Notre Dame of Dadiangas University o Albumin

First Semester SY ‘24-‘25 o Total Protein

o Glucose

PATIENT PREPARATION

Prior to blood collection, the patients must be

given correct instructions on how to prepare for PCCLINCHEM 10: CLINICAL
CHEMISTRY
each laboratory test.
John Alfrey D. Pueblo, RMT,
Utmost care must be observed to minimize MSMT
factors that may influence laboratory results.

FACTORS CONTRIBUTING TO A VARIATION OF IV. POSTURE OR POSITION

RESULTS
I. EXERCISE  Preferred: Upright position or supine (lying)
 Patient should be seated/supine for at least 15-20
Physical Activity can have different effects on minutes before blood collection to prevent
analyte concentrations.  hemodilution or hemoconcentration
May lead to the INCREASE
OF: Changing from SUPINE POSITION TO
 Lactate, Fatty acid, Ammonia, ALT, AST, SITTING/STANDING
CPK, LD. o causes constriction of the blood vessels
and reduction of plasma volume
 Growth hormones, prolactin, testosterone, LH
o INCREASED levels of albumin, calcium,
 Proteins in urine (proteinuria)
and enzymes (ACE)
 Vigorous hand exercise (fist clenching) Increase
Changing from SITTING TO SUPINE
potassium, lactate and phosphate. o cause shifting of water and electrolytes into
tissue causing hemoconcentration
II. FASTING o INCREASED levels of Calcium, Lipids, Iron,
Protein, and BUN (CLIP and BUN)
 8-14 Hours is required for Glucose, lipids and Changing from STANDING TO SUPINE
lipoproteins. o causes extravascular water to transfer to
o Glucose: 8-10
vascular system and dilutes non diffusible
o Lipids: 8-14 hours
 48 hours of fasting- serum bilirubin may plasma constituents
INCREASE o DECREASED levels of TAG, Lipoproteins,
 72 hours of fasting and Cholesterol (TLC)
o Increase: Plasma Triglycerides
o Decrease: Glucose (in healthy women to  Significant elevation of potassium after 30
45mg/Dl) minutes of standing is due to the release of
 Basal state collection: (GluTa CE) potassium from muscles
o Glucose
 Prolonged bed rest results to DECREASED
o TAG PLASMA ALBUMIN due to fluid retention.
o Cholesterol
o Electrolytes V. TORNIQUET APPLICATION

III. DIET  One minute application is recommended

 Prolonged tourniquet application results to;
 High Protein Diet - increase urea
 High CHON, low CHO diets (Atkins diet) a. hemoconcentration (venous stasis)
o greatly increase ketones in the urine b. anaerobiosis
 Serotonin-rich food - INCREASE the urinary  Increase level:
excretion of 5-hydroxyindole acetic acid o Potassium
 Caffeine - INCREASE concentration of glucose; it o Protein(albumin)
promotes the release of catecholamines from the o Enzymes
adrenal medulla and brain tissue. o Lactate
 Increase turbidity or lactescent- TAG level o Cholesterol
exceed 400mg/Dl Contributes to the degree of o NH3
icteric (bilirubin) - 25.2mg/Dl  The pressure from the tourniquet causes
 Icteric samples interfere with tests of: (CAToG) biological analyte to leak from the tissue cells into
o Cholesterol the blood
Dale Ceriales – LMSC ✰
  Prolonged use of a tourniquet with fist exercise  Infants and Children
can increase the serum potassium level by as  Outpatient/ambulatory patient General
much as 1mmol/L.
 For accurate measurements of lactate, tourniquet 2. METHODS OF BLOOD COLLECTION
use should be minimal, ant the patient should not  Human body contains approx. 5 quarts (4.73L)
clench his or her fist at the time of the blood of whole blood
draw. o Male (adult) = 5-6 L whole blood
 Tourniquet application and or muscular activity o Females (adults) = 4-5L of whole blood
decrease venous p02 and pH.
 Whole blood is composed of approximately;
a. 60% of plasma = 3quarts or 2.84L
b. 40% of cells = 2 quarts or 1.89 L
VI. TABACCO SMOKING
 Increased in plasma: Test affected by Diurnal Variations and Posture
o non esterified fatty acid (NEFA) Concentration Cortisol Peak: 4 – 6 A.M.
o catecholamine's and serum cortisol Lowest:
 Increased glucose, GH, Cholesterol, Urea, and
8 P.M. – 12 A.M.
TAG (GGCUT)
50% lower at 8 P.M. than at 8
A.M.
VII. ALCOHOL INGESTION Increased with stress
ACTH Lower at night
Increase:
o plasma concentration of urate and TAG Increased with stress
o GGT Concentration Plasma Renin Lower at night
 It causes hypoglycemia (Chronic alcoholism) Activity Higher in standing than supine
Aldosterone
VIII. STRESS (ANXIETY) Lower at night
Insulin
Growth Hormone
 It affects adrenal hormones secretion Higher in afternoon and evening
 It is also associated with increased levels of ACP
albumin, glucose, insulin, prolactin and Thyroxin Increase with exercise
lactate Prolactin Higher with stress
o INCREASE: Total Cholesterol (with mild stress) Higher levels: 4 and 8 A.M. and
o DECREASE: HDL Cholesterol by as much as at 8 and 10 P.M.
15% Iron Peaks early to late morning
 It also results in hyperventilation in turn, affects Decrease up to 30% during the
acid-base balance. day
Calcium 4% decrease in supine
IX. DRUGS

 Medications affecting plasma volume can affect ARTERIAL PUNCTURE

CHON, BUN, Iron, and Calcium
 A Process by which blood is obtained from
concentrations
patient artery
 Hepatotoxic drugs can elevate liver function
 Arterial blood - oxygenated blood with a bright
enzymes.
red color
 Diuretics can decrease plasma sodium and
potassium levels.  USES: for blood gas analysis and pH measurement.
 SITES:
X. PHYSIOLOGICAL VARIATIONS/DIURNAL o Radial artery
VARIATIONS o Brachial
SPECIMEN COLLECTION AND HANDLING o Femoral
o Scalp
1. PROPER PATIEND ID is the first step in sample o Umbilical artery
collection
Blood sample is collected without a
 Conscious inpatients/hospitalized patients tourniquet
- Verbally ask their full names The femoral artery is relatively large and easy
 Sleeping patients to puncture, but extra care must be given to older
- They must be awakened before blood individuals because the femoral artery can bleed
collection more than the radial or brachial.
 Unconscious, Mentally Incompetent patients Before blood is collected from the radial artery,
Dale Ceriales – LMSC ✰
 MODIFIED ALLENS TEST should be done to collapse as blood is above the intended
determine whether the ulnar artery can provide venipuncture site.
collateral circulation to the hand after the radial According to CLSI, when a tourniquet is used
artery puncture. during preliminary vein selection, it should be
Arterial bleeding is the hardest to control and released and reapplied after 2 minutes.
usually requires special attention. Studies have shown that reusable tourniquet have
 Major Complications: the potential to transmit bacteria, including MRSA
o Thrombosis
o Hemorrhage Disinfection of the site for puncture
o possible infection  70% isopropyl alcohol wipes are used for
cleaning and disinfection of phlebo site when
 Unacceptable sites: drawing blood
o Irritated  SKIN CLEANSING: for alcohol levels -
o Edematous BENZALKONIUM CHLORIDE or ZEPHIRAN
o Near wound CHLORIDE,1:750 SHOULD
o in an area of an arteriovenous (AV) SHUNT or  No trace of alcohol should remain on the skin
fistula because it may cause hemolysis, and may
contaminate glucose testing
VENIPUNCTURE
Needle specifications and bevel position
 Median Cubital vein - Best site largest and the “inversely related to the size of the needle” Example:
best anchored large gauge number, small needle bore
 A process by which blood is obtained from a o 21-22 gauge needles used for blood collection
patient’s vein
o 23 gauge for children
 Venous blood - deoxygenated blood with a dark
o 21-23 and 25 gauge for butterfly needle
color red
o Needle length: 1 or 1.5 inch (1/2 to ¾ inches-
butterfly needle)

 SITES: A 21-gauge needle is considered the standard

o antecubital fossa region for most routine adult antecubital venipunctures
o veins on the wrist and dorsal aspect of hand The color coding for needles indicates the gauge:
o veins on the ankle o White – 16G
 Cephalic Veins - Second choice o Pink – 18G
 Basilic vein - Third choice o Cream – 19G
 Ankle vein should be used only if arm veins have
o Yellow – 20G
been determined to be unsuitable.
o Green – 21G
 If petechiae appear after Venipuncture,
o Black – 22G
indicates that minute amounts of blood have
o Blue – 23G
escaped into Skin epithelium
o Purple – 24G
 For blood gas analysis venous blood is not the
specimen of choice because it usually reflects o Orange – 25G
the acid- base status of an extremity; not the o Brown – 26G
body as a whole.
 In venipuncture, if the phlebotomist accidentally  IV infusion/butterfly set
 Butterfly set holds the needle connected to tubing
punctures the artery instead a vein, he should
with hub ore tube at the end Used when veins are
immediately apply pressure and report the
fragile, small, or hand to reach/find
case to supervisor.

TUBES FOR BLOOD COLLECTIONS

IMPORTANT NOTES

Tourniquet application
 Silica particles cause the blood to clot within 15-30
minutes.
Tourniquet is applied to obstruct the returns of  CLOTTING TIME for tubes using gel separators is
venous blood to the hearty and distend the veins, approximately 30 minutes, and tubes that have clot
and it is discarded after phlebotomy activators, such as thrombin, will clot in 5 minutes
If blood pressure cuff is used as a tourniquet, it is  Plain red - stoppered tubes with no additives
inflated 60mmHg. take about 60 minutes to clot completely.
If tourniquet is closer to the site, the vein may  Tubes with gels are not use used in blood bank or
Dale Ceriales – LMSC ✰
 for immunologic testing, as the gel may interfere 500mg/dL or more.
with the immunologic reactions.  Renin blood level is collected after a 3-day diet,
 TDM samples should not be collected in tubes from peripheral vein.
with gel separators or serum separator tube Basal state collection - early morning blood
collection, 12 hours after the last ingestion of food.
(SST)- Some gels absorb certain drugs (phenytoin,
Bar-Coded Samples: minimize clerical errors
phenobarbital, lidocaine, quinidine, and
carbamazepine) causing falsely low result CRITERIA FOR SPECIMEN REJECTIONS
 A gray-top tube containing fluoride oxalate 1. Unlabeled specimen
should be used for lactate sample collection, as it 2. Missing or inadequately labelled containers
blocks further glycolysis 3. Collected at wrong time Collected in wrong tube
Insufficient specimen
Tubes: color coded; rubber stopper, hemoguard, or
4. Inappropriate blood-to anticoagulant ratio
the tube is colored
Exposure to extreme temperature
1. Blood/tissue culture (sterile) - yellow/black/pink 5. Hemolysed or lipemic (depending on test ordered)
2. Without anticoagulant - red top, plain Clots in anticoagulated tube
tube, SST (SERUM SEPARATOR TUBE) w/ or 6. Nonfasting specimen (if required) Short draws
w/o CLOT ACTIVATOR 7. Contaminated specimen/leaking containers
3. Anticoagulated tubes 8. Discrepancies between requisition and specimen
o Light Blue (Blue-buffered citrate, black- label
buffered sodium citrate for ESR)
o Orange (Thrombin) SERUM SAMPLES
o Green (Heparin  Analysed not later than 4 hours (2 hours for
o Lavender (EDTA) enzymes)
 If delay is expected, store at 4 degree Celsius
o Gray (Fluoride)
(ref) good for several hours
SPECIMENS FOR CHEMISTRY (Most common to least  ALP and LDH are unstable at 4 degree Celsius
common)  ALP will inc. and LDH will DECREASE (due to labile
 Blood - usually serum LD4 and LD5 at 4 degree Celsius)
 Urine - Usually required timed sample in lieu of  Freezing at -20 degree Celsius for longer period
24-hour urine (laborious/difficult to collect) CSF-
Glucose and protein are done with serum SITES TO BE AVOIDED
concurrently to aid in clinical utility of results  (Venipuncture) Intravenous lines in both arms
Pleural, pericardial, and peritoneal fluid Burned or scarred areas
 LDH and Protein, done with serum concurrently  Areas with hematoma
 Synovial - collected with 25 units heparin/Ml OF
 Thrombosed veins Edematous
THE FLUID AFTER 6 HOURS FASTING
 Amniotic - Assess fatal lung maturity (L/S ratio)  Partial/radical mastectomy on one or both arms
congenital disease, HDN, Genetic and gestational  Arms with arteriovenous (AV) Shunt or fistula
age.  Cast(s) or arm(s)

IMPORTANT REMINDERS
 Wear gloves before phlebotomy and change COMPLICATIONS OF VENIPUNCTURE
between patients.
 Ask the patient if he/she has latex (tourniquet Immediate Local Complications
brand) allergy, and use another brand if needed. o Hemoconcentration
 If needle or lancet touch any surface that is not o Failure of blood to enter the syringe/vacutainer
sterile before blood collection, replace it with new tube
one. o Syncope (Fainting)
Traumatic draw as a result of vessel wall injury Late Local Complications
can cause Increase CK, Myoglobin and o Thrombosis – abnormal vascular condition in
potassium
which thrombus develops within a blood vessels
 The site adjacent to IV therapy should be avoided
of the body
(The initial sample 5ML drawn should be discarded)
IV Fluid contamination - Increased infused o Thrombophlebitis - inflammation of the vein
substance such as Glucose, Chloride, Potassium often accompanied by a clot which occurs as a
and sodium with decrease urea and creatinine result of trauma to the vessel wall.
 As little as 10% contamination with 5% dextrose Late general Complications
will increase glucose in a blood sample by o Serum hepatitis and AIDS

Dale Ceriales – LMSC ✰

SKIN PUNCTURE Capillary “arterialization” should not be done if
arterial blood pressure is below 95 mmHg or if the
A fingerstick to obtain blood for routine laboratory area has a poor blood supply
analysis is usually preferred for children older than The best method for blood gas collection in the new
one year old born remains the indwelling umbilical artery
Length of lancet: 1.75mm (preferred: to avoid catheter.
penetrating the bone)
The depth of the incision: CENTRAL VENOUS ACCESS (CVA) COLLECTION
o <2.0mm for infants and children Advantage: Eliminating multiple phlebotomies and
o <2.5mm for adults, to avoid contact with the bone useful in critical care and surgical situations Initial
The distance from the skin surface to bone or cartilage Procedure: 5mL of blood must be drawn and
in the middle finger is 1.5-2.4mm discarded, to eliminate contaminants.
The cut should be oriented across the fingerprints to Disadvantage: not recommended for bacteriology
generate a large drop of blood using a single
deliberate motion. ORDER OF DRAW FROM CATHETER LINES
1. Draw 3-5mL IN SYRINGE AND DISCARD
PREFERRED SITES 2. Blood for blood culture
A. Lateral plantar heel surface-newborn 3. Blood for anticoagulated tubes (lavender, green,
B. Palmar surfaces of the fingers (3rd and 4th fingers light blue etc.)
4. Blood for clot tubes (red, SST, etc.)
C. Plantar surface of the big toe
D. Earlobes-Least sites REASONS FOR RAPID SEPARATION OF BLOOD
(AFTER CENTRIFUGATION)
ORDER OF FILLING MICROCOLLECTION TUBES 1. To prevent Glycolysis
2. Certain Substances are very unstable
A. EDTA 3. To prevent shift of electrolytes
B. Other tubes with additives 4. To prevent hemolysis
C. Nonadditive tubes
 Ideally, ALL measurements should be performed within
45 minutes to 1 hour after collection
ADVANTAGE OF SKIN PUNCTURE
 Serum and plasma should be separated from cells as
 For premature infants - large amount of blood soon as possible, preferable within an hour
required for repeated venipunctures may cause  3000 relative centrifugal force (RCF) for 10 minutes is
iatrogenic anemia. the centrifugation requirements (required RCF may
 For sick infants which require parenteral therapy vary depending on the manufacturers recommendation)
 Often preferred in geriatric patient
 Skin puncture is useful in adults with; INTERFERING CONDITIONS IN THE MEASUREMENTS
o extreme obesity OF ANALYTES
o severe burns thrombotic tendencies
 Most common interfering conditions;
SITES NOT GENERALLY RECOMMENDED FOR SKIN o Hemolysis
o Icterus
PUNCTURE o lipemia
o Central arc area of an infant’s heel  Hemolysis and icterus - strongly absorb particular
o Fingers of a new-born or infants less than one year wavelengths of light
 Lipemic occurs when serum TAG levels exceed
old
4.6mmol/L(400mg/Dl)
o Thumb, index and fifth fingers and fingers on the
 inhibition of assay for:
side of a mastectomy
o Amylase
o Urate
ARTERIALIZED CAPILLARY BLOOD
 Used for blood gas analysis (newborn and infants) o Urea
for measuring pH and PCO2, BUT NOT pO2. o Ck
 Earlobe is the preferred site because of: o Bilirubin
vascularity, low metabolic requirements and ease o Total CHON
with which it can be arterialized Lipemia Scatters light and so blocks its
 Lateral Plantar heel surface is the most transmission
Lipemia can potentially be cleared from a serum or
commonly used site.
plasma specimen by ultracentrifugation
IMPORTANT REMINDERS
Dale Ceriales – LMSC ✰
STORAGE AND TRANSPORT OF SPECIMEN  Volume that can be collected: 20 Ml of CSF (not
The ice crystal formed during storage cause more than 2mL can be remove when the pressure
disruptive effects to molecular structure is greater than 200mm Hg).
particularly to large CHON molecules.
Serum or plasma must be stored at 4 degree Purpose of the CSF Vials/Tubes:
Celsius to 6 degree Celsius if analysis is to be 1. Goes to chemistry for Glucose and CHON
delayed for longer than 4 hours analysis or immunology/serology section
Specimens that require chilling (4 degree 2. Goes to microbiology for culture and gram stain
Celsius): 3. Goes to Hematology for cell counts (the least
o Ammonia likely to be contaminated by a bloody tap at
o Blood Gases collection)
o Catecholamines
o Gastrin II. URINE
o Lactic Acid
 Random specimens may be collected at any time,
o Renin
but a first –morning voided aliquot is optimal for
o PTH
constituent concentration.
o Pyruvate
 For 24-hour urine collection, the first morning
Photosensitive analytes:
specimen should be discarded, record the time,
o Bilirubin
and collect the succeeding voiding for the next 24
o Beta-Carotene
o Folate hours- over collection occurs if the first morning
o Porphyrins specimen is included in thus routine.
o Vitamin A and B6  24 hour urine creatinine - to assess the
completeness of the specimen
IMPORTANT NOTES  SODIUM FLUORIDE can be added to 24-hour
Plasma may be used in medical emergencies urine FOR glucose determinations to inhibit
Rimming the tube should be avoided because it bacterial growth and cell glycolysis.
may cause hemolysis and aerosol infection.  Pediatric collections require special attention to
Excessive centrifugation (>3000RCF) may cause avoid stool contamination.
cell lysis and slight elevation in LD and potassium.
Insufficient centrifugation (<1000 RCF or III. SYNOVIAL AND PLEURAL FLUID
<10minutes) may cause incomplete barrier
formation in gel tubes or cell contamination of the  Synovial Fluid is collected by
specimen. ARTHROCENTESIS, an aspiration of the joint
Whole Blood or plasma transfusion may cause using syringe, moistened with anticoagulant,
INCREASE PLASMA: usually 25 units of sodium heparin per Ml of
o CHON synovial Fluid.
o Bilirubin  Synovial Fluid differ from the other serous fluids in
o LD that it contains hyaluronic acid (mucin) ang may
o Potassium contain crystals
 Sodium heparin is the preferred anticoagulant for
DECREASE
synovial fluid
o Sodium  Some hospitals transfer synovial fluid to
o Chloride aerobic and anaerobic blood culture bottles for
Electrolytes are affected by evaporation of microbiologic culture.
specimen prior to testing.  Thoracentesis is a surgical procedure to drain
fluid(effusion) from the thoracic cavity and is
COLLECTION OF OTHER BODY FLUIDS
helpful in diagnosing inflammation or neoplastic
I. CSF
disease in the lung or pleura.
 Most common method of collection: Lumbar
puncture (between the third and fourth lumbar
IV. PERICARDIAL AND PERITONEAL FLUID
vertebrae, or between the fourth and fifth lumbar
vertebrae)
 Pericardiocentesis and refer to the collection of
 Other methods of collection: Cisternal Puncture
fluid from the pericardium (effusion)
and Lateral Cervical Puncture
 Purpose of collection: to establish diagnosis of  Peritoneocentesis for the collection of peritoneal
infection, malignancy, subarachnoid cavities (ascites); aka: Paracentesis
hemorrhage, MS, or demyelinating disorders.  These cavities normally contain less than 50 ML of
 Required pressure before collection: between fluid.
90 and 180 mmHg  Pleural fluid is an ultra-filtrate of the blood

Dale Ceriales – LMSC ✰

 plasma. It is formed continuously in the pleural
cavity.

10 COMMON ERRORS IN SPECIMEN COLLECTION

1. Misidentification Of Patient
2. Mislabeling Of Specimen
3. Short Draws/Wrong Anticoagulant/Blood Ratio
4. Mixing Problems/Clots
5. Wrong Tubes/Wrong Anticoagulant
6. Hemolysis/Lipemia
7. Hemoconcentration From Prolonged Tourniquet Time
8. Exposure Of Light/Extreme Temperature
9. Improperly Timed Specimens/Delayed Delivery to
Laboratory
10. Processing errors; incomplete centrifugation, incorrect
log-in, improper storage

Dale Ceriales – LMSC ✰