50 - 560 nmol/24h
Dopamine
300 - 3900 nmol/24h

CHOLINESTERASE 1 yellow topped tube 3.0 - 9.3 KU/L

Phenotying
CHROMIUM Random urine in red top 0-2.0 nmol/mmol
creatinine

16
CHROMOSOME 5 ml blood in special Lithium
STUDIES Heparin tube. Phone UHD
Ext 2358

Fragile X Syndrome 5 - 10 ml blood in special

EDTA tube. Phone UHD
Ext 2358

COBALT Random urine in red top 0-3.0 nmol/mmol

creatinine

COMPLEMENT 1 yellow topped tube

PROFILE
C3 0.75 - 1.65 g/L
C4 0.14 - 0.54 g/L

COPPER
Serum 5 ml blood in special plastic 12.6 - 26.7 µmol/L
heaparin tube. Please phone
UHD Ext 2358

Urine 24 hr collection 0.2 - 1.6 µmol/24 hr

please phone UHD Ext 2358

CORTISOL
Serum 1 red topped tube Circadian rhythm
am 300 - 700 nmol/L
pm 30 - 120 nmol/L

Urine 24 hr collection of urine <350 nmol/24 hr

C-PEPTIDE Fasting sample in red topped 1 - 3 µg/L

tube send to Lab immediately

CREATININE
Serum 1 yellow topped tube 55 - 125 µmol/L

Urine 24 hr collection of urine

CREATININE 24 hr urine plus 1 yellow topped 85 - 140 ml/min

CLEARANCE tube taken during 24hr collection

17
CREATININE KINASE
ISOENZYMES
MM, MB, BB
Adults 1 yellow topped tube

CRYOBLOBULINS Contact UHD Lab Ext 2358

CSF
Protein Sterile container 0.15 - 0.40 g/L
Glucose Sterile container 2.2 - 3.3 mmol/L
(60-70% plasma
glucose)

Xanthochromia Sterile container Not normally detected

CSF
Oligoclonal 1 red topped tube plus 3ml CSF
IgG in sterile container.

CYCLOSPORIN 1 purple topped tube 100-250 µg/l

Analysed Tues/Fri

CYSTIC FIBROSIS 1 purple topped tube

Genetic studies

CYSTINE 30 ml random specimen

Urine

DEHYDROEPIAN- 1 red topped tube Male 0.5 - 18.0 µmol/L

DROSTERONE Female 3.0 - 9.0 µmol/L
SULPHATE

DIBUCAINE NUMBERS 1 yellow topped tube Normal 70%

inhibition
Heterozygotes :
inhibition
40 - 70%
Homozygotes :
inhibition
20%

DNA (Double Stranded) 1 red topped tube.

Phone BCH Lab Ext 2607
18
DNA (Genetic Studies) 1 purple topped tube

ELECTROLYTES
Serum 1 yellow topped tube
Sodium Paediatrics - 1 green tube 135 - 145 mmol/L
Potassium 3.5 - 5.2 mmol/L
Chloride 95 - 110 mmol/L
Bicarbonate 22 - 30 mmol/L
Total protein 60 - 80 g/L
Urea 2.5 - 7.5 mmol/L
Creatinine 55 - 125 Umol/L
FAECAL FAT 3-5 day collection <25 mmol/24 hr
See Protocol page 35

FAECAL PH Random specimen PH 5 - 9

FERRITIN 1 yellow topped tube Male 22 - 322 µg/l

Pre Menopausal
Female:-20-291 µg/L
Post Menopausal
Female
22 - 322 µg/L

FRACTIONAL EXCRETION
OF SODIUM
Plasma 1 yellow topped tube Fractional excretion
Random urine in sterile of sodium <1%
container

FREE ANDROGEN 1 red topped tube <7

INDEX

FSH 1 red topped tube Male 1.2 - 9.0 U/L

Female 3.0-15.0 U/L
Post menopause >
30 U/L

GENETICS STUDIES See Chromosome Studies

GLUCOSE 1 grey topped tube 3.5 - 6.5 mmol/L

Serum

19
GLUCOSE 6 1 purple topped tube 120 - 240 U/1012
Phosphate Specimen must not be erythrocytes
Dehydrogenase refrigerated

GLUCAGON 1 green topped tube sent immediately

to Lab on ice. Contact RVH Ext 2735

GLUCAGON Contact RVH Lab Ext 3180

Stimulation Test

GLUCOSE Contact RVH Lab Ext 3180

Suppression Test

GLUCOSE See Protocols Page 36

Tolerance Test

GOLD 5 ml blood in plastic red top tube.

Phone UHD Ext 2358

GROWTH HORMONE Contact RVH Lab Ext 3230

GUT & ISLET 2 green topped tubes Contact RVH Lab.

HORMONE ASSAYS Send to Lab on ice immediately Ext 2533 for further
Exception is Pancreastatin - in interpretation
special bottle obtainable from Upper limit of normal
Gastrin Welcome Lab, RVH Ext 2533 80ng/L
Insulin Other peptide assays available 15 mU/L
Glucagon (N terminal) by special arrangement only 250 ng/L
Glucagon (C terminal) contact RVH 2533. 150 ng/L
Vaso Active Inteseinal Polypeptide (VIP) 100 ng/L
Pancreatic Polypeptide 200 ng/L
Somatostatin 50 ng/L
Calcitonin 150 ng/L
Substance P 5 ng/L
Gastrin releasing peptide (GRP) 40 ng/L
Pancreastatin 50 ng/L
Neurokinin K (NKA) 20 ng/L
Substance P 5 ng/L

HAEMOGLOBIN Alc 1 purple topped tube < 6.5%

20
HEAVY METAL SCREEN Random urine in red top
1 special lithium heparin
container. Phone UHD
Ext. 2358

HIGH DENSITY 1 red topped tube 1.0 - 2.4 mmol/L

LIPOPROTEIN (HDL)

HOMOCYSTEINE 1 purple topped on ice. 6-13 Umol/l

Send to lab immediately

HOMOGENTISATE 25 ml random urine specimen

HORMONE PROFILE 1 red topped tube

FSH must be filled to top Male 1.5 - 9.0 U/L
Female follicular/
luteal:
(3.0 - 15.0) U/L

Post menopause>30
U/L

LH Male 1.5 - 9.0 U/L

Female follicular/
luteal:
(2.5 - 9.0) U/L
Ovulatory peak
<90 U/L
Post menopause
>11 U/L
OESTRADIOL Male <200 pmol/L
Female Follicular
phase
95 - 580 pmol/L
Luteal phase
187 - 804 pmol/L
Ovualatory Peak
253 - 1336 pmol/L

PROGESTERONE Follicular phase < 4

nmol/L
Adequate luteal
fuction >30 nmol/L
21
PROLACTIN Male <375 mU/L
Female <500 mU/L

HUMAN CHORIONIC
GONADOTROPHIN
BHCG
Serum 1 red topped tube <5 U/L

HYDROXYINDOLE Patient preparation sheet 10 - 42 mmol/24 hr

ACETIC ACID Available from Laboratory
(5- HIAA)

17 HYDROXY 1 red topped tube Adult male 2.0-10.5

PROGESTERONE nmol/L
Adult female 2.0-
12.0 nmol/L

HYDROXYPROLINE 24h urine in plastic container 0.11 - 0.35 mmol/24hr

with no preservative. Avoid
foods such as meat, fish and
gelatine for 24h before collection.
Contact Lab for full protocol.

5 24h collection in plastic 0.3-1.3 µmol/24h

HYDROXYTRYPTAMINE with no preservative. Can be
analysed on same specimen
as 5-HIAA

IgE (Total) 1 red topped tube 0 -120 KU/L

IMMUNOGLOBULINS 1 yellow topped tube Age related

Paediatrics-1 green tube reference
range (See page 29)
IgG 5.3 - 16.5 g/L
IgA 0.8 - 4.0 g/L
IgM 0.5 - 2.0g/L
Ig subclasses Paediatrics-2 pink topped IgG1 4.2 - 12.9 g/L
tubes filled completely IgG2 1.2 - 7.5 g/L
IgG3 0.4 - 11.3 g/L
IgG4 0.01 - 2.9 g/L
INDICAN 25 ml random urine specimen

22
INSULIN Fasting sample in red topped <10 mµ/L
tube

INSULIN
Growth Factor IGF-1 1 red topped tube. Send to Lab
immediately. Contact RVH
Lab Ext 3230.

Iron Measured if 11 - 23 µmol/l

TIBC ferritin >400 ng/l
or on request 45 - 75 µmol/l

LACTATE Contact UHD Lab Ext 2358 0.33 - 1.30 mmol/L

LACTIC
DEHYDROGENASE 1 yellow topped tube 120 - 260 U/L

LEAD
Whole blood 5 ml blood in special plastic 0.03 - 1.01 µmol/l
lithium heparin bottle.
Urine 24hr collection <0.25 µmol/24h
Contact BCH 2017

LIPIDS 1 yellow topped tube

Cholesterol 3.4 - 6.0 mmol/l
Triglycerides 0.34 - 2.26 mmol/l

LIPID PROFILE Fasting sample in 1 yellow

HDL cholesterol topped tube 1.0 - 2.4 mmol/L
LDL cholesterol less than 4 mmol/L
CHOL:HDL ratio less than 5

LPa 1 yellow topped tube

Lipoprotein Electrophoresis Fasting sample 5ml of blood in yeIlow topped tube

LIPOSOMES 1 green topped tube. Send Contact BCH Lab

on ice to Lab immediately Ext 3173

23
LIVER PROFILE Adults - 10ml clotted blood
Bilirubin Paediatrics - 1 green tube
total 3 -17 µmol/L
Alk Phos (ALP) 40 - 130 U/L
Aspartate amino
transferase (AST) 17 - 45 U/L
G Glutamyl
transpeptidase (GGT) 10 - 45 U/L
Albumin 35 - 52 g/L

LUTENISING HORMONE 1 red topped tube Male: 1.5 - 9.0 U/L

Female follicular/
luteal
2.5 - 9.0 U/L
Ovulatory peak <90
U/L
Post menopause
>11 U/L

LYSOSMAL ENZYMES 1 green topped tube. Send

immediately on ice to Lab.
Contact RVH Ext 2169

MAGNESIUM
Adults: 1 yellow topped tube 0.75 - 1.25 mmol/L
Paediatrics: 1 green tube

MANGANESE Contact UHD Ext 2358 76 - 396 nmol/L

MELANIN 25 ml random specimen Absent

of urine

MERCURY
Whole blood 10 ml in green topped tube <25 nmol/L
Urine Random urine in red top <10 µmol/mol
creatinine

METHAEMOGLOBIN 1 purple topped tube <1.5%

METHOTREXATE Contact BCH Lab Ext 3168

24
MICROALBUMINURIA Screening: Random Urine <3 mg/mmol
in red top Timed overnight creatinine
collection in special <20 µg/min
container.
contact UHD Lab Ext 2358

MUCOPOLY- 25 ml random urine specimen.

SACCHARIDES

MYOGLOBIN Random urine specimen

NICKEL Random urine in red top 0-13 nmol/mmol

creatinine

OCCULT BLOOD Sample on Haemascreen card.

OESTRADIOL 1 red topped tube Male <200 pmol/L

Female - Follicular
95 - 580 pmol/L
Luteal phase
187 - 804 pmol./L
Ovulatory peak
253 - 1336 pmol./L

OESTROGEN Put tissue in plastic bag.

RECEPTOR Put on ice in insulated
container. Contact
RVH Ext 3180

ORGANIC ACIDS Random urine in sterile

container

OSMOLALITY
Serum 1 yellow topped tube 285 - 295 mOsmol/kg
Urine 25 ml random specimen 250 - 1000 mOsmol/kg

OXALATE 24h urine in bottle 0.2 - 0.6 mmol/24h

containing 30 ml 4N hydrochloric acid.
Contact UHD Lab Ext 2358

PANCREOLAURYL Obtain test pack from Pharmacy T/K >30%

TEST Follow instructions exactly

25
PARATHYROID 1 purple topped tube Normocalcaemia
HORMONE on ice 10 - 55 pg/L

PHOSPHATE Contact UHD Lab Ext 2358 16 - 48 mmol/24hr

Urine 24hr collection with special
preservative

PORPHYRINS Contact UHD Lab Ext 2209

Blood: 1 purple topped tube
Urine: 20ml in sterile container
Faeces: fresh sample
Shield all samples from light with foil
Send to Lab immediately.

POTASSIUM
Urine 24h collection 30 - 90 mmol/24 h

PREALBUMIN 1 red topped tube 0.18 - 0.44 g/L

PROGESTERONE 1 red topped tube Female:-

follicular phase
<4nmol/L

luteal peak >30

nmol/L

PROLACTIN 1 red topped tube Male - <390 mU/L

Female <500 mU/L

PROSTATIC SPECIFIC 1 yellow topped tube 40-49y <2.5 ng/ml

ANTIGEN Levels of 2-20 Ug/L may be 50-59y <3.5 ng/ml
seen in BPH. 60-69y <4.5 ng/ml
Contact UHD Lab Ext 2358 70-79y <6.5 ng/ml
for futher interpretation
PROTEIN
ELECTROPHORESIS 1 yellow topped tube
paediatric - 1 green topped tube
Total protein 57 - 80 g/L
Albumin 25 - 50 g/L
Globulin 16 - 35 g/L

26
PROTEIN
Urine 24 h collection <150 mg/24h

PTH STIMULATION Contact UHD Lab Ext 2358

TEST for Protocol

PYRUVATE KINASE 1 purple topped tube Contact RVH Lab

Ext 3663

PYRUVATE Contact UHD Ext 2358 0.03 - 0.08 mmol/L

RED CELL FOLATE 1 purple topped tube 110 - 700 ng/ml

packed cells

REDUCING Random urine in sterile container.

SUBSTANCES Send to Lab immediately.

RENAL CALCULI Send stones to Lab in

sterile container.

RENAL FAILURE Serum - 1 yellow topped tube

INDEX Urine - Random urine in sterile
container. Contact UHD Lab
Ext 2358

RENIN ACTIVITY Contact UHD Lab Ext 2358 Supine <3.24 ng/ml/h
for special plastic EDTA tube Upright
Send on ice to Lab immediately (1.8 - 6.7) ng/ml/h

SELECTIVITY OF 1 green topped tube plus Selective <0.16

PROTEINURIA random saple of urine with Moderately selective
preservative. Contact UHD 0.16 - 0.30
Ext 2358 Non selective >0.30

SELENIUM Contact UHD Lab Ext 2358 for 0.49 - 2.07 Umol/L
special plastic heparinised tube

SEX HORMONE 1 red topped tube

BINDING GLOBULIN Female: < 100 nmol/L

27
SODIUM 24 h collection 40 - 220 nmol/24h
Urine

SWEAT TEST Contact UHD Lab Ext 2358

SULPHAEMOGLOBIN Contact RVH Lab Ext 3569

TESTOSTERONE 1 red topped tube Male: 10.5 - 30

nmol/L
Female: 0.5 - 2.7
nmol/L

THALLIUM Random urine in red top < 2 Ug/L

THYROID FUNCTION 1 yellow topped tube

Free thyroxine (T4) 9.0 - 22.0 pmol/L
Thyroid stimulating 0.3 - 4.0 mU/L
hormone (TSH)
Triodothyronine (T3) 0.8 - 2.1 pmol/L

TUMOUR MARKERS CA - 125 see page 16

CA - 19-9 see page 16
CEA see page 16
HCG see page 22
PSA see page 26

URATE 1 yellow topped tube 0.08 - 0.41 mmol/L

Urine 24h collection, no preservative <4.7 mmol/24h

UREA
Urine 24h collection 180 - 750 mmol/24h

URINARY SUGARS See reducing substances page 27

UROBILINOGEN Random fresh urine

VITAMIN A & VITAMIN E 1 red topped tube

Vitamin A Paediatrics - 2 green tubes 1.1 - 3.5 mmol/L
Vitamin E Place specimens in 16 - 35 µmol/L
brown envelope

28
VITAMIN B12 & 1 red topped tube deficient <150 ng/L
FOLATE Borderline defic:
150 -200 ng/L
Normal 200 - 900 ng/L

Folate deficient < 3.1 µg/L

Indeterminate
3.1 - 4.8 µg/L
Normal 4.8 - 39.4 µg/L

VITAMIN C 1 purple topped tube on ice. Sent to lab immediately

VITAMIN D 1 red topped tube 12 - 100 nmol/L

(25DHCC) Send to Lab immediately.

ZINC Contact UHD Ext 2358 for 7.7 - 23.0 Umol/L

special plastic heparnised tube
Urine 24h collection in acid washed bottle

REFERENCE RANGES FOR IgG, IgA and IgM

Age IgG (g/L) IgA (g/L) IgM (g/l)

Cord serum 0 - 17.3 below 0.07 0.02 - 0.2

0 - 2 weeks 4.8 - 16.3 below 0.08 0.05 - 0.08
2 - 3 weeks 3.7 - 12.5 0.07 - 0.15 0.08 - 0.4
3 - 6 weeks 2.0 - 7.4 0.07 - 0.4 0.15 - 0.7
2 - 6 months 2.3 - 8.4 0.1 - 0.6 0.2 - 1.0
6 - 9 months 2.9 - 9.6 0.15 - 0.7 0.4 - 1.6
9 - 12 months 3.0 - 10.9 0.2 - 0.7 0.6 - 2.1
1 -2 years 3.0 - 13.2 0.3 - 1.2 0.5 - 1.9
2 - 3 years 3.7 - 15.8 0.3 - 1.3 0.5 - 2.2
3 - 6 years 4.7 - 15.5 0.4 - 2.0 0.5 - 1.9
6 - 15 years 5.5 - 15.5 0.5 - 2.8 0.5 - 1.9
Adult 5.2 - 15.5 0.8 - 4.0 0.5 - 1.9

29
 ALKALINE PHOSPHATE
REFERENCE RANGE FOR ALP (AMP AT 37oc )

Male U./L Female U/L

Neonates Up to 600 Up to 600

Infants 70 - 550 70 - 550
2 - 5 years 140 - 320 140 - 335
5 - 6 years 130 - 350 130 - 345
6 - 7 years 140 - 335 130 - 400
7 - 8 years 135 - 430 140 - 400
8 - 9 years 130 - 415 140 - 400
9 - 10 years 140 - 345 140 - 450
10 - 11 years 140 - 415 140 - 500
11 - 12 years 140 - 445 140 - 460
12 - 13 years 150 - 490 120 - 336
13 - 14 years 140 - 515 80 - 284
14 - 15 years 130 - 510 50 - 212
15 - 16 years 105 - 455 45 - 150
16 - 17 years 65 - 320 40 - 120
17 - 18 years 55 - 320 40 - 120
18 - 19 years 50 - 190 40 - 120
19 - 20 years 40 - 155 40 - 120
Adult 40 - 130 40 - 120
>55 40 - 135 40 - 150

REFERENCE RANGE FOR CALCIUM/CREATININE RATIO

<2 weeks <1.2 mmol : mmol

2 weeks - 7 months <2.4 mmol : mmol
7 months - 18 months <1.7 mmol : mmol
19 months - 6 years <1.2 mmol : mmol
>6 years <0.7 mmol : mmol

30
SIGNIFICANT CHANGES IN SERIAL RESULTS

Changes in serial results in healthy individuals are due to analytical impreci-

sion and day to day biological variation.

Significance of changes in serial results: Unless two results from an

individual patient differ by more than the values given below (for the common
analytes only) they are not significantly different.

Analyte Significant change in serial results

Albumin ± 3.2 g/L

Total Protein ± 5.8 g/L
Phosphorous ± 0.3 mmol/L
Calcium ± 0.14 mmol/L
Creatinine ± 12 mmol/L
Urea ± 1.6 mmol/L
Bicarbonate ± 4.5 mmol/L
Chloride ± 5 mmol/L
Potassium ± 0.55 mmol/L
Sodium ± 4.0 mmol/L
Iron ± 15.0 mmol/L
Urate ± 0.28 mmol/L
GGT ± 17.0 U/L
AST ± 14.0 U/L
Triglyceride ± 0.58 mmol/L
Cholesterol ± 0.95 mmol/L
Glucose ± 0.65 mmol/L

31
 DRUG INTERFERENCES IN TEST RESULTS

TEST DRUG EFFECT *P/A

Alkaline phosphatase parenteral nutrition ^ P

phenytoin, barbiturates ^ P
Amino acids valproate, ampicillin false
Spots A
Amylase codeine, morphine ^ P
Calcium cirate (blood transfusion) v P
phosphate v P
Cholesterol oestrogens v P
CK IM injections ^ P
Glucose Vitamin C v A
frusemide, thiazides ^ P
Glucose tolerance oestrogens, corticosteroids v P
GGT phenytoin, barbiturates, ethanol ^ P
HIAA naprosyn, paracetamol, DF118 ^ A
HIMMA (VMA) isoprenaline, monoamine v P
oxidase inhibitors
Iron iron therapy (especially parenteral) ^ P
Inorganic phosphate insulin v P
Postassium insulin v P
Total protein dextrans ^ A
Sodium and chloride lipid infusion v A
Total thyroxine oestrogens ^ P
amiodarone and other iodine
containing compounds ^ P
phenytoin v P
Urate ethanol, methotrexate ^ P
salicylates ^ P
Urea thiazides, aminoglycosides,
salicylates ^ P

*P = Pharmacological
A = Analytical

^ = increased
v = decreased

32
 COMMON SPECIMEN ARTEFACTS

PROBLEM COMMON CAUSES CONSEQUENCES

Delay in separation of Overnight storage High K+ AST,

serum or plasma Delay in transit LD, Mg+2
Low Na+
(occasionally)

Haemolysis Expelling blood sample through High K+

a neddle into container. High Phosphate
Over vigorous mixing of sample. Low Na+ and C1-
Sample stored in deep freeze. High AST, LD
Excessive delay in transit. High Mg +2
Sample left in hot place. Low glucose

Incorrect container or No enzyme inhibitor. Low glucose and

anticoagulant EDTA tube ethanol
Excess liquid heparin High K+. Low
calcium
Abnormal blood
gases and diluted
analytes.

Lipaemia Taken before intra-lipid is cleared. Interferes with

Taken after fatty meals; anxiety many colorimetric
and stress assays because of
turbidity of
sample. May
cause low sodium
concentration.

Contamination of High MW destrans. Elevated total

blood by infused fluids. Dextrose proteins.
Crystalloid solutions High glucose
Spurious Na+,
K+,C1-etc
Low calcium, high
Na+(if Na+ salt).

Bubbles in blood for Leaking syringe/needle junctions.Low PCO2

arterial gases Inadequate stoppering of syringe Increased PO2
in transit.
33
 TEST PROTOCOLS

The laboratory has protocols for patient investigation available. The more
common protocols are given below. Please contact the laboratory for details
of other protocols, extension
2360/2358 at the Ulster Hospital.

Adverse (ANAPHYLACTOID) Reactions to Intravenous Agents

Packs containing required forms and bottles available in Theatres and
Laboratory

BLOOD SAMPLES Duplicate venous samples

one clotted
one EDTA
taken within 1h, 6h post and 24h post reaction i.e. a
total of 6 samples

URINE SAMPLES Serial samples taken post reaction - first voided, 6h

and 24h

Clinical information required.

Dexamethasome Suppression Test

These test should be preceded by urinary free cortisol and baseline 08.00
and 23.00h serum cortisol estimations if Cushing’s disease is seriously
suspected.

OVERNIGHT LOW DOSE TEST

Dexamethasone (1mg) is given orally at 23.00h - 24.00h. Serum is sampled

between 0800h - 0900h the following morning. A serum cortisol of 50 nmol/l
or less excludes Cushings syndrome.

HIGH DOSE TEST

Dexamethasone (2mg) is given orally every 6 hours starting 0800hr. Serum

cortisol is sampled at 0800h and at 48h after starting the dexamethasone.
Adequate suppression is usually defined as a serum cortisol <50% of
previously measured basal level. This test can be performed immediately
following the low dose test.

34
Faecal Fat Test

Faecal fat estimation is usually carried out to determine the degree of fat
malabsorption, or to determine the response to therapy. This protocol is
essentially a fat balance study.

1. Ask the Dietician to see the patient and prescribe a diet containing 100g
fat per day. If the dietary fat content is less than 100g it is important to
know the fat content of the diet.

2. The patient takes three marker capsules a day, one with each main
meal, for seven days. They must not miss a dose. In all, the patient
takes 21 capsules, obtained from Pharmacy. Each capsule contains
eight radio-opaque pellets.

3. On days six and seven all stool passed is collected into the buckets
supplied from the Laboratory.

4. Patient or ward to send samples to Laboratory. Keep the samples in a

cool place.

CAPSULES FROM PHARMACY

PLASTIC BUCKETS FROM LABORATORY

Please ensure there is no Barium present in the abdomen as this

obscures the markers
Interpretation: Normal fat output <25 mmol/24h

Gilberts Syndrome

Ensure patient is not taking drugs which will affect bilirubin metabolism.
Obtain a 400 calorie diet sheet from a dietician. Collect blood samples
between 0900 and 10.30h on 3 successive days for the following:
Day 1 Normal diet: full blood count, blood film, liver functions tests, direct
bilirubin, haptoglobin
Day 2 400 calorie diet: total and direct bilirubin
Day 3 400 calorie diet: total and direct bilirubin

Interpretation: Unconjugated bilirubin (total - direct) usually rises by more

than 90% within 48h in patients with Gilberts syndrome on a restricted diet.
In patients with liver disease or haemolytic anaemia the rise is usually less
than 50%.

35
Glucose Tolerance Test

The GTT should be performed in cases where random or fasting plasma

glucose measurements are unable to categorise an individual. The test
should be administered in the morning after an overnight fast of between
10hrs and 16hrs, during which only water may be drunk. For a least 3 days
prior to the test, the patient should have had a normal unrestricted diet
containing at least 150g of carbohydrate and should have been normally
physically active. Any recent infections or current medication should be
noted. Ideally, any medication known to influence blood glucose should be
discountinued, if possible, for a period equivalent to five times the effective
half-life of the drug. Smoking should be discouraged at all stages, but
should be prohibited on the morning of the test.

During the test, the patient should be encouraged to sit quietly. A fasting
blood specimen should be collected and an adult patient given a solution of
75g of glucose to drink in a volume of approximately 300ml over 5 mins.
Current WHO opinion is that this should be 75g of anhydrous glucose or
82.5g of monohydrate. The test load for a child should be 1.75g per kg up to
a maximum total of 75g of glucose. Equivalent solutions of partial
hydrolysates of starch in similar volumes are also considered acceptable.
A further blood sample is collected at 2h. Blood samples are spun and
plasma glucose is analysed by the laboratory as soon as possible. Strip
testing methods must not be used for diagnostic glucose measure-
ments.
Urine collected at start and 2 hours and checked on wards.
INTERPRETATION OF GGT

For diagnosis of diabetes (in the non pregnant state) either:

1. Symptoms plus random plasma glucose >11.1 mmol/l

2. Fasting plasma glucose >7.0 mmol/l or
3. 2h plasma glucose after GGT >11.1 mmol/l
* Glucose concentrations should be confirmed on a separate occasion in
asymptomatic people.
* GTT is not recommended for routine testing.
* Fasting plasma glucose in the 6.1 - 6.9 mmol/l range is indicative of
impaired fasting glucose. If resources allow such individuals should go
to a GTT.

36
Growth Hormone Excess
Follow the protocol for Glucose Tolerance Test as above. In addition to
samples for blood glucose take samples for Growth Hormone in red topped
tubes at the stated times. Urine samples are not required.

Interpretation. Growth Hormone levels should depress to <2 mU/L

Growth Hormone Deficiency

Take a 2ml basal sample in a red topped tube for growth hormone. Ask
patient to exercise for 1/2 hr. Take another sample for growth hormone.
The level of GH should rise to >20 mU/L.

Lactose Tolerance Test

* Patient preparation: overnight fast.

* In morning, take a blood specimen for measurement of basal glucose.
Give lactose in an oral dose of 1.5g/kg body weigh up to a maximum of
50g for adults in 10% solution with water.
* Take blood specimen for measurement of glucose at 1/2, 1, 1 1/2 and 2
hours after giving lactose.

Interpretation

Normal: Plasma glucose rise >1.7mmol/L

Borderline: Increase of 1.1-1.7mmol/L
Pathological: A rise of <1.1mmol/L

An abnormal result should be compared to that of a GTT to exclude a

mucosal absorptive defect

Synacthen Test - The 30 minute Synacthen Test Procedure

30 MIN TEST The patient should rest quietly, but need not to be in
bed. Take a baseline venous sample for cortisol
estimation. Give 0.25mg Synacthen IM. Take a
further sample at 30 mins.

INTERPRETATION Normal response: basal >120 nmol/L

30 mins >500 nmol/L
increment >200 nmol/L

37
Thyrotrophin Releasing Hormone (TRH) Test

This test has been largely superceded by the development of highly

sensitive TSH assays; the finding of a measurable TSH level virtually
excludes the diagnosis of hyperthyroidism.

PROCEDURE: Take a basal 5 ml of clotted blood for serum

T4 and TSH estimation. Give 200 µg TRH V. Take
further samples for serum TSH estimation at 20 and
60 minutes.

INTERPRETATION: A normal result shows basal serum TSH 0.2-4.5 mU/

L, 20 minutes >5mU/L, 60 minutes 3-15 mU/L. A
high normal basal TSH with an exaggerated
response at 20min and a slight fall at 60min is
suggestive of early primary hypothyroidism. A
subnormal rise in TSH confirms secondary
hypothroidism and a delayed response (TSH at
60min >TSH at 20 min) suggests secondary
hypothroidism due to hypothalamic dysfuction.

Protocols available in the Laboratory:

Anaphylactic reaction
Faecal fat
Haema screen
Hydroxyproline
Hypoglycaemia
Insulinoma
Microalbuminuria
Pancreolauryl test
Renin Aldosterone
Saline suppression test
Water deprivation test

38
 TOXICOLOGY/THERAPEUTIC DRUG MONITORING

The clinical application of therapeutic drug monitoring is limited to those

drugs where a correlation between plasma concentration and therapeutic
effect has been demonstrated. Drug plasma levels should be monitoried
when a patient exhibits toxicity on a ‘normal’ dosage regimen, when
adjusting a dosage regimen, changing formulation or adding a drug, for
confirmation of adequacy of treatment or when non-compliance or overdose
is suspected. See Microbiology section for antibiotic monitoring.

The timing of the sample in relation to dosage is critical for correct interpreta-
tion of the result. Collection times should be based on the individual
pharmacokinetic properties of the drug, formulation and route of administra-
tion.

The following are general guidelines only:-

Sample type Sampling time

Trough level Immediately before next dose
Peak level (IV) 15-30 minutes after a 30 minute infusion
0-15 minutes after a 60 minute infusion
0-15 minutes after a bolus injection
Peak level (IM) 30-60 minutes after injection
Peak level (oral) 1-3 hours after oral dose
4 hours after sustained release preparation
Steady state level Drawn after five elimination half-lives (t1/2) have
elapsed

Interpretation of results should be in light of the clinical situation using

information which includes:-

Renal function ie. serum creatinine/creatinine clearance

Hepatic function
Patient age, weight and sex
Dosage regimen and dosage form of drug
List of concurrent drug therapy
Time the sample was obtained
Clinical status of the patient
For further information on sampling times or interpretation or drug plasma
levels please contact the Pharmacy department, UHD Ext. 2484. The
Pharmacy department can advise on the dosage level required to achieve a
“therapeutic” drug level when the above information is provided.
39
 TABLE OF DRUG HALF LIFE

Drug Elimination Half Life t1/2 (hr)

Amphetamine 5-21

Antiarrhythmics
Mexiletene 10
Procainamide 2.5 - 4
N-acetylprocainamide 6-7
Quinidine approximately 6

Antiasthmatics
Theophylline - adults 8.3
neonates >8.3

Antidepressants
Amitriptyline 19
Clomipramine 20
Desipramine 22
Dothiepin 25
Desmethylodothiepin 19 - 33
Doxepin 8 - 24
Desmethyldoxepin >24
Imipramine 18
Maprotiline 40
Mianserin 33
Nortriptylne 28
Protriptylene 55 - 198
Trimipramine 23

Antiepileptics
Carbamazepine - single dose 25 - 45
long term use 7 - 25
Ethosuximide 24 - 60
Phenytoin - single dose 9 - 22
chronic administration 15 - 100
Phenobarbitone 50 - 140
Valproic acid 7 - 14

40
 TABLE OF DRUG HALF LIFE (cont.)

Benzodiazepines
Clobazam 35
Diazepam 24 - 48
Desmethyldiazepam 51 - 120
Flurazepam 2
Desalkylflurzepam 47 - 100
Lorazepam 10 - 20
Nitrazepam 30
Oxazepam 7
Digoxin 40
Methotrexate 10
Paracetamol 2.5
Salicylate 2 - 30

41
TEST THERAPEUTIC RANGES SPECIMEN/NOTES

ALCOHOL(ETHANOL) 1 Red topped tube

AMPHETAMINE 30ml urine in

preservative
- free urine bottle
send to Lab
immediately.

ANTIARRHYTHMICS 1 Red topped tube

1. LIDOCAINE 1.5 - 5.0 mg/L Contact BCH Ext
2. N-ACETYLPROCAINAMEDE 6 - 20 mg/L 3168 for sample
3. PROCAINAMIDE 4 - 10 mg/L times.
4. QUINIDINE 2 -5 mg/L
5. DISOPYRAMIDE 3 - 5 mg/L

ANTIASTHMATICS 1 red topped tube

taken pre dose
(trough levels)
THEOPHYLLINE 10 - 20 mg/L or 8 - 12 hour post
dose (peak levels).
Patients on IV
infusions should be
monitored in the first
12 hrs (plus a
baseline level if there
is a likelihood of prior
administration).
Ideally the infusion
should be stopped for
15 mins before
sampling. Overdose:
patients with an acute
OD and serum levels
>100 mg/L or chronic
OD and levels >60
mg/L may require
haemodialysis. If
severe side-effects
are present earlier
intervention is
necessary. Repeat
serum theophylline
and potassium levels
2-3 hourly.
42
ANTIDEPRESSANTS 1 Red topped tube.
1. AMITRYPTILINE 120-250 µg/L (AMI+NOR) Sample with patientat
2. NORTRYPTILINE 50-150 µg/L steady state immedi-
3. IMIPRAMINE 150-250 µg/L (IMI+DES) ately predose. For
4. DESIPRAMINE 150-300 µg/L other anti -depressants
5. CLOMIPRAMINE 100-250 µg/L contact BCH Ext3168.
In tricyclic OD a
useful clue to serious
toxicity is a QRS
interval greater than
0.11sec. Adequate
oxygenation,
correction of any
acidosis maintenance of
serum potassium
should be ensured.
ANTIEPILEPTICS 1 Red topped tube
PHENOBARBITONE 15 - 40 mg/L Samples for all drugs
PRIMIDONE 5 - 12 mg/L taken predose.
ETHOSUXIMIDE 40 - 100 mg/L
VALPROATE (EPILIM) 50 - 100 mg/L
PHENYTOIN (EPANUTIN) 10 - 20 mg/L
CARBAMAZEPINE
(TEGRETOL) single dose regime: 8-12 mg/L
multiple dose regime : 4-8 mg/L
LAMOTRIGINE 1 - 4 mg/L

AMINOGLYCOSIDES see p68 1 Red topped tube

GENTAMICIN sent to Bacteriology
NETILIMICIN Lab

BARBITURATES 1 Red topped tube.

AMYLOBARBITONE Contact BCH Ext
BARBITONE 3168 for ranges
BUTOBARBITONE
PENTOBARBITONE
PHENOBARBITONE

BARBITURATE SCREENING 1 Red topped tube

BENZODIAZEPINES 1 Red topped tube

DIAZEPAM Contact BCH Ext
NORDIAZEPAM 3168 for other
TEMAZEPAM benzodiazepines that
LORAZEPAM can be assayed.
NITRAZEPAM
43
BENZODIAZEPINE SCREENING 1 Red topped tube

CANNABANOIDS 30ml urine

preservative - free

CARBAMAZEPINE See antiepileptics

CARBOXYHAEMOGLOBIN <2% 1 purple topped tube

Smokers may have levels
over 10%. Severe toxicity
occurs at levels >30%

CYCLOSPORIN 100 - 250 µg/L 1 purple topped tube.

Contact BCH Ext 3168.
Therapeutic range
given is for renal
transplant patients.

DIGOXIN 0.8 - 2.0 µg/L 1 Red topped tube.

Sample should not be
taken <6hr after last
dose.

DIHYDROCODEINE Toxic >0.5 mg/L 1 Red topped tube

DRUGS OF ABUSE 30ml urine in

SCREENING preservative - free
Amphetamine, Barbiturates bottle. If there is a
Benzodiazepines, delay in sending
Cannabanoids, sample to Lab check
Cocaine metabolites, LSD, urine pH and record
Opiates. it on the request form
(NB test the pH of a
separate urine
aliquot from that
sent for Lab analysis.

ETHOSUXIMIDE See antiepileptics

44
ETHYLENE GLYCOL 1 Green topped tube.
Difficult to measure
out of hours. Useful
clues are the presence
of an osmolal gap
(difference between
measured and
calculated serum
osmolality) and/or an
anion gap acidosis.
Toxicity can be reduced
by giving ethanol IV
to keep blood ethanol
levels 1-2 g/L. For
levels of ethylene
glycol >0.5 g/L,
haemadialysis should
be seriously considered.
Note: most antifreeze
solutions also contain
methanol.

IRON Adults: 1 Red topped

tube Paediatrics: 2
Pink topped tubes.
Overdose: stat levels
at 2hr for children 4 -
6 hrs for adults serum
Fe<90 µmol/L mild
>90 µmol/L mod/
severe >180 µmol/L v
severe.
If in doubt ask for
TIBC; if serum Fe>
TIBC then there is
free circulating iron
which is toxic and
requires chelation.

45
LITHIUM Prophylaxis: 1 Red topped tube.
0.4-1.0 mmol/L Sample12hr after dose.
Acute mania: If serum Li>5 mmol/L
< 1.2 mmol/L haemodialysis
required; consider HD
at levels > 3 mmol/L if
patient toxic (serum
levels do not accurately
reflect the severity of
an overdose)

METHANOL 1 Green topped tube.

Treatment: ethanol IV
or, if level >0.5g/L,
haemodialysis.

METHOTREXATE 1 Red topped tube. It

is essential that the
BCH Lab Ext 3168 is
contacted before
therapy is started.
Samples should be
taken at 24hr
intervals after high
dose therapy until
serum level is <0.1
µmol/L
NETILIMICIN See Aminoglycosides

OPIATES 30ml urine in

preservative - free
bottle.

46
OVERDOSE SCREEN This involves complex
send samples of: chromatograph
Gastric aspirate analysis for unknown
Urine drugs, takes a long
1 Red topped tube of blood time to completeand
is unsuitable for out
of hours anaysis.
In a emergency,
certain qualitative
tests are available for
generic drug groups
but these will tend to
be positive if the patient
is taking the drugs
routinely.

PARACETAMOL Therapeutic levels at 1 Red topped tube.

4h : 5 - 12 mg/l Sample at >4hr after
OD. If >24hr elapsed
since OD paracetamol
will likely have
disappeared from
serum except in
massive OD.
Transaminases and
prothrombin time
should be measured
in these cases
(although the effect
on these is usually
not maximal until day
3-4). Note that the
action lines are only
an approximate guide
to prognosis.
See Fig. 1, page 49

PARAQUAT 1 Red topped tube.

Sample at >4hr after
overdose.
For screening send a
random urine.

47
PHENOBARBITONE See antiepileptics

PHENYTOIN See antiepileptics

PHENOTHIAZINES 1 Red topped tube

THIORIDAZINE 0.4 - 2.0 mg/L Send on ice to Lab
Toxic >2mg/L immediately.
CHLORPROMAZINE 2 - 120 Ug/L
Toxic >500 Ug/L

SALICYLATE 1 Red topped tube.

Sample at >4hr after
overdose. The
prognosis for acute
salicylate poisoning
cannot be determined
from serum
concentration alone;
clinical features
particularly impaired
consciousness and
the arterial pH must
be taken into
consideration
(acidaemia, regard
less of class of acid -
base abnormality, has
a poorer prognosis).
Haemodialysis is the
treatment of choice
for severe intoxica
tion (>750 mg/L) or
less severe
intoxication if there
are complications.

THEOPHYLLINE See Antiasthmatics

TRICYCLICS See Antidepressants

VALPROATE See antiepileptics

48
 Plasma Plasma
paracetamol
(mg/l)
TREATMENT LINES paracetamol
(mmol/l)
200
1.3
190

180 1.2

170
1.1
160

150 1.0

140
A
Normal treatment line 0.9
130

120 0.8

110
0.7
100

90 0.6

80
0.5
70

60 0.4

50
0.3
40

30 0.2

20 B 0.1
10 High risk treatment line
0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Hours after ingestion

Paracetamol Treatment Graph. High risk treatment line B:

Patients who regularly consume excess alcohol, who take
enzyme inducing carbamazepine, phenytoin, phenobarbitone,
primidone and rifampicin or with conditions of malnutrition or HIV
infection.

(Reproduced with permission of NI Drug and Poisons Information

Service)

49
 DRUG INFORMATION SERVICE

Regional centre: Belfast 02890 248095

Area centres: Londonderry 02871 45717 ext. 3262

Craigavon 02838 334 444 ext. 2976
Antrim 02891 424 278

Local centres: Ulster Hospital 02890 484511 ext. 2484

Belfast city Hospital 02890 329241ext. 2600

POISONS INFORMATION SERVICE

Belfast 02890 240503

Birmingham 0121 554 3801
Cardiff 02920 709901
Dublin 003531 379964 or Dublin 003531 379966
Edinburgh 0131 229 2477 or 0131 228 2441 (viewdata).
Leeds 0113 430715 or 0113 316838
London 0207 632 9191 or 0207 955 5095
Newcastle 0191 232 5131

SPECIALIST INFORMATION AND ADVISORY SERVICES AVAILABLE VIA

REGIONAL CENTRE.

Drugs in breast milk

Drugs in preganacy
Drugs in dentistry
Alternative medicine
Drugs in renal failure
Toxicology and poisoning
Drugs in liver disease
Acquired immune deficiency syndrome
Press index
Drugs in psychiatry
Medicines Resource Centre (MeReC)
Community Services Information
Scottish Medicines Resource Centre (SMRC)
Viewdata Drug Inforamtion Service (VADIS)
Welsh Medicines Resource Centre
German translations
Please note: If advice rather than simple information retrievel is required,
then the full clinical background will be required.
50
NEONATAL AND PAEDIATRIC TEST REQUIREMENTS

A range of paediatric vacutainer tubes is available on wards and outpatients.

These have the same colour coded tops as the adult range, so if using these
please refer to Test and Reference Values section of this Hand Book starting
Page 12. Otherwise the specimen requirements are given below.

TEST SPECIMEN REFERENCE RANGE

Acid Base Status Arterial sample

PH 7.35 - 7.40
PCO2 4.00 - 6.0 k Pa
Bicarbonate 18.0 - 25.0 mmol/L
Base excess -4 to +4 mmol/L
PO2 8.0 - 11.0 k Pa

Admission Profile 1 green tube filled

Sodium completely. 135 - 145 mmol/L
Potassium Please note:- 3.5 - 5.5 mmol/L
Urea Reference ranges 1.0 - 5.0 mmol/L
Creatinine may vary with age Age dependent
Total Protein of child. 54 - 70 g/L
Albumin 25 - 45 g/L
Bilirubin 3 - 17 µmol/L
ALP Age related
AST Age related
GGT Age related
Cholesterol 3.6 - 6.0 mmol/L
Glucose 3.5 - 6.5 mmol/L
Calcium 2.17 - 2.75 mmol/L

Albumin 1 green tube filled 25 - 45 g/L

to 400

Alkaline phosphatase 1 green tube up to 600 U/L

17 alphahydroxy 2 red tubes filled <20 nmol/L

progesterone completely

51
Alpha 1 antitrypsin 2 green tubes 0.9 - 2.2 g/L
Phenotype should
be assessed if <1.6g/L
in babies with
prolonged jaundice.

Amino acid 1 green tube filled

chromatogram completely plus a
random urine.

Ammonia 1 green tube up to 100 mmol/L

send on ice

AST 1 green tube up to 100 U/L

Bilirubin (Total) 1 green tube <10 days of age

up to 200 mmol/L
>14 days of age
(Direct) 1 green tube <40 mmol/L

Bone Profile 1 green tube

Albumin 25 - 45 g/L
Alkaline Phosphatase up to 600 U/L
Calcium 2.15 - 2.75 mmol/L
Phosphate 1.3 - 3.0 mmol/L

Caffeine 1 green tube 5 - 20 mg/L

Calcium 1 green tube 2.15 - 2.75 mmol/L

often a marked fall
after birth with lowest
level (1.8mmol/L) at
around 24 - 48h of
age
Calcium creatinine Random urine Up to 1.2 mmol/mmol
ratio Age related see p30

Chromosome analysis 5ml blood in special

Lithium Heparin tube
obtained from Lab
Ext 2358.
52
Fragile X syndrome 5 ml blood in
special EDTA tube
obtained from Lab
Ext 2358

Chloride 1 green tube 92 - 110 mmol/L

Creatinine 1 green tube 28 - 60 µmol/L

Creatine Kinase 1 green tube up to 2000 U/L

Marked fall during
first week of life
following peak at
24 - 48 h

Creatine Kinase 2 green tubes

isoenzymes

Digoxin 1 green tube taken 1 - 2 µg/L

>6h post dose
filled completely

DNA Studies 5ml blood in special

EDTA tube otained
from Lab Ext 2358

Epanutin
(See Phenytoin)

Electrolytes 1 green tube

Sodium 130 - 145 mmol/L
Potassium 3.5 - 5.5 mmol/L
CO2 18 - 25 mmol/L
Total Protein 54 - 70 g/L
Urea 1.0 - 5.0 mmol/L

Fractional Excretion 1 green tube plus Neonates - 2%

of Sodium random urine >1 month old <0.1%

53
Fragile X (See Chromosome analysis)

Galatose 1 1 green tube filled <4 mg/100ml RBC

phosphate Completely

Galactose 1 1 green tube filled If screening shows

phosphate to 400 deficiency a
uridyl transferase quantitative assay will
be carried out

Glucose (fasting) 1 yellow topped tube 2.0 - 5.5 mg/L

filled to 0.2 line

Hypoglycaemia Use hypopack available

investigations on wards. Please contact
Lab Ext 2358 before
sending specimens

Immunoglobulins 1 green tube filled Age related see page 29

IgG completely 5.0 - 17.0 g/L
IgA up to 0.08 g/L
IgM up to 0.2 g/L

IgG subclasses 2 pink topped tubes filled completely

IgG1 4.2 - 12.9 g/L
IgG2 1.2 - 7.5 g/L
IgG3 0.4 - 1.3 g/L
IgG4 0.01 - 2.9 g/L

Iron Studies 2 pink topped tubes filled completely

Ferritin 36 - 100 µg/L
Iron 10 - 30 µmol/L
TIBC 47 - 75 µmol/L

Lactate (fasting) 1ml blood in special 0.5 - 2.0 mmol/L

tube from Lab
Ext 2358

54
Liver profile 1 green tube
Bilibrubin see bilirubin
(Page 52).
Alkaline Phosphaste (ALP) up to 600 U/L
Asparate amino transferase (AST) up to 100 U/L
G Glutamyl transpeptidase (GGT) <2 weeks up to 250 U/L
>2 weeks up to 150 U/L

Magnesium 1 green tube 0.6 - 1.0 mmol/L

Mucopolysaccharides Random urine Screened for dermatin

and heparin sulphate

Osmolality 1 green tube 275 - 295 mmol/kg

Organic Acids Random urine in

sterile container

Phosphate 1 green tube filled 1.3 - 3.0 mmol/L

completely

Phenobarbitone pre-dose 15 - 30 mg/L

1 green tube

Phenytoin pre-dose 10 -20 mg/L

1 green tube

Protein (Total) and 1 pink topped tube 54 - 70 g/L

Electrophoresis

Potassium See Electrolytes

Sodium See Electrolytes

Theophylline Pre Dose 5 - 12 mg/L

1 green tube

Pyruvate Special tube 0.03 - 0.08 mnol/L

contact UHD
Ext 2358

55
Total parenteral 1 green tube filled
nutrition screen completely
Sodium 130 - 145 mmol/L
Potassium 3.5 - 5.5 mmol/L
Urea 1.0 - 5.0 mmol/L
Total Protein 54 - 70 g/L
Albumin 25 - 45 g/L
Triglyceride 0.3 - 2.0 mol/L
Cholesterol 1.5 - 4.0 mmol/L
ALP up to 600 U/L
AST up to 100 U/L
CO2 18 - 25 mmol/L
Calcium 2.15 - 2.75 mmol/L
Phosphate 1.3 - 3.0 mmol/L

Thyroid Profile (TSH) 1 green tubed filled

completely
Birth - 4 days 1.0 - 38.9 mU/L
2 w - 20wks 0.8 - 8.5mU/L
21w - 24mths 0.8 - 8.0 mU/L
25m - 20yrs 0.3 - 4.0 mU/L

Free Thyroxine (FT4)

Full Term 1-3 days 14.0 - 38.0 pmol/L
4-10 days 14.0 - 28.0 pmol/L
Pre Term 1-3 days 11.3 - 24.0 pmol/L
4-10 days 10.0 - 30.0 pmol/L
Pre Term Sick 1-3 days 8.0 - 18.1 pmol/L
4-10 days 7.0 - 23.0 pmol/L

Urea See Electrolytes

56
MICROBIOLOGY

57
 1. Specimen collection

1.1 Specimen collection - general information

The prompt and accurate isolation of infecting agents is directly

influenced by the quality of the specimen. With the exception of
suspected meningitis it is almost always possible to obtain appropriate
specimens before commencing antibiotic therapy.

The following points should be adhered to:

> Collect specimen before administration of antibiotic therapy.

> Specimen should be transported to the laboratory as soon as
possible.
> Ensure that the specimen container is clearly labelled with the
patient’s details.
> Remember that you may be dealing with pathogenic micro-
organisms and care should be taken while obtaining and
subsequently handling the specimen. See Infection Control
Guidelines.

Specimen containers:

Wide neck container with plastic spoon Faeces

Wide neck sputum container Sputum
Universal container and Urine
red topped urine analysis container
Large (150 ml) container for
early morning urine for Mycobacterium tuberculosis Urine for “TB”
Plain swab Microscopy
Charcoal swab Routine use
Yellow cap clotted specimen container Serological tests
Red cap clotted specimen container Antibiotic assays

The container used for most types of microbiological specimen is the

“Universal container”. If you are in any doubt about the most appropriate
specimen or container, please contact the laboratory for advice.

58
1.2 Specimen collection - Infection control

> Wash hands thoroughly before obtaining the specimen and after it
has been prepared for collection.
> Do not overfill container.
> Ensure that container is securely closed and that the outside of the
container is not contaminated by the specimen.
> Place the specimen in a polybag for transport to the laboratory.

NB Where the request form is not attached to a polybag e.g. Virology, a

separate “biohazard” bag should be used. These may be obtained from
the laboratory.

High Risk: All specimens from suspected or proven cases of HIV,

hepatitis B and C, and tuberculosis must be labelled with a special
biohazard label “Danger of Infection - Take special care. “These
labels are available from the laboratory and should be applied to the
specimen container and to both copies of the request form.

1.3 The request form

Please fill in these correctly and with relevant clinical details - many
requests provide no relevant clinical details! These ensure appropriate
laboratory processing and reporting.

Please use addressograph labels and apply to both copies of the request
form. Please apply “Danger of Infection” labels as appropriate - see
Infection Control Precautions.

The following sections of the request form must be completed.

1. Patient identification data (PID). 3. Requesting details.
Full surname and forename in Name of requestor
block letters. Return address.
Unit number. Bleep/telephone number
Consultant/GP and cypher code. for urgent reports.
2. Specimen details. 4. Clinical information
Date and time collected. Clinical information
Nature and site of sample. relevant to investigation.
Test/s requested. Current/proposed antibiotics.
59
1.4 Reporting
Final reports will be issued as soon as possible. The medical or
laboratory staff will telephone urgent reports. Telephone requests should
be kept to a minimum in the interest of safety, as verbal reports may lead
to transcription errors. Telephone calls for provisional culture results
should be made after 11am.

1.5 Reasons for rejecting specimens for bacteriological

examination

• Improperly labelled samples and samples from patients whose details

do not correspond with the request form.
• Incomplete or illegible request form.
• Specimens received in a non sterile container.
• Specimens which have leaked or where the container has been
damaged during transport to the laboratory.
• Tissue/specimen received in formalin or other fixative.
• Blood cultures that have been refrigerated.

1.6 Collection of specific specimen types

Blood cultures: These should form part of the investigation of every

pyrexial illness. Samples of blood should be taken as soon as possible
after a “spike” of fever and, in almost all cases, should be performed
before initiation of antibiotic therapy.
Ideally a minimum of 2 sets of blood cultures should be collected
(preferably not less that 1 hour apart). A single blood culture set may miss
intermittently occurring bacteraemia and make it difficult to interpret the
clinical significance of certain isolated organisms.

Endocarditis - bacteraemia is continuous in this condition so blood

cultures do not have to be related to pyrexial episode. At least 3 sets of
cultures should be collected and as the density of bacteraemia may be
very low the maximum volume of blood should be inoculated into the
culture bottles - see below.

Blood culture bottles are available from under the centre bench in the
main corridor of the Laboratory. These bottles have a limited shelf life and
should not be stored in bulk at ward level.

60
 Aerobic Blue colour code top, recommended 10ml blood fill
Anaerobic Purple colour code top, recommended 10ml blood fill
Pedi-Bact Yellow colour code top, recommended maximum fill 4ml
blood. Please note that this bottle is for aerobic culture only
and normally to be used with babies or infants, or only in
an extreme case where only small volumes of blood are
obtainable.

Procedure
1. Using an antiseptic handwash solution (Hibiscrub/Betadine
Surgical Scrub) wash and dry your hands before commencing
procedure.
2. Inspect the venepuncture site, wash with soap and water if
visibly soiled and palpate the vein. Carefully clean the
venepuncture area with alcohol soaked swabs. ALLOW THE
ALCOHOL TO DRY.
3. Do not re-palpate the vein after skin disinfection.
4. Inspect broth and sensor (the dark green dot located on the
bottom of each bottle). Ensure that the broth is clear and that
the sensor is intact and a dark green colour. Remove the centre
plastic flip top lids from the BacT/Alert bottles and sterilise the
exposed rubber diaphragms with alcohol.
5. Put on sterile gloves, take the sample of blood and inoculate
recommended volume.

If blood has been obtained for other purposes it is essential to inoculate

the blood culture bottle first to avoid cross contamination from non-sterile
specimen containers. Inoculate the anaerobic bottle first.

6. Dispose of syringe and needle carefully - DO NOT RESHEATH.

7. Label each bottle separately with patient’s name, his/her hospital ID,
date and time of collection. If two sets of blood cultures are taken at
the same time from a central line and a peripheral site please mark
the site sampled on all 4 bottles. NOTE: If paper labels are used,
stick on bottom half of the bottle not over the Bar Code as this is
needed for bottle identification.

61
Blood cultures must be transported to the main Bacteriology laboratory
immediately. Out - of - hour specimens must not be left on the bench
or in the fridge! If no laboratory staff are available the bottles must be
loaded into the blood culture incubator (located in the main Bacteriology
laboratory at the far end of the right hand side) by the person e.g. porter
delivering the specimen.

Reporting: The ward will be informed immediately any blood culture is

found positive. A Gram stain result and any preliminary identification will
be provided. Preliminary sensitivity test results will also be telephoned as
soon as they are available and will be followed by a final report. It is
important to note that these early sensitivities are preliminary and may be
limited. If in any doubt about the most appropriate agent seek advice from
the medical microbiologist.

Cerebrospinal fluid (CSF)

1. Please inform the Laboratory in advance of a request for CSF

examination.

2. Following cannulation of the spinal canal obtain about 2 mls of CSF

(in young children smaller volumes are acceptable) into 3 plastic
universal containers which should be clearly labelled sequentially.

3. Clinical details are essential e.g. is the suspected diagnosis

subarachnoid haemorrhage/bacterial meningitis/viral meningitis etc.

4. Remember to send a blood sugar to the Biochemistry laboratory so a

blood/CSF sugar ratio can be established. If a viral aetiology is
suspected fill in a Virology form and send both a throat swab in virus
transport medium and a faeces sample.

5. Transport the specimens to the laboratory without delay.

The following analysis is undertaken routinely.

> Cell counts and differential analysis

> CSF sugar level (in Biochemistry)
> CSF protein level (in Biochemistry)
> Direct microscopy and culture for bacteria

62
If indicated by the clinical history and/or cell count/sugar/protein profile
antigen detection testing may also be carried out.

Examination for tubercle bacilli is only undertaken if indicated by cell

count/protein level/sugar level profile or on request.

Other specialized tests such as oligoclonal banding must also be

requested separately. Spectrophotometry for xanthochromia is
undertaken by the Biochemistry laboratory.

(See also investigation of bacterial meningitis, page 73)

Eye swab:

Purulent material should be collected from behind the lower eye-lid or

from the inner canthus. If neonatal gonococcal conjunctivitis is suspected
transport the specimen to the laboratory as quickly as possible. If
immunofluorescence for Chlamydia is required, put conjunctival epithelial
cell scrapings (not pus) on a clean glass slide and allow to dry - keep the
area used on the slide as small as possible. Cover with another slide but
keep a space between them to prevent the slides from sticking to each
other, tape them together, put into a slide box and send to the Regional
Virology Laboratory with a completed Virology request form.

Faeces:

Stools may be collected in a clean bedpan and must not be contaminated

with urine/residual soap/disinfectant. Collect a portion into a sterile faeces
container using the spoon attached to the lid. Include material containing
pus/mucus/blood if present. Do not fill the container more than 1/3 full.

Culture for the following enteric pathogens is undertaken routinely -

Salmonella spp, Shigella spp., Campylobacter spp and E. coli O157.
Additional examination (particularly microscopy for enteric parasites, toxin
testing for Clostridium difficile, or examination for unusual pathogens) will
be performed on clinical request or patient’s history. Where relevant,
please provide travel history. Stools are specifically examined for the
presence of cryptosporidia in the under 15s. In all others this is performed
on clinical request.
Where a ward outbreak of gastrointestinal illness is suspected please
contact the Infection Control Department.

If food poisoning is suspected remember this is a notifiable illness and

63
should be reported to the Public Health Department, EHSSB.

For thread worm ova, a cotton wool swab in a dry container is required.
This should be premoistened and applied to the perianal skin area. This
is best done late at night or in the early morning before bathing.
Specimens should be transported and examined as soon as possible.
One examination will detect approximately 50% of infections rising to
90% for three and 99% for five.

Genital tract:

High vaginal swabs: swabs should be taken using a speculum as

contaminating material from the lower vagina may affect results.

*Gonococci:- Swabs should be obtained from the endocervix, urethra and

rectum from female patients and from the urethra and rectum in male
patients. Swabs should be sent in charcoal transport medium ideally
within 30 minutes and the laboratory informed. Direct microscopy for N.
gonorrhoeae in the female urethra is of limited value but a smear from
samples from the male urethra should be prepared.

*Chlamydia:- (Microtrak kit) Female patients - use large swab to clean

cervical os, then discard. Insert second large swab into endocervical
canal. Rotate to obtain endocervical cells. Male patients - insert small
swab into urethra (2-4cm) and rotate to obtain endourethral cells. Place
swab in transport tube and break off at score line.

Bacterial vaginosis/Gardnerella vaginalis:- Two high vaginal swabs

should be taken, one sent in transport medium and the other plain swab
used to make a glass slide smear. This will be examined in the laboratory
for the presence of “clue cells”. Alternatively send an air dried smear in a
slide box to the laboratory.

Trichomonas vaginalis:- A high vaginal swab should be sent in specific

trichomonas transport/culture medium. Allow transport medium to come
to room temperature before using.

* Consider referral to Genito Urinary Medicine

64
Intravenous catheter tip:

Clean insertion site with alcohol and allow to dry. Aseptically remove
catheter and send 5cm tip to laboratory in sterile universal container. If
there is purulent material at the exit site please also send swab for
culture.

Nose and throat:

Throat swab: (e.g. for Group A streptococci) Rub a sterile swab over
tonsillar areas, posterior pharyngeal wall and any areas of ulceration,
exudation or membrane formation. NB If diphtheria is considered as a
diagnosis, please state this clearly on the request form.

Pernasal/nasopharyngeal swab:- (for detection of Bordetella pertussis/N.

meningitidis). These cotton alginate tipped flexible wire swabs are
available from the laboratory. Gently insert the swab along the floor of the
nose into the nasopharynx, rotate it there and withdraw. Notify the
laboratory and transport swab to laboratory immediately.

Nasopharyngeal secretions:- (for detection of Respiratory syncitial virus/

influenza etc). Pass sterile catheter tip through each nostril to the
nasopharynx intermittently applying suction as the catheter is slowly
withdrawn. Send 0.2-0.8 ml secretions in the trap container to the
laboratory. If insufficient secretions are obtained 0.5-1ml of sterile saline
may be introduced into the posterior nares and resuctioned into the trap
container.

Pus / Inflammatory exudates:

If there is any volume of pus present please do not send a swab.

Aspirate the pus/exudate with a sterile syringe and transfer to a sterile
universal container. If there is only a very small volume of material in the
syringe, add some sterile preservative-free saline, mix and transfer to the
sterile container. The site of origin of the material must be clearly stated.
Send to laboratory immediately. Out-of-hours, please notify on-call
Biomedical scientist of any urgent specimens.

65
Semen analysis:

a) Infertility - Sample should be collected after minimum of 3 days and

not longer than 7 days of sexual abstinence. (A second sample, not
less than 7 days after the first may be helpful as sperm counts may
fluctuate widely).
The sample should be obtained by masturbation and ejaculation into
a wide mouthed sterile container. Condoms should not be used for
semen collection. The container should be kept warm and handed to
a member of laboratory staff as soon as possible and preferably with
one hour of collection.

b) Post vasectomy - Samples should be tested at monthly intervals

beginning at 2 months post vasectomy and continuing until two
consecutive monthly specimens show no sperm. Samples should be
collected as above.

Sputum:

Patients should be asked to rinse out their mouths (Use tap water, not
antiseptic mouth wash. If TB is suspected, use sterile preservative free
water) and provide only material resulting from a deep cough. Physio-
therapy assistance may be helpful if a patient has difficulty producing a
suitable sample (salivary samples are unsuitable and may be rejected).
Specimens should be collected into a sterile wide mouthed sputum jar
and sent to the laboratory without delay. (See also investigation of
tuberculosis page 75).

Urine:

Mid stream specimens are collected as follows:

Male - The glans penis is cleaned with soap and water. Micturition is
commenced and after a few mls of urine have been passed, a sterile
urine container is held under the stream and the container filled.

Female - Separate the labia and clean the vulva from front to back with
cotton wool moistened with sterile water. With the labia separated
micturition is commenced and after a few mls have been passed, without
stopping, allow urine to pass into a sterile foil dish. Transfer into a sterile
urine container.

66
Urine is an excellent growth medium for microorganisms. It is important
that if there is to be any delay in transporting the specimen to the
laboratory, it should be refrigerated.

Catheterised patients: samples should only be obtained if there are any

systemic signs of infection. The sample should be obtained from a
sampling port or sleeve. This should be disinfected with alcohol prior to
aspirating the sample with a syringe and needle. Never obtain the sample
from the drainage bag.

Paediatric practice - Suprapubic aspirates are the best samples for

establishing the diagnosis of bacteriuria in infants and small children.
Otherwise, clean catch specimens are preferable to a bag collection. If
washing is required because the perineum is soiled, an initial soap and
water wash followed by a rinse with clean water and careful drying is all
that is required.

(see also investigation of tuberculosis, page 75)

Wound swabs:

Surface wounds and sinuses are often colonised with environmental

bacteria and superficial swabs may not reflect the cause of the infectious
process.

Wherever possible, pus from the base of the wound should be aspirated
by syringe and transferred to a sterile container.

Only when this is not possible should a swab be used. First remove
superficial slough, then extend the tip of the swab deep into the wound
taking care to avoid the skin margins.

The wound site and nature must be clearly stated on the request form.

67
 2. Antibiotic monitoring

• Serum assays are required for certain antibiotic agents to ensure

therapeutic but non toxic levels are achieved. Levels (peak and
trough) are always required for aminoglycosides, vancomycin
and chloramphenicol. Seek the advice of Medical Microbiologist for
the monitoring of other antimicrobials.
• 5 - 10ml blood samples should be taken from a peripheral vein and
placed in red-topped bottles. * In children, a green topped tube filled
to 400 µl is sufficient. Trough levels should be taken just before the
next dose and peak levels taken 60 minutes after the dose, unless
indicated otherwise in accompanying table.

• Monitoring multiple daily dose aminoglycoside therapy - samples

should reach the laboratory by 1.30pm. The test will be performed at
2pm and the results telephoned to the ward by 3pm. On weekends
and public holidays these samples must arrive by 10.30am.
Monitoring once daily therapy - samples obtained out of hours will not
normally be processed until the following morning. This should still
allow sufficient time for dose adjustment prior to next due dose. To
facilitate this arrangement it is best to avoid dosing times between
9-11am.

• For all assays it is essential that the following information be provided

on the request form:
º Time and date of commencement
º Clearly record on both forms and samples whether samples
are pre-dose or post-dose/peak related.
º For aminoglycoside Multiple daily/once daily regimen - if on
once daily dosing and a single level is requested, the exact
time of the sample must be recorded.
º Random samples are usually impossible to interpret!

68
 Suggested serum levels
Agent Condition Levels Comments
Trough Peak
(ug/ml) (ug/ml)
Aminoglycosides Gram-ve pneumonia <2 >7 Assay 2-3 times per
week, first at dose 2-4
Gentamicin, Infective endocarditis <1 3-5 earlier and more
Netilmicin, frequently if impaired
Tobramycin Most other infections <2 >5 renal function or other
toxicity risk factors
Glycopeptides All patients 5-10 18-26 Assay 2-3 times per
receiving drug (2hrs week; first at dose 2-4
Vancomycin post earlier and more
infusion) frequently if impaired
renal function or other
toxicity risk factors
Teicoplanin Severe Staph aureus >20 <60 Discuss with medical
infection microbiologist

Other severe infection 10-20 <60

Chloramphenicol All patients 5-10 15-25 Discuss with medical
especially neonates microbiologist

Once daily aminoglycosides:

• Exclusions - burns, ascites, pregnancy, CF, endocarditis,
myasthenia gravis, patients with serum creatinine >300 µml/l or a rise
in serum creatinine > 35µml/l in preceding 72 hours.
• Baseline renal function.
• Initial dose 5mg/kg independent of renal function.
• Repeat 24hrly unless renal function impaired.
• Monitoring - single sample 6-14 hours post dose, then use Hartford
nomogram or pre-dose level which for once daily must be <1mg/L.
> If the level falls in the area designated Q24h, Q36h or Q48h, the dosage interval
should be 24, 36 or 48 hrs
respectively. If the point is on the
line, choose the longer interval.
> If the level is off the nomogram
administer no further
aminoglycoside until serum
level is <1mg/L
> Serum levels should be
monitored after each dose
initially, once stable, alternate
dose monitoring is sufficient.
69
 3. Investigation of Infectious Diseases
Diagnosis Specimen Comments

Actinomycosis Pus with “sulphur granules” if present Actinomyces-like

organisms
(ALO’s) are
occasionally
seen in cervical
smears. These
may be ignored
in well women
with no symptoms
of pelvic
actinomycosis

AIDS Clotted blood. See how to take an Treat as high

HIV test, page 80 risk specimen

Amoebiasis Clotted blood for serology.

Warm specimen of faeces for
trophozoites (<1 hour)

Anthrax Swab of cutaneous lesions. Treat Consult medical

specimen as high risk. microbiologist
Blood cultures before sending
specimen

Aspergillosis Clotted blood for precipitins

(esp allergic aspergillosis)
Sputum culture
Bronchoalveolar lavage

Bornholm disease Throat swab in virus transport medium, Virology form

faeces for virus isolation

Bronchiolitis Nasopharyngeal aspirate

Brucellosis Blood culture.

Clotted blood for serology
Treat specimen as high risk

Candidiasis Blood cultures.

Swab from suspected lesions.

70
Diagnosis Specimen Comments

Chickenpox Swab from vesicle or scraping of base Usually clinical

of lesion in viral transport medium. diagnosis

Chlamydia See under Genital tract specimens

page 64
Cholangitis Blood cultures.
Specimen of bile in universal container
where available.

Croup Nasopharyngeal aspirate Usually clinical

diagnosis

Cryptosporidiosis Faecal sample

Cytomegalovirus EDTA blood sample (lgM available) Virology form

“Culture negative Clotted blood for Q fever and C. Virology form

endocarditis” psittaci serology

Dengue Clotted blood Please supply full

clinical details

Diarrhoea See under Collection of specimen -

faeces, page 63

Endocarditis Obtain 3 sets of blood cultures before See also

starting therapy - this may be within a collection of
2-4 hour period regardless of any blood cultures
pyrexia. page 60

Epiglottitis Blood cultures.

Enteric fever Blood cultures. Widal test are no

Faeces and urine for culture. Treat longer
specimens as high risk. recommended
for the diagnosis
of typhoid as the
results may be
affected by
previous
immunisation and
by non-specific
reactions.

71
Diagnosis Specimen Comments

Farmer’s lung Clotted blood

Filariasis Clotted blood for ELISA

Thick blood films to haematology lab.

Fungal infection of Skin scraping in universal container

skin/hair/nails Portion of nail or hair stump for fungal
examination.

Giardiasis Faeces examination for cysts. Duodenal

aspirate for trophozoites (transport to
laboratory immediately)

Glandular fever Clotted blood for Paul Bunnell/ See also virology
Monospot guide, page 79

Gonorrhoea See under Genital tract specimens, Consider referral

page 64 to Genitourinary
Medicine

H. pylori Clotted blood for antibody Antibody levels

Urease breath tests (refer to may remain
gastroenterologist) elevated for
prolonged
period after
successful
eradication
therapy.

Hepatitis A,B,C Clotted blood - treat specimens for lgM available for
Hep B and C as high risk HepA ,Virology
form

Herpes simplex Vesicle fluid in virus transport medium Virology form

Clotted blood. (lgM available)

Herpes zoster See under chicken-pox page 71

HIV See HIV testing page 80

Hydatid disease Clotted blood for serology

Influenza Paired clotted samples for “atypical See also virology

pneumonia” Respiratory secretions guide, page 79
72
Diagnosis Specimen Comments

Legionnaire’s Sputum/bronchoalveolar lavage for Please discuss

disease culture. with medical
Paired clotted samples microbiologist
Urine for antigen. before sending
samples.

Leishmaniasis Clotted blood for IFAT.

Biopsy of lesion for histopathology.

Leptospiral infection Clotted blood for serology.

Lyme disease Clotted blood for ELISA for Borellia Please supply full
burgdorferi clinical details for
reference laboratory

Malaria Thick and thin films to Haematology Serology may be

laboratory. useful for
Clotted blood for serology. retrospective
diagnosis or for
investigation of
splenomegaly or
nephrotic syndrome
with appropriate
travel history.

Measles Clotted blood (lgM available) Virology form

Meningitis (viral) See virology guide page 79

Meningitis (bacterial) Blood culture Please specifically

CSF for culture/PCR request
Throat/nasopharyngeal swab. meningococcal
Aspirate from skin lesions for culture. culture for throat
EDTA blood sample for PCR swabs
Paired sera for N. meningitidis
serology

Mumps Clotted blood (lgM available) Virology form

Mycoplasma Paired clotted blood Virology form

infections

Parvovirus B19 Clotted blood (lgM available) Virology form

73
Diagnosis Specimen Comments

Pertussis See under pernasal swab page 65

Pneumocystis carinii Bronchoalveolar lavage

Pneumonia (atypical) a) Paired clotted blood to RVL Legionella antibody

b) Paired clotted blood for Legionella may take 5-6
serology weeks to rise.
c) Respiratory samples for both RVL Urinary antigen
and routine bacteriogy for legionella may
also be useful

Poliomyelitis Faeces sample

Psittacosis Paired clotted blood for “atypical

pneumonia” screen

Q fever Paired clotted blood for “atypical

pneumonia” screen

Rheumatoid desease Clotted blood

Respiratory Syncytial See under Nasopharyngeal aspirate

Virus page 65

Rotavirus Faecal specimen

Rubella Clotted blood (lgM available)

Schistosomiasis Clotted blood Please include

Urine for ova. full clinical details
Rectal biopsy for reference
Faecal specimen. laboratory.

Strongyloides Clotted blood Please include

full clinical details
for reference
laboratory

Syphilis Clotted blood

Tetanus Clinical diagnosis

Toxocara Clotted blood

74
Diagnosis Specimen Comments

Toxoplasmosis Clotted blood Please supply full

Clotted blood for IFAT clinical details for
reference
laboratory

Tuberculosis 3 (minimum) early morning sputum Treat all specimens

(pulmonary) samples. as high risk
Laryngeal swabs (available from the
laboratory) can be used if sputum
cannot be obtained.
Pleural fluid - up to 250mls in plain
sterile container.

Tuberculosis (non- 3 complete successive early morning Treat all specimens

pulmonary) urines in plain sterile containers. as high risk
Swabs are rarely satisfactory and
excised tissue or pus should be sent
in universal containers. Small biopsies
may be sent in sterile saline to prevent
drying out.

CSF where clinically indicated.

Vincent’s angina Throat swab or swab of inflamed gum State suspect

margins diagnosis on
request

Whooping cough See under pernasal swab page 65

Worms Faecal specimen for ova and cysts.

Whole worms or tapeworm segments
may be sent to the laboratory in a
universal container for identification.
For threadworms see page 64

Yersinia enterocolitica Faecal sample Please supply full

Clotted blood clinical details.
Faecal culture for
yersinia is
undertaken on
request or
appropriate
clinical history.

75
 Virology

General Information:

The regional Virus Reference Laboratory is based at the Royal Hospitals

Trust.

Consultant Virologist Dr. Peter Coyle 028 9024 0503

Ext. 2662
Consultant Virologist Dr. Conall McCaughey 028 9024 0503
Ext. 2662
Consultant Clinical Scientist Dr. Hugh O’Neill 028 9024 0503
Ext. 4498

Out of hours emergency service:

Contact the Royal Hospitals switchboard (028 9024 0503) to contact the
Virology Biomedical Scientist on call.

Request form:

A green virology request form should be completed. In addition to

demographic details and return address the following information should
be supplied.

- Date of onset of symptoms

- Provisional diagnosis/other relevant information
- Examination requested.

It is a waste of time to send specimens from a patient with an obscure

illness weeks or months after the onset, in the expectation that the
Regional Virus Laboratory will examine them for all known viruses.
Requests such as viral screening, routine virology, or viral studies without
accompanying information should be avoided.

Collection and transport of specimens

Specimens should be clearly labelled and dated. Place all specimens in

leakproof containers in sealed plastic bags. All specimens suspected of
containing a bloodborne virus/tuberculosis should carry a hazard warning
sticker. Samples requiring direct detection/culture of virus should be
transported to RVL with minimum delay.

76
The specimens most frequently required are listed below:

Blood: Clotted blood samples are required for antibody detection. A 5-10 ml
sample should be taken as early as possible in the illness. Viral specific lgM is
available for a number of virus infections. In most cases a convalescent
sample 10-14 days later (to demonstrate a 4 fold or greater rise in lgG) will be
required. In babies in the first year of life it may be necessary to take the
convalescent serum 4 weeks or more after the acute sample in order to
demonstrate an antibody rise.

For CMV viraemia the blood should be sent in a standard EDTA tube.

CSF: Ideally send 0.5-1ml in a sterile bottle.

Faeces: Collect faeces free from urine and antiseptics. Each sample should
fill about one third of a sterile universal container. Do not add fixatives or
transport medium.

Pleural or pericardial fluid: Send in a sterile bottle.

Post-mortem or biopsy specimens:

Place each organ specimen in a separate sterile labelled container. Do not
add formalin or other fixatives. Take specimens from the main affected system
as well as faeces and a blood clot. Tissue specimens collected at post-mortem
should be taken aseptically and in a planned order to avoid contamination
from the gastrointestinal tract. Separate sterile instruments should be used for
each organ. Where spongiform encephalopathy is part of the differential
diagnosis this should be made clear on the request form.

Respiratory specimens:
Throat swabs, nasal swabs - break the swab into viral transport medium
(VTM).

Nasopharyngeal secretions: Send mucus extractor with the secretions to

RVL. Send all other washings/secretions in a sterile bottle.

Skin lesion:
Vesicles - gently scrape the base of the vesicle with a disposable scalpel
blade, wipe the small amount of fluid and material adhering to the blade onto
the centre of a clean glass slide and air dry. Large vesicles may be aspirated
and the fluid sent in a sterile bottle. Suspected orf - scrape the granulation
tissue underlying the skin with a disposable scalpel blade, transfer the material
to a clean slide and allow to air dry.

Urine:
Send 10-20mls of urine in a sterile universal container.
77
 Common clinical indications for viral testing

Clinical Agent/s Specimens

Aids & HIV HIV 1 and 2 Clotted blood. For

details see HIV
testing page 80

Arthralgia Parvovirus B19, rubella, Clotted blood

Mycoplasma pneumoniae

Cardiovascular
(a) myocarditis Enterovirus Faeces, paired
clotted blood

(b) endocarditis Coxiella burretii clotted blood

Chlamydia psittaci

Conjunctivitis Adenovirus, Herpes simplex, Eye swab in VTM*

enterovirus

Embryopathy Rubella, Cytomegalovirus, EDTA blood samples

Parvovirus B19 from mother and
child at birth and
from child at 3
monthly intervals for
first year. Post
mortem material
may also be sent.

Gastrointestinal Rotavirus, adenovirus, Faeces for election

astrovirus, calicivirus and microscopy/PCR
small round structured viruses
(SRSV)

Genital infection Herpes simplex Swab in VTM*

Hand, foot and Enterovirus (Coxsackie A) Faeces, vesicle fluid

mouth disease in VTM*

Hepatitis Hepatitis A, B&C, Epstein Clotted blood

Barr virus, cytomegalovirus

78
Clinical Agent/s Specimens

Immunity testing Hepatitis A&B, rubella, Clotted blood

varicella zoster virus
Lymphadenopathy Cytomegalovirus, Epstein Clotted blood
& Glandular fever Barr virus, Human herpes
virus type 6

Meningitis/ Herpes simplex virus, varicella Faeces, CSF, throat

encephalitis zoster virus, measles, mumps, swab in VTM* and
enteroviruses paired clotted blood

Organ donation Hepatitis B&C, HIV, Clotted blood

cytomegalovirus immunity

Respiratory Influenza virus A&B, Throat swab in VTM*

Parainfluenza viruses, or sputum or
adenovirus, respiratory nasopharyngeal
syncytial virus, Mycoplasma aspirate and paired
pneumoniae, chlamydia clotted blood
group and Coxiella burnetii

Skin rashes Rubella, measles, parvovirus Clotted blood

B19, herpes simplex, Vesicle fluid in VTM*
molluscum contagiosum or scrapings for EM if
appropriate

*VTM - Viral transport medium, available from the Bacteriology

Laboratory

79
 HIV Testing

Indications for HIV Testing

a) As part of diagnostic investigations; or b) The patient requests an HIV

test after a potential exposure to HIV, or c) A ‘sharp’ used during a
procedure on the patient has caused an injury to health care worker.

Consent

Before blood is obtained for HIV testing the person from whom blood is to
be taken must give their informed consent.

This will require detailed pre-test discussion with the individual and
should be based on the “Guidelines for Pre-Test Discussion on HIV
Testing” issued by the Dept of Health (March 1996). (Copies of this
booklet are available on all wards/departments Ulster Hospital and have
also been issued to all GP’s).

Note:The person obtaining verbal consent from the patient to have

blood taken for HIV testing must document in the patient’s medical
notes that pre-test discussion has taken place and consent
obtained.

Procedures

a) Taking Blood

Only those trained and considered competent at venepuncture should

take blood from patients known or suspected to be suffering from a
blood-borne viral infection.

Care must be taken to avoid needlestick injury.

A specimen of blood should be obtained using a yellow topped

Vacutainer sample tube.

Needle and Vacutainer holder should immediately be disposed of as a

complete unit into a Sharps Box.

A Sharps Box should be easily accessible to enable disposal as close as

possible to the point of use.
80
All venepuncturists should cover cuts or abrasions on their hands with
waterproof dressings before commencing procedure.

NB: Gloves cannot prevent percutaneous injury but they may reduce the
risk of acquiring a blood borne viral infection by reducing the
volume of blood to which the venepuncturist’s hand is exposed in
the event of an injury.

The use of gloves is therefore recommended.

b) Labelling of Specimen/Completion of Request Form

- Specimen to be labelled with patient’s Unit No, Date of Birth and

first initials of forename and surname only eg Mrs X Y

- Virology request form (Green) to be completed in a similar manner

with additional details of the test required, the Consultant/GP in
charge of the patient’s care and an address for return of the test
result.

“HIGH RISK”, “DANGER OF INFECTION”, or “CATEGORY 3

PATHOGEN” labels should be affixed to both the specimen and the
request form.

- If the patient is the ‘source’ of a needlestick injury the form should

be marked accordingly.

Transportation of Specimen to Laboratory

- Specimen and form should be placed in separate pockets of a

BIOHAZARD specimen polybag; and

- A rigid, leakproof container should be used for transportation of the

specimen to the Virus Reference Laboratory, Royal Group of
Hospitals.

Obtaining Results

Results of HIV tests are returned directly to the patient’s Consultant/GP in

a sealed envelope.
If results are required urgently special arrangements should be made with
staff of the Virus Reference Laboratory.
81
 HAEMATOLOGY
&
BLOOD TRANSFUSION

82
1. GENERAL HAEMATOLOGY
1.1 A pink haematology request form, complete with clinical details and full
patient identification information, must accompany all specimens sent to the
laboratory. The Table lists tests that are routinely available
(* indicates availability outside normal working hours)
Test Sample/Comment Reference Range (Adults)
Children - see Section 4
Full Blood Count (FBC) * 1 x purple bottle Male Female
Haemoglobin (Hb) 13-18 11.5-16.5g/dl
Red cell count (RCC) 4.5-6.5 3.8-5.8mil/ul
Haematocrit (HCT or PCV) 0.40-0.54 0.37-0.49l/l
Mean Cell Volume (MCV) 84-99 84-99fl
Mean Cell Haemoglobin
concentration (MCHC) 30.0-35.0 30.0-35.0g/dl
Mean Cell Haemoglobin (MCH) 27.0-32.0 27.0-32.0pg
Reticulocytes (RETICS) 0-2% 0-2%

White Cell Count (WCC) 4.0-11.0 4.0-11.0 x109/6

5 part Differential White Cell Neutrophils 2.0-7.5 x 109/L
Count (DWCC) Lymphocytes 1.5-4.0 x 109/L
Monocytes 0.2-0.8 x 109/L
Eosinophils 0.04-0.4 x 109/L
Basophils <0.01-0.1 x 109/L

Platelets 150-430 mil/ul

Monospot 1 x yellow bottle

(screening test for infectious to serology
mononucleosis)

Erythrocyte sedimentation 1 x purple bottle 1-15mm/hr

rate (ESR)

Plasma viscosity 2 x purple bottle 1.50-1.72 cp

Haemoglobin electrophoresis 1 x purple bottle

Full electrophoresis Hb A2 1.5-3.5%
Haemoglobin A2 and F only Hb F<1%

Haemoglobin S screen 1 x purple bottle

Haemoglobin A1c See biochemistry

(Diabetes monitoring) section

83
1.1 GENERAL HAEMATOLOGY (cont.)

Test Sample/Comment Reference Range (Adults)

P50 Blood gas analysis

See biochemistry
section

Erythropoietin 1 x red tube 10-21 mu/ml

(RVH reference laboratory)

Haptoglobins 1 x red bottle 0.3-2.0g/l

Sample must be
free of haemolysis

Urinary Haemosiderin Universal

container (20mls)

Malarial Parasites * 1 x purple bottle

Fresh blood films
Sample during
temperature spike

Leukocyte Alkaline 1 x green bottle or Score 35-100

Phosphatase (LAP) 3 x fresh slides

84
1.2 TESTS AVAILABLE FOLLOWING CONSULTATION
The following tests are only available on discussion with the laboratory or
Consultant Haematologist. Details of the required samples will be given
on request.

Test Reference Range (Adults)

Ham’s acidified serum test

for detection of PNH clones

Red cell osmotic fragility MCF

(Hereditary Spherocytosis) Pre- incubation 4-4.5 g/NaCL
Post-incubation 4.65-5.9 g/lNCL

Autohaemolysis Glucose (-) 0.2-4.0%

Glucose (+) 0-0.5%
G6PD screen

Red cell enzymes

Peripheral blood cell markers

Malarial antibodies

1.3 BONE MARROW EXAMINATION

Morphological, Immunophenotypic and Cytogenetic features of blood

cells and their precursors may contribute to the diagnosis, staging and
monitoring of various haematological conditions.
Bone marrow examination (aspiration and trephine biopsy) is carried out
under local anaesthetic and / or sedation after written consent has been
obtained.
The test is normally performed in the MacDermott Unit on Monday or
Thursday afternoons, by arrangement with a Consultant Haematologist.

85
2. COAGULATION

2.1 For all coagulation tests addition of the correct volume of

blood to the coagulation tube is essential.

A white coagulation request form, complete with full patient

identification information and clinical details, in particular the use of
anticoagulant drugs, must accompany all specimens sent to the
laboratory.
The following tests are routinely available:
(* Denotes availability outside normal working hours).

Test Sample Reference Range (Adults)

International Normalised 1 x light blue bottle See Section 2.3 for

Ratio(INR)* recommended therapeutic
Warfarin monitoring ranges

Activated Partial 1 x light blue bottle

Thromboplastin Time (APTT) *
(unfractionated heparin
monitoring)

Coagulation Screen * 1 x light blue bottle 10-14 seconds

Prothrombin time (PT) 24-35 seconds
Activated partial thromboplastin 2.0-4.5g/l
time (APTT)
Fibrinogen

Other clotting tests 1 x light blue bottle

Thrombin clotting time (TCT) Quoted normal +/-2 seconds
Reptilase time Quoted normal +/-2 seconds
D-Dimer * <500ng/ml

86
2.2 The following coagulation tests are only available on discussion with
the laboratory or Consultant Haematologist.

Test Sample Reference Range (Adults)

Lupus inhibitor 1 x light blue bottle

Thrombophilia screen 3 x light blue bottle

(RVH reference laboratory) and 1 x purple
Antithrombin lll bottle
Protein C 0.8-1.2 iu/ml
Protein S 0.7-1.4 iu/ml
Factor Vlll 0.6-1.4 iu/ml
Activated protein C resistance 0.6-1.3 iu/ml
Lupus anticoagulant
Factor V Leiden gene mutation
Prothrombin 20210 gene
mutation

Bleeding time 2-10 minutes

Platelet aggregation 4 x light blue bottle

Specific coagulation factors 2 x light blue bottle

Anti Xa assay 1 x light blue bottle

(Monitoring of low molecular
weight heparin if indicated)

Platelet antibodies
(NIBTS reference laboratory)
Neonatal thrombocytopenia 1 x red bottle
(samples from Mother, Father 1 x purple bottle
and Infant)

All other patients 2 x red bottle and

2 x purple bottle

87
2.3 RECOMMENDED THERAPEUTIC RANGES FOR WARFARIN
THERAPY (INR)

Source: Guidelines on Oral Anticoagulation. British Committee for

Standards in Haematology Haemostasis & Thrombosis Task
Force 1998
Br J Haem 1998, 101; 374-387

Indication Target INR Grade of

Recommendation

Pulmonary Embolus 2.5 A

Proximal DVT 2.5 A
Calf vein thrombus 2.5 A
Recurrence of venous thromboembolism when
no longer on warfarin therapy 2.5 A
Recurrence of venous thromboembolism while
on warfarin therapy 3.5 C
Symptomatic inherited thrombophilia 2.5 C
Antiphospholipid syndrome 3.5 B
Non-rheumatic atrial fibrillation 2.5 A
Atrial fibrillation due to rheumatic heart 2.5 C
disease, congenital heart disease,
thyrotoxicosis
Cardioversion 2.5 B
Mural thrombus 2.5 B
Cardiomyopathy 2.5 C
Mechanical prosthetic heart valve 3.5 B

88
3. BLOOD TRANSFUSION

ALL SAMPLES FOR BLOOD GROUPING AND CROSS MATCHING

MUST BE CAREFULLY LABELLED BY HAND -
NO ADDRESSOGRAPH LABELS ON BOTTLES OR FORMS.

3.1 A white Blood Bank request form, complete with clinical details and
full patient identification information, must accompany all specimens sent
to the Blood Bank. All samples sent for blood grouping or cross matching
will be held in the laboratory for 7 days. Plasma samples may be stored
for longer if specifically requested. NB Minimum 3mls.

When requesting blood products it is vital to state the urgency with

which those products are required. For example distinguish between
next day routine operation, same day use or immediate use e.g. “the
massive transfusion” protocol.

Most requests will be dealt with on the same day. However, where
problems arise, e.g. patients with atypical red cell antibodies, a request
may take longer. Where such problems are known to exist, the Blood
Bank should be notified in advance.

3.2 SAMPLES REQUIRED FOR BLOOD TRANSFUSION

(*Denotes availability outside normal working hours).
Test Sample

Blood group and antibody screen* 1 x pink bottle

Cross matching* 1 x pink bottle

Antenatal group and antibody screen 1 x NIBTS bottle (green)

Rubella screening 1 x NIBTS bottle (red)

Kleihauer Test*
Cord blood for group and Direct Coombs 1 x red bottle

Maternal sample for Kleihauer staining 1 x purple bottle

and check blood group

Direct Coomb’s test* 1 x pink bottle

Cold Agglutinins (red cell antigens) 1 x pink bottle

89
3.3 EMERGENCY BLOOD

Four units of Group O Rh negative and Kell negative blood are held in the
laboratory Blood Bank. If these units are required, the Blood Bank must
be informed immediately so that these units can be replaced straight
away.

3.4 CREST GUIDELINES FOR BLOOD TRANSFUSION PRACTICE

All those who are involved in the transfusion process (sampling,

prescribing, administration etc.) should be familiar with the current
guidelines on safe transfusion practice that are listed below. The Blood
Bank has a copy of each guideline for consultation if required.

• Guidelines for Red Cell Transfusion

• Guidelines for the management of Acute Massive Blood Loss
• Guidelines for the use of Blood Components in Obstetrics
• Guidelines for Neonatal Transfusion

3.5 TRANSFUSION REACTIONS

If it is suspected that a deterioration in the condition of a patient is related

to transfusion of any blood product, please contact the Blood Bank
without delay to arrange investigation. The following samples will be
required:

• The blood pack involved

• Blood sample: 2 x pink bottles
• 10 mls urine in a universal container

All serious hazards of blood transfusion are the subject of a

national anonymised reporting system (SHOT).
The Transfusion Handbook contains more detailed information about
serious transfusion reactions. A copy is available for consultation in Blood
Bank, and an electronic version is available on the Trust intranet.
Please report all suspected incidents to Blood Bank staff.

90
3.6 SURGICAL BLOOD ORDERING TARIFF FOR ELECTIVE
PROCEDURES.

The following are suggested blood ordering tariffs for surgery in patients
who have adequate pre-operative Haemoglobin. Anaemic patients may
require pre-operative transfusion or additional blood cross-matched prior
to surgery. In addition if the Consultant in charge feels that in certain
cases heavy blood loss might be expected, they may order blood prior to
surgery.
G&S = group +screen
Number = units cross-matched.

GENERAL SURGERY
Cholecystectomy and exploration of common duct G&S
Splenectomy G&S
Laparotomy (Planned exploration) G&S
Liver biopsy G&S
Gastrostomy, ileostomy, colostomy G&S
Oesophageal dilation G&S
Oesophagectomy 4
Hiatus hernia G&S
Partial gastrectomy G&S
Oesophagogastrectomy 4
Hepatectomy 4
Mastectomy (simple) G&S
ENDOCRINE
Thyroidectomy-partial/total G&S
Parathyroidectomy G&S
Adrenalectomy 3
Pancreatectomy-partial/Whipple 4

COLO-RECTAL SURGERY
Rectum-pouch; resection/excision etc. 2
Antero-perineal resection 2
Intra-abdominal-colectomy etc. 2
Rectoplexy G&S

VASCULAR SURGERY
Amputation of leg G&S
Femoral endarterectomy G&S
Carotid endarterectomy G&S
Femoro-popliteal bypass 2

91
 Aorto-femoral bypass 4
Aorto-iliac bypass 4
Infra-renal aortic aneurysm 4
Thoracic or thoraco-abdominal aneurysm 10
Ruptured aneurysms
(Use massive blood transfusion protocol) 10

ORTHOPAEDICS
Removal hip pin or femoral nail G&S
Nailing fractured neck of femur G&S
Hemiarthroplasty 2
Internal fixation of femur G&S
Internal fixation-tibia or ankle G&S
Arthroplasty-total knee or shoulder G&S
Changing hip prosthesis 4
Dynamic hip screw G&S
Osteotomy/bone biopsy (except upper femur*) G&S (2*)
Bone graft from iliac crest-1 side /both sides* G&S (2*)

UROLOGY
Cystectomy 4
Nephrectomy 2
Nephrectomy and exploration of vena cava 6
Open Prostatectomy 2
TURP G&S
TUR bladder tumour G&S
Cystotomy G&S
Reimplantation of ureter G&S
Urethroplasty 2

ENDOSCOPY
ERCP G&S

PLASTIC SURGERY
Major head and neck dissection + reconstructions 2
Other head and neck procedures G&S
Abdominoplasty G&S
Mammoplasty G&S
Breast reduction G&S
Tram Flap 3

92
MAXILLO-FACIAL SURGERY
Bimaxillary Osteotomy 2

OBSTETRICS AND GYNAECOLOGY

LSCS G&S
ERPC & D&C G&S
Hydatiform mole G&S
Placenta praevia 2
Retained Placenta G&S
APH/PPH 2
Hysterectomy: abdominal or vaginal -simple G&S
-extended 2
Werthelm’s operation 4
Pelvic exenteration 4
Vulvectomy (radical) 4
Oophorectomy (radical) 4

3.7 BLOOD PRODUCTS AVAILABLE FROM BLOOD BANK

The following table (page 94) provides a guide to the products available
from the hospital Blood Bank, along with a brief summary of their
respective characteristics and clinical use. Readers are referred to the
Handbook of Transfusion Medicine (available from Blood Bank and “On-
Line” on the Hospital Intranet) for further details.

The use of the following products must be discussed with a Consultant

Haematologist.

• Coagulation factor replacement products

• Immunoglobulin replacement in hypogammaglobulinaemia
• Immunoglobulin therapy in immune thrombocytopenia
• Irradiated and washed products
• Immunoglobulin for any other therapeutic use.

REMEMBER - WHEN IN DOUBT - CALL THE BLOOD BANK! Ext.2356

93
Product Characteristics Indications Precautions
Red blood cells 280mls ± 60 Maintainance of Compatibility
(Adult) leukocyte depleted Haemoglobin tested
(filtered) levels eg. Regular
Acute haemorrhage observation
Red blood cells 40-50 ml Bone marrow failure during infusion
(Paediatric) A Rh negative and
O Rh negative,
CMV negative

Fresh frozen 300ml approx. Multiple factor Usually group

plasma Source of deficiency specific
(Adult) coagulation Regular
factors observation
Fresh frozen during infusion
plasma 75ml ±10ml
(Paediatric)

Cryoprecipitate Source of fibrinogen Hypofibrinogenaemia Usually group

15ml per pack approx. Suggested dose specific
for adults 10-20 packs Regular
observation
during infusion

Albumin 20% 100ml Hypoproteinaemia Use with diuretic

(Adult) Hypertonic; expands Liver disease Issued with User
plasma volume Nephrotic syndrome Form for return to
Blood Bank

Albumin 20% Regular

observation
(Paediatric) 50ml during infusion

Stable plasma 400ml and 100ml Burns Issued with User

protein solution Exchange fluid Form for return to
(SPPS) 4.5% (plasmapheresis) Blood Bank
Sustained albumin Regular
loss observation
during infusion
Immunoglobulin 250 and 500 units Prevention of Rh
prophylactic anti-D haemolytic disease

Platelets 250ml Haemorrhagic Usually group

Standard adult leukocyte depleted thrombocytopenia specific
therapeutic (filtered) Threshold depends Use platelet
dose on clinical state. giving set
Paediatric use 50ml ±10ml Contact Regular
Haematologist for observation
advice during infusion
.
94
 4. PAEDIATRIC HAEMATOLOGY

4.1 Paediatric Samples

To minimise iatrogenic blood loss, small volume paediatric tubes are
available for the following tests:-

FBP 1 pink topped tube

Group & D/C 1 red topped tube

Coagulation Studies 1 green topped tube filled to 1.3 ml mark

4.2 Paediatric Reference Ranges

The value of many haematologic variables change markedly in the first weeks
and months of life and reference data are important to enable proper
interpretation of laboratory results, both in infancy and until the age at which
normal adult ranges can be applied. Most reference data are affected to some
degree by factors such as racial origin, diet, drug intake and the incidence of
sub clinical illness. The methodology and instrumentation used to obtain the
data may also have an influence.

The following data, covering the commoner haematological parameters, are

compiled from various sources.

95
 4.21 Normal blood counts from birth to 18 years

96
4.22 Reference ranges for coagulation tests in healthy full term infants
during the first 6 months of life.

All values show mean +/- SD

Tests Day 1 Day 5 Day 30 Day 90 Day 180 Adult

PT (s) 13.0+/-1.43 12.4+/-1.48 11.8+/-1.25 11.9+/-1.15 12.3+/-0.79 12.4+/-0.78

APTT(s) 42.9+/-5/8 42.6+/-6.62 40.4+/-7.42 37.1+/-6.52 35.5+/-3.71 33.5+/-3.44
TCT(s) 23.5+/-2.35 23.1+/-3.07 24.3+/-2.44 25.1+/-2.32 25.5+/-2.86 25+/-2.66
Fibrinogen (g/l) 2.83+/-0.58 3.12+/-0.75 2.7+/-0.54 2.43+.-0.68 2.51+/-0.68 2.78+/-0.61
TISSUE PATHOLOGY

97
 Tissue Pathology

The tissue pathology service to the Trust is provided by the Belfast Link
Laboratories and is based at the Belfast City Hospital Trust (BCHT) and
the Royal Group of Hospitals Trust (RGHT). Histopathology and
cytopathology samples from GP surgeries and hospital impatients and
outpatients collected from the Ulster Hospital are analysed in RGHT.
Those collected from Ards Hospital are analysed in BCHT.

Telephone Numbers

Consultant Staff RGHT Ext Consultant staff BCHT Ext

Dr J M Sloan 3224 Dr R W Lyness 2497

Professor P G Toner 2270 Dr D McManus 2606
Dr M D O’Hara 2518 Dr D O’Rourke 2332
Dr H Bharucha 3274 Dr D Allen 3090
Dr C M Hill 3124 Dr Lioe 2035
Dr M Y Walsh 3324 Dr L Caughley 2987
Dr C M Thornton 2625 (Cytopathology)
Dr R I Davis 3508 Dr D McKibben 2281
Dr G McGluggage 2563 Cytopathology)
Dr B Herron 2613
Dr M Mirakhur 2019/2584
(Neuropathology)
Dr N Anderson 2676
On call Histopathologist may be contacted via RGHT switchboard or
Mobile telephone number Telephone 0775 63595

RGHT Laboratory Ext Direct Line Name

Main Histopathology lab 2170 9026 3276 Mr Chris Carland
Main Cytopathology lab 3019 Mr J Whyte
Main office 2070
Central reporting room 4162
Histopathology Fax Number
department 028 9023 3643
Tie line for RVH is 7222

98
BCHT Laboratory Ext Direct Line Name
Main Histopathology lab 2167 Mrs H Foster
Main Cytopathology lab 2977
Main office 2925
Histopathology Fax Number
department 028 9026 3728
Tie line for BCH is 7111

Samples and preservatives solutions

Histology samples:
• Should be fixed in 10% Formalin. Small specimens should be placed
in an adequately sized leak proof container (usually a glass or
plastic bottle) which is filled with Formalin. Large samples may be
placed in plastic buckets with tight fitting lids. Mark the sample with
indelible ink or a suture if orientation is important. Care should be
taken as formaldehyde can sensitise the skin and irritate the lungs.

• The specimen container should carry a label with (i) Patient’s full
name, (ii) Hospital number, (iii) Date of birth, (iv) Ward, Unit or Health
Centre and (v) Nature of specimen.

• Each biopsy MUST be accompanied by a Histological request form

signed by the submitting doctor and providing full and accurate
patient information data and include a brief clinical history. All
samples sent for histopathology should be recorded in the book in
Theatre.

Samples for electron microscopy should be arranged with Mr Brendan

Kelly at the RVH on Ext 2670.

Muscle and nerve biopsies may be carried out at the RVH and
arrangements can be made by contacting the neuropathology lab at Ext
2019 or 2119.

Cytology specimens:
• should be accompanied by a fully completed cytology form.
• Peritoneal/pleural fluid - < 1L in a sterile wide mouthed container with
no fixative
• Urine - the patient should be well hydrated before for 2 hours prior to
obtaining the sample. Discard urine during the hydration period and
submit the next voided sample for cytolological examination. Do not
99
 send early morning samples, which show marked cellular
degeneration. Please state if the patient has been catheterised, has
had any kind of instrumentation, has urinary tract stones or is on any
form of chemotherapy. Send specimen in sterile wide mouthed
container with no fixative.
• Bronchial washings and brushings should be submitted without
fixative. The bronchial brush should be smeared across a glass slide
and the slide placed in industrial methylated spirits within 10 seconds.
The brush should also be submitted in saline.
• Fine needle aspirates - a Consultant Pathologist is available on
Tuesdays and Thursdays as part of the one-stop Breast clinics.
Contact Dr C. Majury, Consultant Radiologist if any further
information required.

All specimens from known or suspected carriers of Category 3

pathogens must be clearly marked both on the request form and
specimen container.

Frozen sections

Samples for frozen sections should be sent by taxi to the histopathology

department in RGHT. It is imperative to book the sample, preferably 24
hours ahead, with the laboratory at Ext 2170 giving the patient’s name,
type of tissue and time of operation. A contact name and phone number
should also be given. This will allow arrangements to be made with the
duty pathologist and facilitate a prompt response.

Post-mortem examinations

Adult:

The clinical consultant in charge of the patient must be aware that an

autopsy is to be requested. Initial enquiries may be made to the mortuary
technician at Ext 2417. If the case is suitable for a hospital post-mortem
the technician will inform the pathologist who may discuss the case
further with the referring clinician.

The following documentation is required in the mortuary before a post-

mortem can be undertaken:

• Post-mortem consent form signed by next of kin.

100
• A written autopsy request detailing a full clinical summary.
• Clinical notes and x-rays.

There are certain clinical conditions in which the post-mortem may be

undertaken at the RGHT mortuary. If a post-mortem is required on a
patient known or suspected to be have had a Category 3 infective
condition, the presence of such a condition must be made known to the
mortuary technician to allow appropriate arrangements to be made.

Paediatric:

All post-mortems are carried out by the Northern Ireland Regional

Perinatal/Paediatric Pathology Service at the RGHT. For further
information/advice contact the paediatric pathologist.

Coroner’s post-mortems:

Coroner’s post-mortems are arranged through the coroner’s office. The

coroner for the greater Belfast area covering the Ulster and Ards hospital
is Mr J L Leckey, Tel: 028 9086 9144. There is an answering telephone
service provided outside the hours of 9.00am - 5.00pm.

A death should be reported to the coroner under the following

circumstances:

• When a death has, or might have, resulted from an accident, suicide

or homicide. This should include cases where the underlying cause of
death is an accident e.g. where a patient dies of bronchopneumonia
as a result of a fractured neck of femur.
• Where there is a question of negligence or misadventure.
• When a patient dies before a provisional diagnosis is made by either
the referring general practitioner or hospital clinician.
• When death is due to an industrial disease e.g. asbestosis or
mesiothelioma.
• Death occurs during surgical operation or anaesthesia

101
 REFERENCE DATA

GUIDELINES FOR BODY WEIGHT

Values given are without clothes. For light dress (without coat) add
approximately 0.5 kg.

BODY MASS INDEX = weight (kg) / height2 (m)

MEN

Height Acceptable Acceptable Obese (kg)*

(m) average (kg) weight range (kg)

1.45
1.48
1.50
1.52
1.54
1.56
1.58 55.8 51-64 77
1.60 57.6 52-65 78
1.62 58.6 53-66 79
1.64 59.6 54-67 80
1.66 60.6 55-69 83
1.68 61.7 56-71 85
1.70 63.5 58-73 88
1.72 65.0 59-74 89
1.74 66.5 60-75 90
1.76 68.0 62-77 92
1.78 69.4 64-79 95
1.80 71.0 65-80 96
1.82 72.6 66-82 98
1.84 74.2 67-84 101
1.86 75.8 69-86 103
1.88 77.6 71-88 106
1.90 79.3 73-90 108
1.92 81.0 75-93 112

Body mass 22.0 20.1-25.0 30.0

index
*value and above for all entries
102
 WOMEN

Height Acceptable Acceptable Obese (kg)*

(m) average (kg) weight range (kg)

1.45 46.0 42-53 64

1.48 46.5 42-54 65
1.50 47.0 43-55 66
1.52 48.5 44-57 68
1.54 49.5 44-58 70
1.56 50.4 45-58 70
1.58 51.3 46-59 71
1.60 52.6 48-61 73
1.62 54.0 49-62 74
1.64 55.4 50-64 77
1.66 56.8 51-65 78
1.68 58.1 52-66 79
1.70 60.0 53-67 80
1.72 61.3 55-69 83
1.74 62.6 56-70 84
1.76 64.0 58-72 86
1.78 65.3 59-74 89
1.80
1.82
1.84
1.86
1.88
1.90
1.92

Body mass 20.8 18.7-23.8 28.6

index
*value and above for all entries

103
 PREFIXES AND THEIR SYMBOLS

Prefix Symbol Factor Numerical value

tera T 1012 1 000 000 000 000

giga G 109 1 000 000 000
mega M 106 1 000 000
kilo k 103 1 000
hecto h 102 100
deka da 101 10
deci d 10-1 0.1
centi c 10-2 0.01
milli m 10-3 0.001
micro µ 10-6 0.000 001
nano n 10-9 0.000 000 001
pico p 10-12 0.000 000 000 001
femto f 10-15 0.000 000 000 000 001
atto a 10-18 0.000 000 000 000 000 001

CONVERSION FACTORS

1 inch = 2.54 centimetres 1 millimetre = 0.03937 inch

1 foot = 0.3048 metre 1 centimetre = 0.3937 inch
1 yard = 0.9144 metre 1 decimetre = 0.3281 foot

1 square inch = 6.4516 square centimetres

1 square centimetre = 0.1550 square inch

1 cubic inch = 16.387 cubic centimetres

1 cubic centimetre = 0.061 cubic inch

1 ounce = 28.35 grams 1 gram 0.035 ounce

1 pound = 453.59 grams 1 hectogram = 3.527 ounces

Temperature conversion Celsius0 = 5/9(F0 - 320)

Fahrenheit0 = 9/5 C0 + 320

Concentration conversion 1 micromol/litre = molecular weight mg/litre

1000

104
Conversion formulae for mg.% to mEq.L. mg.% x 10 x valence = mEq.L.
atomic weight

In the case of gases vol.% x 10 = mM./L.

22.4

To convert mEq./L. to mg.% mEq./L. x atomic wt. = mg.%

10 x valence

In the case of gases mM./L. x 22.4 = vol.%

10

lb kg stones kg mL fl.oz inch cm

1 0.45 1 6.35 50 1.8 1/8 0.32

2 0.91 2 12.70 100 3.5 1/4 0.64
3 1.36 3 19.05 150 5.3 1/2 1.27
4 1.81 4 25.40 200 7.0 3/4 1.91
5 2.27 5 31.75 500 17.6 1 2.54
6 2.72 6 38.10 1000 35.2 2 5.08
7 3.18 7 44.45 3 7.62
8 3.63 8 50.80 4 10.16
9 4.08 9 57.15 5 12.70
10 4.54 10 63.50 6 15.24
11 4.99 11 69.85 7 17.78
12 5.44 12 76.20 8 20.32
13 5.990 13 82.55 9 22.86
14 6.35 14 88.90 10 25.40
15 95.25 20 50.80
16 101.6 30 76.20
17 107.95 40 101.60
18 114.31 50 127.00
19 120.66 60 152.40
20 127.01 70 177.80
80 203.20

105
Mass
1 kilogram (kg) = 1000 grams (g)
1 gram (g) = 1000 milligrams (mg)
1 milligram (mg) = 1000 micrograms
1 microgram (mg) = 1000 nanograms
1 nanogram = 1000 picograms

Volume
1 litre = 1000 millitres (ml)
1 millitre = 1000 microlitres
1 pint is approximately 575 ml

Other units
1 kilocalorie (kcal) = 4186.8 joules (J)
1000 kilocalories (Kcal) = 4.1868 megajoules (MJ)
1 megajoule (MJ) = 238.8 kilocalories (Kcal)
1 millimetre of mercury (mmHg) = 133.3 pascals (Pa)
1 kilopascal (kPa) = 7.5 mmHg (pressure)

106
 TABLE OF WEIGHTS FOR MALES

HEIGHT DESIRABLE WEIGHT (Age 25 and over)

(without shoes)
Minimum Mean Maximum
8st 3lb 9st 1lb 10st 4lb
5’ 2” 115lb 127lb 114lb
1.58m 52kg 58kg 65kg
8st 6lb 9st 4lb 10st 8lb
5’3” 118lb 130lb 148lb
1.60m 54kg 59kg 67kg
8st 9lb 9st 7lb 10st 12lb
5’4” 121lb 133lb 152lb
1.63m 55kg 60kg 69kg
8st 12lb 9st 11lb 11st 2lb
5’5” 124lb 137lb 156lb
1.65m 56kg 62kg 71kg
9st 2lb 10st 1lb 11st 12lb
5’6” 128lb 141lb 161lb
1.68m 58kg 64kg 73kg
9st 6lb 10st 5lb 11st 12lb
5’7” 132lb 145lb 166lb
1,70m 60kg 66kg 75kg
9st 10lb 10st 9lb 12st 2lb
5’8” 136lb 149lb 170lb
1.73m 62kg 69kg 77kg
10st 0lb 10st 13lb 12st 6lb
5’9” 140lb 153lb 174lb
1.75m 64kg 69kg 79kg
10st 4lb 11st 4lb 12st 11lb
5’10” 144lb 158lb 179lb
1.75m 65kg 72kg 81kg
10st 8lb 11st 8lb 13st 2lb
5’11” 148lb 162lb 184lb
1.80m 67kg 73kg 83kg
10st 12lb 11st 13lb 13st 7lb
6’0” 152lb 171lb 194lb
1.83m 69kg 76kg 86kg
11st 6lb 12st 8lb 14st 3lb
6’2” 160lb 176lb 199lb
1.88m 73kg 80kg 90kg
107
 TABLE OF WEIGHTS FOR FEMALES
HEIGHT DESIRABLE WEIGHT (Age 25 and over)
(without shoes)
Minimum Mean Maximum
6st 12lb 7st 9lb 9st 1lb
4’10” 96lb 107lb 125lb
1.47m 44kg 49kg 57kg
7st 1lb 7st 12lb 9st 2lb
4’11” 99lb 110lb 128lb
1.50m 45kg 50kg 58kg
7st 4lb 9st 1lb 9st 5lb
5’0” 102lb 113lb 131lb
1.52m 46kg 51kg 59kg
7st 7lb 8st 4lb 9st 8lb
5’1” 105lb 116lb 134lb
1.54m 48kg 53kg 61kg
7st 10lb 8st 8lb 9st 12lb
5’2” 108lb 120lb 138lb
1.58m 49kg 54kg 63kg
7st 13lb 8st 11lb 10st 2lb
5’3” 111lb 123lb 146lb
1.60m 50kg 56kg 65kg
8st 2lb 9st 2lb 10st 6lb
5’4” 114lb 128lb 146lb
1.63m 52kg 58kg 66kg
8st 6lb 9st 6lb 10st 10lb
5’5” 118lb 132lb 150lb
1.65m 54kg 60kg 68kg
8st 10lb 9st 10lb 11st 0lb
5’6” 122lb 136lb 154lb
1.68m 55kg 62kg 70kg
9st 0lb 10st 0lb 11st 4lb
5’7” 126lb 140lb 158lb
1.70m 57kg 64kg 72kg
9st 4lb 10st 4lb 11st 9lb
5’8” 130lb 144lb 163lb
1.73m 59kg 65kg 74kg
9st 8lb 10st 8lb 12st 0lb
5’9” 134lb 148lb 169lb
1.75m 61kg 67kg 76kg
9st 12lb 10st 12lb 12st 6lb
5’10” 138lb 152lb 174lb
108
 Clinical Chemistry Index
Page No.
Acid base 12,51
ACTH 12
Admission profile 12,51
Adrenal stimulation test (synacthen) 37
Adrenal suppression test (see dexamethasone) 37
Adrenaline (see catecholamines) 16
Albumin (see protein electrophoresis) 26
Alcohol 12
Aldosterone serum, urine 13
Alkaline phosphatase (see liver profile) 24
Alk, phos, isoenzymes 13
N-Acetyl procainamide (see antiarrhythmics) 42
Alpha 1 acidglycoprotein 13
Alpha 1 antichymotrypsin 13
Alpha 1 antitrypsin 13,52
Alpha-feta protein serum, amniotic fluid 13
17 alpha-hydroxyprogesterone 22,51
Alpha 2 macroglobulin 13
Alpha sub unit 13
Aluminium 13
Amino acid chromatogram 52
Aminolaevulinate (ALA) 13
Aminotransferase, Asparate (AST) (see liver profile) 24
Amitryptiline (see antidepressants) 43
Ammonia 14,52
Amphetamine 42
Amylase 14
Anaphlactic reactions 14
Androgen profile 14
Androstenedione 14
Angiotensin converting enzyme 14
Antiarrhythmics 42
Antiasthmatics 42
Anticardiolipin 14
Antidepressants 43
Antiepileptics 43
Apo E phenotyping 15
Apolipoproteins 15

109
 Page no.
B2 microglobulin 15
Barbituates 43
Barbituate screen 43
Bence Jones protein 15
Benzodiazepines 43
Benzodiazepine screen 44
Bilirubin (adults) (see liver profile) 24
Bilirubin (infants) 52
Blood gases (see acid base) 12
Bone profile 15

C-peptide 15
C1 esterase inhibitor 15
C3 (see complement profile) 17
C4 (see complement profile) 17
C3 nephritic factor 15
Caeruloplasmin 15
Caffeine 52
Calcitonin (see also gut and islet hormone assay) 20
Calcium
Serum (see bone profile) 24
Urine 16
Calcium/creatinine ratio 16
Calculi 16
Cannabanoids 44
Carbanazepine - see antiepileptics 43
Carboxyhaemoglobin 44
Carcinoembryonic antigen 16
Cardiac profile 16
Carotene 16
Catecholamines 16
Chloride (see electrolyte profile) 19
Chlorpromazine (see phenothiazines) 48
Cholesterol (see lipids) 23
Cholinesterase (pseudo) 16
Chromosome studies 17,52
Clobazam (see benzodiazpines) 43
Clomipramine (see antidepressants) 43
CO2 (see electrolyte profile) 19
Complement profile 17

110
 Page no.
Copper 17
Serum, urine
Cortisol 17
Serum, urine
C peptide 17
Creatinine kinase (see cardiac profile) 16
Creatinine kinase MB, BB isoenzymes 18
Creatinine 17
Serum, urine
Creatinine clearance 17
Cryoglobulins 18
CSF 18
Cyclosporin 44
Cystic fibrosis - genetic studies 18
Cystine 18

Dehydroepiandrosterone sulphate 18
Desalkyfluorazepam (see benzodiazpines) 43
Desipramine (see antidepressants) 43
Demethylodthepin (see antidepressants) 43
Desmethyldoxepin (see antidepressants) 43
Dexamethasone suppression test (see test procedures) 34
Dibucaine number 18
Digoxin 44
DNA studies 19
DNA (double stranded) 18
Dothiepin (see antidepressants) 43
Dopamine (see catecholamines) 16
Dopexin (see antidepressants) 43
Drugs of abuse screen 44

Electrolytes 19
Epanutin (see anti epileptics) 43
Epilim (see anti epileptics) 43
Ethosuximide 43
Ethylene glycol 45
Ethosuximide (see anti epileptics) 43

Faecal Fat 35
Faecal PH 19
Ferritin 19
111
Flurazepam (see benzodiazpines) 43
Folic acid (see vitamin B 12 and Folate) 29
Follicle stimulating hormone 19
Fractional excretion of Sodium 19
Free androgen index 19

Galactose Iphosphate 54
G6PD screening 20
Gastric inhibitory polypeptide (see gut and islet hormone assay) 20
Gastrin (see gut and islet hormone assay) 20
Genetic studies 19
Glomerular filtration rate (see creatinine clearance) 17
Glucagon (see gut and islet hormone assay) 20
Glucagon stimulation test 20
Glucose serum 20
Glucose suppression test 20
Glucose-6 phosphate dehydrogenase 20
Glucose tolerance test (see test protocols) 36
Glutamyl transpeptidase (see liver profile) 24
Gold 20
Growth hormone 20
Gut and islet hormone assay 20

Haemoglobin A.l.c. 20
Haemosiderin 20
High density lipoprotein (HDL) 21
Homocysteine 21
Homogentisate 21
Hormone profile 21
Human chorionic gonadotrophin (HCG) serum, urine 22
Human growth hormone 20
Hydroxyindole acetic acid 22
17 hydroxyprogesterone 22
Hydroxyproline 22
5-Hydroxytryptamine 22

Imipramine (see antidepressants) 43

Immunoglobulins 22
Indican 22
Insulin (see gut and islet hormone assay) 20
Insulin like growth factor IGF-I 23
Iron serum overdose 45
112
Lactate 23,54
Lactic Dehydrogenase 23
Lactose tolerance test - see protocols 37
Lamotrigine 43
Lead - blood, urine 23
Lidocaine (see antiarrhythmics) 42
Lipids 23
Lipid profile 23
Lipoprotein electrophoresis 23
Liposomes 23
Lithium 46
Liver profile 24
Lorazepam (see benzodiazpines) 43
Lutenising hormone (LH) 24
Lysosomal enzymes 24

Magnesium 24
Maprotiline (see antidepressants) 43
Melanin 24
Mercury - Blood, urine 24
Methaemoglobin 24
Methanol 46
Methotrexate 46
Mianserin (see antidepressants) 43
Microalbuminuria 25
Mucopolysaccharides 25
Myoglobin 25

Neurotensin (see gut and islet hormone assay) 20

Nitrazapam (see benzodiazpines) 43
Nor adrenaline (see catecholamines) 16
Nordiazapam (see benzodiazpines) 43
Nortriptyline (see antidepressants) 43

Occult blood 25
Oestradiol 25
Oestrogen receptor 25
Opiates 46
Organic acids 25,55
Osmolality - Serum, urine 25
Overdose screen 47
Oxalates 25
113
 Page no.
Oxazepam (see benzodiazpines) 43

Paediatric tests - Electrolytes, Calcium, Bilirubin 51

Pancreatic polypeptide (see gut and islet hormone assay) 20
Pancreolauryl 25
Paracetamol 47
Paraquat 47
Parathyroid hormone (PTH) 26
Phenobarbitone 43
Phenothiazines 48
Phenytion (see anti epileptics) 43
Phosphate (serum see bone profile) urine 26
Porphogilinogen (see porphyrins) 26
Porphyrins 26
Potassium (adults)
Serum (see electrolytes) 19
Urine 26
Prealbumin 26
Primidone 43
Procainamide 42
Progesterone 26
Prolactin 26
Prostatic specific antigen (PSA) 26
Protein eletrophoresis 26
Protein - Urine 27
Protriptyline (see antidepressants) 43
Pseudocholinesterase (see cholinesterase) 16
Pyruvate kinase 27

Quinidine 42

Reducing substances 27
Renal calculi 27
Renal failure index 27
Renin activity 27

Salicylate 48
Secret in (see gut and islet hormone assay) 20
Selectivity of proteinuria 27

114
Selenium 27
Sex hormone binding globulin 27
Page no.
Sodium (adults) 19
Serum (see electrolytes)
Urine 28
Sodium valproate (see anti-epileptics) 43
Somatostatin (see gut and islet hormone assay) 20
Stones (see calculi) 27
Substance P (see gut and islet hormone assay) 20
Sugar (see glucose) 20
Sulphaemoglobin 28
Sweat test 28
Synacthen (see test protocols) 37

T3 28
T4 28
Tegretol/Carbamazepine (see Therapeutic Drug Monitoring) 43
Temazepam (see benzodiazpines) 43
Testosterone 28
Theophylline (see anti asthmatics) 42
Thioradazine (see phenothiazines) 48
Thyroid function tests 28,56
Thyroid stimulating hormone 28
Thyrotrophin releasing hormone test (see test protocols) 38
Tricyclic antidepressants (see antidepressants) 43
Tricyclic antidepressant screen 43
Triglycerides (see lipids) 23
Trimipramine (see antidepressant) 43
Tumour Markers 28

Urate 28
Urea (adults) 28
Serum (see electrolytes) 19
Urine 28
Urinary sugars 27
Urobilinogen 28
Uroporphyrins (see porphyrins) 26

Valproate/Epilim (see Theraputic Drug Monitoring) 43

Vasocative intestinal polypeptide (see gut and islet hormone assay) 20
115
Vitamins A and E 28
Vitamin B 12 and Folate 29
Vitamin C 29
Vitamin D 29

Zinc 29

116
NOTES

117
NOTES
NOTES
NOTES
 INFECTION CONTROL PRINCIPLES

Protect yourself, your patients and your colleagues from

the hazards of cross-infection.

1. HAND HYGIENE - The most important infection control

measure. Decontaminating your hands between patient
contacts makes a real difference.
2. WHITE COATS - Change your white coat regularly and
as soon as possible after contamination with blood or
body fluids. Coats should be removed before carrying
out an aseptic procedure. Never keep needles or other
sharp objects in pockets and always check pockets are
empty before sending to laundry.
3. SHARPS - Dispose of sharps carefully. Never re-sheath
used needles.
4. STETHOSCOPES - Are a potential source of cross-
infection. Disinfect with a 70% alcohol swab in between
patient contacts.
5. PROTECTIVE CLOTHING -

• Plastic aprons should be worn when in direct contact

with a patient with an infectious condition or when
contact with blood or body fluids is likely.
• Gloves are required for the same indications.
• Masks may be necessary in some instances
• Eye protection may be necessary where splashes or
aerosols of blood or body fluids are likely.

IF IN DOUBT - ASK. CONTACT A MEMBER OF THE

INFECTION CONTROL TEAM AT EXT: 2437