Unacceptable Specimen Log

[bbkdiane]

I need some input from my peers on two issues:

1. Do you keep a log book to document unacceptable specimens for BBK?

It is a requirement for some accreditation groups. My director found an article that stated the quantity of unacceptable specimens (for any reason) should be 0.45% or less. She is applying this "standard" to every lab. It works fine in the Chemistry and Hematology areas because they average 10,000+ samples per month; however, the Blood Bank averages 1500 specimens and we are more picky about hemolysis, clerical omissions, etc. So, if you have such a log book and have criteria to share, please bring it on. I never make the standard set by my boss for this monitor.

2. Our Labor and Delivery nurses draw each patients' admission blood work through the IV cannula before starting the IV. We see more hemolysis with our Blood Bank samples when they are drawn via this method. Since these samples are for academic Type and Screen (we get no pre-natal work on these patients), is there a level of hemolysis that you would routinely work with to save the patient from a second stick? We use Gel. One person told me that their criteria to accept a sample with hemolysis present was to hold printed material behind the sample: if they could read the print through the hemolysis, they could use the sample. Just curious what your policy might be. We were always taught that a sample should be free from hemolysis, but with the Gel system, slight hemolysis to moderate hemolysis does not seem to interfere with the interpretation of the test (according to Ortho). There is also the dilemma with the immediate spin crossmatch with the slight to moderate hemolyzed sample. Should all crossmatches performed on hemolyzed samples be Coombs rather than just immediate spin since the point of immediate spin was to catch ABO errors which cause hemolysis? This hemolysis issue is a major problem with the L&D folks right now. They get upset when we call and ask for a new sample; so I'm looking for some peer help. Thank you.

[Lcsmrz]

We use our computer system statistics on cancels to determine rejection rate and the reason. Blood Bank should apply their rejection criteria the same as any other lab area -- it's not the tech's fault if a sample is unacceptable, unless he/she drew it !!

Any visual hemolysis is a cause for rejection, unless your SOP states otherwise. Hemolysis is a psoitive reaction, and you can't see it if the sample is already hemolyzed.

I'll do ABO/Rh testing on a hemolyzed sample, though, unless I think there's some contamination.

[janet]

Hemolysis in a plasma sample would not be a reason to reject (seeing as in the plasma sample you would not see hemolysis as a reaction since the complement cascade has been stopped in anti-coagulating the sample!).

On the other hand if you use serum samples; pre-existing hemolysis could prevent interpreting a hemolysis reaction.

[labgirl153]

True, in vitro complement activation doesn't occur in EDTA plasma (C4 needs Mg+ and Ca+2 ions from serum for this, and besides which, C3 from in vivo activation is the important one from a clinical standpt.)...

...But basically, as noted in the first post, her question has really more to do with interference: that is... will the hemolysis interfere with reading the gel cards? I accept slight to moderate hemolysis in plasma specimens, IF the patient hasn't been recently transfused or if there are extenuating circumstances.

The greater concern for me is to have a "baseline" specimen and really has nothing to do with blood bank testing. Is this hemolysis I'm seeing prior to even beginning to test due to a bad draw? or is it a true indication of what's happening to my patient in vivo? We've all seen hemolyzed specimens from patients who are experiencing delayed hemolytic reactions or from patients burned or who've suffered massive trauma or DIC.

Since OB patients are prone to DIC stemming from eclampsia and other disorders, if their initial specimen is hemolyzed, it's best to get a redraw...Besides which, it's likely that other labs are drawn at the same time on admission, and hemolysis will adversely affect those labs as well. At various institutions where I've worked in the past, OB depts. and ERs have this problem and they always balk. They need some orientation when they draw their specimens on inserting an IV (that usually takes an act of congress). They're either not placing the lines in properly or they're pulling back too rapidly (if they use syringes). If they can't handle the job, then a phlebotomist needs to step in (that would require another act of congress).

When discussing the need for a non-hemolyzed specimen, it's a good idea to explain to them (if they'll listen that is) that we (meaning nursing too) need to know if the patient is truly hemolyzing in vivo or not. This is especially important if a patient is later transfused and undergoes a transfusion reaction...if the pre and post specimens are hemolyzed this complicates matters, even if the DAT is negative.

Cutting to the chase... since we can't dictate what nursing does: get a new specimen if it's convenient to, and if not, gauge the degree of hemolysis so far as it affects the gel card reading. Note nursing's refusal to redraw, proceed accordingly.

[Llehman@ecmc.edu]

Greetings from Erie County Medical Center, Buffalo, New York. I have read with interest the postings on "hemolyzed samples". At our 08/21/08 Transfusion Committee meeting, an Anesthesiologist complained that he uses the biggest needle to draw samples to a syringe, & the Blood Bank still rejects the sample due to hemolysis. I read BD's LabNotes where they mention Needle size (too large or too small), as one cause (plus several other causes) of hemolysis. I plan to use the Guidelines from BD's LoveNotes (Winter 2003) as a reference to make our Guidelines. Does anyone have Guidelines that I could also cite as my reference? Your help will be greatly appreciated. Thanks

Rose

[SMW]

Has anyone observed the entire process? Collecting the blood is only one part of the scenario. After collecting into the syringe, how is the blood transferred into the tube? The force created by the vacumn of an evacuated tube drawing through a needle on a syringe is significantly different than drawing the blood from a vein. In my experience, this is the part of the process where the hemolysis occurs. Also what type of manipulation (or not) is occurring once the blood is in the tube? Mixing and agitation mean different things to different folks..........