Tips & Techniques in

Preanalytics

1

Prof. Dr. Ralf Lichtinghagen

Foreword

Prof. Dr. rer. nat. Ralf Lichtinghagen obtained his doctorate after
studying chemistry and biology at Ruhr University Bochum inthe ﬁeld of neurobiochemistry. At the beginning of the 1990s
he undertook further training at Hannover Medical School(‘MHH’) to qualify as a Clinical Chemist/European Specialist inLaboratory Medicine (EuSpLM). He acquired his authorization toteach Clinical Chemistry at a university and he currently works
as Chief Clinical Chemist in the Central Laboratory of MHH. In
addition to his responsibilities in patient care and research, he also gives lectures inClinical Chemistry / Laboratory Diagnostics in the medicine course of studies.

The brochure “Tips and Techniques in Preanalytics” is particularly aimed at doctorsof medicine, healthcare providers, nurses and medical staff in clinics and doctors’
practices.

He is also academic head of the Medical Laboratory Assistants School. Within thenational laboratory medicine society (‘DGKL’) he organises revision courses in thesubject of Clinical Chemistry for specialised scientists undergoing further training
and for junior doctors. His main areas of research at the MHH’s Institute of Clinical
Chemistry are Molecular Diagnostics and new biomarkers.

As a Clinical Chemist I am particularly well aware of the importance of preanalytics
within the process as a whole – from the laboratory request and sample collection to
the interpreted laboratory ﬁndings. After all, preanalytics in particular accounts for amajor part of laboratory medicine quality management.

By working through this brochure the reader should gain a comprehensive
impression of the many different aspects of preanalysis.
The sections concerning the collection of analysis materials are specially tailored tothe use of Sarstedt systems (S-Monovette®, Microvette®, Minivette®, etc.) and, after
specialised familiarisation has taken place, they make it easier to use the describedcollection techniques properly, particularly for new users.

Error-free application of laboratory medicine diagnostics is only possible if therelevant inﬂuencing factors and interfering factors are strictly taken into account. This
brochure particularly addresses that issue and especially aims to sensitise clinicalcolleagues to the topic. It is they who, in their capacity as clients requesting medicallaboratory diagnostics, make a major contribution towards ensuring that the process
as a whole can take place with as little disruption as possible, by performing sample
collection properly.

Prof. Dr. Ralf Lichtinghagen

2

3

Table of contents
1
1.1
1.2
1.3

What is preanalytics?
Principles of preanalytics?
Common consequences of preanalytical errors
Communication as a key to success

2
2.1
2.1.1
2.1.2
2.2

Inﬂuencing factors and interfering factors
Inﬂuencing factors
Non-modiﬁable inﬂuencing factors
Modiﬁable inﬂuencing factors
Interfering factors

10-19
11
12 - 14
14-17
18-19

3
3.1
3.2
3.3
3.4
3.5
3.6

Venous blood collection
Patient preparation
What is the responsibility of the person collecting the blood?
Identiﬁcation
Application
Order of draw
Avoiding underﬁlling

20-27
21
21
22-24
25
26
27

4
4.1
4.2
4.3
4.4
4.5
4.5.1
4.5.2
4.5.3
4.6
4.7
4.7.1
4.7.2
4.7.3

Carrying out venous blood collection
Standard conditions for blood collection
Obtaining diagnostic samples: 12 steps
Tourniquet application and puncture sites
Problems before/during blood collection
Aspiration technique and vacuum technique
S-Monovette® aspiration technique
S-Monovette® vacuum technique
A summary of the 2 collection techniques
Blood collection from catheters
Blood collection for blood culture diagnostics
Hygienic requirements
Handling during blood collection
Sample volume and number of vials

28-43
29
29
30-31
32
33
33-35
36
37
38-39
40
41
42
43

5
5.1
5.2
5.3
5.3.1
5.3.2
5.4
5.5
5.6

Blood collection in paediatrics
Medical history
Prerequisites for blood collection
Blood collection in paediatrics
Venous blood collection
Capillary blood collection
The difference between capillary blood and venous blood
Reference ranges
Haemostasis in paediatrics

44-55
45
46
46
47-48
49-51
51
52-54
54-55

4

Pages 6-9
7
8
9

6
6.1
6.2
6.3
6.4

Blood gasType of blood collection
Storage
Avoiding errors
Collection technique – Blood Gas Monovette®

56-61
57
58
58-59
60-61

7
7.1
7.2
7.3

Safety when collecting blood
Safety needle
Safety-Multiﬂy® needle
Multi-Safe disposal boxes

62-67
64
65
66-67

8
8.1
8.2
8.3
8.4
8.5

Centrifugation
Correct handling for centrifugation
Difference between ﬁxed-angle and swing-out rotors
Serum collection
S-Monovette® centrifugation conditions
Gel ascent during centrifugation

68-73
69
70
71
72
73

9
9.1
9.2
9.3
9.4

Haemolysis – what is it?
In vivo haemolysis
In vitro haemolysis
Consequences of haemolysis
Clinical relevance

74-79
76
77
78
79

10
10.1
10.2

Storage and transport
Sample transport
Inﬂuence of temperature, time and cellular metabolism

80-87
81-82
83-87

11
11.1
11.1.111.1.2
11.2
11.3

Capillary blood collection
Carrying out capillary blood collection
Safety Lancet and Safety Incision Lancet
Microvette® – order of draw and techniques
Centrifugation conditions for capillary blood collection
Minivette® POCT

88-99
89-91
92-94
95-97
98
99

12
12.1
12.2
12.3
12.4
12.5

Urine sample collection
Sample collection
Storage and transport
Types of analyses
Types of urine samples
Handling urine sample collection systems

100-111101
101
102 - 103
104 - 107108-111

13

List of references

114 - 115

14

Index

116 - 122

15

Imprint

123

5

1 What arepreanalytics?

1.1

Principles of preanalytics

On average, the preanalytical phase accounts for about 57%1 of the entire process
between the patient and the analysis result. This phase includes the indication,
informing and identifying the patient, sample collection with subsequent transport,
and storage until centrifugation and sample distribution.
In short, it involves a large number of different steps and areas.
1

Guder et al.; Proben zwischen Patient und Labor; 2009

The range of possibilities for inﬂuencing and changing analytical results during
individual steps in this process is correspondingly large.
Note:

About 25% of errors in preanalytics haveconsequences for the patient!

It is all the more important for every participant to be informed of the potential
inﬂuences and sources of error, so that with this awareness they can act
appropriately in order to avoid errors. After all, a test result can only be as good as ispermitted by the patient sample obtained.

“Preanalytics comprises all the processes that occur
before the laboratory analysis.”

6

7

1.2

Common consequences of preanalytical errors

1.3

Communication as a key to successCommunication between those persons involved in blood collection facilitates work
procedures, avoids misunderstandings and prevents preanalytical errors due tomissing or incorrect information.

Can values be changed during blood collection?

Common errors

Patient
Haemolysis

44 %2
2

Underﬁlling

17 %2

Blood clot

MedicalAttendinglaboratory

physician

8 %2

Adapted from: Bonini et al; Errors in Laboratory Medicine; Clin Chem 48:5; 691-698 (2002)

Note:

Note:

3

70-85% of clinical decisions are based on the
results of laboratory analyses! 3

Foubister, Vida. Cap Today Bench press: The Technologist/technician shortfall is putting the squeeze on laboratories nationwide
September 2000; Datta, P. Resolving Discordant Samples. Advance for the Administrators of Laboratories; July 2005: p.60.

Problems in the area of preanalytics can never be resolved by asingle individual but only by close cooperation of the persons
involved such as doctors, medical assistants, nursing personnel
or the laboratory.

Aim
Standardised conditions for …
s Preparing for the blood collections Blood collection procedures Storage/transport to the laboratory

Results Safety for patientss Process cost reduction (working time!)

89

2 Inﬂuencing factors
and interferingfactors

2.1

Inﬂuencing factors

What responsibility does the patient bear?
s Correct details from their medical historys Medication (list, possibly discontinue)s Nutrition (particular diet, fasting)s Correct collection (blood, urine, faeces, etc.)

For correct details concerning medical history, it is important that appropriatequestions are asked before sample collection.
Taking into account possible inﬂuencing factors is important because:
Inﬂuencing factors change the concentration of analytes.
The effect on the concentration depends on the medical condition and must
be considered when evaluating the results.

The list of inﬂuencing factors and interfering factors in the following section is not
exhaustive. Various examples are presented to illustrate the issues.

“From blood collection and the generation ofplausible analysis results to result interpretation,
it is absolutely essential to have detailed knowledgeof inﬂuencing factors and interfering factors, andtake them into consideration.”10112.1.1 Non-modiﬁable inﬂuence factors
Population (Race)

Age

Signiﬁcant differences in blood values can be found in African populations
when compared with European populations. In African populations:- Leucocyte counts are signiﬁcantly lower- The vitamin B12 concentration is 1.35 times higher- The reference ranges for creatinine, CK and alpha amylase are much higher
In Asians the activity of alcohol dehydrogenase is lower than in Europeans. There isalso a higher level of lactose intolerance in the Asian population.

With increasing age there is often an increase in the cholesterol value in both
sexes. The activity of alkaline phosphatase in blood plasma is inﬂuenced by bonemetabolism and is therefore highest in children during the growth phase and after
bone fractures.
In infants there are higher bilirubin, haematocrit and HbF levels (for more examples
see Section 5 – Blood collection in paediatrics).
That is why age-dependent reference ranges are desirable, but often non-existent,
for many parameters.

GenderApart from other gender-speciﬁc components (e.g. hormones) muscle mass has an
impact on various parameters.
- CK and creatinine are dependent on muscle mass so men are usually found tohave much higher levels- For many parameters it is appropriate to use gender-speciﬁc reference ranges

300
250

mg/dl

Pregnancy
1

There is a 5-fold increase in the erythrocyte sedimentation rate during pregnancy.
1

Guder et al.; Proben zwischen Patient und Labor; 2009

Cholesterol

200
150

LDL

100
50

5

HDL

0

Sarstedt; Tipps & Tricks in der Präanalytik; 2014

15

25

35

45

55

65

Years
5

+100 %

Deviations in %

-20
4

0

20

40

60

80

Triglycerides
Leucocytes
CHOL
AP
Iron
Total protein

Sarstedt; Tips & Techniques in Preanalytics; 2014

Biological rhythm
Vitamin D production (25-OH) ﬂuctuates over the course of a year. In summer,
higher UV levels mean that more vitamin D is synthesised than in winter.

100

Seelig et al; Präanalytik; 2008

1213

Circadian rhythm

Substance use: Alcohol

Also known as rhythmical daily ﬂuctuation, referring to expected differences inconcentration throughout a day for certain clinical chemistry parameters andendocrinological parameters (e.g. renin, cortisol, adrenaline, noradrenaline, VMA
and TSH).
With such parameters the time of collection is of fundamental importance. Follow-up
measurements should always be collected at the same time of day. As a rule, thetime of the collection must be documented and communicated to the laboratory.
Alternatively, 24 hour composite samples (e.g. urine or saliva) can be useful toestablish comparable results. Cortisol as a stress indicator is a familiar example.
The highest cortisol concentration can be measured in the mornings.

μg/dl

30
25
20
15
10
5
0

Cortisol

0
5

Note:
The circadian rhythm (thebiological clock) can be disrupted
by travelling to different timezones and/or shift work. Ifparameters have been affectedby daily rhythm, this issue
should be included in questions
concerning medical history.

6

12

18

Chronic alcohol abuse causes an increase in liver enzymes, e.g. Ȗ-GT, AST/ALT
whilst folic acid and vitamin B6 values decrease.

Deviations in %

-50
4

0

50

150

250

350

450

Seelig et al; Präanalytik; 2008

Substance use: Nicotine
Chronic nicotine use increases the counts of leucocytes, tumour markers such as
CEA (highly signiﬁcant in men) and placental AP (PLAP).

24

Sarstedt; Tips & Techniques in Preanalytics; 2014

Deviations in %2.1.2 Modiﬁable inﬂuencing factors
Drug use
In the case of regular drug use, e.g. cannabis, heroin or morphines, clinicalchemistry parameters can change in the blood. Below are some examples of thesechanges:With cannabis use the levels of chloride, urea, insulin, potassium and sodiumincrease in the blood. In contrast, glucose, uric acid and creatinine levels fall.
The levels of cholesterol, potassium and thyroxine increase during heroin use.
During the intake of morphines there is a rise in ALT, amylase, AP, bilirubin, lipase,prolactin and TSH. Insulin and noradrenaline decrease during morphine use.

14

a-GT
AST
Noradrenaline
Adrenaline
Cortisol
Triglycerides
CHOL
VMA
LDL

+1000 %

-60
3

-40

-20

0

20

40

60

80

ACE
Prolactin`-carotenoids
Pyridoxal phosphate
Selenium
HDL cholesterol
LDL cholesterol
Cholesterol
Haematocrit
MCV
Fibrinogen
Copper
MCHC
Cadmium
Monocytes
Lymphocytes
Granulocytes
CEA

Seelig et al; Präanalytik; 200815

Substance use: Caffeine

Effect of body position

Even 200 mg caffeine (2 cups robusta coffee or 2-4 cups arabica coffee) increases
levels of adrenaline, noradrenaline and cortisol (cortisol +40%).

The distribution of water in the body depends on the position of the body. This leads
to parameters such as blood cells, proteins and substances bound to proteins being
more concentrated in seated patients than in lying patients.

Medication use
Under the inﬂuence of penicillin and ibuprofen, the level of potassium in plasma canincrease, whilst under the inﬂuence of insulin it decreases. With penicillin use, thethromboplastin time (Quick) increases.
Due to the intake of acetylsalicylic acid (ASA) the levels of AST (GOT), ALT (GPT),
creatinine and uric acid rise, depending on the dose.
The medication phenobarbital, which is used to treat epilepsy and for anaesthesia
induction, has an enzyme-inducing effect. The activity of AP and y-GT increases
whilst bilirubin concentration in the blood decreases.
Diuretics also have an effect on the electrolyte balance. This is seen, dependent on
the substance class, in the levels of potassium, calcium and magnesium, for example.
If pantoprazole (proton pump inhibitor) has been administered, the concentration of
calcium in the blood may be reduced.
Laxatives can lead to a reduction in potassium.

HDL cholesterol
Haematocrit
Erythrocytes
Aldosterone
Adrenaline
Renin
0
5

5

3

Albumin, total protein

Creatine kinase (CK)
Pyruvate kinase
AST (GOT)
Urea
Uric acid
Inorg. phosphate
GlucoseAlbuminCalcium
Alk. phos.
SodiumPotassium
4

50

60

Change in %FastingStandard meal

- 10

+5
+ 15

Calcium+5- 50

GlucoseAST (GOT)

+ 15
+ 30

ALT (GPT)
Uric acid

+ 20

+5

Urea

- 20

+5

Creatinine

+ 10
+ 20

Phosphorus
Triglycerides
4

+ 20
+ 10

Potassium

Sarstedt; Tips & Techniques in Preanalytics; 201416

40

Bilirubin
a-glutamyltransferase (a-GT)

5Physical activity in this case refers to exceptional physical stress. For healthy people,
this can be a marathon whereas for bedridden patients just the journey to the clinic
can count as exceptional physical stress.

30

Sarstedt; Tips & Techniques in Preanalytics; 2014

Analytex-fold increase in the values

20

Diet-related changes

Physical activity, as compared with the condition at rest, can cause an increase invarious clinical chemistry parameters in the blood.

2

10Changes in analyte concentrations with 4 weeks of fasting or after a standard mealof 800 kcal.

Physical activity

1

Increase in %

+ 15
- 40

Seelig et al; Präanalytik; 2008

17

2.2

Interference factors are classiﬁed as internal (endogenous) or external (exogenous).
Examples of interference factors are described below:

Interfering factors

Interfering factors can alter test results and cause disruptions, depending on
methods used.
By changing the test method it may be possible to eliminate interfering factors.

Internal interference factors (endogenous)
Cause

Consequence-¤ Hyperbilirubinemia = jaundice¤ Possible disruption, e.g. in

Gilbert’s syndrome
Crigler-Najjar syndrome
Acute hepatitis
Acute liver failurecholesterol, creatinine, uric acid- Spherocytosis- Immune haemolysis- Haemolytic antibodies- Haemoglobinopathy¤ Haemolysis¤ Signiﬁcant falsiﬁcation of a large- Hyperlipoproteinemia- Lipid metabolism disorder¤ Lipaemia¤ Patient not fasting at time of blood

number of methods of opticalmeasurement¤ Higher measurements due to therelease of erythrocytes(e.g. potassium, LDH, AST)

collection¤ Signiﬁcant distortion of a large
A

Image

Description

BC

number of methods of opticalmeasurement False-low levels
in electrolyte analyses (sodium,
potassium) due to dilution effectD

6

Lipaemia

Disease-related or patient did not fast

B

Jaundice

Syndrome or disease-related

C

Haemolysis

Preanalytical error or disease-related

Normal¤ Elevation of PTT and aPTT6- Haematocrit < 20%¤ Reduction in PTT and aPTT

Possible cause

A

D- Haematocrit > 65%

Good and correct preanalytical conditions

G. Endler et al; The importance of preanalytics for the coagulation laboratory; Hämostaseologie 2/2010; 30: 63-70

External interference factors (exogenous)
Cause- Medication (infusion solution, antibiotics,
blood products)- Anticoagulants (contamination due tocarryover from preparation)- Contamination (bacteria, fungi, bacterial
bioﬁlm from CVC for blood culture)- Cycling or riding

18

Consequence¤ False measurements(elevation and reduction possible)¤ Can increase the PSA value

19

3 Venous bloodcollection

3.1

Patient preparation

Informing the patients Informing the patient about the forthcoming procedure helps to alleviate possible
anxiety and stress.

Explaining certain regulations
that must be complied with should supplement the patient information, e.g.
s Use of medicationss Adherence to a particular diets Sample collection when fasting (except for emergency diagnostics)
Children in particular require careful preparation but the information must be adapted
to their ability to understand.

3.2

What is the responsibility of the personcollecting the blood?

s Organisation of the blood collections Correct documentation (patient identiﬁcation and time of day)s Instructing and preparing the patient for the sample collections Preparation of the sample (centrifugation if necessary)s Storage until collection (refrigeration/heating if necessary)“Venous blood is the most important material tested toanswer medical questions.
Correct blood collection technique is thus ofconsiderable signiﬁcance.”

Note:

Communication with the laboratory and, where
necessary, with the transport service is essential forthe transport and correct storage!

You can ﬁnd more information in Section 10 – Transport & storage.

20

21

3.3

Identiﬁcation

Patient identiﬁcations Surnames First names Date of births Possibly: admission number, ward, room number

Errors occur not only with common names.
Important:
Never:

Always ask direct questions.
“You are Mr Miller?”

When asked of patients who are partially/completely deaf or cognitively impaired,such questions may be simply answered with an afﬁrmative nod.
The person seated on the side of the bed may just be a visitor.

Identiﬁcation of the samples Never analyse sample containers that are not clearly identiﬁed.
s Barcode labels enable reliable identiﬁcation.
s Identiﬁcation should always be placed on the primary receptacle.
s Use only waterproof felt-tip pens for glass or plastic containers.
s Additives (anticoagulants, clot activators, gel) are identiﬁed bycolour coding of the sample container. A lack of international
standardisation means that additional identiﬁcation may benecessary.

Never use the lid, outer packaging ortransport container to identify the sample.

If the identity of the patient is not clear, samples should not becollected until there is further clariﬁcation.

Identiﬁcation of the person collecting the blood
It must be possible to determine the identity of the person who collected thesample.
s Place identiﬁcation on the request form if appropriate
Questions about the type and time of the collection, the patient’s condition andother important details may be of use in case of unclear results.

Identiﬁcation of the ordering doctor
The identity of the requesting doctor makes it possible to ask questions in the event ofs illegible requests (e.g. referral notes)
s erroneous requests (e.g. prostate phosphatase for a female patient)s restriction to the most relevant analyses if the volume of the sample material is too
small

22

23

Legal requirements & labelling

3.4

s The submitted analysis material and any parts of this material must be able to beclearly assigned to one patient. If this is not possible, the material must not beprocessed by the medical laboratory.
7

Application
Preparation

Application

Serum

Clinical chemistry, serology, special analyses

Serum gel

Clinical chemistry, serology (only routine diagnostics)

Lithium
heparinPlasma collection for clinical chemistry, serology

EDTA K

Haematology (e.g. Hb, Ht, erythrocytes, leucocytes)

Citrate 1:10

Coagulation analyses (e.g. Quick, PTT, TT, ﬁbrinogen)

Citrate 1:5

BSG determination according to Westergren or
S-Sedivette®

Fluoride

Glucose determination Lactate

GlucoEXACT

Glucose determination (48 h stability, at RT)

RiLiBÄK; § 6.1.7. Part A

Solution: Label sample tube with the barcode immediately before collecting
the blood.

®

®

®

Name

Name

Name

Name

s Sample tubes are correctly labelled if: the contents are still freely visible
 it is possible to check the ﬁlling volume
 the screw cap can be easily removed
 the tube and label do not get stuck or
stick together in the centrifuge

24

Nam
e



25

3.5

Order of draw

3.6

In the past, the correct order of draw was repeatedly and intensively discussed. The
latest ﬁndings and studies show that when using a modern blood collection system,
carryover of additives is highly unlikely with proper handling of a closed bloodcollection system. For example, when collecting with the Safety-Needle and the
S-Monovette®, no carryover of EDTA is detected.8
In case of carryover of EDTA into a serum or heparin tube, potassium may beelevated and calcium lowered, for example.9
To ensure the greatest possible safety even for the worst possible conditions during
blood collection, we nevertheless recommend adhering to one of the following
drawing orders:
89

Avoiding underﬁlling

To avoid erroneous measurements or rejection of samples in the laboratory due tounderﬁlling, a precise ﬁlling volume is necessary. This should be taken into accountfor all preparations.
Precise ﬁlling of the blood collection system is of particular importance for citratetubes for coagulation analyses.
Underﬁlling here results in an excess of citrate in the tube (ratio of blood topreparation). Because citrate binds calcium, more calcium will thus be bound than is
expected. This has a direct effect on the analysis results.
If when collecting blood with a Safety-Multiﬂy®-Needle, citrate blood is collected ﬁrst,
this leads to underﬁlling due to the dead volume in the tubing.

RA Sulaiman, Effect of order of draw samples during phlebotomy on routine biochemistry results; J Clin Pathol. 2011 Nov;64(11):1019–20
RR Calam et al; Recommended “Order of Draw” for Collecting Blood Specimens into Additive-Containing Tubes; Clin. Chem.;
Vol. 28, No. 6, 1982

Note:

The longer the tubing used,
the greater the underﬁlling

Recommended order of draw
10

10
11

11

According to Gurr :According to CLSI :Blood culture

Blood culture

Serum/Serum-Gel blood

Citrate blood

Citrate blood

Serum/Serum-Gel blood

Heparin/Heparin-Gel blood

Heparin/Heparin-Gel blood

EDTA blood

EDTA blood

Fluoride/Citrate-ﬂuoride blood

Fluoride/Citrate-ﬂuoride blood

Dead volume = volume in the tubing:
30 cm tubing: > 450 μL
20 cm tubing: > 300 μL
8 cm tubing:> 120 μL

Underﬁlling!

Therefore, to ﬁll/vent the tubing, a tube (citrate/neutral) is ﬁrst used and thendiscarded (empty tube/discard tube). Only then is the actual citrate tube to be used.

Gurr et al “Musterstandardarbeitsanweisung Präanalytik” J Lab Med 2011
CLSI Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture, Approved Standard,
6th edition GP 41-A6 (former H3-A6), 27 (26) 2007

26

27

4 Carrying out
venous bloodcollection

4.1

s No unusual, extreme physical activities in the 3 days prior to blood collections No alcohol excess on the day before (abstain from alcohol for 24 hours)s Fasting between 7 pm and 9 am (i.e. no eating for 12 to 14 hours, drinking wateris allowed)s Rest for at least 10 minutes before the blood collection (sitting or lying)s Avoid pumping! Opening and closing the ﬁst leads to a considerable increase in
the potassium level (up to 2 mmol/L)s Apply a tourniquet for a maximum of 1 min. (better 30 seconds)s Puncture vessel, loosen tourniquet, collect bloods Medications: in consultation with the doctor, take or discontinue

4.2“The technique for venous blood collection– step by step – for correct procedure in the clinic”

28

Standard conditions for blood collection

Obtaining diagnostic samples: 12 steps

1. Disinfect hands! Wear gloves!
2. Apply tourniquet
3. Observe veins and select one
4. Disinfect!
5. Do not touch the puncture site again!
6. Remove the protective sleeve from the Safety-Needle!
7. Face the bevelled edge of the needle upwards!
8. Keep the puncture angle less than 30°!
9. Pull the skin until it is taut, ﬁx the vein!
10. Possibly forewarn the patient!
11. Loosen the tourniquet when the blood starts to ﬂow!
12. Collect sample; note the order of draw!

29

4.3

Tourniquet application & puncture sites
Disinfect in accordance with avalid hygiene plan

Stasis time
Stasis lasting longer than 1 minute can lead to shifts in the concentration of
measurements. In the case of high-molecular substances (e.g. total protein) andprotein-bound calcium, false-high measurements can occur (generally very relevant
for parameters with relatively narrow reference ranges). Potassium levels can drop
as constriction time increases.

Comparison – 2 min stasis versus 6 min stasis
Apply the tourniquet one hand’s
width above the puncture site

15

The pulse must be perceptible(tourniquet pressure:
50-100 mmHg)

10

Medical deviation of t0 in %A hand’s width above
the puncture site

Maximum constriction time:
1 min.
5

2

3

A

4

Bilirubin
Bilirubin
Cholesterin
Cholesterin
Iron, ALT
Eisen,ALT
GGT
Protein, GGT
Protein,
CKAlbumin,Albumin,CK
AST,
TG
AST, TG

5

Calcium
CalciumCreatinine
Kreatinin

06Natrium
Natrium1
GlucoseGlucoseKaliumPotassium-5Puncture sites
 Basilic vein
 Median cubital vein (this refers to the non-blue translucent, thick, deep veinthat is only visible as a bulge at this point) Cephalic vein, runs on the thumb side Cephalic vein
 Basilic vein
 Dorsal venous network of hand

30

2

4

6

Constriction time (min)12

Lichtinghagen et al.: Einﬂuss der Stauzeit auf normalisierte Laborwerte; J Lab Med 2013; 37(3): 131–137

31

4.4

Problems before/during blood collection

Very difﬁcult vein conditions
s Look for another puncture site
s Apply a heat pack or warm cloths Use Safety-Multiﬂy® needles Use the aspiration method to collect the blood

4.5

Aspiration and vacuum technique4.5.1 S-Monovette® aspiration techniqueStopping blood ﬂow during collection
Needle opening is up against
the vein wall
Solution:
Withdraw the needle slightly until the ﬂow
is restored.

IMPORTANT:s Just before puncturing the skin, lock the Safety-Needle to the S-Monovette® bytwisting it slightly clockwise.

Needle has pierced the vein
Solution:
Withdraw the needle slightly until the
blood ﬂow is restored.

Vein has collapsed
Solution:
Wait until the vein has recovered, thencarefully aspirate.

s Pumping the ﬁst leads to an increase in K+ and Mg2+ due to muscle activitys Extended stasis changes parameters such as K+, a-GT
s Bending the Safety-Needle is not necessary when using the S-Monovette®
system because the penetration angle is very ﬂat. Changing the lumen bybending the needle can damage cells (haemolysis).
s Haemolysis can also be caused by using a needle that is too narrow.

32s Use the thumb of the free hand to pull the skin taut.
Hold the vein in place. Forewarn the patient and puncture the vein.
As soon as the vein is successfully punctured, the ﬁrst drop of blood enters the
S-Monovette®. This lets the user know that the vein has been reached.

s Loosen the tourniquet and slowly withdraw the plunger.
Wait until the blood ﬂow stops.

33

Snap








Click



s Change the S-Monovette for multiple collections. Remove
the S-Monovette® from the Safety-Needle by turning it slightly
anticlockwise. The needle remains in the vein.
®

IMPORTANT:

Pull the plunger
straight back until
the piston locks
in with an audible
CLICK.

After blood collection

Only then should
you break theplunger off.
SNAP!




Pull the piston rightÖ
out to the endÖ

For all S-Monovettes, when blood collection
is complete, withdraw the plunger into the“snap” position and break off.

s First remove the S-Monovette® and then withdraw the
Safety-Needle from the vein.

SNAP!
CLICK!

34

35

4.5.2 S-Monovette® vacuum technique4.5.3 A summary of the 2 collection techniques
Aspiration technique

Vacuum technique

Snap

 



Click

s The Safety-Needle must already be in the vein before the collection.
As a rule, we recommend ﬁlling the ﬁrst S-Monovette® with the aspiration
technique so that the blood collection starts gently. The collection can thencontinue using the vacuum technique.
s Immediately before blood collection, pull the plunger back and lock the piston into
the base of the S-Monovette (“click”). Then break off the plunger (“snap”).
s Push the evacuated S-Monovette® onto the Safety-Needle and secure by twisting
clockwise.

s Wait until the blood ﬂow stops, remove the S-Monovette® from the Safety-Needle
and then remove the Safety-Needle from the vein.

36

37

4.6

Haemolysis risk factor: Catheter

Blood collection from catheters

With blood collection from catheters, the vacuum technique is not recommended
due to the high ﬂow velocities of the blood. This is associated with a high risk of
haemolysis.14-17

Blood collection from catheters
should be avoided due to possible
distortion of measurements.
Haemolysis and contaminationfrom infusions are possible risks.
However, if blood collection froma catheter is unavoidable, comply
with the following:

Using the aspiration technique, slow, gentle ﬁlling18 of the S-Monovette® ispossible. This greatly reduces the risk of haemolysis.
14

Margo A et al.; Obtaining blood samples from peripheral intravenous catheters: best practice; AJCC, 9.2009, 18 (5)Lippi et al.; Prevention of hemolysis in blood samples collected from intravenous catheters; Clin Biochem 46: 561–564, 2013
Heyer et al.; Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory medicine best practices systematic review
and meta-analysis Clin Biochem 45: 1012-1032, 201217
Grant MS; The Effect of Blood Drawing Techniques and Equipment on the Hemolysis of ED Laboratory Blood Samples; J Emerg Nurs
29:116-121, 200318
Benso S; Can a blood sample for diagnostic exams be drawn from a peripheral venous catheter?; Assist Inferm Ric; 34(2):86-92;
Apr-Jun 201515
16

s To avoid dilution effects and contamination, at least 15 minutes should elapse
between the last infusion and the blood collection. The time depends on theinfusion and should comply with internal hospital regulations.6
s Recommendations for the time of blood collection after infusions1
Infusion

Earliest time (hours) for blood collection afterending the infusion1

Lipid emulsion

8

Carbohydrate-rich solution

1

Amino acids, protein hydrolysate

1Electrolytes

1Multi-Adapter – the direct connection
The S-Monovette® can be directly connected to the catheter with the Multi-Adapter.
The use of single-use syringes and the associated risk of haemolysis and crosscontamination can be avoided.

s If the catheter has been rinsed with solution containing heparin, it should be
rinsed with saline before blood collection for coagulation analyses.13
s Before the blood collection, at least 5-10 ml of blood should be discarded. To
avoid any mix-ups, this tube should be appropriately labelled.13
As a rule, a note to the laboratory that the sample was collected from a catheter cansimplify the interpretation of any implausible analytical results. For therapeutic drug
monitoring (TDM), the risk of a contamination must be noted in particular. See pageof traces of medication can lead to erroneously high results.
1
6
13

Guder et al; Proben zwischen Patient und Labor; 2009
G. Endler et al; The importance of preanalytics for the coagulation laboratory; Hämostaseologie 2/2010
M. Spannagl et al; Hämostaseologische Globaltests; Hämostaseologi 1/2006

s The Multi-adapter can be connected to the S-Monovette® with Luer connections,e.g. in vitro catheter or three-way stopcock.

38

39

4.7

Blood collection for blood culture diagnostics

Sepsis is known colloquially as blood poisoning. What is not as well known is thatthe mortality (lethality) is about 50%19.

4.7.1 Hygiene requirements
False-positive blood cultures result, as a rule, from improper hygiene measures andmay be associated with extended hospitalisation, unnecessary antimicrobial therapy,
additional diagnostics and considerable extra costs.21

Common symptoms:s Apathy/weakness
s Fever, chillss Confusions Laboured and rapid breathings Rapid pulse, low blood pressures Cold hands and feet with poor blood ﬂow (centralisation)

Sepsis is an emergency that requires the earliest possible diagnosis and immediate
treatment: international and national treatment guidelines stipulate administration of
antibiotics within one hour. Before administering antibiotics, at least 2 blood cultures
must be collected.
It is recommended to collect the blood at the start of a fever episode from aperipheral vein.
Blood collection from a venous access (e.g. CVC) is not suitable.
The validity is affected to a high degree by the avoidance of contamination, thetransport time, storage conditions and communication of clinical information.21

Blood collection using blood culture ﬂasks must be done in accordance with thehygiene requirements.

To avoid contamination, the following steps are necessary:
1. Hygienic hand disinfection
2. Wear gloves
3. Disinfection of the puncture site (e.g. with 70% isopropyl alcohol or skindisinfectant)a. Apply the disinfectant and distribute by wiping
b. Apply disinfectant again and let it dry for 60 seconds

Important: After the skin disinfection, do not palpate the puncture site again.
4. Disinfect the blood culture ﬂasks
a. Remove the cap
b. Disinfect the rubber septum

The following information should be communicated to the laboratory20:s Site of collections Date of collections Patient identiﬁcations Suspected diagnosiss Details of the ongoing antibiotic therapy if applicable
19

Pschyrembel; 2004
J. P. Borde et al; Abnahme von Blutkulturen; Dtsch Med Wochenschr; 135:355-358; 2010
21
Simon et al; Blutkulturdiagnostik – Standards und aktuelle Entwicklungen; J Lab Med; 36(4):199–207; 2012
20

40

21

Simon et al; Blutkulturdiagnostik – Standards und aktuelle Entwicklungen; J Lab Med; 36(4):199–207; 201241

4.7.2 Handling during blood collection
4. You can then carry out the blood collectionin the usual manner with the Safety-Multiﬂy®
needle.

1. Carry out the hygiene steps listed above.
Connect the universal blood culture adapter
to the guide sleeve of the Safety-Multiﬂy®
needle.
Puncture the vein and ﬁx the needle inplace.

21G

21G

2

1
2
1

2
1

2. Insert the blood culture ﬂask in an upright/
vertical position into the holder. The culture
medium of the ﬂask must not contact the lidof the blood culture ﬂask.
Because of the vacuum in the blood culture
ﬂask, it ﬁlls automatically.
Note: Note the ﬁlling volume.

21G

1
2

42

3. If additional blood collections are requiredwith the S-Monovette®, remove the universal
blood culture adapter from the guide sleeveof the Safety-Multiﬂy® needle.

21G

1
2

Important:s The manufacturer’s instructions for handling the blood culture ﬂasks must be
followed.
s After the blood collection, the contents must be carefully mixed.
s Do not aerate the ﬂask as this is not necessary.
s The inoculated ﬂask must be sent at room temperature to the laboratory as
quickly as possible.

4.7.3 Sample volume and number of ﬂasks
Note:
The blood volume should be checked during the collection using the scale. The
vacuum volume of the ﬂask may be larger than the required ﬁlling volume.
Marking the ﬁlling level on the ﬂask before the collection simpliﬁes checking theblood ﬁlling volume during the collection.
The sensitivity of the blood culture diagnostics depends on the number of pairs
collected and the sample volume.
There are different recommendations regarding blood volume, number of blood
culture pairs and the use of aerobic and anaerobic ﬂasks.
Always follow the manufacturer’s information for this reason.

43

5 Blood collection
in paediatrics

Paediatrics
Paediatrics is the branch of medicine dealing with children and adolescents. An
important focus of paediatrics is neonatology, the treatment of premature infants.
Premature infants are viable from week 23 of pregnancy provided the infants have abirth weight of about 500 grams.
These small patients have special needs and place high demands on personnel andcollection systems.

5.1

Medical history24

The details of the paediatric medical history are obtained by asking a third party,
usually a parent or legal guardian.
School-aged children should always be asked directly.

The medical history should include the following informations Details of the current illness
s The complete medical history of the childs Details of the pregnancy and births The medical history of the families of the parents

Important:
A child may still present in relatively good general condition despite a life-threatening
disease. The patient may deteriorate during the recording of the medical history, theclinical examination or even after hospitalisation.

“Paediatric and neonatal patients have special needs
and place high demands on personnel andcollection systems”

44

24

Speer et al; Pädiatrie; 2013

45

5.2

Prerequisites for blood collection

5.3.1 Venous blood collection

Between 7 months and 3 years of age, resistance from the child may prevent normal
blood collection.

For venous blood collection, there is a choice between closed venous bloodcollection and the drip technique (e.g. from a cephalic vein).

To ease the situation, the following tips may help:

Puncture sites Shorter waiting timess Bright, warm and child-friendly rooms with toys for allages
s Small gifts (particularly plasters, bravery awards, etc.)
s Friendly, understanding atmospheres If necessary, treat the child on the parent’s lap
s Warm hands and equipments Consider feelings of embarrassment even in childhood

Cephalic vein

Premature
infantNeonateInfantOnly if < 1 week Recommended Recommended

Toddler

School child--

Brachial vein

Perhaps

Perhaps

Perhaps

Recommended

Recommended

Back of hand

Recommended

Recommended

Possible

Recommended

Recommended

Top of footRecommended

Recommended

Possible

Perhaps (painful)-

Closed venous blood collection

5.3

Blood collection in paediatrics

The total blood volume of a healthy neonate is about 300 ml. A premature infant of
1,000 g has a total blood volume of about 80 ml. Because of this small volume, it isessential to collect as little blood as possible while still ensuring as much blood asnecessary is collected.
In addition, sample collection from premature infants, neonates and infants can beproblematical. Choosing the correct collection technique combined with suitablesample tubes eases these difﬁcult conditions as much as is possible.

46

Thanks to the option for gentle blood collection
using the aspiration technique (see Section
4 – Carrying out venous blood collection), the
S-Monovette® combined with the short
Safety-Multiﬂy® needle is the optimal solution
for difﬁcult vein conditions in paediatrics.

47

Drip blood collection

5.3.2 Capillary blood collection

The Micro-Needle combinedwith the prepared Micro Tubes
simpliﬁes blood collection from thecephalic vein.
Difﬁcult handling of broken Luer
needles is no longer necessary.
Broken needles are small,cumbersome and may cause
haemolysis (formation of burrs in
the needle).

For capillary blood collection, the Neonatal Safety Lancet or the Safety Incision
Lancet can be used depending on the patient and the blood volume required.

Comparison of the Safety-Lancet and the Safety Incision Lancet
Standard Lancet:

Incision Lancet:

s Vertical ﬁring direction of
the blades Cylindrical punctures Haematoma formations Crescent-shaped incision paths Shallow penetration depths Minimises formation of
haematoma

Handling the Micro-Needle
1. Remove the protective cap.

2. Remove the Micro-Needle from the protective sheath.

Safety-Lancets Mini and Neonatal are suitable for collecting small or medium to highvolumes of blood, as required.
DesignPenetration depth

Needle size

Blood volume

3. Disinfect the puncture site. Puncture the vein anddrip the blood into a prepared Micro Tube.
If the blood ﬂow stops, the Micro-Needle can besafely rotated by 360° using the handle.

Neonatal

1.2 mmBlade 1.5 mm

Medium to high

4. Place the Micro-Needle in a suitable disposal box.

Mini

1.6 mmNeedle 28 G

Low

If there is a risk of bone injury, however, Incision Lancets are recommended because
these have a shallower penetration depth.

48

49

Microvette®

Product range – Safety Incision Lancet
Thanks to the special puncture technique, optimal blood ﬂow with a high blood
volume is possible even with a shallow penetration depth. The shallow penetration
depth ensures rapid healing and minimises the formation of haematomas.
DesignApplication

Penetration depth

Incision length

Neonates

1.0 mm

2.5 mmDepending on the requirements, Microvette®
tubes with a cylindrical or conical inner tube
shape and a volume range of 100 to 500 μl
are available. There is the option to collectcapillary blood using the capillary techniqueor the collection rim.

Premature infants

0.85 mm1.75 mm

The special cap design minimises any
aerosol effects when the tube is opened.

Handling the Safety Incision Lancet
1

Select and disinfect asuitable puncture site.

After pressing the ﬁring
button, remove thelancet from the heel.

4

Microvette® – Collection methods
To meet the speciﬁc requirements of capillary blood collection, there are twocollection techniques available: Capillary method using the end-to-end capillary
 Gravitational principle using the collection rim
2Remove the safetymechanism bypressing sideways withthe thumb.

Dispose of the lancet ina suitable disposal box

5

Note:

5.4
Lift the foot into a suitable
position. Press the blade
opening ﬂat against the
selected and disinfectedpuncture site and press thetrigger button. The safety
incision lancet must always be
positioned and triggered parallelto the length of the foot (neveracross the heel)! The triangle
points to the blade exit point.

Discard the ﬁrst dropof blood. Then ﬁll thecapillary tube.

6

200

3

EDTA

The difference between capillary blood and venous blood

Taking into account the sample material is important for assessing the analyticalresults. Between capillary blood and venous blood there are differences in theconcentration of various parameters. For example, the serum concentrations of total
protein, bilirubin, calcium, sodium and chloride are signiﬁcantly lower in capillary
blood compared to venous blood.23
Glucose, lactate and CK, however, have higher levels of concentration in capillary
blood than in venous blood.
23

50

Letting blood drip into a capillary tube by means of aLuer needle does not constitute capillary bloodcollection.

Kupke et al; On the composition of capillary and venous blood serum; Clin Chim Acta. 112(2):177–85; 5 May 1981

51

5.5

Reference ranges

AnalyteAnalyteSamplesourceSI

Conventional

μmol/L

mg/dL

NeonateBilirubin(total)

Day 1

< 68

<4

Day 2-3< 154<9

Day 3-5< 239< 13-14

Infant1.7-14

0.1-0.8

Adult

1.7-22

0.1-1.3

mmol/L

mg/dL

Child/Adult

0.5-2.2

4.5-20

Neonateμmol/L

mg/dL

Day 1

37-113

0.41-1.24

Week 114-86

0.15-0.95

Week 412-48

0.13-0.53

Infant22-55

0.24-0.61

Toddler25-64

0.28-0.70

Children

23-106

0.25-1.17

Adult74-1100.81-1.21

LactateCreatinine

52

Remarks
Indirect bilirubin inneonates may beelevated due to increased
breakdown of erythrocytes.
Value > 16-18 mg/dl risk ofkernicterus.
In neonates, direct
photometric measurement
is possible, direct bilirubincannot be detected inhealthy children.
Neonates can have higher
values on day 1.
Elevated in
mitochondriopathy, tissue
hypoxia, etc.

Values depend on muscle
mass; women have lower
values.
Creatinine concentration in
the serum only increases
when the glomerular
ﬁltration rate is < 50%.

Haematocrit (HCT/Ht)

Kohse et al.; National and international initiatives and approaches for the establishment of reference intervals in pediatric laboratory
medicine; J Lab Med 2015; 39(4): 197-212

Haemoglobin (Hb)56

Erythrocytes

Depending on the age of the child, concentrations of analytes in different ranges
are normal compared to adults. For this reason, it is important to always assess theanalytical results relative to the age-appropriate reference/standard ranges56.
Some parameters are shown in the following table as examples.

SamplesourceSI

Conventional

Tpt/L(1012/l)106/μl

3.9-6.5

3.9-6.5

3.6-5.8

3.6-5.8

Infant

3.0-5.4

3.0-5.4

Toddler Child

4.0-5.4

4.0-5.4

Adult (m)4.5-5.9

4.5-5.9

Adult (f)3.9-5.2

3.9-5.2

Fraction I/I%

Neonate0.45-0.65

45-65

Infant0.30-0.55

30-55

Toddler Child

0.31-0.48

31-48

Adult (m)0.39-0.52

39-52

Adult (f)0.35-0.4735-47mmol/lg/dl

9.3-13.7

15-22

7.8-12.4

12.5-20

Infant5.9-9.9

9.5-16

Toddler / Child

6.8-9.9

11-16

Adult (m)8.1-11.2

13-18

Adult (f)7.5-9.3

12-15

NeonateWeek 1
NeonateWeek 2

NeonateWeek 1
NeonateWeek 2

Remarks

Rapid breakdown after
birth.
Elevated (polycythaemia)with dehydration and with/after sustained high levels.

Ht elevated withdehydration, lowered withhyperhydration

53

Analyte

Platelets

SamplesourceSI

Conventional

Gpt/l (109/l)

103 Cells/μl

Neonate100-250

100-250

Toddler

220-500

220-500

Children150-350150-350Adult

150-400

NeonateDay 1
NeonateLeucocytes
Weeks 1-4
Infant/Toddler/
Child
Adult (m)24

Remarks

Age-related reference values (example reference value)
AgeaPTT [s]*AgeAntithrombin [%]D-dimers [μg/L]

1-3
Months39 (28-49)

1 day

76 (58-90)1470 (410-2470)

4-6
Months36 (31-44)

3 days74 (60-89)1340 (580-2740)

150-400

7-12Months35 (29-42)

1-12
months109 (72-134)

220 (110-420)

Gpt/l

Cells/μl

Up to 4years

33 (28-41)

1-5 years

116 (101-131)

250 (90-530)

9-35

9,000-35,000

5-9
years

34 (28-41)

6-10 years

114 (95-134)

260 (10-560)

5-20

5,000-20,000

10-18
years

34 (29-42)

11-16 years

111 (96-126)

270 (160-390)

5-18

5,000-18,000

Adults31 (26-36)

Adults96 (66-124)

180 (50-420)

4-10

4,000-10,000

Thrombocytopenia e.g.
due to mumps 30 Gpt/L:
increased bleeding
tendency.

Changes in the leucocyte
count during the ﬁrst
weeks of life/year.
Increases (leucocytosis) areusually caused by elevatednumbers of neutrophil
granulocytes.

* measured with Pathromtin SL
22
Barthels et al; Das Gerinnungskompendium; 2012

Speer et al; Pädiatrie; 2013

5.6

Haemostasis in paediatrics

Some components of the coagulation system change in childhood and dramaticallyso, particularly in the ﬁrst year of life, to adapt to the change in conditions.
Reduced thrombin formation with a simultaneous reduction in thrombin inhibition isa protective mechanism in neonates.
As a rule, neonates have considerably lower values for most coagulation factors
than an adult. The reduced liver synthesis rate in the neonate is usually considered
responsible but an accelerated turnover is also a possibility, particularly regarding thebirth.
Many components reach adult reference values after 1 year of age. Antithrombin is
about 10% higher compared to an adult from 1 month of age and into childhood.
Values for aPTT are generally longer in childhood than in adults. Factor II and VII
remain about 10-20% lower.
Note:

54

Due to a physiologically higher haematocrit, the quantity of plasma in neonates islower.
Haematocrit correction is not necessary here because the age-related reference
values were determined under these conditions and a correction therefore does nothave to be made.
What is important is that sufﬁcient sample material is collected for the required
analyses in light of the low plasma yield.

There are a number of special physiological characteristics
of children of which the user must be aware so that they canbe reliably differentiated from pathological changes.

55

6 Blood gas
6.1

Type of blood collection

Blood gas collection and blood gas analyses are carried out in many different areas
such as emergency admissions, intensive care units, outpatient clinics, operatingareas, cardiac catheterisation and pulmonary diagnostic laboratories.
Because the parameters have different concentrations depending on the bloodvessel (pCO2 is higher in venous blood, the concentration of pO2 and sO2 is lower
in venous blood than in arterial), the puncture site for the sample should be noted
and taken into account (e.g. arterial access, CVC, peripheral artery).25 Arterial bloodshould always be the material of choice.
For children, arterialised capillary blood is often taken from the earlobe or ﬁngertip orfor infants from the side of the heel.
For ventilated patients, the setting of the ventilation equipment should also be noted
and taken into account.
25

Michael D Davis RRT et al.; AARC Clinical Practice Guideline: Blood Gas Analysis and Hemoximetry: Respiratory Care; 58(10); Oct. 2013

Important:

For calcium measurement using blood gas analysers(ISE method), calcium-titrated heparin (balanced, equilibrated)
as in the blood gas capillaries and the Blood Gas Monovette®
must be used. Total calcium must therefore not be determinedusing the Blood Gas Monovette®.

“It is also true for blood gas that the better the
preanalytics, the more meaningful the result”

56

57

6.2

Air bubbles

Storage

Always aim to measure parameters immediately after the blood collection. If themeasurement cannot be done within 15 minutes, the sample should be stored
refrigerated (about 4°C).25
25

To avoid erroneous measurements due to air contamination, air bubbles must be
removed immediately after the blood collection (see venting). The longer the samples
are stored with air bubbles and the larger the air bubble(s), the greater the change inthe values.

Michael D Davis RRT et al; AARC Clinical Practice Guideline: Blood Gas Analysis and Hemoximetry: Respiratory Care; 58(10); Oct. 2013

After storage the samples must be carefully mixed because sedimentation can leadto erroneous measurements of the Hb.

LoweredElevated

pCO2

pH
pO2

Cellular metabolism may lead to changes in the concentration over extended
storage periods.

6.3

LoweredElevated

pH

pCO2

pO2

Calcium

Glucose

LactateTroubleshooting

Clotting
Samples with clots cannot be correctly drawn up into the analytical equipment andthe results will not be representative.

Solutions Use liquid-dosed heparin because this mixes more quickly with the sample.26
s Mix the samples carefully and immediately after the samples are collected.
s Use the mixing aid for the blood gas capillaries.
26

Gruber et al; Heparin release is insufﬁcient in syringes with platelets as heparin source; Clinica Chimica Acta, 395: 197, 2008

58

sO2

Blood collection from a catheter
Contamination by infusions or ﬂushing solutions are possible risks. Before the bloodcollection, it must be ensured that an adequate blood volume is discarded.

Contamination with liquid heparinContamination with NaCl solution

LoweredpO2, Na+, Cl-

Na+, Cl-

Elevated

pCo2, K+, Ca++, gluc, lactate, tHb

Haemolysis
Haemolytic samples have erroneously high potassium concentrations anderroneously low sodium and calcium concentrations.

Possible causes of haemolysiss Shearing forces:s Collection technique:s Temperatures:- Sample shaken too hard during mixing or sample
transport- Too much pressure is applied (milking) to the puncturesite during collection of arterialised capillary blood- Extremly high temperatures in summer- Extremly low temperatures, e.g. sample frozen orplaced directly on ice

59

6.4

Mixing the Blood Gas Monovette®

Collection technique – Blood Gas Monovette®
b21

In contrast to mixing in the inverted position, which is encouraged by the air bubble in the standard S-Monovettes, theprocess of mixing the Blood Gas Monovette® is as follows:a

Place the membrane adapter (item no.: 14.1112) on the Luer lock of the Monovette®
(a) and complete the Blood Gas Monovette® with the Safety-Needle (b) or the SafetyMultiﬂy® needle.

3
Mix the blood sample immediately after collection by rolling the Blood Gas Monovette® between the palms of the hands.
The tubes must be mixed by rolling between the palms of the hands rather than inverting.
®

Important:

Blood gas analyses should be carried out as soon as
possible after blood collection, at the latest 15 minutes
after the samples are collected.

Collection technique – blood gas capillaries
For skin puncture we recommend using the safety lancets, item no. 85.1015 to 85.1019.
Remove the orange protective
cap from the Blood Gas
Monovette®.

Remove the blood sample according to the work instructions. When puncturing theartery, a 45° angle is recommended.

1. Select the puncture site and encourage blood ﬂow.
2.

3. Insert a mixing wire into the capillary and advance until it reaches theattached cap.

3.

1.

2. Attach a cap loosely to the end of the capillary.

Venting the Blood Gas Monovette®

4. Clean the puncture site with disinfectant.
Puncture the skin to produce a good blood ﬂow.
Discard the ﬁrst drop. Remove the attached cap.
Then place the capillary horizontally and hold one end in the middle of theblood drop and ﬁll the capillary completely without any air bubbles.

To avoid erroneous measurements due to air contamination, after completing the blood collection the air must be
removed from the Blood Gas Monovette® as follows:

5. Firmly close both ends of the capillary with the caps.
5.

5.

6. Using the magnet, move the mixing wire back and forth along the entire
length of the capillary 10-15 times to mix the blood with theanticoagulant.

6.

1

2

3

4

Place the ventilator (item no.
14.1148) on the Blood Gas
Monovette®.

Carefully push the plunger
upwards.

Remove and dispose of theventilator.

Place the protective cap on
for the mixing procedure.

60

7. Immediately before the analysis, mix the sample again.
Then position the mixing wire at the end of the capillary.
8. Remove both caps.
9. Allow the analysis equipment to suction up the blood sample.

61

7 Safety whencollecting
blood

Safety – why?
The most important infectious agents that can be transmitted by needle stick injuries(NSI) are hepatitis B virus, hepatitis C virus and HIV.
Using suitable protective measures, these incidents can be almost completely
avoided.27
The EU Directive 2010/32/EU28 Prevention of sharps injuries in the hospital andhealthcare sector requires the safest possible working environment for employees in
the healthcare sector.
27
28

The underestimated workplace accident, infection risk due to needle stick injuries; SAFETY FIRST! initiative
EU Directive 2010/32/EU of the Council of the European Union from 10 May 2010 Prevention of sharps injuries in the hospital andhealthcare sector

Preventive and protective measures
s Introduction of safe working regulationss Maintain general hygienes Vaccinations (against hepatitis B)
s Suitable personal protective equipments Wear glovess Cover any cuts and grazes with waterproof plasterss Avoid unnecessary use of sharpss Provide medical instruments with integrated safety and protective mechanisms
s Forbid the replacement of protective caps on used needles (no re-capping)“Informing, training and providing safe working
equipment are the keys to avoiding needle stick injuries
and the associated risk of infection”

Note:
57

62

Over half of all needle stick injuries occur during disposal.57

SAFETY FIRST, Germany - www.nadelstichverletzung.de

63

7.1

Safety-Needle

7.2

The Safety-Needle is ready to use, thus
sparing the step of attaching the needle in
the needle holder and thus reducing thepotential risk of a needle stick injury at theback of the needle.

Safety-Multiﬂy® needle

The adapter of the Safety-Multiﬂy
iﬂy® needle
is already pre-assembled andforms a ready-to-use unit.
The single-handed operationof the needle protector of the
Safety-Multiﬂy® needle offers
maximum protection.

Handling
After blood collection:
Remove the last S-Monovette® from the
Safety-Multiﬂy® needle.

Handling
After blood collection:1

Detach the last S-Monovette® from the Safety-Needle andthen withdraw the Safety-Needle from the vein.

Hold the needle protector at its back end with your thumbon top and your foreﬁnger below and withdraw the SafetyMultiﬂy® needle from the vein.

Hold the Safety-Needle on the adapter, place the needle
protector on a stable, ﬂat surface and lock the needle into
the needle protector by pressing gently downwards until it
makes a noticeable and audible click.

2aGently hold the tubing by pressing it slightly into the palm of
your hand and push the needle protector over the needle…

Click
Alternatively, you can also activate the needle protector withyour index ﬁnger. For reliable function, ensure that this isdone at the bottom end of the protector.

2b

Click
Click
3

...until the needle is noticeably and audibly locked into theprotective casing.

After activating the protective mechanism:
Discard the safely locked Safety-Needle in a disposal box.

After activating the protective mechanism:
Discard the safely locked Safety-Multiﬂy® needle into adisposal box.

Safety activation is always done with one hand only!

64

65

7.3

Multi-Safe disposal boxes

For collecting sharps, waste containers must be provided and used that meet therelevant regulations TRBA 250 (Technical Rules for Biological Materials – German
regulations) and ISO 23907.

Ź As a rule, when disposing of potentially infected medical single-use items,
ensure they are disposed of in a hygienically correct manner.

These regulations deﬁne the following features of the containers, for example:- Shape and appearance- Container must not rupture when dropped from a particular height in tests- Container walls must resist penetration up to an applied pressure of 15 N
If the sharps containers are supposed to be disposed of through a medical waste
disposal service and are placed on the street, UN certiﬁcation of the disposal box ismandatory. The certiﬁed containers are identiﬁed by a multiple digit UN code that isnormally located on the top of the lid. Disposal boxes without this identiﬁcation must
be disposed of inside a container with this identiﬁcation.

Safe disposal

Recommendation:
Only ﬁll the Multi-Safe container
to about 2/3 of its volume.
Do not overﬁll the Multi-Safe:
Risk of injury!
Note the ﬁlling line

2/3
Filling line noted
See marking

66

Overﬁlled

Safety instructionss Only use containers of a size that is suitable for holding the items to be disposedof.
s The lid must be on the container and locked into place before it is ﬁlled.
s Connect containers with the recommended adhesive adapter by rotating or ﬁxing
by hanging in the wall holder to prevent accidents.
s Do not use the day lid to press down the items to be disposed of.
s Scalpels must be disposed of in the container with particular care. If too muchforce is used when throwing scalpels in or if other items are placed on top, there
is a risk of the angle changing and damaging the container walls or the base of
the container.
s Only place items to be disposed of upright in the container.
s Do not press items into the container with force.
s Do not place any liquids in the container.
s Do not place hands or any other objects in the container (risk of injury).
s Do not throw, shake or drop the container.
s Before sealing the container, ensure that no items are projecting through the
opening.
s Before disposing of the container, carefully check that the lid is tightly sealed.

67

8 Centrifugation
8.1

Correct handling for centrifugation

Most laboratory analyses require serum or plasma, the liquid component of theblood. This is obtained by centrifuging the sample. Inside a centrifuge a rotor withtube holders rotates at a speed of several thousand revolutions per minute.
This rapid rotation produces a multiple of gravity (g) inside the tube holder.
This causes the liquid and solid components of the blood to separate.
What is important is to differentiate between the revolutions per minute and theg force (gravitational force).
The g force is the value that is relevant for a good centrifugation result.
For this reason the g force is of particular importance when setting the centrifuge.
The g force can be calculated using the radius (cm) and the revolutions per minute(RPM):
g = 11.18 × r × (min-1/1,000)2
r = radius in cm
min-1 = revolutions per minuteTo convert from g force to RPM [min-1] or vice versa,
you can use the centrifugation calculator atwww.sarstedt.com/en/service-consultation/centrifugation-calculator.
The centrifuge radius r can be found in the information provided by the centrifuge
manufacturer or it can be determined using the following image:

Fixed-angle rotor

Swinging bucket rotor“Centrifugation is a physical separation process thatis based on the different density characteristics ofsubstances such as blood cells and plasma”

68

69

8.2

Difference between ﬁxed-angle and swinging bucket rotors

8.3

Serum collection
S-Monovette® Serum-Gel withcoated beads to accelerate
coagulation*For gel-prepared S-Monovettes, we recommend using swinging bucket rotors only.
The sample holder is arranged at a ﬁxed oblique angle in a ﬁxed-angle centrifuge.
The sample holder in a swinging bucket rotor moves during the centrifugation froma vertical position to a horizontal position. In this way, the force during centrifugationacts evenly from the lid towards the base.
The result is a well-shaped, horizontal gel layer.

Fixed-angle rotor

Swinging bucket rotor

After blood collection, the serum samples must coagulate for 15–30 minutes.
This means that as the coagulation proceeds, the coagulation factors (e.g. ﬁbrin) areconsumed and the blood cells form a blood clot.
The coagulum forms in the shape in which the blood cells are present in the tube.
This means that if the S-Monovette® is placed horizontally after the blood collection,
the blood cells sediment along the horizontal tube and form a long shape.
The resultant shape can be compressed during the centrifugation. After thecentrifugation, it springs back in a concertina shape (sausage phenomenon).
The serum from such a sample cannot be automatically pipetted.
It is therefore important to store serum samples upright after blood collection.

Sample that has
clotted uprightafter centrifugation

70
Sample that has
clotted horizontally
after centrifugation

71

8.4

S-Monovette® centrifugation conditions

8.5

Gel ascent during centrifugation

Standard
Alternative range Temperature
recommendation

PreparationMin.

S-Monovette®
Serum

10

2,000 x g

1,800 - 2,500 x g

18 - 25°C

S-Monovette®
Serum-Gel*

102,500 x g

2,200 - 3,000 x g

18 - 25°C

S-Monovette®
Li-Heparin10

2,000 x g

1,800 - 2,500 x g

18 - 25°C

0

1

2

3

4

5

10
minutes®

S-Monovette
Li-Heparin-Gel*
or

10
15

3,000 x g
2,500 x g

2,700 - 3,300 x g
2,300 - 3,000 x g

18 - 25°C

S-Monovette®
EDTA-Gel*

102,500 x g

1,800 - 2,500 x g

18 - 25°C

S-Monovette®
Citrate10

1,800 x g

1,800 - 2,300 x g

18 - 25°C

These centrifugation conditions (see p. 72) are recommendations. The values are
based on what we consider to be the worst-case conditions, e.g. an older model
centrifuge that requires considerably more time to reach the necessary g force
than a new high-performance centrifuge. In isolated cases, it may be that thecentrifugation conditions deviate from the standard recommendations shown in thetable while achieving the same results.
The details of the standard centrifugation conditions are always printed on the labelof the inner carton as well.
* For gel-prepared S-Monovettes, we recommend using swinging bucket rotors only.

S-Monovette®
Fluoride/GlucoEXACT72

102,000 x g

1,800 - 2,500 x g

18 - 25°C

73

9 Haemolysis– what is it?

Characteristic feature of haemolysis
If more than 0.5% of the erythrocytes are destroyed, the serum/plasma is
discoloured.

mg/dl29“The destruction of erythrocytes due todamage of the cell membrane leads to leakageof haemoglobin into the plasma/serum. A reddish
discolouration of the serum/plasma can be seen.”

+

++

+++

++++

0

50

150

250

525

After centrifugation, this can be seen as a reddish colour of the plasma or serum.
The cause is leakage of haemoglobin, which gives the erythrocytes their red colour.
Above a concentration of about 20 mg haemoglobin/dl , haemolysis can be seenin the serum/plasma.
The absence of a red colour does not exclude interference due to haemolysis.
Haemolysis – the destruction of erythrocytes – is classiﬁed as in vivo haemolysis(pathological) or in vitro haemolysis (physiological) based on its cause.
29

74

-

CLSI; Hemolysis, Icterus, and Lipemia/Turbidity Indices as Indicators of Interference in Clinical Laboratory Analysis; Approved Guideline;
C56-A; 32(10); 2012

75

9.1

In vivo haemolysis

9.2

In vitro haemolysis

Disease can cause the destruction of erythrocytes within the body. This is referred
to as in vivo haemolysis or haemolytic anaemia.

This type of haemolysis develops outside the body and is responsible for morethan 90% of haemolytic samples. The cause is always due to preanalytics.

Such a disease may be inherited or acquired.

Common causes during blood collection

Inherited

Haemoglobinopathy e.g.: sickle cellanaemia, thalassaemia

Glucose-6-phosphate dehydrogenase
deﬁciency

Defects in the erythrocyte membrane (e.g.
hereditary spherocytosis or hereditaryelliptocytosis)

Pyruvate kinase deﬁciency = erythrocyte
enzymopathy

Acquired
Mycoplasma pneumoniae infection
Cold agglutinin disease
Autoimmune haemolytic anaemia (AIHA)
Autoimmune diseases, e.g.: Lupus
erythematosus, chronic lymphatic leukaemia(CLL)
Infections (e.g.: malaria, babesiosis,
Clostridium)

Mechanical stress in the circulatory systeme.g.: Disseminated intravascular coagulation(DIC) Haemolytic uraemic syndrome (HUS)
Thrombotic thrombocytopenic purpura (TTP)
HELLP syndromes Prolonged/too tight venous stasiss Physical shearing forces (needle too thin, bent needle)s Traumatic venous puncture (poking)s Blood collection from catheters using the vacuum technique15
s Intravenous catheter combined with too large vacuum force31-38
s Infusion solutions (dilution, distortion)

15

Lippi et al.; Prevention of hemolysis in blood samples collected from intravenous catheters Clin Biochem 46: 561–564, 2013

31

Ong, et al. Reducing blood sample hemolysis at a tertiary hospital emergency department. Am J Medicine 2009;122:1054e1–e6.

32

Halm, et al. Obtaining blood samples from peripheral intravenous catheters: best practice? Am J Crit Care 2009;18:474–8.

33

Wollowitz, et al. Use of butterﬂy needles to draw blood is independently associated with marked reduction in hemolysis compared to
intravenous catheter. Ac Emerg. Med 2013;20:1151–1155.

34

ENA’s Translation Into Practice. Reducing Hemolysis of Peripherally Drawn Blood Samples. December, 2012
(Emergency Nursing Association).

35

Heyer et al.; Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory medicine best practices systematic review
and meta-analysis; Clin Biochem 45: 1012-1032, 201236

Grant MS; The Effect of Blood Drawing Techniques and Equipment on the Hemolysis of ED Laboratory Blood Samples;
J Emerg Nurs 29:116-121, 2003

37

Straszewski et al J; Use of seprate venipunctures for IV access and laboratory studies decreases hemolysis rates;
Intern Emerg Med 6(4):357-359, 201138

Dugan et al.; Factors Affecting Hemolysis Rates in Blood Samples Drawn from Newly Placed IV Sites in the Emergency Department;
J Emerg Nurs 31(4): 338-345, 2005

Burns

Drugs, toxins

Blood transfusion from incompatible blood
group

30

Lippi et al; In vitro and in vivo hemolysis, an unresolved dispute in laboratory medicine; 201276

Common causes after blood collections Too vigorous mixing/shakings Transport inﬂuences (too much mechanical stress, e.g. pneumatic tube system)s Sample too old (the risk of haemolysis increases as the sample ages)s Sample cooled / heated too much / frozen

77

9.3

Consequences of haemolysis

9.4

The following parameters are affected:

Release of cell contents – differences in concentration
Substances that are present inerythrocytes in higher concentration(intracellular concentration) arereleased into the serum/plasma(extracellular concentration)
because the erythrocyte membrane
is destroyed during haemolysis.
The result is erroneously
higher measurements.

Iron

Clinical relevanceK+

Slight haemolysis (* 30-60 mg/dl):
LDH, potassium, AST , ALT

LDHModerate haemolysis (* 60-200 mg/dl):
Troponin*, ß-HCG, glucose, CK, PTT, aPTT,
D-dimer (*depends on the method)

ALT
AST

Severe haemolysis (* 200 mg/dl):
All parameters

Release of cell contents – visual interference
During haemolysis haemoglobin, which gives blood its red colour, is released into theserum/plasma. This can lead to erroneous measurement signals during photometricanalyses due to the absorbance of haemoglobin itself.
Erroneous measurement signal = incorrect result

39

Lippi et al Hemolyzed specimens: a major challenge for emergency department and clinical laboratories,
Crit Rev Clin Lab Sci 48:143–153, 2011

Release of cell contents – method-speciﬁc interference
The individual test methods may be affected and interfered with due to the enzymes
released from the cells.
Released cell content

Affects analysis

Free haemoglobin

Bilirubin

Adenylyl kinase

CK, CK-MB

Hydrolase

Coagulation

Note:

The analytical results are altered by haemolysis and do not reﬂect
the conditions in the patient. This can lead to an incorrect
diagnosis, no diagnosis or unnecessary diagnostics.

In many cases, repeat blood collection to determine the correct analytical values isnecessary.
This causes avoidable patient stress, time wasting and additional costs.31,40,41,42

Release of cell contents – shifts in volume
In cases of extensive or severe haemolysis, there may be an increase in the volumeof the liquid fraction in the sample (because there are hardly any or no cells present
any more). This leads to a dilution of the serum/plasma.

78

31

Ong, et al. Reducing blood sample hemolysis at a tertiary hospital emergency department. Am J Medicine 2009;122:1054e1–e6.

40

Cadamuro et al; The economic burden of hemolysis; CCLM 201541

Jacobs et al; Cost of hemolysis; AnnClinBiochem 2012; 49: 412–413

42

P Jacobs et al; Haemolysis Analysis; An Audit of Haemolysed Medical Admission Blood Results; AcuteMed 2010; 9(1): 46-47

79

10 Storage andtransport

10.1

Sample transport

To ensure correct storage, transport conditions and sample shipping, the relevant
shipping regulations43, 44 and the stability of the individual parameters must be taken
into account. This assumes optimal organisation.
Important:

43

P650 IATA/ADR

44

TRBA 100

The sender is responsible for shipping the sample
and choosing the correct transport system.

Sample transport compliant with the Packaging Instruction
P650 of the ADR and IATA

“Sample transport and storage must be chosen
so that the analytical results are not affectedby transport/storage”

80

Before transporting samples of liquid biologicalmaterials in category B in connection withtransport boxes and cases, the sender should
enquire whether the samples will be shipped via aland, rail or air transport route.
The P650 Packaging Instruction, which is also
incorporated in the ADR (European Agreement
concerning the International Carriage ofDangerous Goods by Road) and in the IATA
(International Air Transport Association),
applies speciﬁcally for these individual routes.
These regulations state that samples must betransported in packaging that consists of 3components:s Primary receptacle (leakproof)s Secondary packaging (leakproof)s Outer packaging (rigid; with a minimum dimension of 100 × 100 mm; labelled‘BIOLOGICAL SUBSTANCE, CATEGORY B’ with the UN code ‘UN3373’ printed ina rhombus with a minimum dimension of 50 × 50 mm)
The primary receptacle or the secondary packaging must also be able to withstandan internal pressure of 95 kPA without leakage. There must also be an absorbent
material placed between the primary receptacle and the secondary packaging that
can absorb the entire contents of the primary receptacle.

81In-house transport / TRBA 100

10.2 Inﬂuence of temperature, time and cellular metabolism

For safe in-house transport of samplesof biological working materials andsubstances, these must be transported
in containers that are enclosed, rigid,
non-breakable and leakproof and havean external surface that can be disinfected
and permanently labelled. These containers
must also not be able to be inadvertently
opened by external impacts.44

Concentrations that are measured, change due to the stability of the individual
parameters and cellular metabolism. Mechanical or physical stresses placedon the sample materials may also produce changes.

44

Cellular metabolism
Blood is a living substance. This meansthat there are metabolic processes, thatis, cellular metabolism, occurring in thesample tube after blood collection.

TRBA 100

Transporting “exempt medical samples”
Samples that are not considered infectious substances
in category A and B are not subject to the ADR/IATA
regulations but must be packaged as follows.
3-component packaging consisting of:s Primary receptacle (waterproof)s Secondary packaging (waterproof)s Outer packaging (minimum dimension 100 × 100 mm
with the label “EXEMPT MEDICAL SAMPLE”
or “EXEMPT VETERINARY SAMPLE”)
An absorbent material that can absorb the entire contents of the primary receptacle
must also be placed between the primary receptacle and the secondary packaging.
As a rule, the P650 is the same in both regulations.
Exception:

82

Shipping boxes and transport cases that are used totransport samples of biological substances in category B
must be tested in accordance with the P650 Packaging
Instruction.

Note: Blood is alive!

Effect of storage on various parameters
Parameter

Value

LactateIncreases

Ammonia

Increases

Potassium

Increases

Glucose

Falls

pCO2

Falls

Depending on the parameter, the changes in the values may be prevented by
special stabilisers in the various preparations or by physical separation (gel,Seraplas® ﬁlter, preparing aliquots).

83

Inﬂuence of storage temperature on glucose and potassium

Sample storage and transport

Glucoses Blood samples should be taken to the laboratory for
analysis as soon as possible.
s After centrifugation, separating gels or ﬁlters prevent
diffusion of substances from the erythrocytes into theserum/plasma.

Storagetemperature
4 °C

90
80
70
mg/dL

60
Storagetemperature
23 °C

50
40
30
20

Storagetemperature
30 °C

10
0
0

2

4

6

8

24

Whole blood without serum/plasma separation
using gel or a ﬁlter must not be frozen under any
circumstances.
This would result in complete haemolysis.

48

hours
5

Sarstedt; Tips & Techniques in Preanalytics; 2014

Clinical chemistry:Potassium
Storagetemperature
4 °C

12
10
mg/dL

8

Storagetemperature
23 °C

6

Coagulation diagnostics:

4
Storagetemperature
30 °C

2
0

s For coagulation diagnostics, the sample should be transported at room
temperature (18-25°C) as a rule.6

Haematology:
0

2

4

6

8

24

48

hours
5

s For long-term storage, the serum should be stored at 2-4°C in closed containers.
s Serum or plasma samples can be stored at -20°C for extended periods.
s Special cool transport containers should be used to protect samples
during prolonged transit.
s For some analyses, the sample must be transported promptly(e.g. ammonia within 15 min.).

s EDTA blood for a blood count can be stored at room temperature (18-25°C)
for up to 24 hours.45

Sarstedt; Tips & Techniques in Preanalytics; 2014

Note:

84

There is no ideal temperature.
Correctly collected, fresh samples ensure correct results.

6

G. Ender et al; The importance of preanalytics for the coagulation laboratory; Hämostaseologie 2/2010; 30: 63-70

45

N. Tatsumi et al; Specimen Collection, Storage, and Transmission to the Laboratory for Hematological Tests; International Journal of
Hematology 75; 261-268; 200285

Checklist for transports Seal sample (prevent evaporation)s Store serum/plasma at 4-8°C
s Store uprights Store EDTA for blood count at room temperatures Avoid repeated freezing & thawings Protect from exposure to sunlight for light-sensitive
parameters (e.g. bilirubin)s Use special preparation for stabilisation(e.g. S-Monovette® HCY-Z-Gel for homocysteine)

By complying with the following tips, samples can be transported using a pneumatictube system without signiﬁcant effects on the values.50,51
s Maximum speed 5 m/s
s “Gentle” curves and shapess Brake gently before curves
s Use cushioning lining in pneumatic tube system carrierss Cushioned horizontal sending and receiving zoness Send serum samples only after the coagulation is complete

Pneumatic tube transport systems
Pneumatic tube transport systems can considerably shorten the time between
blood collection and analytical result.46 However, it is not a case of the faster the
better. Poor quality or incorrectly set transport systems can lead to haemolysis andactivation of coagulation.47,48,49
For monitoring, the LDH values, potassium value, leucocyte count, PTT and
D-dimers are compared with and without pneumatic tube transport.

46

Koessler et al; The preanalytical inﬂuence of two different mechanical transport systems on laboratory analysis; Clin Chem Lab Med;
49(8): 1379 1382; 2011

50

Koçak et al; The effects of transport by pneumatic tube system on blood cell count, erythrocyte sedimentation and coagulation tests;
Biochemia Medica;23(2):206-10; 2013

47

Kratz et al; Effects of a pneumatic tube system on routine and novel hematology and coagulation parameters in healthy volunteers;
Arch Lab Med; 131: 293 6; 2007

51

Tiwari et al; Speed of sample transportation by a pneumatic tube system can inﬂuence the degree of hemolysis; Clin Chem Lab Med;
50(3):471-474;201248

Sodi et al; Pneumatic tube system induced haemolysis: assessing sample type susceptibility to haemolysis; Ann Clin Biochem;
41:237 40; 2004

49

Steige et al; Evaluation of pneumatic-tube system for delivery of blood specimens; Clin Chem; 17:1160 4; 1971

86

87

11 Capillary bloodcollection

What is capillary blood?
Capillary blood is a mixture of ﬂuids and is comprised of the blood from arterioles,
venules and capillaries as well as interstitial and intracellular ﬂuids.
Note:

This mixture of ﬂuids cannot be used for a precise coagulation
analysis due to its composition. For this reason, capillary tubes
are not provided with a citrate preparation.

Applications of capillary blood collections Paediatricss Geriatrics
s In adults for blood gas analyses, glucose and lactate measurementss Point-of-care testing

Exclusion criteria for capillary blood collections Quantities > 1 ml (e.g. blood culture)s Coagulation analysess Inﬂammationss Patients in shock

11.1“Particularly in paediatrics and for POCT, obtaining
samples from the ﬁnger tip, heel or earlobe is ofparticular importance”

Carrying out capillary blood collection

 Preparation- Materials- Patient- Puncture site
 Puncture Sample collection

88

89Materials required

Advantages of warming the puncture sites Glovess Swabs Skin disinfectant
s Semi-automatic single-use lancet (Safety-Lancet)s Sample tube (BGA capillary tube, Microvettes, bilirubin capillary tubes, etc.)
s Multi-Safe Box for disposals Plaster, if required (not advised for small children because they are a choking
hazard)s Up to 7x increase in blood ﬂow
s Requirement for capillary blood gas analyses

Patient preparations Identify the patients Inform the patient about why the blood is being collected and explain theprocedures Select the puncture sites If necessary, encourage blood ﬂow at the puncture site by warming the area

Puncture sites
 Finger tip

 Heel Earlobe

Encouraging blood ﬂow leads to arterialisation of the capillary blood and thus toacceptable comparability with the analytic values obtained from arterial blood.

Procedure for warming the puncture site
s The foot or hand of the patient is wrapped in a cloth warmed to 39°C to 40°C.
s For the best result, pull a rubber glove over the top.
s Leave for 3-5 min.
s For capillary BGA in adults, the earlobe can be rubbed with a hyperaemiainducing ointment.

Puncturing and samplings Pull on glovess Skin disinfection- Disinfectant- Leave to air dry (until the disinfectant has completely dried)s Correct hand movement to ﬁx the ﬁnger or the foots Puncture with a Safety-Lancet

Important informations Discard the ﬁrst drop of bloods Hold the puncture site downwardss Avoid smearing the blood drops Ensure that the sample tube is held in the correct positions Avoid applying repeated strong pressure (milking)Causes haemolysis and contamination of the samples with tissue ﬂuid

9091

11.1.1 Safety-Lancet and safety incision lancet

Product range – Safety-Lancet

The sterile single-use products prevent needle stick injuries because the needle andblade are always safely enclosed within the lancet body before and after use.
The secure trigger button prevents inadvertent, unintentional activation andinactivation of the system.
The Safety-Lancets and the safety incision lancets also comply with the EU Directive
2010/32/EU28, BioStoffV52 and TRBA 25053.

The 5 versions of the Safety-Lancets provide a range of different needle sizes andblades with different penetration depths for sampling from the ﬁnger, earlobe and
heel.

28

EU Directive 2010/32/EU of the Council of the European Union from 10 May 2010 Prevention of sharps injuries in the hospital andhealthcare sector
Biological Agents Regulations – BioStoffV; regulations on occupational health and safety at workplaces using biological working materials
from 15 July 2013
53
TRBA 250 Biological working materials in the healthcare sector and social welfare organisations; Edition of March 2014 amended on
21.7.2015, GMBI no. 29
52

DesignMini

Normal

Extra

Super

Neonatal

Penetration
depth

1.6 mm

1.8 mm

1.8 mm

1.6 mm

1.2 mmNeedle size

28 G

21 G

18 G

Blood
volumeLow

MediumMedium tohighBlade 1.5 mm Blade 1.5 mm
HighMedium tohigh

Product range – Safety Incision Lancet
Thanks to the special puncture technique, optimal blood ﬂow with a high blood
volume is possible even with a shallow penetration depth. The shallow penetration
depth ensures rapid healing and minimises the formation of haematomas.
Design92

Application

Penetration depth

Incision length

Neonates

1.0 mm

2.5 mmPremature infants

0.85 mm1.75 mm93

11.1.2 Microvette® – order of draw & techniques

Product range – Safety-Lancet
The handle with its secure, ﬂattened surface enables the lancet to be held in various
ways with a deﬁned wing and notch on the serrated lancet body.

1

Depending on the requirements, Microvette®
tubes with a cylindrical or conical inner tube
shape and a volume range of 100 to 500 μL
are available. There is the option to collectcapillary blood using the capillary techniqueor the collection rim.

1. Twist the protective cap (1/4 turn).

The special cap design minimises any
aerosol effects when the tube is opened.

23

2. Hold the Safety-Lancet against the selected
and disinfected puncture site. The small
and transparent contact area enablesprecise puncturing.
Press the trigger button.

3. Place the Safety-Lancet in a suitabledisposal box.

Microvette® – order of draw54
EDTA
Lithium Heparin /Lithium Heparin-Gel

4

Fluoride

4. Discard the ﬁrst blood drop and then collectblood.

Serum /
Serum-Gel

54

94

CLSI Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens; Approved Standard – 6th edition GP42-A6(formerly H04-A6); 28 (25) 200895

Microvette® – Collection methods
To meet the speciﬁc requirements of capillary blood collection, there are twocollection techniques available:

B. Sampling with the collection rim
12 Capillary method using the end-to-end capillary

2. Attach the cap to the base of the tube.

500

EDTA K Gravitational principle using the collection rim
Note:

1. Remove the cap by turning it slightly.

Letting blood drip into a capillary tube by means of a Luer needle
does not constitute capillary blood collection.

500

EDTA K

A. Capillary method using the end-to-end capillary
31

3. Collect the blood dripping from the puncturesite using the collection rim.

1. Hold the Microvette® in a horizontal or slightly
inclined position and collect the blood sample
with the end-to-end capillary.

50

0

200

K
TA
ED

EDTA

2

2. Collection is complete when the capillary isentirely ﬁlled with blood.

45

4. Remove the cap from the tube base and close
the Microvette® (“click” position).
500

K
EDTA

200

5. Mix the sample gently but thoroughly.
500
EDTA K

EDT

500

3. Hold the Microvette® upright to allow blood to
ﬂow into the collection tube.

200

EDTA KEDTA K

200

5

6

K

4

EDTA

3

4. Twist to remove the cap including the capillary
and discard as a complete unit.

5. Remove the cap from the tube base and close
the tube (“click” position).
200

K
EDTA

6. Mix the sample gently but thoroughly.
200

EDTA
K

200

96

97

11.2 Centrifugation conditions for capillary blood collection

Preparation

Microvette® Serum
Microvette® CB 300 Serum
Multivette® Serum

Min.

5

Standard

Min.

recommendation (alternative)

10,000 × g

10Alternative
Temperature
range

2.00010,000 × g

POCT (point-of-care testing) or immediate
bedside diagnostics is rapid diagnostics with nopreparation of reagents and/or analysis material.

20°C

The Minivette® POCT is available in different versions with a range of different
volumes and preparations for collecting capillary whole blood, saliva or urine.

5

10,000 × g

104,00010,000 × g

20°C

Microvette® Heparin
Microvette® CB 300 Heparin
Multivette® Heparin52,000 × g

102.00010,000 × g

20°C

5

10,000 × g

10Minivette® POCTThe Minivette® POCT is used for capillary bloodcollection for immediate bedside diagnostics (alsoknown as POCT).

Microvette® Serum-Gel*Multivette® Serum-Gel*

Microvette® Heparin-Gel*Multivette® Heparin-Gel*

11.3

4,00010,000 × g

20°C

Handling the Minivette® POCTThe Minivette® POCT is used for collecting and directly dispensing samples witha small volume. The drip-free handling enables easy sample collection and direct
dispensing with no-drip transfer to the test card or sample tubes.
1. The Minivette® POCT is held on the sides
below the wings in a horizontal or slightly
angled position. When collecting blood drops
with the capillary tip, the ventilation hole at thepiston end should not be covered. Do notpush the piston down - ﬁll the capillary
ensuring there are no air bubbles.

1

Microvette® Fluoride
Microvette® CB 300 Fluoride
Multivette®

52,000 × g

102.00010,000 × g

20°C

These centrifugation conditions are recommendations. The values are based onwhat we consider to be the worst-case conditions, e.g. an older model centrifugethat requires considerably more time to reach the necessary g force than a new
high-performance centrifuge. In isolated cases, it may be that the centrifugation
conditions deviate from the standard recommendations shown in the table whileachieving the same results.
The details of the standard centrifugation conditions are always printed on the labelof the inner carton as well.
* For gel-prepared tubes, we recommend using swinging bucket rotors.

98

2. The blood collection is automatically ﬁnishedwhen the capillary is ﬁlled with blood to thewhite blocking ﬁlter.

2

3a

3b

3a. Place the capillary tip on the test ﬁeld anddispense the complete blood sample bygently pressing on the piston.
3b. Alternatively, the sample can be dispensed
into a micro tube.

99

12 Urine sample
collection

12.1

Sample collection

Any type of urine sample requires a hygiene procedure that complies with thefollowing rules:
s The patient should have the correct procedure for collecting urine samples
explained.
s Before collecting the sample, the patient should thoroughly wash their hands
and genital area and then remove any traces of soap.
s To avoid contamination, the sample should be collected from mid-stream urine
where possible.
s The urine should be collected in the single-use collection container/bottle55
provided.
s The containers must be clean and dry and for bacteriological testing theyshould also be sterile.
s The containers must be labelled carefully with a waterproof pen to prevent
mix-ups.
s Avoid collecting urine during or shortly after menstruation (this results incontamination of the urine with blood).
55

CLSI Urinalysis; Approved Guideline – 3rd edition GP16-A3; 29(4) 200912.2 Storage and transport
Urine samples should not be exposed to direct sunlight or heat.
The analysis should be carried out within two hours of collection. If this is notpossible, the urine should be stored at a temperature of +4°C to +8°C.

Extended storage may cause the following changes, e.g.

“Hippocrates analysed the odour and colour of urine aslong ago as 400 BC and urinalysis still plays a key rolein the diagnostic examination”

s Disintegration of leucocytes and erythrocytess Bacterial growths Bacterial decomposition of glucose
Before the analysis, samples should be brought to room temperature and thoroughly
mixed just before applying to a test strip.
Depending on the parameter, appropriate stabilisers should be used for the storage.

100

101

12.3 Types of analyses

Clinical chemistry tests

Urine can be analysed in a wide range of ways.
Here are some of the most common methods:

Clinical chemistry tests provide semi-quantitative and quantitative results for greater
speciﬁcity for screening tests (e.g. during pregnancy) or when preparing diagnoses
for heart, liver or kidney diseases or cancer.

Test strips
Depending on the number of test ﬁelds, the test strips enable a rangeof different values to be tested such as speciﬁc gravity, haemoglobin,
glucose, pH, protein, leucocytes, etc. Information obtained bycomparing the colour change of the test ﬁeld is only an initial indicatorand should be speciﬁed using additional tests.
What is important is that the test strip is completely and thoroughly
wetted and then appropriately dried before reading the result.
The correct incubation times must be complied with and the relevant
information about these times can be found in the manufacturer’s
instructions.

Urine sediment testing
Urine sediment is a preparation of the urine to assess the solid components off
the urine using microscopy or ﬂow cytometry. These assessments can provide
information about kidney or urinary tract diseases.
To prepare the urine sediment, a deﬁned fraction (e.g. 10 ml) of a urine sample iscentrifuged (5 min at 400 × g) and the supernatant is decanted so that about 0.5 mlof urine remains; the sediment is mixed with the residual urine and then analysed
microscopically.

The following parameters can be analysed using clinical chemistry analytics:
Electrolytes, creatinine, albumin, Į2-macroglobulin, Į1-microglobulin, BenceJones proteins, glucose, 5-hydroxyindoleacetic acid, immunoglobulins, proteins,catecholamines, porphyrins, vanillylmandelic acid (VMA)

Microbiological tests
With a suspected urinary tract infection after a positive test stripp
result and abnormal urinary sediment, it is essential to carry out
microbial identiﬁcation (microbial differentiation, bacterial countand subsequent monitoring of the antibiotic therapy).
This provides information about the type and quantity ofpathogen (usually bacteria, possibly fungi).
IMPORTANT:The samples should be collected before
starting any antibiotic therapy.
For subsequent therapeutic monitoring,
provide the laboratory with details of any
antibiotic therapy.

The following parameters can be assessed using microscopy, for example:s Cells such as erythrocytes, leucocytes, epithelial cells, etc.
s Urinary casts such as hyaline tests, granular casts, cellular tests, etc.
s Other elements such as yeast cells, bacteria, urine crystals

102

Drug detection
Drug detection is a sensitive examination due to the consequences off a positivei i test
result.
Urine is often used as a sample material because it is easily collected and drugs
and their metabolites can be easily detected for long periods after use (compared toblood or saliva). However, urine can also be easily manipulated.
Drug users often try to generate negative results.
This can be caused by excessive drinking, applying third-party urine, addition of acidor mixing in urine-coloured liquids (e.g. apple juice, energy drinks, etc.).

103

12.4 Types of urine samples

Mid-stream urine collection is divided into:

Urine samples are differentiated by the time and type of collection.

First morning urine
The components in the ﬁrst urine passed in the morning are more concentrated.

Mid-stream urine
Collecting a urine sample using mid-stream urine is recommended in principle toobtain the purest possible sample

Correct sample collection:
1. Correct cleaning and drying of the hands andexternal genital area.

1s Application:
Suitable for bacterial tests, test strips, sediment, clinical chemistry tests, protein
diagnostics.
s Advantage:Due to the long retention time in the bladder, the morning urine is ideally suited tonitrite and protein measurement.

Second morning urine
The second morning urine can possibly provide the mean values for individual
parameters and can be used in isolated cases as a substitute for 24-h urine
collection.
2. Release the ﬁrst urine in the toilet (a) and thencollect the mid-stream urine with the urine container(b). The remaining urine is also disposed of in the
toilet (c).
Avoid contamination.

2s Application:
Test strips, glucose, proteins Drawback:Not suitable for the nitrite test

c

a
100
00 ml

75/40

90
80
70
60
50
40
30
20

b

Spontaneous urine

103

3. Securely close the container with the lid.

The urine can be collected at any time. Spontaneous collection is useful in cases ofsuspected urinary tract infection or intoxication.
Note:
s 0ARTICULARLY IMPORTANT FOR MICROBIAL TESTS
s 2EQUIREMENT #OOPERATIVE PATIENT

104

s Application:
Is completely adequate for many chemical and microscopic parameterss Advantage:
Easily collecteds Drawback:Dilution errors – for correct assessment always take the speciﬁc gravity (density)
into account105

Suprapubic aspiration of urine
The bladder is punctured suprapubically while
ensuring strict aseptic technique. The invasivenature of this type of urine collection means that
although this method has the smallest risk ofcontaminating samples, it is rarely used.
However, in paediatrics the advantages of thismethod can outweigh the drawbacks of classic
collection (particularly for bacterial tests).

24 Hour urine collection
Splittable trocar
Urinarycatheter

Pubic bone
UrethraProstate
Bladder

The entire urine produced is collected over a period of
24 hours. Collection over this period compensates forany variations in concentration of parameters during
the day.
Typical applications for 24 hour urine collection include
measuring catecholamines or creatinine clearance.
When measuring catecholamines and other unstableparameters, adding a stabiliser (e.g. 20% HCl) to theurine is necessary.
There are ready-to-use products such as the UriSet 24
available for this purpose.

Catheter urine
For sample collection from catheters, single-use catheters and indwelling urinary
catheters are differentiated.

Intermittent catheter urine
Collecting urine using intermittent catheterisationis very rarely carried out because it is painful forthe patient and the risk of infection is high.

Collected urine volume
Because the patient is usually responsible for collecting the urine, it is essential toprovide the patient with clear instructions for correct handling.
The volume of the bottle is of particular importance here. Studies have shown thatcollection bottles with a volume of 2,000 ml were only adequate for 60% of allvolunteers.
Volumein litre

Volumes of the 116 24 hour urine collections

3 litresIndwelling catheter urine
For patients with an indwelling urinary catheter,
this type of urine sample collection is the easiest
and most hygienic method. The urine should becollected from a special adapter on the inlet tube
and not from the collection bag, however.

Note:

106

For diagnostic purposes, urine should
not be collected from the urine bag.

91,4 %

Number of donors

That is, in these cases a second bottle must be used and a tube must be ﬁlled fromeach bottle. The particular quantity of urine in the collection bottle must then be
noted on both tubes. The urine from the two tubes is then mixed in the laboratory inthe correct ratio.
To circumvent this potentially error-prone process, a collection bottle with a volumeof 3,000 ml should be used.

107

12.5 Handling urine sample collection systems

Urine-Monovette®

Collection procedure for 24 hour urine

The Urine-Monovette® is suitable for sample collection, transport, as a container for
immersing the test strip and for centrifugation.

START
1

Bacteriology



S
M

TS





Bacteriology

SA
Mo



Urine Z

TS

During the collection period, about 1.5-2 litres should bedrunk throughout the day.
Thoroughly wash hands and the genital area before eachcollection step and rinse away any traces of soap.

Urine Z




Z

108



logy

4. Collect the ﬁrst morning urineon the next day at the sametime as the day before,e.g. 7:00 am

END(24 hours)

IMPORTANT:

Insert the suction tip into
the cup and and draw
up the Urine-Monovette®
piston to the base line.

.
.
.

S
M



Bacterio

2. Collect the second morning
urine and add stabiliser ifnecessary
3. Collect
all
urine
and
mix

3

TS

Urine

1. Discard the ﬁrst morning urine
Note the time, e.g. 7:00 am

2

10/06

Time 5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
24:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00

Hold the Urine-Monovette®
with the suction tip upwards
and withdraw the plunger indownward direction until thesuction tip is empty.

AbfallWithdraw the tip,break off the plunger,
attach the cap.

Urine-Monovette® with boric acid
In a ﬁlling volume of 10 ml, the boric acidconcentration is 1.5%. Microorganisms arestabilised for up to 48 hours when stored at room
temperature.
Important:s Adhere to the stated volume
s Thoroughly mix after urine aspirations Not suitable for clinical chemistry tests,
strip tests, etc.

109

V-Monovette® Urine
By using a closed system, hygiene and comfort is signiﬁcantly improved both for thepatient and for the user.

C: Grasp the safety label on the ﬂap and remove from thelid of the collection bottle.
Please do not touch the collection area in the lid
Risk of injury!

C

A: Immerse the transfer device into the urine sample.

A

The collection bottle is placed with the recessed grip
facing upwards on a ﬂat surface.
Insert the tube into the collection area and press ﬁrmly.
1200 ml

Insert the V-Monovette® into the transfer device andpress ﬁrmly until the needle penetrates the cap.
700 mlA

1200 ml

B: Remove the safety label from the lid using the ﬂap.
Please do not touch the collection area in the lid
Risk of injury!

B

B

For small collection volumes between 700 and
1200 ml, the V-Monovette® Urine can also be ﬁlled
upside down.
For collection volumes < 700 ml, the collection bottle
must be opened.
The collected urine is then transferred to a container.

First insert the V-Monovette® Urine with the cap in thecollection area and press ﬁrmly.
The tube ﬁlls with urine by itself. Only remove the tube
when the ﬂow stops.

Mix the V-Monovette® Urine with preparation, e.g.
boric acid.
/Exp.

110

111

13

List of references
31. Ong, et al. Reducing blood sample hemolysis at a tertiary hospital emergency department.
Am J Medicine 2009;122:1054e1-e6.

1.

Guder et al.; Proben zwischen Patient und Labor; 20092.

Bonini et al.; Errors in Laboratory Medicine; Clin Chem 48:5; 691-698 (2002)

3.

Foubister, Vida. Cap Today Bench press: The Technologist/technician shortfall is putting thesqueeze on laboratories nationwide September 2000; Datta, P. Resolving Discordant Samples.
Advance for the Administrators of Laboratories; July 2005: p.60.

4.

Seelig et al.; Präanalytik; 2008

5.

Sarstedt; Tips and Techniques in Preanalytics; 2014

6.

G. Ender et al.; The importance of preanalytics for the coagulation laboratory; Hämostaseologie 2/2010; 30: 63-70

7.

RiLiBÄK § 6.1.7 Part A5

35. Heyer et al.; Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory
medicine best practices systematic review and meta-analysis; Clin Biochem 45: 1012-1032, 20128.

RA Sulaiman, Effect of order of draw samples during phlebotomy on routine biochemistry results;
J Clin Pathol. 2011 Nov;64(11):1019-20

36. Grant MS; The Effect of Blood Drawing Techniques and Equipment on the Hemolysis of ED
Laboratory Blood Samples; J Emerg Nurs 29:116-121, 2003

9.

RR Calam et al.; Recommended “Order of Draw” for Collecting Blood Specimens into
Additive-Containing Tubes; Clin. Chem.; Vol. 28, No. 6, 1982

37. Straszewski et al J; Use of separate venipunctures for IV access and laboratory studies decreases
hemolysis rates; Intern Emerg Med 6(4):357–359, 2011

10. Gurr et al.; Musterstandardarbeitsanweisung Präanalytik; J Lab Med 2011
11. CLSI Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture, Approved
Standard, 6th edition GP 41-A6 (former H3-A6), 27 (26) 2007

32. Halm, et al. Obtaining blood samples from peripheral intravenous catheters: best practice?
Am J Crit Care 2009;18:474-8.
33. Wollowitz, et al. Use of butterﬂy needles to draw blood is independently associated with marked
reduction in hemolysis compared to intravenous catheter. Ac Emerg. Med 2013;20:1151-1155.
34. ENA’s Translation Into Practice. Reducing Hemolysis of Peripherally Drawn Blood Samples.
December, 2012 (Emergency Nursing Association).

38. Dugan et al.; Factors Affecting Hemolysis Rates in Blood Samples Drawn from Newly Placed IV
Sites in the Emergency Department; J Emerg Nurs 31(4): 338-345, 2005

12. Lichtinghagen et al.: Einﬂuss der Stauzeit auf normalisierte Laborwerte; J Lab Med 2013; 37(3): 131-137

39. Lippi et al Hemolyzed specimens: a major challenge for emergency department and clinical laboratories, Crit Rev
Clin Lab Sci 48:143–153, 2011

13. M. Spannagl et al.; Hämostaseologische Globaltests; Hämostaseologi 1/2006

40. Cadamuro et al.; The economic burden of hemolysis; CCLM 2015

14. Margo A et al.; Obtaining blood samples from peripheral intravenous catheters: best practice; AJCC, 9.2009, 18 (5)41. Jacobs et al.; Cost of hemolysis; AnnClinBiochem 2012; 49: 412-413

15. Lippi et al.; Prevention of hemolysis in blood samples collected from intravenous catheters;
Clin Biochem 46: 561-564, 2013

42. P Jacobs et al.; Haemolysis Analysis; An Audit of Haemolysed Medical Admission Blood Results;
AcuteMed 2010; 9(1): 46-47

16. Heyer et al.; Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory
medicine best practices systematic review and meta-analysis Clin Biochem 45: 1012-1032, 2012

43. P650 IATA/ADR

17. Grant MS; The Effect of Blood Drawing Techniques and Equipment on the Hemolysis of ED
Laboratory Blood Samples; J Emerg Nurs 29:116-121, 2003

45. N. Tatsumi et al.; Specimen Collection, Storage, and Transmission to the Laboratory for
Hematological Tests; International Journal of Hematology 75; 261-268; 2002

18. Benso S; Can a blood sample for diagnostic exams be drawn from a peripheral venous catheter?;Assist Inferm Ric; 34(2):86-92; Apr-Jun 2015

46. Koessler et al.; The preanalytical inﬂuence of two different mechanical transport systems on laboratory analysis;
Clin Chem Lab Med; 49(8): 1379-1382; 201119. Pschyrembel

47. Kratz et al.; Effects of a pneumatic tube system on routine and novel hematology and coagulation
parameters in healthy volunteers; Arch Lab Med; 131: 293-6; 2007

20. J. P. Borde et al.; Abnahme von Blutkulturen; Dtsch Med Wochenschr; 135:355-358; 2010
21. Simon et al.; Blutkulturdiagnostik – Standards und aktuelle Entwicklungen; J Lab Med; 36(4):199-207; 2012
22. Barthels et al.; Das Gerinnungskompendium; 2012
23. Kupke et al.; On the composition of capillary and venous blood serum;
Clin Chim Acta. 112(2):177-85; 5 May 1981

44. TRBA 100

48. Sodi et al.; Pneumatic tube system induced haemolysis: assessing sample type susceptibility tohaemolysis; Ann Clin Biochem; 41:237-40; 2004
49. Steige et al.; Evaluation of pneumatic-tube system for delivery of blood specimens; Clin Chem; 17:1160-4; 1971

24. Speer et al.; Pädiatrie; 2013

50. Koçak et al.; The effects of transport by pneumatic tube system on blood cell count, erythrocyte
sedimentation and coagulation tests; Biochemia Medica;23(2):206-10; 2013

25. Michael D Davis RRT et al.; AARC Clinical Practice Guideline: Blood Gas Analysis andHemoximetry: Respiratory Care; 58(10); Oct. 2013

51. Tiwari et al.; Speed of sample transportation by a pneumatic tube system can inﬂuence the degreeof hemolysis; Clin Chem Lab Med; 50(3):471-474;2012

26. Gruber et al.; Heparin release is insufﬁcient in syringes with platelets as heparin source;
Clinica Chimica Acta, 395: 197, 2008

52. Biostoffverordnung – BioStoffV; Verordnung über Sicherheit und Gesundheitsschutz bei Tätigkeiten
mit Biologischen Arbeitsstoffen vom 15. Juli 2013

27. Der unterschätzte Arbeitsunfall, Infektionsrisiko durch Nadelstichverletzungen;Initiative SAFETY FIRST!

53. TRBA 250 Biologische Arbeitstoffe im Gesundheitswesen und in der Wohlfahrtspﬂege; Ausgabe
März 2014 mit Änderung vom 21.7.2015, GMBI Nr. 29

28. EU-Richtlinie 2010/32/EU des Rates der Europäischen Union vom 10. Mai 2010 Zur Vermeidung
von Verletzungen durch scharfe/spitze Instrumente im Krankenhaus- und Gesundheitssektor

54. CLSI Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens;
Approved Standard – 6th edition GP42-A6 (ehemals H04-A6); 28 (25) 2008

29. CLSI; Hemolysis, Icterus, and Lipemia/Turbidity Indices as Indicators of Interference in ClinicalLaboratory Analysis; Approves Guideline; C56-A; 32(10)2012

55. CLSI Urinalysis; Approved Guideline– 3th edition GP16-A3; 29 (4) 2009

30. Lippi et al.; In vitro and in vivo hemolysis, an unresolved dispute in laboratory medicine; 2012

56. Kohse et al.; National and international initiatives and approaches for the establishment of reference
intervals in pediatric laboratory medicine; J Lab Med 2015; 39(4): 197-212
57. SAFETY FIRST, Germany - www.nadelstichverletzung.de

112

113

14

Index

Blood collection, capillary, preparation

24-h urine collection

107

5-Hydroxyindoleacetic acid (5-HIAA)

103_1-microglobulin

103_2-macroglobulin

103

ACE (angiotensin-converting enzyme)

15

Acetylsalicylic acid (ASA)

16

Adrenaline

14, 15, 16

Adrenaline

17

Age

13, 52, 54, 55

Albumin16, 17, 31, 103

Alcohol

15, 29

Alcohol abstention

29

Aldosterone

17

Alkaline phosphatase (AP)12, 13, 14, 16

ALT, alanine transaminase (GPT)

14, 15, 16, 17, 31

Ammonia, NH3+

83, 85Amylase12, 14

Antithrombin (AT III)

55

aPTT (activated partial thromboplastin time)

19, 54, 55, 79, 86

Arterial access

57

Arterial blood

57

ASA (acetylsalicylic acid)

16

Aspiration technique

33-37, 39, 47

AST, aspartate aminotransaminase (GOT)15, 16, 17, 19, 31, 78, 79

AT III (antithrombin, antithrombin III)

55`-carotenoids

15`-HCG (chorionic gonadotropin)

79

Bacteria

19, 102, 103

Bacterial count103

Bence-Jones proteins

103

Bilirubin

13, 14, 16, 17, 19, 31, 51, 52, 78, 86, 90

Biological rhythm

13

Blood clot

8, 58

Blood collection technique, capillary61, 96-97

Blood collection technique, venous

20, 37, 46, 60

Blood collection, arterial, collection technique

60

Blood collection, capillary49-51, 57, 58, 59, 61, 88-99

Blood collection, capillary, collection technique

61, 96-97

114

89-91

Blood collection, capillary, procedure

61, 89-91, 96-97, 99

Blood collection, venous

20-43, 47-48

Blood collection, venous, collection technique20, 37, 46, 60

Blood collection, venous, ending

34

Blood collection, venous, for blood culture diagnostics 26, 40-43
Blood collection, venous, from a catheter

38-39, 59, 77

Blood collection, venous, preparation

9, 21

Blood collection, venous, procedure

28-43

Blood collection, venous, with butterﬂy needle

27, 32, 42, 43, 47, 60, 65

Blood collection, venous, with Safety-Needle

26, 29, 32, 33, 34, 36, 60, 64

Blood culture adapter

42-43

Blood culture diagnostics

40-43

Blood gas56-61, 89, 91

Blood gas analysis, clotting

58

Blood gas analysis, collection technique60, 61

Blood gas analysis, haemolysis

59

Blood gas analysis, storage

58

Blood gas analysis, ventilation

59, 60Blood sedimentation (BSR = blood sedimentation rate) 12, 25
Blood-collecting person

21

Body position

17

BSR (blood sedimentation, blood sedimentation rate)

12, 25

Cadmium

15
16

Caffeine++

Calcium (Ca )16, 17, 26, 27, 31, 51, 57, 58, 59

Cannabis

14

Carryover of additives / preparation

19, 26

Casts (urinary)102

Catecholamines

103, 107

Catheter urine106

CEA (carcinoembryonic antigen)

15

Cellular metabolism: Temperature, time

58, 83Centrifugation

7, 21, 68-73, 75, 85, 98, 109

Centrifugation conditions, capillary

98

Centrifugation conditions, venous

72, 73Chloride (Cl-)

14, 51, 59

Cholesterol (Chol)

12, 13, 14, 15, 17, 19, 31

Chorionic gonadotropin (`-HCG)

79

Circadian rhythm

14

115

CK (creatine kinase)12, 16, 31, 51, 78, 79

CK-MB

78

Cl- (chloride)

14, 51, 59

Coagulation analyses

25, 27

Coagulation diagnostics

85

Collected urine volume

107

Collection rim

51, 95, 97

Collection techniques, capillary61, 96-97

Collection techniques, venous

20, 37, 46, 60

Colour code

23

Communication

9, 21

Copper15

Cortisol

14, 15, 16

Creatine kinase (CK)12, 16, 31, 51, 78, 79

Creatinine

12, 14, 16, 17, 19, 31, 52, 103, 107

Crystals (urinary)

102

CVC

19, 40, 57

D-dimers

55, 79, 86

Dead volume

27

Decisions, clinical

8

Diet

11, 17

Disposal box

48, 50, 64, 65, 66-67

Diuretics

16

Drip technique

47

Drug detection

103

Drug use

14

End-to-end capillary51, 96

Endogenous interference factors

19

Epithelial cells

102

Error, preanalytical

7, 8, 18, 113

Erythrocytes

17, 19, 25, 52, 53, 74, 75, 76, 78, 85, 101, 102

Exempt medical sample

82

Exogenous interfering factors

19

Fasting

1, 18, 21, 29

Fe (Iron)12, 31, 78

Fibrinogen15, 25First morning urine

105

Fixed-angle rotor

69, 70

Folic acid

15

Gender12, 13116

a-Glutamyltransferase (a-GT, GGT)

15, 16, 17, 31, 32

Glucose14, 16, 17, 25, 31, 51, 58, 59, 79, 83, 84, 89,
101, 102, 103, 105

Glucose-6-phosphate dehydrogenase deﬁciency(G-6-PDH deﬁciency)

76

GOT, aspartate aminotransaminase, see AST

15, 16, 17, 19, 31, 78, 79

GPT, alanine transaminase, see ALT

14, 15, 16, 17, 31

Granulocytes

15, 54

Haematocrit (HCT, Ht)

13, 15, 17, 19, 25, 53, 55

Haematology

25, 85

Haemoglobin (Hb)

13, 25, 53, 58, 59, 74, 75, 78, 102

Haemoglobinopathy

76

Haemolysis

8, 18, 19, 32, 38, 39, 48, 59, 74-79, 85, 86, 91

Haemolysis risk factors

77

Haemolysis, in vitro

77

Haemolysis, in vivo

76

Haemostasis, paediatrics

54-55

HDL-Cholesterol

13, 15, 17

Heroin14Hyperbilirubinaemia = jaundice

19

Hyperlipoproteinaemia = lipid metabolism

19

Identiﬁcation of the ordering doctor

22

Identiﬁcation of the person collecting the blood

22

Identiﬁcation of the sample

23

Immunoglobulins

103

In vitro haemolysis

77

In vivo haemolysis

76

In-house transport

82

Indwelling catheter urine

106

Infection risk

62, 106

Inﬂuence of sample storage

58, 83, 84, 85, 101

Inﬂuencing factors

10

Inﬂuencing factors, modiﬁable

14-17

Inﬂuencing factors, non-modiﬁable

12-14

Infusion

19, 38, 59, 77

Inorg. phosphate

16

Insulin14, 16

Interference factors

18-19Intermittent catheter urine

106

Iron (Fe)12, 31, 78

Jaundice

18, 19117

Labelling24

Phenobarbital

Lactate25, 51, 52, 58, 59, 83, 89

Phosphorus

17

Lactate dehydrogenase (LDH)19, 78, 79, 86

Physical activity

16

Laxatives

16

PLAP (placental AP)

15

LDH (lactate dehydrogenase)19, 78, 79, 86

Plasma13, 16, 25, 29, 55, 68, 69, 74, 75, 78, 85, 86

LDL cholesterol

13, 15

Platelets

54

Leucocytes

12, 15, 25, 54, 86, 101, 102

Pneumatic tube system for sample transport

77, 86-87

Lipaemia

18, 19pO2

57, 58, 59

Lipase14

POCT88, 99Lymphocytes

15

Porphyrins

103

Potassium (K+)

14, 16, 17, 19, 26, 29, 31, 32, 59, 78, 79, 83,
84, 86Preanalytical errors

7, 8, 18, 113++

Magnesium (Mg )16, 32MCHC (mean corpuscular haemoglobin concentration) 15
MCV (mean corpuscular volume = mean red cellvolume)15

Medical history

16

Pregnancy

12, 45, 103

11, 14

Preparation

19, 25, 27, 72, 83, 86, 89, 98, 99

Medications (see also Medicinal drugs)

16, 19, 21, 29, 38

Prolactin

14, 15

Medicinal drugs (see also Medications)16, 19, 21, 29, 38

PSA (prostate-speciﬁc antigen)19

Mg++ (Magnesium)

16, 32

PTT (thrombin time = TT)

19, 25, 79

Microbial differentiation

103

Puncture sites, capillary blood collection

90

Microbiological tests in urine

103

Puncture sites, venous blood collection

30

Mid-stream urine

101, 104-105

Pyridoxal phosphate

15

Modiﬁable inﬂuencing factors

14-17

Pyruvate kinase

16, 76

Monocytes

15

Quick (thromboplastin time = TPT, prothrombin time)

16, 25Morphine

14

Race

12

Na+ (sodium)14, 16, 19, 31, 51, 59

Reference ranges, paediatrics

52-55

Needle stick injury

62, 63, 64, 92,

Release of cell contents

78

Neonatology

45

Renin

14, 17

Nicotine

15

Rhythmic daily ﬂuctuation

14

Nitrite

105

RPM

69

Non-modiﬁable inﬂuencing factors

12-14

RPM and g force

69, 72, 98

Noradrenaline

14, 15, 16

Safety products

Order of draw (blood), capillary

95

26, 27, 29, 32, 33, 34, 36, 42, 47, 49, 50, 60,
61, 62-67

Order of draw (blood), venous

26

Sample identiﬁcation

23, 24P650

81, 82

Sample storage

21, 58, 80-87

Packaging instructions for sample transport

81, 82

Sample transport

81-87

Paediatrics

44-55, 88-99

Samples for clinical chemistry25, 85

Patient identiﬁcation

21, 22, 40

Second morning urine

105

pCO2

57, 58, 59, 83

Selenium

15

16

Sepsis40

Serum51, 52, 69, 71, 72, 74, 75, 78, 85, 86, 87, 95,
98

Penicillin
pH

118

58, 59, 102

119

sO2

57, 59Sodium (Na+)

14, 16, 19, 31, 51, 59

Speciﬁc weight102

Spontaneous urine

105

15

Imprint

Stasis time30, 31

Legal notice:

Storage58, 59, 80-87, 101

Substance use

15, 16

Suprapubic aspiration urine

106

We would like to point out that the topics addressed in ‘Tips and Techniques in
Preanalytics’ covering the ﬁelds of venous blood collection, capillary bloodcollection and urine collection are recommendations only and do not, under any
circumstances, replace medical, scientiﬁc or technical advice.

Swinging bucket rotor

69, 70, 73, 98

Test strip test

101, 102, 103, 105, 109

TG (triglycerides)

12, 15, 17, 31

Thrombin

54

Thrombin time (PTT, TT)

19, 25Thromboplastin time = TPT (Quick)

16, 25Thromboplastin time, activated partial (aPTT)

19, 54, 55, 79, 86

Thyroxine

14

Tips for difﬁcult vein conditions

32, 47

Total protein

12, 17, 31, 51, 102, 103, 105

Tourniquet application

30-31

TRBA 100

81, 82

TRBA 250

66, 92

Triglycerides (TG)12, 15, 17, 31

Troponin79

TSH (thyrotropin)

14

TT (thrombin time, PTT)

19, 25, 79

Underﬁlling

8, 27

Urea

14, 16, 17

Uric acid14, 16, 17, 19

Urinary tract infection

103, 105Urine sample

100-110Urine sediment (see Urinary sediment)

102, 103

Vacuum technique36, 37, 39, 77

Vanillylmandelic acid (VMA)14, 15, 103

Venous puncture

29, 30, 47, 48, 77

Vitamin B12

12

Vitamin B6

15

Vitamin D

13

VMA (vanillylmandelic acid)14, 15, 103

Yeast cells

102

120

Subject to technical modiﬁcations.
This publication may contain information about products that may not be available inall countries.

© 2015 · SARSTEDT AG & Co.
Postfach 12 20 · D-51582 Nümbrecht
Telefon +49 22 93 305 0 · Telefax +49 22 93 305-3450
info@sarstedt.com · www.sarstedt.com

121

Notes122123

21-453-0000-200

SARSTEDT AG & Co.
P.O. Box 12 20
D-51582 Nümbrecht
Phone +49 2293 305 - 0
Fax +49 2293 305 - 2470
info@sarstedt.com
www.sarstedt.com

Tips & Techniques in Preanalytics

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