QUICK REVIEW Q & A'S TABLE OF CONTENTS INTRODUCTION. —— ee Seen GENERAL LABORATORY PRACTICE REVIEW CLINICAL CHEMISTRY REVIEW. CLINICAL MICROBIOLOGY REVIEW HEMATOLOGY REVIEW IMMUNOLOGY REVIEW «rss - = W245 IMMUNOHEMATOLOGY REVIEW... : eee 273 URINALYSIS AND BODY FLUIDS REVIEW aoeeee = e329 MANAGEMENT AND EDUCATION REVIEW 7 365 ‘TOPICAL INDEX. a : oo : 383 vilGENERAL LABORATORY PRACTICE REVIEW CREDENTIALING Compare certification and secreditation, Certification and accreditation are both Voluntary non-governmental redentialir for achievement of high standards, Insti futons are accredited. Individuals are certified The Joint Commission on Accreditation of Heath Cate Organization (JCAHO), which accredits the and the College of Am: rican Pthologists (CAP), which acres clnial laborator entire hospital, ries, How often does the College of American Pathologists inspect acredited laboratories? Every to years, CAP inpestions ae pee reviews, Namea non-governmental agency that accredits blood banks, ‘The American Association of Blood Ban ‘What isthe diterence between certification and licensure? Ty process by which a non quirements and demonstrat andar process by which some sates gran pe ‘occupation ‘governmental agency grants reeopnition ted entry-level competency by examina mission to an individual or organization t ‘© an individual who has n, Licensure ig a ‘0 engage in a given Which states require licensure of clinical laboratory personnel? California, Florida, Georgia, Hi Sal Lousiana, Montana, Nevada North Dako, Rhode Island, Te West Virginia, Other sates req mnessee, and ube licensure of clinical laboratories but not laboratory perscnnel, Name several professional organizations tha certify lineal laboratory personnel, The Amerisan Society for Clinical Pathology (ascp), the National Credentialing Agency for Labotatory Personnel (NCA), American Medical Technologists (AMT), and the American Associaton of Bioanalysis (AAB),QUICK REVIEW Q & aS A hospital ad reads “Medical Technologist, [ASCP or equivalent”, Which ofthe following credentials would be equivalent: CLS(NCA), CLT(NCA), MLT(AMT), POLT(SCLT), CPT(NPA)? CLS(NCA), NCA uses the title Clinical Laboratory Scientist instead of Medical Technologist and Clinical Laboratory Technician instead of Medical Laboratory ‘Technician. REGULATORY ISSUES 2 4 9. Which federal agency issues regulations to ensure employes safety? “The Occupational Safety and Health Administration (OSHA), what reporting is required for serious accidents that rest in fatalities oF hospitalization of three or more employees? ‘They must be reported 10 OSHA within 8 hours ‘Which federal agency regulates ‘blood banks? “The Food and Drug Administration (FDA), The FDA has authority over blood banks besause blood is considere= oth a biologic and a drug. Which agency regulates market entry of instruments and reagents? “The Food and Drug Administration (FDA). Which federal agency regulates facilities that use radioisotopes? “The Nuclear Regulatory Commission (NRC). Which federal agency regulates packaging, labeling, and transportation of biological products? ‘The Department of Transportation (DOT). Which federal agency regulates disposal of toxic chemical and biohazardous wastes? “The Environmental Protection Agency (EPA). State or local regulations may apply as well Which federal agency issues mandatory guidelines for laboratories performing forensic toxicology? “The Substance Abuse and Mental Health Services Administration (SAMHSA), formerly known as the Natios= Institute on Drug Abuse (NIDA). What isthe federal legstation that regulates almost all einieal Jaboratories in the U.S.? “The Clinical Laboratory Improvement Amendments of 1988 (CLIA 88), It establishes regulations Gualifcations, competency assessment, patent est management 8 control, quality assurance, testing.GENERAL LABORATORY PRACTICE REVIEW 10. Which laboratories are subject to regulation under CLIA "88? All laboratories that examine human specimens for diagnosis, prevention, or treatment of disease, There are exemptions for the Veterans Administration, the armed forces, and the Substance Abuse and Mental Health Services Administration, Work done for legal or employment eligibility purposes and research not used for patient care are also exempt. 11, What are the levels of testing complexity under CLIA ‘88? Waived, provider-performed microscopy, moderately complex, and highly complex. 12, Laboratories of which complexity level are required to perform quality control and participate in proficiency testing? All except waived. 13, What is the complexity level of most of the analyses performed in clinical laboratories? Approximately 75% ate classified as moderately complex. 14, What is CLSI? ‘The Clinical and Laboratory Standards Institute, an organization that issues standards of laboratory practice developed through a voluntary consensus process. It is not a regulatory agency. CLSI was formerly known as the National Committee for Clinical Laboratory Standards (NCCLS). 15, Whats the role of the Centers for Disease Control and Prevention (CDC)? Itissues standards and guidelines for hospitals and laboratories, primarily related to infection control and safe work practices. Its role is advisory; itis not a regulatory agency and does not have enforcement authority LAB SAFETY 1 Which bloodborne pathogens are of greatest concern to laboratorians? 4 Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV). Hepatitis C (HCV) does not appear to be transmitted efficiently through occupational exposure to blood. ‘Which bloodborne pathogen ean be transmitted by contact with environmental surfaces? HBV. It has been demonstrated to survive in dried blood on environmental surfaces for at least 1 week. Which clinical specimens are potentially infectious? Whole blood, plasma, serum, pus and purulent fluids, semen, vaginal secretions,cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic uid, and breast milk, ‘What are OPIM? (Other potentially infectious materials (besides blood), such as pus and purulent fluids, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid peritoneal fluid, pericardial fluid, amniotic fluid, and breast milk5. 1 10. 12. 13. QUICK REVIEW Q & A'S Which specimens are usually not infectious, unless visibly bloody? Urine, feces, sputum, nasal secretions, sweat, tears, and vomitus. What are the routes of entry for occupationally-acquired bloodborne pathogens? Percutaneous exposure or contamination of non-intact skin or mucous membranes (eyes, nose, mouth). ‘What is the most common route of exposure to bloodborne pathogens for healthcare workers? Percutaneous, by contaminated needles. What is the risk of HIV transmission after # percutaneous exposure to HIV-infected blood? Approximately 0.3%, The risk increases with exposure to larger quantities of blood. The risk after a mu membrane exposure is estimated to be approximately 0.09%, An MLT student sticks himself with a dirty needle while performing phlebotomy on a combative pz ‘What should he do? Follow the laboratory's exposure control plan. A typical course of action would be to purge the puncturs =<" slight pressure, then immediately and thoroughly wash the wound with soap and water, apply 70% alcc=: * supervisor, and complete an incident report What follow-up should be provi Jed for an employee following an occupational exposure? HIV, HBV, and HCV testing of the source patient (after consent is obtained), appropriate clinical and evaluation of the employee, and post-exposure prophylaxis (PEP), if indicated, According to the CDC, which profession has the largest number of documented cases of occupatic acquired HIV? ‘Nurses. Clinical laboratory technicians are second. Fifty-seven health care workers have been docume! contracted HIV from occupational exposure and another 139 cases are considered possible cases of oct exposure, No new documented cases of occupationally-acquired HIV/AIDS have been reported since D=::~°= 2001 Explain the concept of Universal Precautions. All specimens should be handled as if they are infectious. The rationale is that a patient can be infected "~~ symptoms or laboratory evidence of infection. Altemative concepts in infection control are called Body $ Isolation (BSI) and Standard Precautions. These latter terms define all body fluids and substances as in: health care workers must routinely use appropriate barrier precautions to prevent skin and mucous me ‘exposure when contact with blood or other body fluids is anticipated When should gloves be worn? When performing phlebotomy and when handling blood or other potentially infectious materials, bioh: waste, or contaminated equipment. Gloves should never be washed and re-used,M4 15, 16. 1. 18. 19. 20, a. n, 28 u GENERAL LABORATORY PRACTICE REVIEW ‘A.new employee develops an itchy rash from wearing latex gloves. What should she do? Notify her supervisor. She probably has a latex allergy and should be provided with non-latex gloves. ‘When should face shields be worn? Whenever spraying, splashing, or spatter of blood or body Mus is possible. Face shields protect the mucous membranes ofthe eyes, nose, and mouth ‘What s the proper way to dispose of sharps? {In a sharps container, Needles should not be recapped or broken. Syringes should be discarded with needles atached. ‘What are the design requirements for sharps containers? ‘They must be puncture resistant, closable, leakproof, and either color coded or labeled with a biohazard label When should hands be washed? ‘After contact with blood or body fluids, between patients after removing gloves, and before leaving the la. Handwashing isthe single most effective method to prevent the spread of infection. [Name the disinfectant that should be used to clean up spills of blood or body fluids. A freshly prepared 10% solution of sodium hypochlorite (household bleach). ‘What is biomedical waste? ‘Any solid or liquid waste that may present a threat of infection, It should be disposed of in a biohazard container. How often does OSHA require employee safety training? Upon hiring and annually thereafter Under OSHA regulations, who must provide and launder employee lab coats? ‘The employer, at no expense tothe employee, Employees should not take ab coats home for laundering because of the risk of taking infectious agents into the home Under OSHA regulations, which immunization must the employer offer to the employee free of charge? Hepatitis B. Ifthe employee refuses, a signed declination must be placed in his her personnel file. The employee ‘maintains the right to request the vaccine inthe future, There currently is no vaceine for HIV or hepatitis C. ‘What isthe Needlestick Safety and Prevention Act? ‘A measure that mandates that employers who are subject othe provisions of the Bloodborne Pathogens Standard put safer needles into the hands oftheir employees. The act was passed in 1999 and became effective on April 18, 2001 Safer needles include retractable eles ani meddle With Bin safety shields.28. 26. 21. 28. 29. 30. 31 32, 33, 34, 38, QUICK REVIEW Q & A'S How can laboratories reduce the risk of injury due to bre age of glass? By using plastic evacuated tubes and discontinuing the use of glass capillary tubes. What is the Hazard Communication Standard? ‘An OSHA standard that requires employers to inform employees about hazardous substances in the workp: educate and train them in safe and proper handling, The standard is commonly known as the “Right to Kno — What is a chemical hygiene plan? A plan to minimize personnel exposures to hazardous chemicals. I is required under OSHA's Occupationa’ Exposures to Hazardous Chemicals in Laboratories, also known as the “Laboratory Standard”, ‘A new employee spills a chemical in the chemistry lab. He is uncertain if the chemical is hazardous or #:* 0 handle the spill. The supervisor is attending a meeting in another building. What should the employee ¢: Consult the material safety data sheet (MSDS) for the chemical, This will give information about the chemi: hazardous properties, first-aid procedures, and information on spill and disposal procedures, MSDS are ob from the manufacturer and must be readily available to employees at all times. What types of chemicals may pose physical hazards to the laboratory environment? Flammables, combustibles, oxidizers, reactives, and explosives. What is a flammable? A chemical with a flashpoint below 100° F., The flashpoint isthe lowest temperature that produces suflicie=: =» 8 form an ignitable mixture atthe surface of a liquid. A heat source, such as an electrical spark or open flame present to ignite the vapor. Examples of flammables are acetone, xylene, ethanol, methanol, and isopropan: What is a combustible? ‘Acchemical with a flashpoint between 100° F and 200° F. What is an.oxidizer? A cheinical that promotes combustion in other materials, for example, nitric acid and sulfuric acid. Oxidize=: - use not be stored near organic acids What is a reactive? ‘A chemical that is unstable when subjected to heat, shock, or pressure, Sulfuric acid is an example of a ree: ‘Name several explosives that may be found in a clinical lab. Pieric acid, sodium azide, and compressed gases, Picric acid becomes shock-sensitive when dehydrated Powerful explosive than TNT. Name several categories of chemicals that pose health hazards. Initants, corrosives, sensitizers, toxic agents, and carcinogens.—_— GENERAL LABORATORY PRACTICE REVIEW 36. Whatis an irritant? ‘chemical that causes reversible inflammation of tissue, for example, formaldehyde 37, What isa corrosive? { 4 ‘A chemical with a pH <2 or > 12. These chemicals cause ireversible damage to tissue upon contact and may also produce injury upon inkalation, Examples are sufi ci, hydrochloric acid, and sodium hydroxide 1 38. Atwhat level should corrasives be stored? Below eye level. There is less chance thatthe botles willbe dropped and broken, For the same reason, sock battles cof concentrated aids shouldbe transporte in bote carers. 38, What sa sensitizer? ‘Acerca o which a person may develop an allergy aftr repeated exposure, such as bleach or formaldehyde, 40. Whatisa toric agent? ‘Achemicl that an cause serious effets ifevena small amounts inhaled, ingested, or contacted, 41, Whatisa carcinogen? ‘Acheital tat ean cause cancer, for example, bene, potassium crore and formaldehyde 42, Whatis a mutagen? A chemical that induces chromosomal changes 43 What isa teratogen? A cheanical hat induces congenital malfommatins | 44. AnMLT is asked to organize the laboratory's chemical storage room. She begins to arrange chemicals in alphabetical order so that they wll be easy to locate and inventory, Why is this nota satisfactory sytem? | Stcould result in an unsafe situation in which chemicals that reac are stored next o each other. Chemials should be ‘organized according to reatvity, Inorganic acids should be separated ftom onganic acids and oxidizers should be separated fom reducing agents, 43, What are threshold limit values (TLVs) and where can they be found? ‘The maximum amount of axe sbstanceto which a person can be exposed without adverse effec. This information i ‘can be found in the MSDS. 46, Name chemical used in histology that requires environmental monitoring, i Formaldehyde. OSHA's Fomaldehyde Slandard requires monitoring of formaldehyde exposure, engineering Il contol, personnel protective equipment, taining, and an emergency ation plan47, 48, 49. 50. 51. 32. 53, 54; 56. QUICK REVIEW Q & A'S ‘Name several ignitable chemicals commonly used in # clinical laboratory. Xylene, ether, acetone, and alcohols, {A jar of a chemical is labeled with the following National Fire Protection Association’s (NFPA) label: red diamond 3, blue diamond 1, yellow diamond 0, Explain how to interpret this label ‘The NFPA Hazard Idemtfication System uses four diamonds to communicate information about the hazards associated with a chemical. The red diamond represenis its fie hazard, the blue diamond its health hazard, the yell> diamond its reactivity, and the white diamond communicates special hazard information, for example, ifthe chem:: isa corrosive or oxidizer. Numbers from 0-4 in each diamond indicate the degree of hazard, (0 = minimal, 1 2= moderate, 3 = serious, 4 = severe.) In the example given, the chemical isa serious fire hazard (flashpoint below 100° F) and a slight health hazard, Work should be performed in fume hood and personal protective equipment should be worn, How should concentrated acids be diluted? ‘The acid should be slowly added to the water. “Always Add Acid” ‘What labeling is required for a 24-hour urine container that contains an acid preservative? The name of the chemical and any precautions the patient should take. For example, ifthe container contains 10% HCL, the label should state thatthe urine should be collected in another container and poured into the 24-hour collection container slowly to avoid splashing of the acid preservative. When should a fume hood be used? When working with flammable, toxic, or corrosive chemicals. Flammables should not be stored in a fume hood an.= should not be cluttered with items that could block the vents How often must fume hoods and biological safety hoods be inspected? ‘Annually. ‘When working with a flammable, what should be kept at a safe distance? Sources of heat and electrical equipment that could ignite the flammable. Where should flammables be stored? Ina flammable safety cabinet or can. How should ether be stored? Inan explosion proof reigerator. These refrigerators have all wiring and switches on the outside to eliminate the risk ofa spark igniting flammables, Most laboratories have changed to procedures that do not use ether, in order eliminate the risk and expense. ‘What is the only type of chemical waste that should be flushed down the drain? ‘Water soluble chemicals. They should be followed by copious amounts of water. Strong acids and bases should be neutralized before disposal3. 60. a. 8 sng commpaile classes, and poked wp by am EPAclvenstd Same bacteria aent that forms expose ss many etal and poses a risk of explosion iit builds up in drain pipes. Sou acide. is someines used es baste agen cherixal reagents. metic ils buildup in dein pies, even tise of wrench may rest ina vie exposion. The we of zs shoul be avoided or minimized a oft exlosve potential end beast eye EBSD fon shoul be taken when a corrosive chemical comes in contact with skin or eyes? ‘The site shouldbe fished with copious mounts frunning water frat east 15 minutes. Ifeomacts extensive, @ safety shower shouldbe used. How often should eyewashes be checked? “Te American Natl Sana Insite (ANSD ous at eyevases be checked weekly They mus ler 1S int steam of eid wae and must alow the ands tobe fie to hold the eyelids open for thorough flushing of theeye. How should gas cylinders be stored and transported? “hy shold aay be hai rie sere a censored sing aba ca. Valve protein caps shoud refuting anspor ascyindrs ae presuize I ey mocked over, the ylinder valve can be broken and the force ofthe escaping gas can propel the eylnder throug the sir like a missile Which type of ire extinguisher shoud be used fo eatngish resin comptes or operating etic ‘equipment? CO; (BC) and dry chemical (ABC) fire ‘extinguishers can both be used but CO: extinguishers have the edvantage of rot leaving behind a residue that might cause damage tothe equipment Which ype offre extinguer shouldbe se for fires involving Nammable liquids? Dry chemical (ABC) or carbon divide (BC) Which typeof fire shuld not be eninge with pressurized water? lectin fir’ or baring liquids What procedures shouldbe flowed when a fires discovered? © RACE: + Rescve patients and personnel Activate lam. ‘+ Conlin freby closing dors and windows. + Bningish ire ifposible, or evacuate.QUICK REVIEW Q& A'S 66. Describe the correct way to use a fie extingulsher, PASS + Pullthe pin, # Aimar the base of ire + Squeeze the handle + Sweep beck and forth | ‘SPECIMEN COLLECTION AND PROCESSING 1, What isthe difference between plasma and serum? Plasma contin fibrinogen and serum does no. Fibrinogen is converted t fibrin during coagulation. When plasm = required, blood is collected with an anticoagulant. 2, Name the anticoagulant in tubes with the following colored stoppers and explain the use of each~ green, grey lavender, light blue, STOPPER ANTICOAGULANT USE. | Green Sodium or lithium heparin Plasma determinations in Chemistry Gray Potassium oxalatefsodium | Glucose fluoride { Lavender K:EDTA | Hematology. Cen also be used for ABO, Rh, and antibody serening. Light blue Sodium ciate Coagulation i 3, What are pink top evacuated tubes? K,EDTA nes with a special crossmatch label for information required bythe American Association of Blood Banks (ABB). They can be used fr blood bank testing (ABO, Rh, and antibody screens) and for whole blood hematology detenminations, Although theadtive is the same a ina lavender top tube, hematology laboataris = not accept pink top tubes if the sizes not accepted by the automated analyzer. 4, When are royal blu top tubes used? For trace-element, toxicology, and nutritional chemistry determination, The tubes contain only low levels of trac: elements, ‘When are tan top tubes used? For lead determinations. The tube is certified to contain less than 0.01 pein. of lead 6 What s the purpose of the ge in serum separation tubes? ‘cforms a physical barier between the serum or plasma end the red blood cells during cetifugation. a10. , 13. GENERAL LABORATORY PRACTICE REVIEW ‘What additive can be used for stat serum determinations? ‘Thrombin, Clotting usually curs in less than S minutes. Thrombin tubes ae identified by orange or gray/yellow stoppers ‘Which type of serum tube is recommended for blood banking? Glass tubes without additives or gel (red top), Plastic tubes are not recommended for blood banking because they contain a clot activator, In what order should evacuated tubes be drawn? ‘The National Coramite for Clinical Laboratory Standards (NCCLS) issued new guidelines in 2004 that apy regardless of the type of tube being filed (glass or plastic) and regardless of whether the specimen is dravm using evacuated tubes or syringe. The new, simplified order of daw is: Sterile tubes 1. Sterile rubs for blood cultures fi 2. Sodium citrate tube (light blue top) light bic top 3 Serum tube (with or without lot activator or gel—re ed/lack, or god top) 4, Heparin tube (green top) 5. EDTA tube (lavender top) 6. OxalateMuoride tube (gray top) This oder prevents eroneous resus due to additive cary-over. Tubes with clot ectvatos are citi additive lubes and shoul be collected afer coagulation tubes since elt-actvator carry-over ean affet coagulation results, [NAACLS noted that glass nonaditve serum tubes canbe drawn before te citrate tube but, for simplicity, it grouped all serum tes together. How many times should evacuated blood collection tubes be inverted atthe time of collection? Most additive tubes should be inverted 8 times. The exceptions ar sodium citrate tubes (light blue top) which should be inverted 3-4 times and plastic serum tubes (with clot activators) which shouldbe inverted 5 times, Glas serum tubes do not require mixing since they contain no adtive, How do anticoagulants prevent coagulation? EDTA, citrate, and oxalate bind Ce™ Sit snot available for the coagulation cascade. Heparin inactivates thrombin, How does EDTA prevent coagulation? Itchelates Ca”. Chelation isthe combining of metalic ions with certain heterocyclic ring structures so that the ion is held by chemical bonds from each paicipating rng, When this structure is diagramed it appears thatthe metalic ion is being held by a claw. ‘Why is EDTA the preferred anticoagulant for differentials? Itprevents platelet clumping and causes minimal morphological changes in cells14, 15. 16, 17. 19, 20. 21. QUICK REVIEW Q& A'S ‘Why is sodium fluoride used when collecting blood for glucose determi ns? Sodium fluoride prevents glycolysis. Either sodium fluoride or lithium iodoacetate should be used when glucose analysis will not be performed for more than an hour after collection, Sodium fluoride preserves glucose for 24 hours al room temperature and 48 hours at 4°C. Why should sodium fluoride not be used when collecting blood for enzymes or for assays that use enzymes as reagents (ex: BUN by urease or uric acid by uricase)? Sodium Nuc is an “enzyme poison” that inhibits enzymatic reactions. A prothrombin time is ordered on a patient with polycythemia vera, What should be done prior to drawing hls blood? When the hematocrit is greater than 55%, the volume of sodium citrate should be reduced, otherwise over- anticoagulation will artfactually lengthen the PT. What is the proper ratio of sodium citrate to blood for accurate coagulation results? 1:9. Over-anticoagulation due to a short draw will artifactually lengthen the coagulation times. Why should blood not be drawn from above an IV site? The IV fluid may contaminate the specimen, increasing the concentration ofthe analytes contained in the IV fluid and decreasing the concentration of other analytes by dilution. Whenever possible, either the other arm should be used or, ifa large quantity of blood is not needed, a fingerstick could be performed, If neither of these options is possible, the blood should be drawn distal to the IV, with a tourniquet between the IV and the venipuncture site. If it is impossible to use a site distal to the IV, the IV should be shut off for at least 2 minutes and the first S mL. of blood discarded. The contents of the IV solution should be documented. What procedure should be followed when blood is collected from an indwelling line or heparin lock? The first 5 mL of blood should be discarded to avoid heparin contamination, Laboratory personnel usually do not draw from lines. ‘What is the most important step in collecting a blood specimen? Proper patient identification. Inpatients should only be identified by the identification bracelet, with special attention to two identifiers, usually name and identification number. Room number should never be used as an identifier. Ifa patient is not wearing an identification bracelet, the responsible nurse should be notified. Outpatients should be asked to state their name and provide some other identifying information such as social security number or address. The phlebotomist should not ask, “Are you Mrs, Jones?” Ifthe patient has difficulty hearing, she might respond affirmatively to someone else's name, leading to an improperly identified specimen. ‘When should blood collection tubes be labeled? Labels should always be applied at the bedside, never in advance, A 3-way check should always be performed, comparing patient identification information on the requisition, the patient's armband, and the tubes of blood 12n B. uM 25, 26. 2. 28. 29, 30, a GENERAL LABORATORY PRACTICE REVIEW ‘What are the advantages of the new systems that allow the phlebotomist to scan the patient's armband and generate labels at the bedside? Positive patient and specimen identification. Since multiple collection labels are not taken into the patient's room, there is no chance of accidentally applying a label with another patient's name. Why is important to follow the laboratory’s policy for placement of labels on blood collection tubes? Automated analyzers cannot read labels that are not properly placed ‘What type of gloves should phlebotomists wear? Because ofthe risk of hypersensitivity to latex proteins, phlebotomists should use only non-latex gloves for patient contact. ‘Which of the following needles has the largest bore: 18, 20,21) or 23 gauge? ‘The lower the number, the larger the bore, The most common needle size used for adult venipuncture is 21 gauge. ‘Why has OSHA prohibited the reuse of evacuated tube holders (adapters)? Because removal of the double-ended needle poses a risk to the employee, Also, studies showed that a high percentage of tube holders were contaminated with blood even after one use. Which phlebotomy products are associated with the highest rate of accidental needlesticks? Winged infusion sets (butterflies) and syringes. Recent design modifications have improved the safety of these devices. ‘When are winged blood collection sets (butterflies) used? For patients with small or fragile veins or those who are unable to move tothe arm-down position, Butterflies are expensive and have been associated with a higher rate of accidental needlesticks than the evacuated tube system. ‘They should be used judiously Why should the wings of the butterfly be held during insertion? For greater control and to ensure thatthe safety shield doesn’t slide over the needle when the needle makes contact with the skin, After insertion, the wings should never be touched again ‘Why shoulda’t the butterfly be withdrawn ig the wings? The safety shield cannot be pushed over the needle when the wings are being held. When using a blood collection set to collect omly a sodium citrate tube for PT and/or APTT, what additional step is required? A plain glass discard tube should be drawn first to purge the air from the tubing and allow a full draw into the citrate tube. 332. 33. 34. 35. 36. a. 38. 39 40. QUICK REVIEW Q & A'S Why i t best to purchase all venipuncture equipment from the same manufacturer? To ensure proper fit between components so that needles do not unscrew and tubes do not pop off. How do plastic serum tubes differ from glass serum tubes? Since plastic does not activate clotting like glass does, plastic tubes for serum testing (red top) must contain a cl- activator. If even a minute amount of the blood/ctot activator mixture carries over to the blue top tube, the physic = could adjust a patient's anticoagulant therapy based on erroneous results; therefore the plastic red top tube shou notification of critical values, result reporting, test interpretation by physician, follow-up patient care 24i, 3 2 14. GENERAL LABORATORY PRACTICE REVIEW In which phase of testing do most errors occur? In the preanalytical phase Define analytical sensitivity. The ability to detect small amounts of the analyte Define analytical specificity, ‘The ability to detect only the substance being measured, Freedom from false positives. Define accuracy. Closeness ofthe result to the trie value. Define precision. Reproducibility According to CAP, how often must quality control statistics be calculated? At least monthly. ‘What is the name of a sample which is chemically and physically simllar to the unknown and which is tested in the same manner as the unknown'@s monitor the precision of the test system? A conto How often should\controls be run for quantitative tests? A lest 2 levels of conta shouldbe run at ast once each dy of patient testing How often should controls be run for qualitative tests? A positive and negative contro shouldbe included with each run of patient specimens. What i the definition of an analytical run? The interval within which the accuracy and precision of the measuring system is expected to be stable, based upon manufacturer's recommendations and not to exceed 24 hours, Who should run controls? Personnel who routinely perform patient testing When should results of controls be verified for acceptability? Before patient results are reported. 2515. 16. A 18, 19. 20. ne. 2. 2. 24, 25, QUICK REVIEW Q & A’S How does one determine the mean of a series of test results? ‘The sum of the results divided by the number of tests performed, What is the minimum number of analyses needed to caleulate standard deviation? Twenty. In a normal Gaussi distribution, what percentage of the population falls between + 2 SD? 95.45%, ‘What is the coefficient of variation for a procedure whose mean is 100 mg/dL and whose standard deviatioz = 3 mg/dL? 3%, (CV = SD / mean x 100) ° What are the upper and lower limits of acceptable results for a control if the mean is 100 mg/dL and stands deviation is 3 mg/dL (95% confidence limits)? 94-106 mg/dL. (The mean +2 SD.) What is an outlier? A control value that falls outside of ¢ 2 SD. An outlier is due to random error. Random error is usually a one-tir: event that does not affect all results, for example, inaccurate pipetting of one sample. An outlier does not alway’ ‘mean that the procedure is out of control. How often is a control value expected to fall outside of 2 SD, due to normal variation? One time in twenty runs, ‘What is random error? —e ‘A foon-recirring er¥or due to factors such as diny glassware use ofthe wrong pipette, voltage fluctuation, or sampling érror. What is systematic error? Recurring error that affects all results. A dirty photometer, a faulty ISE, or evaporation or contamination of or reagents Would cause systematic error. Which type of error is inherent to some extent in all analyses? Random. ‘What is a trend? Control values increasing or decreasing for six consecutive runs. A trend is duc toa slowly developing syst error, for example, a feiling photocell or a deteriorating reagent or standard 2626. 1 28. 29. 30. 31 2. 3, GENERAL LABORATORY PRACTICE REVIEW What isa shift? Six consecutive control values on the same side ofthe mean. This isthe result ofa systematic eror. Improper calibration of an instrument or a change in lot numbers of reagents could lead toa shift in control values. Is it possible for a procedure to be out of control if all control values fall within the acceptable range? Yes, fa shift or trend is present. What isa false rejection? ‘A false rejection is when the analyst concludes that he procedure is out of control, when in fact the results were secure Explain the Westgard multirules. ‘Westgard multrules are applied across controls as well as across runs. RULE EXPLANATION 13s __ | One control exceeds the mean by more than 2 SD, but less than 3 SD. sg __| One control exceeds the mean by more than 3 SD. + ‘Two consecutive controls exceed the mean by more than 2 SD, but less than 3 SD, in the same direction. Res 4s, 10, __| Ten consecutive controls fall on one side ofthe’ mean, Which Westgard rule is a warning flag and not always a signal for rejection? J. The remaining rules must be tested to determine if here isa problem, ‘Which Westgard rule violations point to random error? Ig and Ras ‘Which Westgard rule violations point to systematic error? 2k 5, and 10, What is the advantage of using Westgard multirules? Westgard multirues ae used to reduce the number of false rejections and to facilitate the evaluation of two or three levels of control atthe same time. Computers aid inthe interpretation of these rules. 24, 35. 36. 37. 38. 39. QUICK REVIEW Q& A'S What steps are taken when a control value falls outside of the acceptable range? The laboratory's protocol should be followed. Following are typical steps. After each step is taken, the routine C pools are analyzed. If the results are within limits, the problem has been resolved. Ifthe results are still not acceptable, the next step is taken, 1, Do not release patient test results 2. Repeat the control. 3. Runa newly reconstituted control. Controls can be mishandled, resulting in changed analyte concentration: because of deterioration or evaporation, 4. Look for obvious problems--clots, reagent levels, mechanical problems. 5. Recalibrate the instrument forthe out-of-control analyte, then reassay all controls 6, Install a new bottle or new lot number for one or all of the reagents, recalibrate, and reassay all ofthe cont 7. Perform periodic maintenance, recalibrate, and reassay all ofthe controls 8. Ifcontrols are still ou, notify supervisor. 9. Document problem, investigation, and resolution in Out-of-Control Log Book. 10. Once the problem is resolved, rerun the patient specimens. 11, Patient test results obtained since the last acceptable test run should be re-evaluated to determing significant clinical difference in results, if there is = What is a primary standard? A standard prepared by weighing a highly purified chemical and dissolving itin a diluent tothe desired concentration. ‘What is a secondary standard? ‘A standard whose concentration is determined by a réference method using a primary standard for ‘What is the minimum number of standards required for construction of a standard curve? Three, Define calibration, Calibration refers to the operations that establish the relationship between instrument sesponse and the concer of afanalyte. Calibration is required when there isa change of reagents, when controls ae out of range, after instrurgent maintenance or service, when calibration verification fails, and when recommended by the manufe:~— Define calibration verification. Calibration verification is the process of confirming thatthe system will accurately measure the enalyte aver analytical measurement range. Materials with a matrix closely resembling the patient test samples and with k values are analyzed in the same manner as patient specimens. At least 3 levels must be tested~minimum, mic and maximum values for the analytical measurement range. 284 2. 4 44, 45, 46. a. GENERAL LABORATORY PRACTICE REVIEW ‘When should calibration verification be performed? © When QC fails to meet established eriteria + When ot numbers of reagents change + After major maintenance or service «When recommended by the manufecturer «Atleast every 6 months ‘What is matrix effect? ‘The matrix is all ofthe components ofa sample other than the analyte. The preparation of calibrators, quality control materials, and proficiency-testing samples may involve processes such as freezing or lyophilization or the additicn of substances such as preservatives that cause them to react differently than fresh patient specimens. Ths is known as matrix effect ‘What is linear range? Itis the range of analyte values that a method can directly measure on the specimen without any dilution, concentration, or other pretrealment not part ofthe usual assay process. It is also known as analytical range, analytical measurement range (AMR), or reportable range. The range must be revalidated at least every 6 months and following changes in ot numbers of reagents or major system components ‘What must be done when the patient value exceeds the linearity of the analyzer? The specimen must be diluted and run again. The answer obtained must be multiplied by the reciprocal ofthe dilution used. For example, 2 1:2 dilution would be tltiplied by 2. Meny analyzers are capable of doing this automatically What is autoverification? AA process by which the computer performs the initial verification of test results. Any data that fall outside of set parameters should be reviewed by the human operator. The autoverification process should be tested atleast annually and whenever there isa change tothe system. ‘What isa delta check? ‘A comparison of patient’ test results wit hisher previous results. When the change exceeds a predetermined limit, the cause must be investigated to rule out laboratory error. How are reference ranges established? ‘One hundred to 150 data points are gathered from a representative healthy client population and arranged in sequential order. The reference range is the values between the 2.5% position atthe low end and the 97.5% position at the high end. Since this represents the 95% confidence limit, one normal person in 20 will fall outside the reference range. Each laboratory should establish its own reference ranges or verify the use of published data, Reference ranges used to be called normal values. When should reference ranges be reevaluated? ‘When there i a change in methodology or patient population. 2948. 49, $0, 51. 32. 33, 54. 56. a QUICK REVIEW U6 AD ‘What must be done when a critical value is obtained on a specimen? ‘The physician or other responsible healthcare professional must be notified immediately. Ifthe results are delivered verbally or by phone, the receiver should read back the values to ensure accuracy. Critical value notification may be by computer or fax but delivery must be confirmed by telephone call. No read back is required. Critical value notification must be documented, This documentation should include the date, time, responsible laboratory individual, person notified and test results. The laboratory should document any failure of attempts to notify the appropriate person of critical results. What is turnaround time? The interval berween specimen receipt by laboratory personnel and results reporting, The laboratory must have defined tumsround times for each ofits tests and a policy for notifying the requester when testing i delayed, In general, 48 hours for routine tests and 1 hour for sats s usually considered acceptable, although there may be some exceptions. ‘When more than one instrument is used for a particular test, the lnboratory must verify that patient results produced are comparable. How often must this be done? i ‘Atleast twice a year. Fresh samples should be used rater than commercial controls, which maybe subject toa mat effect. What isa correlation study? A study to verify the accuracy of a new method, A minimum of 40 spit patient samples are analyzed by the existce ‘method and the new method. Values obtained by the existing method are plotted on the x-axis and those obtained t the new method on the y-axis. Perfect correlation is indicated by a straight line passing through the zero point at 8 45° angle. What is the correlation coefficient (r)? ‘A mathematically derived value that shows the degree of correlation between 2 methods, Values range from = 1 ‘+1, with +1 indicating a perfect direct relationship between the methods. A value of 0.95 or higher is considered excellent correlation How long should serum and body fluids be retained? At least 24 hours, except for blood bank specimens which should be retained for 7 days post-transfusion or 10 é: post-crossmatch How should erroneous laboratory reports be corrected? A corrected report should be generated and communicated to the physician as soon as possible. The original in result should be flagged as an error and remain in the medical record, Errors should not be deleted from the m== record What are proficiency tests? ‘Samples sent from an outside agency (ex: College of American Pathologists) that are tested as unknowns by & Taboratory. Results obtained are compared to those of other participating laboratories and reference labs 3056. 3. GENERAL LABORATORY PRACTICE REVIEW How should proficiency test samples be handled? Exactly like patient samples. They should not receive preferential treatment For exemple, a pathologist consult should nt be requested if one would not be requested for similar results ona patient specimen nor should the test be done by a special analyst unless that person routinely tess patient samples, Laboratories should not compere results with othe laboratories prior to submitting their sults to the proficiency testing agency. ‘When is replicate testing of proficiency samples allowed? (Only when patient specimens are routinely analyzed inthe same manner. ‘What should laboratory personnel do if they have concerns about a quality or safety issue? They should fist communicate their eoncems to ther supervisor or other laboratory manager. Ifthe concems are not addressed by laboratory management, they should communicate wit hospital administration. If the concems are still not addressed, they should communicate with the eppopriate accrediting egency or regulatory agency.QUICK REVIEW Q & A's 32Ss CLINICAL CHEMISTRY REVIEW % CARBOHYDRATES 1 Define glycolysis, elycogeness,elyeogenolyss and gluconeogenesis. «+ Glycoysis= Conversion af glucose to pyruvic acid rl ecid 1+ Glycogenesis = Production of glycogen from glucose + Glyeogenalysis = Production of glucose fem glyeogen 4 Gluconeogenesis = Production of glucose fom noncarbohy drat sources 2, Whatisthe end product of anaeroble glycolysis? Lactic acid 4, Which ug accounts fr ney al lod sugar andi the Body's major sure of cellular energy? : Glucose 1 4. Name$ hormone that regulate glucose level and tel wheter each ralses or lowers thelevel ee 2 Epinepin Insulin lowers glucose. Glucagon, cose, epinephrine and growth hormone all increse it, with gheagmn being for the greatest effet. 5, Whatisthe reference range fora fasting glucose in an adult? 70=110malal. 6 Compare the normal blood glucose level for newborns and adults -themean blood gcse eel for neonates is 38 mpl. Guests lower inthe newborn because ofthe small -giyeopen reserve inthe iver 1. Ho do ghsoe evel fern venous an capa specie? Following ingestion of ses gucos ves reali highrin copay bod In fasting specie, values are the same. 310. n 13. rr QUICK REVIEW Q & A'S What are critical values for glucose? Each laboratory establishes its own critical levels, but < 40 mg/dL and > 600.mg/dL are often used. When ac value is obtained and verified, the physician or other appropriate healthcare professional must be notified immediately so tat therapy can be initiate. What is glucosuri Glucose in the urine. Glycosuria is @ more general term, referring to the presence of any sugar in the urine Define renal threshold, The blood concentration of a substance that can be reabsorbed by the renal tubules. For glucose, the average r=~ threshold is 160-180 mg/dL. When the blood level exceeds this amount, glucose is excreted inthe urine. What is hyperglycemia? High blood suger. tis most often due to diabetes mellitus Compare Type 1 and Type 2 diabetes mellitus. TYPE | CAUSE, | CHARACTERISTICS Type! Pancreatic beta cell destruction Onset usually below age 40 Formerly known as juvenile | Absence of insulin Dependency on injected insuli= ‘onset diabetes.or insulin Autoimmune. Antibodies to insulin & | Prone to ketoacidosis and diabs: | dependent diabetes melfius | ise cells | complications (IDDM) Genetic predisposition (HLA DR.3 4) | Type 2 ‘Underproduction of insulin or insutin | Most common type Formerly known as adultonsei | resistance Onset usually after age 40 diabetes or non-insulin Associated with obesity Not dependent on exogenous i dependent diabetes mellitus Not prone to ketoacidosis (N'DDM) Which testis recommended by the American ion for screening for diabetes, except du pregnancy? ‘A fasting plasma glucose. What are the criteria of the American Diabetes Association for the diagnosis of diabetes mellitus? Any of the following on 2 occasions: a random plasma glucose 2 200 mg/dl, fasting plasma glucose 2 126 ‘or one oral glucose tolerance test (OGTT) value 2 200 mg/dL. The values were recently lowered so that diagne could be made earlier, It is thought that earlier treatment will reduce the risk of diabetic complications ‘What patient preparation is required for an oral glucose tolerance test (OGTT)? ‘An overnight fast. A fasting specimen is drawn and the patient is given a glucose oad (75 grams for an adult, 1~ grams per kg of body weight fora child), The 3-hour OGTT is falling out of favor because of its poor reproduc and the inconvenience to the patient, New guidelines from the American Diabetes Association recommend a and 2-hour specimen only, except during pregnancy. 34QUICK REVIEW Q& A'S. serum-separata tubes, following centrifugation, the gel forms @barier between the cells andthe serum, preventing alycolyss. 28 Whats glycated hemoglobin?) Hemoglobin A with glucose attached tothe beta chains (hemoglobin A). tis comprised of hemoglobin Ay Any and Are, Hemoglobin A isthe largest fraction, Some procedures measure tolal glycated hemoglobin; others measure | only hemoglobin Ay. Other names used are glycohemoglobin, glycosyated hemoglobin, an fest hemoglobin but the term “glycated hemoglobin” is prefered. Because of the confusing nomenclature, the term “Alc test” has been suggested Tits Textbook of Clinical Chemistry and Molecular Diograstics, 2096) Glycated hemoglobin is a useful indicator of fong-trm glucose contol 24, What specimen is required for glycated hemoglobin (hemoglobin A,.)? Whole blood, Fasting is not required. 25, What are the most common methods for glycated hemoglobin (hemoglobin Ay) in the U.S.? 12003 virtually all eboratris that participated in @ CAP survey used immunoassay or ion-exchange chromatography. Tiet Textbook of Clinical Chemistry and Molecular Diegnostics, 2006) 26, Whats the lineal signfeance ofan elevated glyated hemoglobin (hemoglobin A.) D> Iinctes por gucose conil ovr the past 68 weeks. Valuef2 12 ae pia of poor diabetic cont ‘Acordng tothe Ameccan Diabetes Assocaion’s (ADA) Clnkal Practice Recommendations of 2006, the hemoglobin A, ol for patent in general is than 7%, The ADA recommends Ale testing a east every 6 ‘months in patents who have stable lye corto. More fequent testing may be indicated in certain cnicl situations 27. Whyis the Ate test invalid in a patient with hemoglobin S or C? I Because of the shortened lifespan ofthe RBCS. | 28, A patient has a FBS of 10 mg/dL and a glycated hemoglobin (hemoglobin Ay) of 12%, What do these results indicate? Good short-term control, but poor long-term control. Fructosamine is glycated protein that can be used to determine glycemic contol over the past 2-3 weeks. The assay can be automated and is more precise and less expensive than glycated hemoglobin but there is curently no consensus on ils clinical value 30, What is microalbuminuria? Excretion of urinary albumin at a rate of 20-200 minute or 30-300 mg/24 hr. These low levels are below the sensitivity of routine urine screening methods, Mieroalbuinuriai highly predictive of diabetic nephropathy in type 1 : disbets. Early detection and tight plyeemie contol retard progression to nephropathy, Detection is by an | jmmunochemical measurement of te albumin excretion rate on 8 24-hour urine specimen using antibodies to human albumin 3618, 19. 20, 2, CLINICAL CHEMISTRY REVIEW ‘What is the screening test for'gestational diabetes? ‘The woman is given a $0-gram load of glucose at 24-28 weeks of gestation. The time of the last meal is not important. A 1-hour plasma glucose 2 140 mg/dl is abnormal and should be followed by an OGTT. Some » with gestational diabetes develop type 2 diabetes years later. How does the oral glucose tolerance test differ for a pregnant woman? ‘The standard testis the 100-gram OGTT pérformed after a 8-14 hour fast. A fasting, 1 hour, 2 hour, and 3 specimen are drawn, Gestational diabetes is diagnosed by two or more of the following venous plasma glucc values: fasting 2 95.mp/AL, | hour 2 180 mg/dL. 2 hour 2 155 mg/dL, and 3 hour 2 140 mg/dL. (Tietz Text: Clinical Chemistry and Molecular Diagnostics, 2006) ‘What should be done when # patient scheduled for a OGTT has a fasting glucose of 150 mg/dL? ‘The physician or pathologist should be consulted, Since the patient's glucose is already elevated, he/she shc be given a glucose load, If confirmed on another occasion, a fasting glucose of 150 mg/dL. is sufficient for = diagnosis of diabetes mellitus, An oral glucose tolerance test isnot required. [Name two enzymatic methods for glucose determinations. Glucose oxidase and hexdkinase. Glucose oxidase catalyzes the conversion of glucose to hydrogen pero Bluconic acid. The second step of the reaction is @ peroxidase reaction, which is much less specific than oxidase reaction, Hexokinase catalyzes the phosphorylation of glucose to glucose-6-phosphate, which is th: ‘oxidized by G-6-PD in the presence of NADP". The hexokinase method is more specific than the ghucose reaction. A 60-year-old diabetic has a blood glucose of 210 mg/dL. His urine glucose is negative, Assuming t! substances in his urine to inhibit the glucose reaction, what might account for the apparent diserepsr these test results? Diabetics may develop elevated renal thresholds, That is why urine testing is not a good screening test for = mellitus. — AA diabetic patient who performs home monitoring of his glucose is ordered by his physician to be te: local hospital laboratory. The patient is suspicious of the quality of care he receives from his HMO. immediately before going to the lab to have his blood drawn, he tests it himself, His result is 128 mg = laboratory result is 150 mg/dL. Assurning that both tests were performed correctly and that controls were within the ac: range, what might account for the discrepaney in values? ‘Home testing uses capillary whole blood; laboratory methods use venous plasma or serum. Whole blood : - 10-15% lower than plasma glucose, In addition, different methodologies re used. A specimen for a fasting glucose is drawn in a tube without anticoagulant at SAM in a nursing hor placed in a rack for pickup by the courier. The sample is picked up at 9 AM, delivered to the lab 2 and analyzed at 11:30 AM. Will the results be adversely affectéd by the handling of the specimen’ ‘Yes. Serum stiould be removed from cells within I hour of collection to prevent a decrease in glucose ¢ glycolysis. A preservative such as sodium fhuoride or lithium iodoacetate should be used when testing = delayed. Other options are to centrifuge the blood and remove the serum or to use serum-separator tbe: 3531 32. 3 Me 35, 36. 37. UPIDS ‘CLINICAL CHEMISTRY REVIEW ‘What are the most common causes of hypoglycemia? Inappropriate insulin production, insulin injection or ingestion of oral hypoglycemic agents Why isthe $ hour oral glucose tolerance test no longer recommended for the diagnosis of hypoglycemia? Because at east 10% of healthy individuals have glucose levels below 50 mg/dl. during this procedure Hypoglycemia is recognized by the presence of Whipple's trad plesma glucose less than 40 mg/dL, symptoms of hypoglycemia nervousness, anxiety, neurologic abnormalities), and relief of symptoms by administration of glucose. What happens when glucose levels drop below 20-30 mg/dL? Central nervous system dysfunction. ‘When are ketones present in the blood? ‘Whenever thee is impaired carbohydrate metabolism with breakdown of fatty acid, such as uncontrolled diabetes relitus, starvation, vomiting, or low carbohydrate diet. The Ketones are acetone, acetoacetic acid (diactic acid), and beta-hydroxybutyric acid (bela-hydroxybutyate) High levels lead to metabolic acidosis (ketoacidosis). ‘What reagent is used to detect ketones in blood and urine? \ Sodium nitroprusside, Actes tablets or Kets are frequently used, They are insensitive to beta-hyeroxybutyate, therfore, a negative nitroprusside est doesnot rule out ketoacidosis ‘What is the purpose ofthe lactose tolerance test? It aids inthe diagnosis of lactase deficiency. Lactase isthe enzyme that cleaves lactose into glucose and galactose. Following ingestion of mi or mil produc, affected individuals experience cramps and diarthea a lactose inthe tine i metabolized by bacteria. Inthe lctose tolerance test, glucose is measured inthe blood following oral administration of lactose. An increase in glucose of less than 20 mg/L. indicates that lactose was not broken down, and absorbed. Ithas been showa tat the most reliable method of determining lactose absorption isthe measurement ofthe amount of hydrogen in exheled breath after the ora administration of lactose. Levels ae above normal with lactase deficiency because hydrogen is one of he by-products of bacterial metabolism of lactose, The definitive diagnosis of lactase deficiency is made by tissue enzyme asstys on biopsies ofthe intestinal mucosa ‘What isthe purpose ofthe D-xylose absorption test? 1 itferentiates malabsorption of intestinal origin from malabsorpton:due to pancreatic insufficiency. D-xylose is pentose suger that is absorbed inthe small intestine without the action of pancreatic enzymes. Following oral atinisatin of D-xyose, blood or urine (olleted over a5 hour prio) is obained. Low levels of _ylose are suggestive ofan absorptive defect inthe jejunum. Describe the solubility properties of lipids. Lipids are insoluble in water and soluble inorganic solvent, Inblod, lipids are soluble due to their combination with protein (ipoproteins) 37