What does your facility do when you have platelet clumping?

[TVC15]

Hi everyone,

I am a well trained generalist but have only worked in blood bank reference labs since my training.

I have just encountered a startling situation...based on my training. The CLS's where I work are trained to vortex any CBC specimen if it is suspect for platelet clumping and then re-run it on the analyzer to see if it increases the platelet count. Is it just me or do you guys think this is nuts?

[TVC15]

Anyone out there?

[Deny Morlino]

Make and stain a smear looking for platelet clumping. If present consider a recollection advising phlebotomy to collect a sodium citrate specimen in addition to the normal EDTA specimen in case of EDTA sensitivity in the patient. If the recollected EDTA specimen still demonstrates platelet clumping, run the citrate sample and correct the platelet result by multiplying by 1.1 for dilution correction.

[SMILLER]

We came across a journal article on this years ago. We do try this on specimens that show clumped platlelets on the slide. I would say it works about half the time for "regular" clumpers. It does NOT work for EDTA clumpers. If you know you have a patient that is an EDTA clumper, draw a citrate as has been suggested. And of course, if there are clots in the tube, you have to get a redraw.

Anyway, to do it properly, you need to aliquot a small amount like 1/2 to 1 ml, and vortex it for 2 to 3 minutes. This is a long time to stand at the vortexer feeling your hand going numb, but if you want to work, you do need to do it longer than a few seconds. Then you make a smear with the vortexed specimen AND run it. If there are no clumps on the slide, you can report the platelelet count off the vtxd specimen.

Scott

[jayinsat]

I have vortexed. It works

[TVC15]

I have vortexed. It works

I called M.D. Anderson last night and asked the hematology crew and they were in total schock that anyone would do such a thing. It is not a good practice. Below is a part of an email from a hematology friend of mine here in CA at a large teaching facility. I 100% agree with him!

Thanks everyone!

You do not have to callM.D. Anderson, no one in his right frame of mind would allow such practice.Vortexing will cause significant hemolysis and will not remove clumping. You donot have to believe such statement…

[Mabel Adams]

I agree that there was an article about this some years past and it is standard practice in some places. It certainly was where I used to work. Not sure of the new place since I don't get out of BB much.

[TVC15]

I agree that there was an article about this some years past and it is standard practice in some places. It certainly was where I used to work. Not sure of the new place since I don't get out of BB much.

Hi Mabel,

This was the only article I could find when I googled http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=cap_today%2Fq_and_a%2Fqa_0401.html&_state=maximized&_pageLabel=cntvwr

This seems to be a very outdated practice. M.D. Anderson Cancer Center is the most outstanding Cancer Center on the planet...if they were shocked as much as I was and others I have mentioned it to...then it can't be all that common today. Logically it just does not make sense to me especially when there are other means to resolving this.

You guys that vortex...did you ever consider that vortexing will break up RBC's and other cells and the bits that are broken off might be counted as platelets? Therefore you get a falsely elevated platelet count.

[jayinsat]

Hi Mabel,

This was the only article I could find when I googled http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=cap_today%2Fq_and_a%2Fqa_0401.html&_state=maximized&_pageLabel=cntvwr

This seems to be a very outdated practice. M.D. Anderson Cancer Center is the most outstanding Cancer Center on the planet...if they were shocked as much as I was and others I have mentioned it to...then it can't be all that common today. Logically it just does not make sense to me especially when there are other means to resolving this.

You guys that vortex...did you ever consider that vortexing will break up RBC's and other cells and the bits that are broken off might be counted as platelets? Therefore you get a falsely elevated platelet count.

Typically, you vortex after you've run the CBC initially and found the platelet count to be suspiciously low. You simply compare the pre-vortex results to the post-vortex result and make a technical judgement as to whether or not the results are valid. This is another one of those scenarios where each individual lab, and tech, has to do what's comfortable practice for themselves. Just because M.D. Anderson despises it doesn't make it wrong.

[TVC15]

Typically, you vortex after you've run the CBC initially and found the platelet count to be suspiciously low. You simply compare the pre-vortex results to the post-vortex result and make a technical judgement as to whether or not the results are valid. This is another one of those scenarios where each individual lab, and tech, has to do what's comfortable practice for themselves. Just because M.D. Anderson despises it doesn't make it wrong.

LOL! I would take M.D. Anderson's long history of outstanding experience and accept it more than a M.T. who thinks that vortexing is the correct thing to do. Did you question who taught you to do this or just blindly accept it since everyone else in your lab is doing it? You never raise standards by being just a sheep that follows and never questions.

Additionally what sort of technical judgement are you practicing when vortexing no doubt breakes up RBC's and generatates cellular fragments...then you run this through the analyzer again and assume that the platelet count is actually only platelets that were counted vs. the fragments generated by vortexing?

Please show a link to the standards that support such a practice.

BTW M.D. Anderson did not say that they despsied it...they just could not make one ounce of logic as to why anyone would do such a thing.

Edited September 20, 2012 by TVC15

[jayinsat]

LOL! I would take M.D. Anderson's long history of outstanding experience and accept it more than a M.T. who thinks that vortexing is the correct thing to do. Did you question who taught you to do this or just blindly accept it since everyone else in your lab is doing it? You never raise standards by being just a sheep that follows and never questions.

Additionally what sort of technical judgement are you practicing when vortexing no doubt breakes up RBC's and generatates cellular fragments...then you run this through the analyzer again and assume that the platelet count is actually only platelets that were counted vs. the fragments generated by vortexing?

Please show a link to the standards that support such a practice.

BTW M.D. Anderson did not say that they despsied it...they just could not make one ounce of logic as to why anyone would do such a thing.

Did you read the CAP article? "Based on these data, it seems reasonable to attempt to vortex samples as a first-line attempt to resolve platelet clumping." This is from CAP. I'm pretty sure that the people working at M.D. Anderson are M.T.'s. Theirs is just an opinion. The article, produced by CAP (I believe they are still reputable) says that in 50% of the cases it works. Here, i'll link it again:

http://www.cap.org/apps/cap.portal?_...geLabel=cntvwr

Again, we have to agree to disagree. I don't believe any harm is being done to the patient. I would argue that, at least 50% of the time, we are saving a patient from an un-necessary recollect.

[jayinsat]

http://labmed.ascpjournals.org/content/32/7/361.full.pdf

This is the original study that led to the article you linked earlier. It is written by

Gabriele Mues, MD, Frank H. Wians, Jr, PhD, MT(ASCP), DABCC, FACB, and Steven H. Kroft, MD, FASCP

From the Department of Pathology, University of Texas Southwestern Medical School, Dallas, TX.

"1. Vortexing of blood specimens

has been reported to be successful incompletely breaking up platelet clumpsin approximately half of EIPA cases.10Either the entire tube or an aliquot ofblood may be vortexed for 1 to 2 minutesat the highest vortex setting withoutadversely affecting CBCparameters. A postvortex peripheralblood smear should be examined to determinethe efficacy of this procedure

before reporting the platelet count."

the study may have been performed in 2001 but that doesn't mean its outdated. I would venture that these individuals are intelligent and knowlegeable even if i'm not.

[TVC15]

f

Did you read the CAP article? "Based on these data, it seems reasonable to attempt to vortex samples as a first-line attempt to resolve platelet clumping." This is from CAP. I'm pretty sure that the people working at M.D. Anderson are M.T.'s. Theirs is just an opinion. The article, produced by CAP (I believe they are still reputable) says that in 50% of the cases it works. Here, i'll link it again:

http://www.cap.org/apps/cap.portal?_...geLabel=cntvwr

Again, we have to agree to disagree. I don't believe any harm is being done to the patient. I would argue that, at least 50% of the time, we are saving a patient from an un-necessary recollect.

You bet I read it and from what I read it does not have much evidence or support to make this into a gold standard.

Secondly this was not written or produced by CAP It was answered by a doctor on a CAP Q&A section.

Did you take note on how old the references are? Did you also miss the part where he said they did an informal study...that's right informal study. So there is only one published paper out there from ages ago commented on by a doctor who did his own informal study and found only 50% of the time it worked. Yep sounds like this really ought to be a high hematology standard.

I would rather have a patient redrawn in order to obtain a proper platelet count v.s mickey moussing around with a practice that only gives a 50% shot at it and is not commonly used.

I challenge you to show me a standard that supports this practice. You won't find one out there since it is not a good practice...if it were then it would certainly be a standard.

This is why he states "The most commonly employed solution to this problem is to redraw the specimen into a different anticoagulant, usually either sodium citrate or acid citrate dextrose; this resolves the problem in most cases".

BTW you are dead wrong about M.D. Anderson. That is one of the top notch research instutions on this planet. I obtained my CLS degree from there and we were trained by physicians as well as very experienced MT's. I am thankful to have gained my experience from the top Medical Center and Cancer Center in the world. They did not get to that level by following poor practices.

[TVC15]

http://labmed.ascpjournals.org/content/32/7/361.full.pdf

This is the original study that led to the article you linked earlier. It is written by

Gabriele Mues, MD, Frank H. Wians, Jr, PhD, MT(ASCP), DABCC, FACB, and Steven H. Kroft, MD, FASCP

From the Department of Pathology, University of Texas Southwestern Medical School, Dallas, TX.

"1. Vortexing of blood specimens

has been reported to be successful incompletely breaking up platelet clumpsin approximately half of EIPA cases.

10Either the entire tube or an aliquot ofblood may be vortexed for 1 to 2 minutesat the highest vortex setting withoutadversely affecting CBCparameters. A postvortex peripheralblood smear should be examined to determinethe efficacy of this procedure

before reporting the platelet count."

the study may have been performed in 2001 but that doesn't mean its outdated. I would venture that these individuals are intelligent and knowlegeable even if i'm not.

I think you need to be more astute when reading. The study was conducted in 1997. http://labmed.ascpjournals.org/content/32/7/361.full.pdf See reference #10 from this paper.

Interesting that you think all docs are spot on. I was unfortunately misdiagnosed in 2009 by a team of doctors from UT Southwestern in Dallas...imagine that. A team of UT Southwest doctors misdiagnosed that I had osteomylitis in my dominant wrist and hand bones. This misdiagnosis resulted in permanent damage to my dominant hand bones and wrist bones. A team of 12 doctors from UT Southwestern and not one of them got it right!

Edited September 21, 2012 by TVC15

[TVC15]

Hey guys I looked up the doctor who wrote the CAP article. I emailed him and this is what he had to say:

Hi Dr. Kroft,

I would like to ask you about your answer on the CAP Q&A vortexing CBC specimen to get rid of platelet clumping.

I read what you wrote on that site and find it highly shocking. I studied at M.D. Anderson and the hematology department could not believe that anyone would do this to a CBC specimen to resolve the issue. I think it is a terrible practice that could lead to a falsely elevated platelet count.

Vortexing will certainly break up some RBC’s and other cells and thus could be counted as platelets when run through the analyzer a second time.

Do you still think this is a good practice?

Thank you,

His response:

I have never actually employed this procedure. The information regarding vortexing was based on a single paper in the literature that studied its effectiveness in resolving platelet clumps. I don't have the paper at hand, and I don't recall whether they evaluated the post-vortex sample for red cell fragmentation. The reference should be provided in the CAP Today column, and I would encourage you to to dig it up and see what they did. Your point is certainly a reasonable consideration, although I have no specific knowledge that vortexing fragments red cells. It would be worth testing the hypothesis, and I would be interested in the results of such an experiment.

Regards,

SHK

Edited September 21, 2012 by TVC15

[SMILLER]

I believe that this is the original article:

Gulati GL, Asselta A, Chen C. Using a vortex to disaggregate platelet clumps. Laboratory Medicine. 1997;28:665-667.

Good luck finding it on the internet tho, I think its too old.

Having said that, if anyone has doubts about the appriateness of the method, don't waste time in philisophical arguments here, just go and test it out in your own lab yourself. We have been using it for years. RBC, WBC, etc. counts before and after are the same. Some notes:

Always get a redraw with an additional citrate (in case its an EDTA-clumper) if possible. Of course the problem here comes when a patient is an outreach case or whatever and it is not practical to get a redraw.

Vortex a small amount for at least minute or two. Make a smear and rerun it.

If the post-vortex smear still shows clumps (about 1/2 the time in our experience) you will have to report an estimate anyway. Otherwise, take the platlelet count from the vortexed run and use that for the platelet count. Do not use any other results from the vortexed specimen.

Having said all that, remember that if the draw was rough enough to clump platelets, some of the other results may be comprimised also, even though they are not flagged on the analyzer. So careful review is always necessary just like with any suspect specimen. Always best to get a redraw! But this method does work in some cases.

Scott

[jayinsat]

agree to disagree.

I can't convince you that there are times when this practice has proven itself, even though I've seen it in over 25 years of experience. I don't need a study that proves what i've seen in practice. Maybe with a few more years of experience you will gain some wisdom that will give you practical application to your knowledge. I've seen 6mo old babies drawn whose platelet counts read on the analyzer 200,000 and flagged for plt clumps. All indicies were normal. Said sample was vortexed and reran, generating a count of 240,000. Indicies relatively unchanged. Do I restick this child? What benefit would it serve in said childs care? Consider the patient and families point of view. Even dropping the platelet values 100,000 would not affect treatment or diagnosis.

I'm done. Peace Sir. Train on and keep inquisitive. It will take you far, yet be willing to think outside the box.

[SMILLER]

agree to disagree.

I can't convince you that there are times when this practice has proven itself, even though I've seen it in over 25 years of experience. I don't need a study that proves what i've seen in practice. Maybe with a few more years of experience you will gain some wisdom that will give you practical application to your knowledge.

I'm done. Peace Sir. Train on and keep inquisitive. It will take you far, yet be willing to think outside the box.

Yikes! This IS the internet, isnt it!

Scott

[jayinsat]

Yikes! This IS the internet, isnt it!

Scott

TVC15,

I apologize for the tone and aggresivness of my last post. Emotional responses lend nothing to good academic discussion. I would simply edit or delete the comment but, as you can see, It would still remain under Scott's post. I also apologize for the negative light it puts you in. I'm sure you have a lot to offer to our career field and truly wish you the best. I hope this does not turn you off to this site or great group of people that contribute here. While I stand by my arguments, I am ashamed of the way I've made them.

Peace to you my collegue.

James

[TVC15]

TVC15,

I apologize for the tone and aggresivness of my last post. Emotional responses lend nothing to good academic discussion. I would simply edit or delete the comment but, as you can see, It would still remain under Scott's post. I also apologize for the negative light it puts you in. I'm sure you have a lot to offer to our career field and truly wish you the best. I hope this does not turn you off to this site or great group of people that contribute here. While I stand by my arguments, I am ashamed of the way I've made them.

Peace to you my collegue.

James

No worries James,

I understand how people react when challenged on something they firmly believe in. I have solid experience as a CLS for many years. I was well trained as a generalist at M.D. Anderson. I did all of my rotations in the Texas Medical Center at some of the best hospitals in the nation. The one thing about training in the TMC is the entire complex is a teaching and research complex with cutting edge technology and practices. The M.D. Anderson CLS's are very lucky to get exposure to this. I find that us modern day trained CLS's see and do things much differently than the longer careered CLS's. For example old blood bankers do some of the strangest things I have ever seen. Some of them are still stuck in the 70's era. Technology and practices constantly evolve...but unfortunately many CLS's don't evolve with them.

I do think outside the box that is why I question things. I have never been asheep that goes along with what people tell me. I research and find out for myself.

Peace

[cthherbal ☆]

No worries James,

I understand how people react when challenged on something they firmly believe in. I have solid experience as a CLS for many years. I was well trained as a generalist at M.D. Anderson. I did all of my rotations in the Texas Medical Center at some of the best hospitals in the nation. The one thing about training in the TMC is the entire complex is a teaching and research complex with cutting edge technology and practices. The M.D. Anderson CLS's are very lucky to get exposure to this. I find that us modern day trained CLS's see and do things much differently than the longer careered CLS's. For example old blood bankers do some of the strangest things I have ever seen. Some of them are still stuck in the 70's era. Technology and practices constantly evolve...but unfortunately many CLS's don't evolve with them.

I do think outside the box that is why I question things. I have never been asheep that goes along with what people tell me. I research and find out for myself.

Peace

Thanks for a lively discussion. 2 years ago I was a hematology supervisor where we also practiced this vortexing. We had it in our policy how to do it and that a comment of platelet clumping was reported as the result, estimate appears normal, increased, or decreased based on the vortexed slide estimate. We also recommended retesting with a citrated tube in the report. We did not actually report the vortexed PLT numerical value but the thought was that the clumping probably had to do with the patient and the EDTA anticoagulant itself, or some kind of interfering medication. Sorry I do not have the references from my policy, but I would agree that it worked a good amount (60-70%) of the time. I don't ever remember seeing RBC fragments in these cases and whenever we made and viewed a slide we would also note the RBC and WBC morphology and count estimate in the report.

[Alan Neal]

I have never heard or used the votex method and would have concerns Re fragmentation of other blood cells giving rise to false platelet counts (As per previous comment).

Re comment Re EDTA clumping phenomenon.

We have recently reviewed the use of Amykacin to prevent this problem.

We have used a commercial product and this seem to resolve the problem in the few cases to date (Out experience matches publications & product information).

WE plan to use this methodology where platelet count is essential e.g. Chemotherapy patients, patients on warfarin or other situation where platelet estimate suggest platelet count redduced but unable to quantitfy.

[Mabel Adams]

The good thing about science is that we are always open to improvement. Someone should repeat the studies done back in the 90's (that seems recent to me ) and verify the procedure. Maybe there are now techniques available that will answer the questions raised more readily than they were then. Of course, good science does not go in trying to prove at all costs an expected outcome so an open mind is necessary. Please let us know if a paper gets published.

[TVC15]

I have never heard or used the votex method and would have concerns Re fragmentation of other blood cells giving rise to false platelet counts (As per previous comment).

Re comment Re EDTA clumping phenomenon.

We have recently reviewed the use of Amykacin to prevent this problem.

We have used a commercial product and this seem to resolve the problem in the few cases to date (Out experience matches publications & product information).

WE plan to use this methodology where platelet count is essential e.g. Chemotherapy patients, patients on warfarin or other situation where platelet estimate suggest platelet count redduced but unable to quantitfy.

Hi Alan,

How do you perform the methodology? What commercial product do you use?

Thanks

[Alan Neal]

We use a product from sarstedt - see link below.

http://www.medicalsearch.com.au/Blood-Collection-S-Monovette-ThromboExact-for-Pseudothrombocytopenia/p/69255

A limited validation has been done and we agree with product information.

Hope this of help.

Alan