CC PART 7 (SPECIMEN) Flashcards
The following analytes are affected by hemolysis:
KLAMPAT
○ K+: Potassium
○ L: LDH
○ A: AST, ACP, Aldolase
○ M2+: Magnesium
○ PO4-: Phosphate
○ A: Albumin
○ T: Total Protein
The primary intracellular anion
K+: Potassium
2ND MOST ABUNDANT ICF (Intracellular Fluid Cation)
M2+: Magnesium
■ MOST AFFECTED ENZYME in Hemolysis
■ Increased LD1 in RBC
L: LDH
■ MOST ABUNDANT ICF (Intracellular Fluid Cation)
PO4-: Phosphate
(3) Characteristics of Lipemia
○ Creamy
○ Turbid
○ Clear
● Chylomicrons
● EXOGENOUS Tg
● APO B48, non-fasting
If the sample looks like a creamy or opaque layer
● ≥ 400 mg/dL = sample will
appear turbid
● The highest lipid is triglycerides.
● The lipoprotein is VLDL.
● ENDOGENOUS, APO B100,
Fasting
If the sample looks turbid
● This is considered a rare case
because commonly, triglycerides are higher than cholesterol in
hyperlipidemia.
● Cholesterol can be collected
even without fasting.
● Use tube EDTA plasma since it
is done without fasting
If increase cholesterol = clear only, no turbidity
Ice for blood gases
IMPROPER TRANSPORT CONDITIONS
ABG sample is not transported with ICE; it will:
● Decrease ___
● Increase ____
● Decrease ___
● Decrease pH
● Increase pCO2
● Decrease pO2
● Short draws
● Wrong volume
IMPROPER BLOOD COLLECTION TUBE
Which level of triglyceride is difficult/hard to measure?
A. 600 mg/dL
B. 400 mg/dL
C. 200 mg/dL
D. 100 mg/dL
A. 600 mg/dL: This is already considered “milky.”
Remedy for Milky specimen:
Dilute sample
In the Friedewald equation, how many hours of fasting are needed for a lipid profile?
A. 10 hours
B. 12 hours
B. 12 hours
Reference range of Fasting for Lipid Profile is
10-12 hours.
● Explanation: In lipid metabolism, if you ate at 12PM
○ Food will be digested from the stomach down to the liver and to the small intestine in 1-3 hours. It takes 6–9 hours for a complete transport from the liver, then the
lipids’ level will return to its normal value.
○ However, ideally, 10–12 hours is the reference range of lipid profile.
TRUE OR FALSE:
● You can measure cholesterol without fasting? In what sample?
TRUE, in EDTA plasma, not
serum.
If bilirubin, hemoglobin, and lipids are high, what will you use?
Use Sample Blank
If the sample is icteric, lipemic, or hemolyzed?
Use Sample Blank
Which 3 analytes are the most seriously affected by hemolysis?
Potassium, LDH, and AST
● Liquid portion of the blood (plasma) from arterial and
venous
● Purpose: For STAT and POCT
WHOLE BLOOD
● Liquid of unclotted or anticoagulated blood (with
fibrinogen)
PLASMA
● Best Sample of Choice for STAT:
Lithium Heparin
● Best Sample of Choice for STAT: Lithium Heparin
● However, ______ is not used in enzyme assays because
it inhibits the enzymes.
PLASMA
● Most blood chemistry is run on blank serum samples.
SERUM
● Liquid portion of clotted blood without fibrinogen
SERUM
Why serum over plasma?
○ Serum is clearer than plasma.
○ It has no anticoagulant, which is a source of interference.
Ideally, ___ glucose tests should be performed alongside ____ protein tests
CEREBROSPINAL FLUID (CSF)
WHY? This test is used to differentiate between meningitis, tuberculosis, and other clinical
microscopy-related diagnoses.
CSF glucose =
CSF protein
3 TUBES of CEREBROSPINAL FLUID (CSF)
- Immunosero and Clinical Chemistry
- Microbiology
- Cell Count in Hematology
For GFR or creatinine clearance
○ If a person does not have kidney disease, you can compute the GFR, or creatinine clearance.
○ However, if the person is diabetic or has other
conditions, creatinine clearance can no longer be used.
■ Instead, it is estimated GFR (eGFR).
24 HOUR URINE
________ and _______ are good markers of GFR without computing eGFR.
Cystatin C and creatinine
DIURNAL VARIATION
CORTISOL
● Peaks at 4-6 AM
● Lowest 8 PM-12 AM
● 50% lower at 8 PM than 8 AM
● Peaks at _____
● Lowest _____
● 50% lower at 8 PM than_____
● Increases with stress
CORTISOL
CORTISOL
● Best time to collect:
6 am to 8 am (morning)
Cushing Disease
pituitary problem
is higher in the morning.
CORTISOL
Cushing Syndrome
adrenal problem
Cortisol ↑
ACTH ↑
Cushing Disease
● Lower at Night
● Higher value while standing than supine
PLASMA RENIN ACTIVITY
Cortisol ↑
ACTH - Not affected
Cushing Syndrome
● Lower at night
● Increases with stress
ACTH
● Lower at night
ALDOSTERONE AND INSULIN
● Higher in the afternoon and evening
GH AND ACP
● Increase with stress
THYROXINE
● Higher with stress
● Higher levels at 4 and 8 am and 8 - 10 pm
PROLACTIN
Drawn in successive days to avoid diurnal variation
Serum iron
● Peaks early to late morning, decreases up to 30% during
the day
IRON
● 4% decrease when in supine position
CALCIUM
Increase
● ACTH
● Catecholamines
● Cortisol
● Albumin
● Insulin
● Prolactin
● Lactate
Decrease
● HDL
● Respiratory alkalosis
STRESS
Increase
● Albumin
● Cholesterol
● Ca2+ when standing
● Aldosterone
● Bilirubin
● Cortisol
● Total Protein
● Triglycerides
● Rbcs
● Wbcs
● Thyroxine (T4)
● Plasma Renin
● Catecholamines
Decrease
● Lipids due to hemodilution
POSTURE
concentration of these analytes increased within 10 minutes
from supine to standing
Catecholamines
A marker for chronic alcoholism is
GGT
Increase
● Tg and GGT
Decrease
● Glucose due to ethanol
ALCOHOL
Increase
● Glucose
● Insulin
● Gastrin
● Tg
● Na
● Uric Acid
● Iron
● Ld
● Ca2+
Decrease
● Chloride
● Phosphate
● K+
RECENT FOOD INTAKE
● Bilirubin
● CK
● Steroid Hormones
● Tg
DAY TO DAY VARIATION
● The patient can drink water during fasting, unless the order is NPO.
FASTING
FASTING:
↑ Plasma Tg; ↓ glucose
72 Hours
FASTING:
↑ Bilirubin
48 Hours
Increase
● Glucose
● Triglycerides
● Aspartate aminotransferase (AST)
● Bilirubin
● Blood Urea Nitrogen (BUN)
● Phosphorus
● Uric Acid
● Growth Hormone
● Cholesterol
● Lipoproteins
○ High-Density Lipoprotein (HDL)
○ Low-Density Lipoprotein (LDL)
NON-FASTING
Urea increases
High-protein diet
Ketones increase
High protein and low CHO
○ Urine 5-HIAA (5-hydroxyindoleacetic acid)
Serotonin-rich food
■ Banana
■ Tomato
■ Pineapple
■ Avocado
■ Chocolate
■ Coffee
■ Tea
Serotonin-rich food examples
● Increases sample turbidity
● 400 mg/dL or more TAG = turbid serum; lipemia
TRIGLYCERIDES > 400 mg/dL
Most common error in hemoglobin measurement
Hgb & Total Bilirubin
Tourniquet may be reapplied after 2 minutes to avoid
hemoconcentration
PROLONGED TOURNIQUET > 1 MINUTE
● Cardiac muscles:
● CK-MB = 20%
● CK-MM = 80%
○ Increased
IM INJECTIONS
most cardiac-specific enzyme (first enzyme to increase during cardiac arrest)
CK-MB = 20%
JAUNDICE:
The normal value of Hgb in plasma is
2-4 mg/dL
≥ 2 mg/dL
indicative of Jaundice
25 mg/dL
indicative of Icteric
If there is diurnal variation, there is a systematic error.
Who has cushing’s syndrome?
● Patient 1; AM - 100; PM - 50
● Patient 2; AM - 100; PM - 100
Patient 1 has loss of diurnal ACTH.
Which analyte is significantly affected by a change in posture from supine to a sitting or standing position?
A. Protein
B. Calcium
C. Aldosterone
D. Magnesium
Protein, increase 10% when standing.
Which serve as first responders to stress by acting within seconds?
A. Cortisol
B. DHEA
C. Aldosterone.
D. Catecholamine
Catecholamine, Epinephrine, and Norepinephrine; cortisol increases within minutes.
The level of cortisol in the morning __________.
A. Higher
B. Lower
C. No effect.
D. None of the choices
A. Higher
What is the best time to collect a sample?
Basal state (early morning)
How to determine if you have a high protein diet
If stool does not float, fiber is insufficient.
Nothing to eat or drink (except
water) for at least 8 hours (except
lipids).
Fasting
Place in a slurry of crushed ice
and water. Do not use ice cubes alone because RBCs may lyse
Chilling
Use a 37-degree C heat block, heel warmer, or hold in hand.
Cryoglobulins are proteins that
precipitate at low temperatures.
Warming
Wrap in aluminum foil.
Bilirubin is photosensitive.
Protection from direct light exposure
LD 4 and 5 are labile at low
temperature = falsely decreased.
Freezing of sample
Fill out the chain of custody form.
Chain of custody
Centrifuged within 1 hour or
up to 2 hours
Minimize glycolysis
Delivery time
If you’re the phlebotomist, which of the following will you prioritize?
a. FBS
b. Cortisol
c. CBC
a. FBS
Rationale: FBS and cortisol are both timed, but the most correct answer is A. FBS. If FBS was not
prioritized, the patient might become hyperglycemic or miss intake of their medicines or procedures.
Serial bilirubin determination are charted below with the bet explanation for the results due to:
a. Sample hemolysis and hemoglobin deterioration
b. Sample exposure to light
c. Sample left in unwarm location
d. Reagent deterioration
b. Sample exposure to light
Notice the time difference bet the collection time and assayed time. The Shift of values from day
one, lowered in day 2, then increased on day 3, signifies the error and the point of investigation, which should be on day 2
a photosensitive form, can cause
brain damage (kernicterus) if it crosses the blood-brain barrier. Newborn babies often struggle
to break down B1 into a soluble form in their liver.
B1 bilirubin
Exposing babies to morning sunlight helps convert B1 into a soluble form, preventing it from
entering the brain and causing harm
● Use the opposite arm or
perform fingerstick if possible.
● Stop IV for 2-5 minutes
IV
● Draw from opposite arm
Fistula
● Draw first 5 mL then
discard.
● Draw blood below the IV
line if nothing is being transfused.
Indwelling lines and catheters, heparin locks, cannulas
● Select other site
Sclerosed veins
● Draw below
Hematoma
● Hold pressure until bleeding
has stopped
Streptokinase/Tissue plasminogen Activator (TPA)
● Select another site
Edema, Scars, Burns, Tattoos
● Draw from the opposite arm
Mastectomy
● Ask nurse to ID before
drawing
Unidentified patient
Stop IV for
2-5 minutes
Exposing babies to morning sunlight helps convert B1 into a ___________, preventing it from
entering the brain and causing harm.
soluble form
The intern drew blood from the patient’s arm, resulting in a hematoma, even though the
intern was considered the best phlebotomist in the lab. What went wrong when the intern drew blood from the patient?
○ The patient’s folded his/her arm after the blood draw, combined with their antithrombotic therapy, led to a hematoma.
○ Always ask the patient if they are taking any medications such as warfarin, coumadin, etc.
