Overall supervision & management of lab personell and procedures.

Certification: Pathologist

-Provide administrative direction for lab.

-Maintains quality control data.

Testing Personnel

-Medical Technologist (MT)

-Medical Laboratory Technician (MLT)

Phlebotomist : job description?

-Confirm disease or condition

-"Rule Out" certain conditions

-Monitor effectiveness of therapy

-Provide prognostic info or assess disease severity

-Screen for disease

What can effect a reference range?

-Test methodology

-Age, gender & geographic location

-Each Labs policies and procedures

Adult 10 pints

Newborn < 1 pint

Top: Liquid (plasma/serum)

Middle: "Buffy Coat" (WBC's & Platelets)

Bottom: RBC's

Red Top and Red/Gray Top

a) Anticoagulants- Yes or No

b) If yes, what type

Purple Top

a: Anticoagulants Yes or No

b: If yes what type of anticoagulant

a: Yes

b: Ethylenediaminatetraacetic Acid (EDTA)

Light Blue Top

a) anticoagulants- Yes or No

b) if yes, what type

a) Yes

b) Sodium Citrate

Green Top

a) Anticoagulant- Yes or No

b) If yes, what kind

a) Yes

b) Heparin

-Many chemistry test

-Aterial blood gases

Gray Tube

a) Anticoagulant- Yes or No

b) If yes, what kind

a) Yes

b) Potassium Oxalate

Dark (Royal) Blue Tube

a) Anticoagulants- Yes or No

b) If yes, what kind

-Toxicology

-Trace Metals

-Other Special Testing

1. Blood Culture

2. Red or Red/Gray Top

3.Light Blue Top

4. Green Top

5. Lavender Top

6. Gray Top

(7. Other coagulant-collection tubes)

a) Antecubital Fossa (AC)

b)Back of the hand

Venipuncture Procedure

Before sticking the patient

(5 Steps)

1. Complete test requisitio (Order Proper Test)

2. I.D. and position patient

3. Organize equipment & supplies

4. Put on gloves

5. Apply tourniquet

Venipuncture Procedure

Blood Collection Part

(6 Steps)

1. Select Venipuncture site (cleanse w/ alcohol)

2. Anchor vein

3. Insert needle ( Bevel Up)

4. Collect Specimen(s)

5. Release Tourniquet

6. Remove needle & apply pressure to site

Venipuncture Procedure

Post Blood Collection

(6 Steps)

1. Properly dispose of needle (DON'T RECAP)

2. Bandage pts arm

3. Label Tubes

4. Remove gloves and dispose properly

5. Wash hands

6. Deliver to lab

Acceptable Aterial Sample Sites

(4 area types)

1. Large enough for 23 gauge

2. Near the skin surface

3. Area where surrounding tissues are not critical

4. Area where other arteries will supply blood if there is damage of arterial site

Common Arterial Sites

(2 sites)

1. Radial Artery

2. Brachial Artery

Arterial Blood Collection Procedure

Pre-collection (4 steps)

1. Complete requisition

2. Organize equipment and supplies

3. Suppor & hyperextend pts wrist

4. Perform Modified Allen test

Arterial Blood Collection Procedure

Blood Collection Part (5 steps)

1. Put on gloves

2. Place cleansed, gloved finger over puncture site

3. Insert needle (bevel up) @ 45° - 60° angle approx 10-15 mm below palpating finger

4. Allow syringe to fill

5. Remove needle and apply pressure

Arterial Blood Collection Procedure

Post-punture (9 steps)

1. Bandage arm

2. Expel air bubbles from syringe

3. Remove needle and cap syringe

4. Dispose of needle properly

5. Mix sample in syringe

6. Label Specimen & place in ice bath

7. Re-check radial pulse below punture site

8. Remove gloves & dispose properly

9. Keep pressure for 10-15 minutes

Infants/neonates

Eldery

Chemotherapy pts

Burn pts

Medial or Lateral Heel

<15 months

-Palmer side of non-dominant finger

- >15 months

-Eating

-Strenuous Exercise

-Emotional Stress

-Extended contact between serum & cells

-Hemolysis

-Formation of microclots

-Specimen drawn from wrong pt

-Specimen drawn at wrong time

Types of Urine Specimens

(4 types)

-Random

-First morning

-Clean-catch

-Timed

-Pt voids into container

-Label container & send to lab w/in one hour of colletion

-UTI

-Evaluate renal function

-Detect metabolic or systemic diseases

-Pt collects specimen immediately upon waking up

-Label collection & deliver to lab w/in one hour of collection

First Morning Collection Test for ?

-Best specimen for Pregnancy Testing

-Better testing for U/A

Clean-catch Urine Procedure

-Clean genital area

-Begin urinating

-Stop momentarily, then collect

-Label collection & deliver immediately to lab

Clean-catch Urine Test for ?

-Pt does not collect first void of urine

-Collect following voids of urine for desigated time

-In between collections urin must remain in a refrigerator

-Label collection and deliver to lab

Timed Urine Collection Test for ?

Reason for refirgeration of Timed Collection

(4 reasons)

1. Prevents bacterial growth

2. Doesn't interfere w/ chemical test

3. May prevent rise in specific gravity

4. Help prevent precipitation of amorphous phoshate and urate crystals

1. Increase Bacterial Growth

2. Decrease in Glucose, Ketones, Bilirubin & Urobilinogen

3. Disintegration of Cells, Casts & Crystals

4. Color Change

1. Hep B

2. Hep C

3. HIV

4. Other bacteria and viruses

Routes of transmission for pathogens

(2)

1. Dermal Puncture

2. Mucosal membrane contamination (ex: eyes or gengiva)

Hematology?

(Definition)

Formed elements of Bood

(3 elements)

RBC's (erythrocytes)

WBC's (leukocytes)

Platelets (thrombocytes)

Anemia?

(definition)

Causes of Anemia

(3 causes)

-Increased desctruction of RBC's

-Excessive Blood Loss

-Decreased production of RBC's

Indicative test results of Anemia

(3 test results)

-Low Hgb

-Low HCT

-Low RBC count

Aplasia?

(definition)

Aplastic Anemia

(definition)

-Caused by aplasia of bone marrow

-Destrucion by chemical agents or other physical factors

-cytosis or -philia?

(definition)

-penia?

(definition)

Hemolysis?

(definition)

Hemolytic Anemia?

(definition)

Hyperplasia?

(definition)

Hypoplasia?

(definition)

Hematopoiesis?

(definition)

Extramedullary Hematopoiesis?

(definition)

-Formation of blood cells in sites other than the Red Bone Marrow

(primarily the Liver & Spleen)

Sites of Hematopoiesis

Before birth & After birth

Before : Embryo & Fetus

After : Red Bone Marrow

Main Site of Red Bone Marrow after 20 yrs of age?

(3 sites)

-Flat bones

-Vertebra

-Pelvis

-I.D. and quantify (%) of WBC types

-I.D. and estimate abnormal RBC morphology

-Estimation of platelet count

Cell I.D. looks for?

(3 things)

-Cell size

-Nucleus (size, shape, apperance of chormatin & presence of nucleoli)

-Cytoplasm (color, presence of ganules)

Length of maturation for RBC?

7 Total days

5 days- in bone marrow

1-2 days- in the periphery

Order of Maturation Stage

( 8 stages)

1. Burst-forming unit (BFU)

2. Colony-forming unit (CFU)

3. Pronormoblast (Rubriblast)

4. Basophilic Normoblast (Prorubricyte)

5. Polychromatophilic Normoblast (Rubricyte)

6. Orthochromic Normoblast (max hemoglobin synthesis)

7. Cell nucleus ejected

8. Reticulocyte

RBC Production : Steps

(3 steps)

1. Low O₂ levels signals kidneys

2. Kidneys increase production of erythopoietin

3. Erythopoientin increse erythrocyte development in bone marro.

RBC Morphologies

(Normocytic)

-Normal sized RBC's

Clinical Significance: None

RBC Morphologies

(Normochromic)

-RBC w/ normal hemoglobin concentration

Clinical Significance : None

RBC Morphologies

(Hypochromic)

-RBC's with low concentration of Hemoglobin

Clinical Significance: Fe deficiency anemia

RBC Morphologies

(Macrocytic)

-Cells which are predominately larger than normal size RBC's

Clinical Significance: Vit. B-12 and Folate Deficincy

RBC Morphology

(Anisocytosis)

RBC Morphology

(Microcytic)

-Cells that are smaller than normal

Clinical Significance: Fe Deficiency Anemia

RBC Morphology

(Poikilocytosis)

RBC Morphology

(Spherocytes)

-Spherical cells w/ decreased surface membrane that apper microcytic and hyperchromic

Clinical Significance: Immune Hemolytic Anemia

-Cells with rounded spicules around its surface

Clinical Significance: Renal Disease, Liver Disease or Burns

RBC Morphology

(Helmet Cells)

-Cells w/ distinctive projections

Clinical Significance: Glucose-6-Phosphate Dehydrogenase Deficiency

RBC Morphology

(Schistocytes)

-Small bizzare shaped cells

Clinical Significance: Sickle Cell

RBC Morphology

(Acanthocytes)

-Normal sized cells with 3-8 finger like projections

Clinical Significance: Sever Liver Disease

RBC Morphology

(Ovalocyte/Elliptocyte)

-Oval or egg shaped

Clinical Significance: Thalassemias

RBC Morphology

(Target Cells)

-Cells that look like targets

Clinical Significance: Liver disease

-Look like tear drops

Clinical Significance: Idiopathic myelofibrosis

RBC Morphology
(Stomatocytes)

- Cells that have a rectangular or slit-like central pale area

Clinical Significance: Acute alcholism

RBC Morphology

(Rouleaux)

-Cells look like a roll of quaters

Clinical Significance: Abnormal Protein Levels

RBC Morphology

(Basophilic Stippling)

-Cells look like a Robbin's egg

Clinical Significance: Lead poisoning

RBC Morphology

(Howell-Jolly Bodies)

-Cells w/ small, round and blue/black inclusions

Clinical Significance: Seen following a splenectomy

RBC Morphology

(Pappenheimer Bodies)

-Small, irregular magenta-colored granules

Clinical Significance: Sideroblastic anemia

-Small, scattered blue dotlike structures varying size in RBC

Clinical Significance: Glucose-6-Phosphate Dehydrogenase Deficiency

Megaloblastic Anemia?

(definition)

Myelopoiesis?

(definition)

Length of WBC Maturation?

Types of WBC's

(2 types)

-Granulocytes

-Agranulocytes

Types of Granulocytes

(3 types)

-Neutrophils

-Eosinophils

-Basophils

Types of Agranulocytes?

(2 types)

-Monocytes

-Lymphocytes

Causes of Megaloblastic Anemia?

Function of WBC's

-Neutrophils (50-70%)

-Eosinophils (0-5%)

-Basophils (0-1%)

-Lymphocytes (20-40%)

-Monocytes (0-7%)

-Colony-forming unit-granulocyte/monocyte

-Myeloblast

-Promyelocyte

-Myelocyte

-Metamyelocyte

-Band Granulocyte

-Segmented Granulocyte

Lymphopoiesis

(definition)

Abnormal WBC Apperances

(Two Appearances)

-Hypersegmentation (>6 lobes & seen in B12/Folate deficiencies)

-Hyposegmeted (<2 lobes)

Neutrophil Cytoplasmic Inclusion : Seen in Acute Infections

(2 types)

-Toxic Granulation (granules: more numerous, larger & stain deeper color)

-Vacuolization (apper as "holes" in cytoplasm)

Neutrophil Cytoplasmic Inclusions seen in Rapid Cell Maturation due to infection

(1 type)

Reactive Lymphocytes seen in:

(3 things)

-Viral Infections

-Pertussis
-Toxoplasmosis

Inneffective Granulopoiesis

(definition)

CBC results:

(9)

1. RBC Count

2. WBC Count

3. Hgb

4. HCT

5. MCV

6. MCH

7. MCHC

8. RDW

9. Platelet Count

RBC Indices

(4)

1. MCV (Microcytic or Macrocytic)

2. MCH (Avg. weigh of Hgb in each RBC)

3.MCHC (Estimate of concentratin of Hgb in each RBC)

4.RDW (Anisocytosis: Size variation)

Non-Routine Hematology Test

(Reticulocyte Count)

Increased Retic Count idicative of :

(2)

-Bone marrow producing RBC properly

-Acute or Chronic Bleeding

Decreased Retic Count indicative of:

(2)

- Aplastic anemia

-Ineffective erythropoiesis

Erythrocyte Sedimentation Rate (ESR) test for:

Increased ESR indicative of :

(5+)

1. Acute or Chronic Infections

2. Tisseu necrosis & infarction

3. Malignancies

4. Rheumatoid Collagen disease

5. Chronic Renal Disease

6. many others

Anemias are based on:

(2)

-Size of RBC (Microcytic, Normocytic or Macrocytic)

-Color of RBC (Hypochromic or Normochromic)

Affects of Globin chain synthesis

(2)

a. Deficiency of Alpha creates reduced rate in synthesis of Beta

b. Heme synthesis

Normal Hemoglobin production dependent on:

(3)

a. Adequate Iron delivery to RBC

b. Adequate synthesis of protoporhyrin IX

c. Adequate globin chain synthesis

Extravascular Catabolism of Hemoglobin

(Broken down into 3 parts)

a. Globin Chains (recycled)

b. Iron (recycled)

c. Protoporphyrin IX

Intravascular Catabolism of Hemoglobin

(2 parts)

-Iron (recycled)

-Bilirubin (excreted in urine & feces)

Function of Hemoglobin

(2)

-Uptake of O₂

-Delivery of O₂

CO

(Is 210 great affinity than O₂)

Which state is better for Iron uptake Fe²⁺

 (Ferrous) or Fe³⁺ (Ferric)

Sulfhemoglobin?

(definition)

Four major problems that can occur in Hemoglobin Synthesis

1. Qualitative effects

2. Quantitative effects

3.Defects in synthesis of heme portion

4. Defects involving incorporation of Iron

Structural Abnormalities of Hgb

(3)

1. Hemoglobin S (high altitudes)

2. Hemoglobin C (Form oblong crystals)

3. Hemoglobin F

Hemoglobin S forms what types of cells

Results of Sickle Cells:

(4)

1. vaso-occlusion

2. tissue hypoxia

3. extreme pain in area of blockage

4. tissue death

Quantitative Abnormalities

(2)

1. Alpha Thalassemia

2. Beta Thalassemia

Both result in reduced or absence of there normal amnt of chains.  

-Deficiency or dysfunction w/in normal heme synthesis

-Causes blistering of skin when exposed to sun

1. Uroporphyrin

2. Coproporphyrins

3. Protoporphyrin

In RBC (70%)

Stored (30%)

1.Inadequate dietery intake

2. Decreased Iron absorption

3. Chronic Blood Loss (GI bleeding & Heavy menstruation)

4. Increased body iron usage (Pregnancy & Lactation)

Causes for Sideroblastic Anemia (Iron linked)

(2)

1. Inherited

2. Aquired (Alcohol abuse, Exposure to Vit. B6 inhibitory drugs & Lead poisoning)

Chronic Diseases that can cause Anemia:

(4)

1. Cancer

2. Liver Disease

3. Renal Disease

4. Chronic infection or inflammation

Hemochromatosis

(explanation)

Serum Iron test looks for :

Fe²⁺ bound to transferrin

or

Iron circulating as free hemoglobin

Hemostasis

(definition)

Hemorrhage

(definition)

Types of hemorrhage

(2)

-Petechiae: small, pinpoint intradermal hemorrhages

-Ecchymoses: Intradermal hemorrhage(s), larger than petechiae (a.k.a bruises)

Purpura

(definition)

Causes of Petechiae

(4)

-Platelet defects

-Coagulation factor defects

-Infectious diseases

-Disseminated intravascular coagulation (DIC)

Two phases of Hemostasis

1) Primary: interaction between platelets & walls of injured blood vessels

2)Secondary: Coagulation factors are activated to form a clot to reduce & eventually stop bleeding via Intrinsic and Extrinsic pathways

-Change in shape

-Extended pseudopods

Effect Aspirin has on Platelet Function

(2)

-Inhibits the pseudopod formation that allos for platelet aggregation

-Also prevents platelet signaling

Lab test to assess Platelet function:

(1)

Fibrin I (Fibrinogen)

Pathway location

Factor II (Prothrombin)

Conveted to:

Factor III -Tissue Thromboplastin

Located in what pathway

Factor V-Labile Factor

Sensitive to what?

Factor VII-Stable Factor

Located in what pathway:

Factor VIII comprised of two components:

a) Factor VIII

b) von Willebrand Factor (vWF)

Factor IX- Christmas Factor

Located in what pathway

Factor X- Stuart-Prower Factor

Activated by which pathway

1.)XII to XIIa

2.) XI to XIa

3.)IX to IXa

4.)VIII to VIIIa

5.)activation of X to Xa

1.)Factor III with Factor VII to Factor VIIa

2.) Activate X to Xa

1.) Xa with Va active V

2.) V activate II to IIa

3.) IIa activate I to Ia

4.)Ia activate XIII to XIIIa

1. Prothrombin Time (PT)

2. INR

3. Activated Partial Thromboplastin (APTT)

4. Activated Clotting Time (ACT)

5. Thrombin Time

6. Plasma Fibrinogen Level

7. Factor VIII Assay

PT test screens for deficiency in:

(5)

1.Factor I

2.Factor II

3. Factor V

4. Factor VII

5. Factor X

PT test used for:

(3)

1. Monitor anticoagulant therapy

2. Screen for coagulation disorders

3. Evaluate Liver functions (Vit. K)

Anticoagulant Therapy Drug : Coumadin given to:

(3)

1. Pts with atrial fibrillation/flutter

2. DVT (Deep vein thrombosis)

3. Heart valve replacement

A normalized PT time test result that provides a workable refence range for all lab reports

Activated Partial Thromboplastin Time (APTT)

asseses what?

APTT used for:

(3)

1. Monitor heparin anticoagulant therapy

2. Coagulation Disorders

3. Evaluate liver functions

Activated Clotting Time (ACT)

Collected where:

Fibrinolysis

(definition)

-tPA (Tissue Plasminogen Activator)

-Urokinase

-Streptokinase

Fibrinolysis Components

(3)

-Plasminogen

-Plasmin

-Plasmin Inhibitors

Process of Fibrinolysis

1.Plasminogen binds strongly to Fibrin

2. Plasminogen activated to Plasmin

3.Plasmin digest Fibrin

Fribinolysis Lab Test

(2)

1. Thrombin Time

2. D-Dimer

Thrombin Time asssesses

D-dimer Assay used to assess

(3)

1. DVT

2. PE

3. Disseminated intravascular coagulation (DIC)

-Antithrombin III

-Protein C

-Protein S

-Lupus Anticoagulant

-Heparin

Lupus Anticoagulant can lead to what coagulation test(s) to be prolonged

Heparin also used as a medication for:

(3)

1. MI

2. DVT

3. Heart Surgery

1. Indistinguishable by pt. history & symptoms alone

2. Pt more likely to be deficient in VIII than IX

3. If suspect hemophilia order VIII assay

4. Hemophilia A is most common

1. Common congenital disorder of hemostatis

2. Most pts w/ disorder rarely have severe symptoms

3. Symptoms similar to Hemophilia A and B

1. VII first coag factor to become deficient

2. Result in prolonged PT & APTT tests

1. Characterized by hyper-stimulation of ALL coag and fibrinolytic activity simultaneously

2. Affects the entire body