DR Lal Pathlabs DR Lal Pathlabs Lpl G Dat 005 Reference Guide
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— answers from the official manualAnswers from the official manual.
Common questions
Common Questions
20 totalHow do I properly label and barcode a blood sample tube?
Label each submitted specimen tube with the patient's name exactly as it appears on the Lab Form or Test Request Form. Barcodes must be affixed longitudinally on the tube, keeping the barcode number to the left without any folds or alterations. Do not use ink or write by hand directly onto the barcode label (Page 10).
What should I do if a patient has difficulty in finding veins for venipuncture?
In cases where patients have difficulty finding proper veins, alternative blood drawing sites can be selected or the IV drip should be shut off for at least three minutes before specimen collection. Specimens collected below the infusion site on the same arm are acceptable for most tests except those analytes contained in the infusion solution like glucose and electrolytes (Page 10).
How quickly should I complete sample collection to avoid inaccurate test results?
Samples should be centrifuged within two hours after collection. For SS7 and red top tubes, a clotting period of 30 minutes is required before they can be spun down (Page 15).
What are the proper specimen handling instructions for immunohistochemistry?
For Immunohistochemistry, formalin-fixed paraffin-embedded blocks should be submitted with appropriate clinical history and a copy of any previous Histopathology report if available. Alternatively, specimens can be collected as per routine histopathology; detailed clinical history must accompany the specimen along with contact number of the referring doctor (Page 17).
How should I transport urine samples that require refrigeration?
Refrigerated specimens at 2-8°C should be packed by placing a prefrozen gel pack at the bottom of the box, covered with perforated sponge, followed by the sealed zip lock sample bag and another layer of perforated sponge. Another prefrozen gel pack is added before closing the thermocol lid and sealing the cardboard box (Page 19).
What environmental factors can influence specimen concentrations?
Controllable variables affecting analyte concentration include posture changes, prolonged bed rest, exercise intensity, and dietary habits. Non-controllable variables such as genetics, age, race, environment, and seasonal influences also affect concentration levels (Page 5).
Show 14 more questions
How should filter paper blood specimens from newborns be stored and mailed?
What are the customer care hours for Dr Lal PathLabs?
How do I book a home collection of samples?
What is the turnaround time for critical alert notifications?
How should blood samples be centrifuged for proper separation of serum or plasma?
What is the correct order of draw for multiple specimen collection?
What are the common errors in specimen collection that can affect test results?
How can I access my test reports online?
What personal protective equipment (PPE) must phlebotomists wear during sample collection?
What are the barcoding instructions for specimen tubes?
What information must I fill out for a newborn's heel prick blood collection?
What are common errors that occur during specimen collection?
What factors affect test results in blood samples?
How should histopathology samples be prepared before submission?
Full Manual
21 pages
Dedicated to the memory of my father and our founder Late Dr. (Major) S K Lal Dr Lal PathLabs
Reference Guide
Lpl/G/Dat/005
Eleventh Edition Copyright © 2022 Dr Lal PathLabs Ltd, Delhi 110 085 No part of this publication may be stored in a retrieval system, transmitted or reproduced in any form or by any means without the prior agreement and permission in writing of the publisher. Published by Dr Lal PathLabs, Sector 18, Block E, Rohini, Delhi - 110085 For private circulation only
vii
Quality Assurance
Services
Logistics 7o ensure specimen integrity and quick turnaround times, LPL runs an e൶cient courier service with vast experience in providing logistics over broad geographical boundaries. 7rained Logistic personnel, provide support in specimen pickup, distribution of supplies and test reports. LPL utilizes the services of various modes like air, road and trains to ensure sample delivery to the nearest laboratory depending on the test menu. Logistics team uses specially designed transport boxes to maintain sample stability at the recommended transport temperature. Data loggers are placed within the boxes to record temperature variations if any, during the transport. Customer care Quali¿ed Customer support representatives are available days a week (0on through Sat .30 am to 10 pm and Sunday .30 am to 9 pm) to handle all customer queries. 7hey also deal with activities pertaining to customer complaints & customer satisfaction assessment. Customer care channelizes calls to the technical personnel to provide interpretive information whenever required. Home Collection 7o facilitate patient convenience trained home collection team is available on appointment by calling S7D code 39885050 only for Pathology tests. Clients can also book home collection of samples through the website and mobile App. Clinical Trials Dr.Lal Pathlabs Clinical 7rials provides global central laboratory services, to meet the needs of our pharmaceutical and Clinical Research 2rganizations. For this purpose dedicated sta൵ is designated to provide customized, e൶cient and timely services to its clients. Testing Policies Repeat determination: Performed routinely as part of the laboratory's ongoing Quality Assurance Program. In addition, tests can be repeated when requested by the attending physician. Samples are routinely retained as per the Lab Retention Policy at appropriate temperatures to maintain stability during storage. All Pre analytical Analytical Post analytical repeats requested require fresh sampling within days of original sample collection. Contact Customer care services for repeat determinations. Test Additions / Cancellations: 7ests may be cancelled without charge while specimens are in transit. 2nce the specimen has been registered, cancellation requires authorization from concerned department through the Customer care. Cancellations shall not be entertained once the specimen has been assayed. 7est Additions can be requested provided the specimen is adequate and viable. Addition of tests requires authorization from concerned department through the Customer care. Veterinary Testing Veterinary Pathology Diagnostic centre "PathVets"- pan India samples are tested. 7his diagnostic centre provides facilities for Pathology tests, X-Rays and Ultrasounds for all Domestic pets, Poultry farms, Dairy animals, Animal breeding farms & National Zoological parks. Address: Block B, 4050 GF, ChittaranMan Park, New Delhi-110 019, Tel. 011-490584040 Critical Alert noti¿cations Critical alert is de¿ned as a value that presents a pathophysiological state at such variance with normal or expected values that it is considered life threatening unless a corrective action is undertaken.
viii Critical values do not necessarily correspond with normal reference ranges, toxic range or therapeutic ranges but are based on a level at which medical action is considered necessary. All critical value limits are informed within 120 minutes to the concerned client through S0S & emails. 7he S0S facility is available till 8 pm. 1oti¿cation of Delay 5eSeat results Due to unforeseen circumstances, reports may not be available on the due date. LPL maintains a speci¿c procedure for addressing delays repeats of patient tests. 7he clients are informed through S0S Email within 2 hours of noti¿cation from the concerned department. 7he S0S facility is available till 8 pm. Turnaround Time (TAT) 7he most meaningful and quanti¿able measures in healthcare are accuracy and speed of diagnosis. LPL is committed to providing the fastest turnaround time possible to improve patient management. Lab monitors the 7A7 stringently and evaluates areas for improvement on a daily basis. Primary SamSle Storage Sample Collection Facilities (SCFs) store the primary sample at required temperatures till their dispatch to the testing laboratory. In the testing laboratory, all samples requiring scheduled tests are stored at the designated temperatures till they are tested. All tested samples are stored as per their documented retention time. HIV Counselling As per NAC2 guidelines, LPL o൵ers Pre & Post test counselling to all its clients registered for an HIV test. Special forms have been designed for Pre-7est counselling and patient consent. Post 7est counselling is available at all our laboratories. Genetic Counselling 7he Genomics division- Genevolve has Genetic counsellors to guide & advise the individuals and families a൵ected or at risk of genetic disorders to help them understand and adapt to the medical, psychological & familial implications of genetic contribution to disease. Business Continuity Plan & Disaster Management In accordance with Good Lab Practices, LPL has a well de¿ned Business Continuity Plan with redundancy built into the I7 systems to provide alternate source of servers and networking which can take over the functions of the laboratory within 30 minutes. 7he main server is located in 0umbai while back up server is in Delhi which carries complete patient and lab information. In the event of a crises a൵ecting patient care services, LPL has a well documented Disaster management plan for patient support services. Noti¿cation of clients, alternative transport facilities, timely pickup of specimens and proper backup procedures form a part of the contingency plan. Reference & Satellite laboratories provide facilities for alternative laboratory testing during crises. Holiday Coverage Dr.Lal Pathlabs National Reference Laboratory, is open 24x, 35 days a year except on Sunday evenings (Sunday timing - am to pm). Satellite Laboratories usually work 12 hours during the day as per laboratory speci¿ed timings. Collection centres & Patient Service Centres are open till 1 pm on all working days & holidays. LPL's listed holidays: New
1
General Instructions
General Instructions
Pre-Analytical Variables
Human body is composed of di൵erent compounds and elements whose concentration and activity may reÀect an individual¶s health or pathophysiological state. 0any factors other than disease a൵ect the concentration or activity of these analytes. Preanalytical variables can be controllable or non-controllable.Controllable Variables
Posture In an adult, change from lying to upright position reduces blood volume by about 10 thereby reducing plasma volume of the blood and increasing plasma protein concentration. Normally decrease with change from lying to standing position is complete in 10 minutes. However an interval of 30 minutes is required for reverse change to occur from standing to lying position. Application of tourniquet at the time of blood collection mimics the e൵ect of change from lying to standing position thereby increasing the plasma concentrations of proteins, enzymes, protein bound constituents, blood cell counts, hematocrit and hemoglobin.Variation In Analyte Concentration With Change In Posture From
Lying To Standing
Analyte
Average Increase In %
Alanine aminotransferase 7 Albumin 9 Alkaline phosphatase 7 Amylase 6 Aspartate aminotransferase 5 Calcium 3 Cholesterol 7 IgA 7 IgG 7 Ig0 5 7hyroxine 11 7riglycerides 6 Prolonged bed rest :ithin a few days of the start of bed rest, plasma volume decreases thereby increasing hematocrit by 10 within 4 days. Prolonged bed rest is associated with increased urinary nitrogen excretion. Calcium excretion increases to a maximum of 0 after weeks of bed rest. Excretion of sodium, potassium, phosphate and sulphate increases to a smaller extent. V0A excretion is reduced by one fourth after 2-3 weeks of bed rest. :hen an individual becomes active after a period of bed rest, ! 3 weeks is required before calcium excretion reverts to normal and another 3 weeks before positive calcium balance is achieved. Exercise Nature and extent of exercise plays an important role in a൵ecting serum analytes. Beta endorphins and catecholamines almost double within a minute of strenuous exercise. 0oderate exercise increases blood glucose which stimulates insulin secretion. Strenuous exercise for 10 minutes increases plasma renin activity by 400. Cortisol secretion is stimulated and normal diurnal variation is abolished.
Dr Lal PathLabs Reference Guide Specimen Collection 2
Effect Of Strenuous Exercise On Serum Constituents
Constituent
% Increase
Acid phosphatase 11 Alanine aminotransferase 41 Alkaline phosphatase 3 Aspartate aminotransferase 31 Calcium 1 Chloride 1 Cholesterol 3 Creatinine 1 Phosphate 12 7otal Protein 3 Urea Nitrogen 3 Uric acid 4Constituent
% Decrease
Albumin 4 Bilirubin 4 Iron 11Ldh
1 Potassium 8 Sodium 1 7otal Lipids 12 Physical training Athletes generally have a high serum activity of enzymes of skeletal muscle origin as compared to non-athletes. Serum concentrations of urea, uric acid, creatinine and thyroxine are higher in athletes due to increased muscle mass. Physical training also increases HDL cholesterol and decreases LDL cholesterol and triglycerides. Circadian variation 0any body constituents exhibit cyclical variation throughout the day. Factors contributing to this variation include posture, activity, food ingestion, stress, daylight or darkness and sleep or wakefulness. Concentration of serum iron increases as much as 50 from 8 am to 2 pm. Hormones are specially a൵ected by cyclical variations ± Corticotropin secretion increases 3-5 fold from minimum value between afternoon and midnight to its maximum around waking. Cortisol is maximum between -8 am Aldosterone and Renin activity is maximum in the early hours of morning during sleep reducing to a minimum by afternoon. GFR is 20 greater in the afternoon. Urinary 1 .etosteroids and 1 Hydroxycorticosteroids are lowest at night reaching maximum at mid afternoon. Prolactin concentration is greatest during sleep Serum 7SH is maximum between 2-4 am and minimum between -10 pm Higher glucose values occur when glucose tolerance test is done in the afternoon
3
General Instructions
Travel 7ravel across several time zones a൵ects normal circadian rhythm due to altered pituitary and adrenal function. During a 20 hour Àight serum glucose and triglyceride levels increase and Àuid and sodium retention occurs. Diet High protein diet: Increases serum cholesterol, phosphate, urea, uric acid, ammonia & urinary urea & uric acid High fat diet: Increases serum triglycerides High carbohydrate diet: Decreases serum LDL cholesterol, triglyceride, total cholesterol and protein Food Ingestion Plasma analytes are a൵ected by the time between ingestion of meal and collection of blood. 0any analytes require overnight fasting for 10-14 hours before blood collection making it an optimum time. A protein rich meal in the evening may increase serum urea nitrogen, phosphorus and uric acid upto 12 hours. 7he e൵ect of carbohydrate meals is less than protein meals. Bran : Habitual ingestion of bran a൵ects absorption of certain compounds like calcium, cholesterol and triglycerides from the gastrointestinal tract. Food constituents : 0any fruits like bananas and vegetables contain serotonin which increases excretion of 5-HIAA. Avocados impair glucose tolerance by a൵ecting insulin secretion. 2nions reduce plasma glucose and insulin response to glucose. Garlic ingestion may reduce cholesterol level by about 9. Caৼeine: It stimulates adrenal medulla resulting in 2-3 fold increase in plasma epinephrine concentration. It also a൵ects adrenal cortex, increasing plasma cortisol with increased excretion of free cortisol, 11-hydroxycorticoids and 5-HIAA. Ingestion of 2 cups of co൵ee may increase plasma free fatty acid level by 30. Serum gastrin level may be increased by 5 times on drinking 3 cups of co൵ee. Vegetarianism Long standing vegetarians show reduced levels of VLDL cholesterol by 12 as compared with non-vegetarians. Serum creatinine levels may also be slightly low due to reduced ingestion of proteins. An individual on a vegetarian diet for 3 months shows 20 reduction in serum copper, 10 reduction in selenium and zinc. Urine pH is usually higher in vegetarians due to reduced intake of precursors of acid metabolites. Malnutrition Plasma concentrations of most proteins like total proteins, albumin, pre-albumin and beta globulin are reduced in malnutrition. Serum cholesterol and triglycerides may be only 50 of the concentration in healthy individuals. Activity of most of the enzymes is reduced. Long Term fasting and starvation :ithin 3 days of start of a fast, blood glucose decreases by 18 mgdL. Insulin secretion is also greatly reduced. Amino acids are increased but urea decreases. 2rganic acids accumulate leading to metabolic acidosis. A fasting ! 0 hours shows reduced insulin by 50 and C-peptide by 30. Glucagon, Epinephrine and Norepinephrine are doubled and Growth hormone is increased 5 fold. Smoking Nicotine increases concentration of epinephrine in plasma and urinary excretion of catecholamines. Glucose levels increase by 10 mgdL within 10 minutes of smoking a cigarette and this increase persists for 1 hour. 7he lactate pyruvate ratio increases signi¿cantly within 10 minutes. Plasma growth hormone levels are very sensitive to smoking and increase 10 fold within 30 minutes after smoking. Cholesterol, 7riglycerides and LDL cholesterol levels are high in smokers. Smoking also a൵ects the immune response of the body lowering IgG, IgA & Ig0 levels. CEA is reported to be 0 higher in habitual smokers. Sperm count of male smokers is reduced and number of abnormal forms is greater. Alcohol Prolonged moderate ingestion of alcohol increases the blood glucose by 20-50. Serum triglyceride levels increase by !20 mg dL, plasma aldosterone by 150 and prolactin by 40-50. HDL cholesterol also rises while LDL cholesterol reduces. Chronic alcoholism increases GG7 by 1000 fold, AS7 by 200 and AL7 by 0.
Dr Lal PathLabs Reference Guide Specimen Collection 4 Drug Administration Large doses of a drug administered over a long time a൵ect the concentration of body Àuids by their therapeutic intent, side e൵ects and patient idiosyncratic response to their administration. Co-administration of certain drugs may a൵ect their metabolism and pharmacological e൵ects. C., Aldolase and LDH - muscle component increase in the serum on intramuscular administration. Herbal Preparations Herbal preparations lack regulatory standardization and may a൵ect metabolism of therapeutic drugs. Ginseng ingestion reduces Prothrombin time and INR in patients taking :arfarin. Grapefruit Muice increases bioavailability of drugs like 0ethadone, Amiodarone and Simvastatin. Aloe vera and Senna have laxative e൵ects and prolonged use may lead to hypokalemia. Liver damage may be caused by impure constituents of herbal mixtures.
Non-Controllable Variables
Biological inÀuences Genetics plays an important role in determining the concentration of blood constituents like cholesterol, glucose, urea, urate and bilirubin. Females with blood group µ0¶ have a lower hemoglobin concentration than other blood groups.Age: Has a notable e൵ect on reference intervals of each analyte and in general population is divided into 4 groups namely Newborn, 2lder child to puberty, Sexually mature adult and Elderly adult.
Gender: After puberty, characteristic changes in the concentrations of sex hormones a൵ect test results. Serum levels of Alkaline phosphatase, AL7 , AS7, C. & Aldolase are greater in men than in women. Hemoglobin and bilirubin levels are slightly lower in women but reticulocyte counts are higher.
Race: 7otal serum protein concentration is higher in blacks than in whites though serum albumin is less. Carbohydrate and Lipid metabolism di൵er in black and white races. Glucose tolerance is less in Blacks, Polynesians and Native Americans. Lipoprotein (a) level in blacks is twice higher than whites. Environmental factors
Altitude: Individuals living at high altitude have higher hemoglobin and PCV levels due to reduced atmospheric oxygen. Basal Growth hormone levels are high in individuals living in high altitudes but concentrations of Renin and Aldosterone are low.
Temperature: Acute exposure to heat expands the plasma volume and reduces glomerular ¿ltration. Extensive sweating can lead to hemoconcentration rather than hemodilution.
Place of residence: Geographic location a൵ects concentration of body Àuids with signi¿cant increase in serum levels of cholesterol, triglycerides and magnesium in areas rich in hard water. Carboxyhemoglobin concentration is higher in places with heavier automobile tra൶c as compared to rural areas. Seasonal inÀuences During summer in northern hemisphere, blood volume increases and in winter plasma proteins increase by 10. Cholesterol is higher in winter than in summer whereas 7riglycerides are higher by 10 in summer. Menstrual cycle Plasma corticosterone level is 50 higher in luteal phase than in follicular phase. Plasma androstenedione and aldosterone levels increase from follicular to luteal phase. Cholesterol and triglyceride levels are higher in mid cycle corresponding to maximum estrogen secretion. 7his cyclical variation of cholesterol is not observed in women with anovulatory cycles. Obesity Serum levels of cholesterol, triglycerides and beta lipoproteins are positively correlated with obesity. Lactate dehydrogenase and glucose are increased in both sexes with increase in body weight. In males AS7, creatinine, 7otal protein & hemoglobin rise with increasing body weight whereas in females calcium rises with weight gain. Acute phase reactants are higher in obese as compared to lean individuals.
5
General Instructions
Pregnancy Since blood volume increases during pregnancy from 200 mL in early pregnancy to 3500 mL at 35 weeks gestation, plasma proteins are reduced specially albumin levels. Urine volume is 35 greater and glomerular ¿ltration is 50 greater during 3rd trimester of pregnancy. All acute phase reactant proteins increase during pregnancy and ESR rises by 5 fold. Stress Anxiety stimulates increased secretion of aldosterone, angiotensin, catecholamines, cortisol, prolactin, growth hormone, 7SH & renin. Stress decreases albumin by 5 but cholesterol levels increase. Fever Fever provokes many hormonal responses and appears to reduce the secretion of 7hyroxine. It accelerates lipid metabolism and is often associated with respiratory alkalosis. Shock and Trauma Regardless of the cause of shock and trauma, certain characteristic biochemical changes occur like 3-5 fold increase in serum cortisol concentration, increased excretion of 1-hydroxycorticosteroid. Stress of surgery reduces serum 73 levels by 50 in patients without thyroid disease. Transfusion and Infusion 7ransfusions to replace blood loss because of inMury reduces sodium & chloride. Extensive blood transfusions can lead to siderosis and increased serum iron concentration. Infusions of glucose solution usually reduce plasma phosphate and potassium concentrations. After an infusion it is not advised to collect blood for 8 hours as it a൵ects accuracy of test results.Analytical Variables
Biologically common phenomena which can lead to analytic variation are: Cold agglutinins Rouleaux formation 2smotic matrix e൵ects Platelet agglutination Giant platelets Nucleated erythrocytes 0egakaryocytes Red cell inclusions Circulating mucin Leukocytosis In vitro hemolysis Bilirubinemia Lipemia Immunoassays are aৼected by: Interference by Paraproteins Heterophile antibodies Very high hormone levels ± Hook e൵ect 0acro forms of Prolactin, Amylase, Creatinine kinase & LDH elevate test resultsPost-Analytical Variables
0anual & telephone reporting must be discouraged as it is subMect to transcription errors at the receiver end. Report delivery process & design should be such that correct & timely reporting with correct reference range & test interpretation is achieved.
Dr Lal PathLabs Reference Guide Specimen Collection 6
Specimen Collection
Patient Identi¿cation Phlebotomist must con¿rm the identity of the patient by requesting patient to call out his her full name. Same is matched with the test request form. Positive identi¿cation of the patient is made before Primary sample collection. In cases of pediatric patients, the attendant must be asked the same. For certain tests like HLA, additional patient identi¿cation is required by checking the photographs stapled to the lab form and matched visually. Certain mandatory forms have to be ¿lled & attached for specialized tests. Personal Protective Equipment (PPE) Phlebotomists must wear gloves, face mask and lab coat before approaching the patient and take standard precautions against potentially infectious material and limit the spread of infectious disease from one patient to another In certain cases like collection of 7hroat Nasal swabs in Swine Àu patients, special collection kit has to be worn prior to sample collection. Donning & do൶ng of PPE for Sars-CoV-2 test Covid-19 disease should be strictly followed. Pre-test requirement checks If a fasting specimen or dietary restriction is required, con¿rm patient has fasted or eliminated foods drugs from diet ordered by the Physician. Patient position Patient should be comfortable, seated or supine and should be in this position as long as possible before sample is drawn. Venipuncture should never be performed on a standing patient.Blood Sample Collection
Duly Filled Consent Form For Phlebotomy Procedure (Form-50) Is Mandatory
Selection of Venipuncture site 0edian Cubital vein in the antecubital fossa or crook of the elbow is the preferred site for collecting venous blood in adults because the vein is large and close to the surface of skin. Veins on the back of the hand or at the ankle may be used but these are less desirable and should be avoided in patients with Diabetes and other individuals with poor circulation. An arm with an inserted intravenous line, cannula, arteriovenous ¿stula, extensive scarring or hematoma should be avoided. Arm on the same side as 0astectomy should not be used as surgery causes lymphostasis there by a൵ecting blood composition specially if the surgery is within months. For severely ill patients and those requiring intravenous inMections, alternative blood drawing site should be selected. For patients on prolonged intravenous Àuid therapy with di൶culty in ¿nding proper veins, the IV drip should be shut o൵ for at least 3 minutes before specimen is collected. Specimens below the infusion site in the same arm are satisfactory for most tests except for those analytes which are contained in the infusion solution like glucose and electrolytes. Prior to Venipuncture Phlebotomist should estimate the volume of blood to be drawn and select appropriate number and types of tubes required for blood samples as per tests requested. In case of multiple collections, order of draw should be decided. Proper Labeling of Tubes Each submitted specimen tube must be labeled with the patient¶s name, (written exactly as it appears on the Lab Form 7est Request Form) and the tests to be conducted. 7he tubes should be bar coded . 7he time of specimen collection and the identity of the phlebotomist collecting the Primary sample is recorded.
7
General Instructions
Barcoding Instructions(a) Do not change the numbers on the barcode by hand.
(b) Do not use ink or write on the barcode label by hand.
(c) Do not soil the barcode.
(d) A൶x barcodes without any folds.
(e) Barcode should not cover the entire tube as this blocks physical viewing of the sample for gross hemolysis, lipemia and sample volume. Preparing Venipuncture site Area around the intended puncture site should be cleaned with the spirit swab containing 0 alcohol in a circular motion from inside to outside. Skin should be air-dried and no alcohol should remain on the skin as traces may lead to hemolysis. Do not touch the site after it has been cleaned. Venous Puncture Technique using Evacuated tubes / Vacutainer Sanitize hands & wear gloves with consideration of latex allergy. Apply a tourniquet preferably of Velcro or soft rubber strips and ask the patient to make a ¿st without vigorous hand pumping. 7ourniquet should not be tied for more than 3 minutes as it a൵ects biochemistry parameters. Ideally tourniquet should not be tied for more than 1 minute. Holding the green colored section of the needle shield in one hand, twist and remove the white section of the needle with the other hand. Screw needle onto the holder. Leave the green colored shield (21 inch gauge) or if necessary black colored shield (22 inch gauge) on the needle. Puncture the skin with the needle at approximately 15 degree angle with the bevel of the needle facing upwards. Insert the needle smoothly and fairly rapidly to minimize patient discomfort. If using an evacuated system, as soon as the needle is in the vein, insert the vacutainer tubes forward in the holder, puncturing the diaphragm of the stopper. Remember to insert vacutainer tubes maintaining the correct order of draw. Release the tourniquet when blood begins to Àow into the vacutainer. :hen the tubes have ¿lled upto the indicator mark, apply soft pressure with the thumb against the Àange of the holder to disengage stopper from the needle and remove tube from the holder. If more samples are needed, repeat the same procedure. Remove the last tube from the holder before withdrawing needle from the vein. Never withdraw the needle without removing the tourniquet. Apply pressure to the venipuncture site with a dry swab & place adhesive band aid when blood stops Àowing. 0ix and invert all tubes as per chart below. Do not shake the tubes vigorously. Dispose of contaminated material in designated containers using universal precautions as per local state guidelines. In case of contamination of the holder glove, discard and replace with a new one.
Dr Lal PathLabs Reference Guide Specimen Collection 8 Blood collection with Syringe Syringes are used for patients with di൶cult veins. Place the needle ¿rmly over the nozzle of the syringe and remove cover of the needle. .eep bevel of the needle upwards. Align syringe and needle with the vein to be punctured and push the needle into the vein at an angle of 15 degrees. As soon as the vein is pierced, stop the forward pressure on the syringe and draw blood by gently pulling back the plunger of the syringe. After adequate blood volume has been drawn, remove the syringe with the needle from the vein and immediately place a dry swab over the puncture site. Puncture the color coded top of the evacuated tubes with the same needle and allow the tube to ¿ll passively. Do not uncap and forcefully push the blood into the evacuated tube. Venipuncture in children 7echnique for venipuncture in adults and children is similar. However children are likely to make unexpected movements, hence assistance in holding them is required. Use 0icrotainer evacuated tubes and preferably 23 gauge butterÀy needle with attached tubing to collect specimens. Completion of sample collection :hen blood collection is complete and needle is withdrawn, patient should be instructed to press the puncture site with a dry swab and arm raised without bending at the elbow, to lessen the leakage of blood. Apply band aid once the bleeding has stopped. Discard needle syringe swabs as per the Biomedical waste disposal guidelines. Recommended Order of Draw for multiple specimen collection Color of Stopper Additive Inversions Blood Culture bottle Broth 8 :hite 7op No Additive 0 Light Blue 7op Sodium citrate 3-4 Gold 7op - SS7 Gel Separator 5 Red 7op No Additive 5 Green 7op Sodium heparin 8 Royal Blue 7op
.2 Ed7A
8 Lavender 7opEd7A
8 Grey 7op Sodium Àuoride 8Common Errors In Specimen Collection
9
General Instructions
Factors Affecting Test Results
Blood Collection Procedure In Newborns On Filter Paper
Materials required Sterile, disposable lancet or automated lancet device (maximum tip length 2.4 mm) 0 alcohol swab 3 sterile cotton wool or gauze swabs Disposable gloves Blood collection card Filter paper Sample Collection Procedure :ear gloves. Ask the mother to cuddle the baby on her knee to assist you and comfort the baby. Place a paper towel on the lap of the person holding the baby to protect from any blood drips.
Dr Lal PathLabs Reference Guide Specimen Collection 10 Ensure that the heel is warm. Hold the heel in warm hands for 3 minutes or dip heel in warm (not hot) water. :arming the heel will enhance the blood Àow and positioning the foot in a downward position from the heart will help to collect specimen adequately. Clean the heel with sterile spirit swab and air dry. Do not leave any alcohol on the skin as this may dilute the sample and adversely a൵ect the test results. Encircle the heel with ¿ngers and thumb and squeeze gently until skin is taut and su൵used with blood. Puncture the heel with a ¿rm deliberate stab with lancet. 7he length of the puncture should not exceed 2.4mm. If a second puncture is necessary, make this a few millimeters away from the ¿rst puncture or use the other foot. After the puncture, wait for ¿ve seconds as vasoconstriction occurs initially. 7hen gently apply intermittent pressure with the thumb to the area surrounding the puncture site. Avoid excessive pressure as this may bruise the site. Always wipe away the ¿rst drop of blood as it is often diluted with tissue Àuid and may lead to false negative results. 7ouch the circle marked on the card gently to the hanging drop so that blood soaks through to the other side. Do not ever try to put blood drop on both sides of the card. It is very important that blood should soak through the card. Do not press the card on to the skin. Do not apply multiple drops to ¿ll each circle or one drop on top of another. Do not touch blood spot with ¿nger. Press clean cotton wool ¿rmly on the puncture site until bleeding stops. It is not advisable to place adhesive bandages over skin puncture sites in newborns. Dry the sample at room temperature on a clean non-adsorbent surface for 4 hours. Alternatively, venous blood can also be taken by syringe and drops of blood are poured on ¿lter paper. Skin punctures must never be performed on the ¿ngers of newborns. Never prick bruised heel. Filling Out IEM Cards It is extremely important that all requested information on screening card is ¿lled completely and legibly. 7he information requested is vitally important for screening and follow up. Accurate and complete patient and physician information is critical for rapid follow up in the event of abnormal test result. Name, date of birth and specimen date are particularly important. Ensure physician information is accurate and complete.7he timing of collection and medical information on transfusion, medication, pre-maturity and other requested data are needed to interpret results and determine appropriate follow up procedures. Use ball point pen only to enter information on the card. Do not use a typewriter to ¿ll the form because it may contaminate the ¿lter paper.
11
General Instructions
Mailing Instructions for ¿lter paper specimens Preferably send the cards on the same day of collection. If it is not possible to send the sample on the day of collection, then store at 4C after the sample has dried. If stacking several cards, do not directly place one blood spot on top of another as this can cause contamination rotate each card in the stack to alternate the collection areas Place the blood specimen card in paper envelope. If paper envelope is not available, wrap a sheet of clean white paper around the cards ensuring that the blood spots are completely covered. 7here is minimal risk of infection from dried blood samples. Dried blood specimens must N27 be packaged in airtight, leak proof plastic bags. 7he lack of air exchange in a sealed plastic bag causes heat buildup and moisture accumulation which can damage the dried blood spot. High temperatures can degrade enzymes. Sample card must be transported refrigerated. Precautions for ¿lter paper collections Circles have to be completely ¿lled with blood drops and avoid over ¿lling. 0ilking or squeezing the puncture site can cause hemolysis and mixing of tissue Àuids with blood. Layering or applying successive drops of blood in the same printed circle causes caking and or non-uniform concentrations of blood. Ensure that blood soaks through the card. Do not apply blood on both sides of the card. Contamination of sample during collection, drying, or mailing with urine samples will render the results unreliable. Such samples will be reMected. Inadequate or inappropriate drying. Humidity and moisture adversely a൵ect the quality of sample and analyte recovery. Excess heat or sunlight bakes the sample. Excess cold leads to separation of red blood cells and serum. Placing the sample in a plastic bag generates moisture and promotes bacterial growth.Urine Specimen Collection
A clean early morning fasting specimen is usually the most concentrated and is preferred for microscopic examination and detection of abnormal amounts of constituents like proteins and HCG. First 10 mL of urine voided is most appropriate for bacterial examination. 0id stream specimen is best for investigating bladder disorders. Catheter specimens can be used in critically ill patients or in those with urinary tract obstruction. It is advisable to clean patient¶s genitalia before voiding urine for routine and culture examinations in order to obtain true concentration of white cells.24 Hour Urine Collection
Patient must be properly instructed on the collection technique. Discard ¿rst morning urine sample. Collect all the urine samples in the required container including ¿rst morning sample of next day. If container has preservatives like HCl, each void should be in a separate container which is emptied into the larger container. 7his two step procedure prevents danger of patients splashing themselves with the acid. Add appropriate volume of 50 or N HCl as per table 1 to stabilize the pH between 1 & 3.
Dr Lal PathLabs Reference Guide Specimen Collection 12 .eep the container at 40C during the entire collection period or alternatively keep the container in a bucket of ice. For 24 hour collection a 5 litre urine container su൶ces. Urine should not be collected at the same time for 2 or more tests requiring di൵erent preservatives. Removal of an aliquot is not permissible during 24 hour collection, because excretion of most compounds varies throughout the day and test results will be a൵ected. Prior to testing, smaller aliquots must be made after thoroughly mixing the urine in the 24 hour container to ensure homogeneity. 0easure and note the total volume of the well-mixed 24 hour urine collection and send 50mL aliquot in a screw-cap plastic container refrigerated (2-80C), for analysis. Record 24-hour urine volume on test request form (7RF) and urine container. Collection for Specialized Urine Tests Trace metal analysis: It is mandatory to use trace metal containers. Do not measure 24 hour volume. For arsenic test, do not eat shell¿sh 48 hours prior to specimen collection. Calcium: Do not take laxatives during the collection period. 5-HIAA: For 48 hours prior to specimen collection, limit the following to one serving per day ± fruitsvegetablesnuts ca൵einated beverages or foodmedicines like aspirin, antihistamines, cough syrups. VMA/Catecholamines/Metanephrines: food & beverage restrictions 2 hours prior to specimen collection. Table 1 Urine Output in mL Volume of HCl to be added 50±100 0.5 mL 101±200 1 mL 201±400 2 mL 401±00 3 mL 01±800 4 mL 801±1000 5 mL 1001±1200 mL 1201±1400 mL 1401±100 8 mL 101±1800 9 mL 1801±2000 10 mL Table 2 24 hour Urine Collection Preservatives Tests None Amino acids, Amylase, Citrate, Chloride, Creatinine, ALA, Immunoelectrophoresis, Phosphorus, Potassium, Protein, Protein electrophoresis, Sodium, Urea, Uric acid 10 g Boric acid Aldosterone, Cortisol 10 mL N HCl Catecholamines, Cystine, HVA, Hydroxyproline, 0etanephrine, 2xalate, V0A, 5HIAA, Calcium 0.5 g Sodium Àuoride Glucose 50 Alcohol Cytological examination
13
General Instructions
Random Urine Collection Random urine specimen should be acidi¿ed with 50 HCl (prepared by mixing equal volumes of concentrated HCl and deionized water) to a pH between 1.0 and 3.0 immediately after collection. Acid should be added drop-by-drop, checking the pH regularly till it falls between the desired range. Avoid excess addition of acid do not use concentrated acid. :ell-mixed 50mL aliquot of this collection should be sentstored refrigerated (2±8C) for analysis.Histopathology / Biopsy Specimen Collection
Specimen Handling for Routine Submission Immediately place each specimen in a tightly secured container with 10% Neutral bu൵ered formalin. Specimen must be totally immersed in formalin. Do not allow specimen to dry. Use a separate container for each separately identi¿ed specimen but register all specimens under single Lab number. Do not crush the specimen with forceps, hemostats, or other instruments. Cautery will cause heat artifact. DO NOT FREEZE formalin ¿xed specimens. Do not force a large specimen into a small container. Formalin must surround the specimen for proper ¿xation. Formalin volume to Specimen ratio should be 10:1. Label each container (not the lid) with patient’s name, source of specimen & bar code. Complete Histopathology test requisition form and send with specimen(s). 2nly one Histopathology test requisition form is needed per patient. Each container and specimen must be separately identi¿ed on the test requisition form. 7he Requisition Form must be ¿lled by the referring DoctorClinicianCentre from where specimen is received. The test requisition form should contain pertinent clinical information including Patient’s date of birth, gender, clinical information and anatomic location of tissue removed.Specimen Handling For Special Tests
Immunohistochemistry (IHC) Formalin ¿xed para൶n embedded blocks to be submitted with appropriate clinical history and copy of previous Histopathology report if available. Alternatively submit specimens as for Routine Histopathology. Immunohistochemistry is a specialized test which requires accurate clinical history and ¿ndings for processing of the specimen. Direct ImmunoÀuorescence Submit minimum 3 mm punch biopsy of Skin / Renal / Conjunctival specimen in bu൵ered normal saline. Ship refrigerated. ImmunoÀuorescence cannot be performed on formalin ¿xed tissues. Special Stains Submit specimens as for Routine Histopathology or submit formalin ¿xed para൶n blocks. Attach Histopathology report and relevant clinical history. Oncology Resection Specimens Collect specimens as for routine histopathology.
Dr Lal PathLabs Reference Guide Specimen Collection 14 Complete surgical pathology requisition form for Oncology Resections and send with the specimen. Each container and specimen must be separately identi¿ed on the test requisition form. 7he Requisition Form must be ¿lled by the referring DoctorClinicianCentre from where specimen is received. Test requisition form (TRF) should contain pertinent clinical information including Patient’s date of birth, gender, clinical information and anatomic location of tissue removed.
Electron Microscopy (Em)
7ransmission electron microscopy (7E0) is a technique in which a beam of electrons is transmitted through an ultra- thin specimen, interacting with the specimen as it passes through and creating its high resolution image. 7his analysis is performed by special microscopes called 7ransmission Electron 0icroscopes (7E0s).
7E0s are capable of imaging at a signi¿cantly higher resolution than light microscopes, owing to the small wavelength of electrons. 7his enables the instrument's user to examine ¿ne detail which is thousands of times smaller than the smallest resolvable obMect in a light microscope.
7E0s ¿nd application in diagnostic pathology, cancer research, virology, materials science as well as pollution, nanotechnology, and semiconductor research. 7he high magni¿cation of the electron microscope enables observations not possible by light microscopy, and electron microscopy is considered to be an essential component of human diagnostic renal pathology, neuromuscular pathology, and is a useful tool in di൶cult cases in oncosurgical pathology.
In renal pathology, ultrastructural features may enable a diagnosis to be made where the light microscopy is apparently normal, eg. 0inimal change, 7hin membrane disease, Hereditary nephropathy, Fibrillary and Immunotactoid glomerulonephritis. In addition, it can provide information to con¿rm the diagnosis, as in Immune complex glomerulonephritis, Renal amyloidosis, Dense deposit disease, Diabetes etc.
In muscle biopsy, the characteristic diagnostic features of several 0yopathies, Glycogen storage vacuoles, Nemaline myopathy, Actinopathies, and Hyaline body myopathy etc. are seen only with the use of 7E0. Additionally, when samples for electron microscopy are inadequate, valuable diagnostic information can be obtained from ultrastructural investigations on reprocessed para൶n- embedded material. Electron Microscope facility at LPL LPL has a dedicated 7ransmission Electron 0icroscopy laboratory, backed by experienced personnel and housing state of the art 120 kV -E2L 7ransmission Electron 0icroscope. Sample collection for Electron microscopy (TEM) Samples should be collected in special vials containing 3 bu൵ered glutaraldehyde solution, available from LPL. 7he specimen should be shipped refrigerated. Detailed clinical history should accompany the specimen along with contact number of the referring doctor.
Water Collection
Collection of Water Samples for Presumptive Coliform Count Hold the sterile bottle by the base in one hand. Use the other hand to remove the cap keeping the bottle vertical. 7he cap should be held in the hand face up, while the bottle is ¿lled. Screw back the cap immediately. 7o prevent contamination, do not touch the surface or inside the cap. If the bottle becomes contaminated it should not be used. 0inimum 180 mL of water sample is mandatory. Collection of a sample from Tap Clean the nozzle of tap with spirit. 7urn the tap on full and allow the water to Àow for 1minute. Collect the water in a sterile bottle.
15
General Instructions
Collection of water from rivers / lakes 7he stopper should be removed carefully with one hand and with the other hand bottle held at its base should be inserted, mouth downwards, a foot below the surface of the water. 7he bottle is then turned so that mouth is directed to the current and water Àows into the bottle without coming into contact with hand. If there is no current the bottle is moved horizontally, so that water Àows into it. 7he bottle is then brought to the surface and capped immediately.Centrifugation
SS7Red top tubes must be placed vertically for 30 minutes to allow blood to clot prior to centrifugation. For all blood samples collected, plasmaserum should be separated from cells within 2 hours. Uncentrifuged samples should be kept at room temperature to decrease hemolysis. 7hese samples should not be refrigerated at 4 C unless centrifuged. Plasma samples for 0olecular diagnostics should be centrifuged immediately and frozen. Blood samples must be centrifuged at 3500 rpm for minimum 10 minutes for proper separation of serumplasma. Urine and other body Àuids may be centrifuged at 1000 rpm for 5 minutes to concentrate particulate matter as sediment. Precautions 7ubes should be well stoppered and balanced. :eight of buckets, tubes & their contents on opposite side of the rotor should not di൵er by more than 1. 7ubes ¿lled with water may be used to equalize the weight if required. 7he speed control switch should be at zero before starting the centrifuge & adMusted to the required speed. Do not open the lid while the centrifuge is in operation. Do not stop the rotating tubes with your hands. Let them stop on their own. In case a tube breaks, the bucket, cushion & chamber should be opened after 30 minutes & then carefully cleaned with 1 Sodium hypochlorite solution. Always wear gloves to protect yourselves as any spillage can be hazardous. .eep serumplasmaurine refrigerated frozen till packed and transported to the laboratory at the required temperature as per the Alphabetical List of 7ests. Note : Premature separation of serum should be avoided as continued formation of ¿brin can clog sampling devices in testing equipment. Incomplete centrifugation can a൵ect test results. Centrifugation time should be strictly followed. 7ubes must be stoppered and then centrifuged to reduce evaporation and prevent aerosolization of infectious particles and volatile substances like Ethanol. Stoppers also maintain anaerobic conditions which are important for measurement of Carbon dioxide and Ionized calcium. It also helps to preserve blood pH which is important for enzymatic measurement of Acid phosphatase. Samples for 0olecular diagnostics should not be exposed to repetitive cycles of freezing and thawing as this can lead to shearing of DNA.Instructions For Packaging Specimens And Test Requisitions
Specimens must be packed and shipped properly for accurate testing, which helps ensure that patients receive optimal treatment. A specimen may not be viable for testing if it becomes too cold or too hot. It may be necessary to collect another specimen from the patient, which may delay treatment. Specimens at the testing facility must be At the correct temperature for testing Intact in the container, without breakage or leakage
Dr Lal PathLabs Reference Guide Specimen Collection 16 Shipped in the shortest possible time In compliance with all applicable regulations Note: 7his guide has been prepared to help understand the role in accomplishing these goals. By following the guidelines for proper specimen preparation, packing, shipping, and documentation, one can comply with regulations and safely transport specimens. How to pack Enter the Patient Information, tests requested and other details in the 7RF Fold the 7RF with the patient¶s name and bar code facing out. Specimen bag has 2 pouches. Place the specimen(s) wrapped in absorbant paper, in the rear pouch (printed side) and the 7RF in the front pouch (un-printed side) with the bar code facing out. Seal the Zip Lock bag. 7his will prevent the sample from contaminating the 7est Request Form in cases of accidental leakage. Note: Samples from Sample Collection Facilities (SCFs) are scanned, packed and the package with a master barcode is transported to the processing laboratory. Transportation to Laboratory 7ransport requirements are of 3 types Frozen Refrigerated At 18±22C Use of transport boxes supplied by LPL are recommended. Please refer to the Stability and Minimum Volumes in the Alphabetical List of Tests before using appropriate mode of transport to laboratory. Frozen (0-2 degrees C)
17
General Instructions
Billing
Payments can be made by cash credit card Pay70 Demand Draft 2nline in favour of ³Dr. Lal PathLabs Ltd´ payable at New Delhi OR Electronic transfer directly to LPL bank accounts. An additional courier charge of Rs.1500 Rs.5500 as applicable per test per patient should be included for samples to be sent to USA.
Dr Lal PathLabs Reference Guide Specimen Collection 18
Test Reports
7he turnaround time for each test is indicated in the Alphabetical List of 7ests. For samples sent to USA, the reports are available in 2 to 3 weeks time from the date of dispatch to USA.Mode Of Collection Of Test Reports
Self: Collection of 7est reports by the patients or their representatives on production of the receipt issued. Courier / E-mail on request at the time of Sample Collection. Website: Patients may access their reports online on our website (www.lalpathlabs.com) via the link ³View 7est Report´ on the home page. Under this link there are two columns ³LabVisit ID´ and ³Password´.LabVisit ID is patient¶s unique identi¿cation number Lab number
Password to be used is patient¶s surname. In case patient does not have a surname, the password would be hisher ¿rst name.
Veri¿cation code must be typed in capitals.
2nline reports can be viewed forever on the website with e൵ect from August, 201. Mobile App: Lal PathLabs 0obile App on Android and i2S helps in ¿nding the nearest centre Lab based on patient¶s location, gives information about various tests and helps in booking a Home collection. Patient will also be able to see the current and all the past reports on the App itself. 2pen menu draw in the App Click on µ0y reports¶ Select µCheck your report using lab ID and password and press enter after ¿lling in the same Click on the download icon to download the report or send the report to your email ID Cumulative Reports Current last 3 reports available simultaneously Valid for test results with quantitative values only