Laboratory Medicine and Anatomic Pathology ChemistryImmunology MicrobiologyVirology Transfusion Medicine Apheresis Blood Bank HematologyFlow Cytometry Tumor Profiling Autopsy Cytology ID: 909854
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Slide1
Meet the Consultants:
Lab Medicine
Slide2Laboratory Medicine
and Anatomic Pathology
Chemistry/Immunology
Microbiology/Virology
Transfusion MedicineApheresisBlood BankHematology/Flow
Cytometry
Tumor Profiling
Autopsy
CytologySurgical PathologyBone and Soft TissueBreast PathologyDermatopathologyGenitourinaryGI and LiverGynecologicHead, Neck & Endocrine
HematopathologyMolecular DiagnosisBioinformatics
Medical RenalNeuropathologyOphthalmicPediatricThoracic
Slide355 Park Street
6
th
Floor:MicrobiologyVirology
5th FloorProcessingChemistryHematology4
th
Floor
HematopathologyImmunology
Flow CytometrySpecial Chemistry3rd FloorBlood BankStem Cell Lab
Sample Delivery
Bags and Tags forTransfusion ReactionsOther Locations:NP 8 Apheresis Clinic
Slide4Slide5Slide6Slide7Slide8Service Duties
Patient CareSign-OutCritical ValuesApproval of Off-Label Use of Clotting Factors
ConsultationLaboratory Management
CLIA RegulationsEvidence-Based PracticeProtocolsQC/QA/QI
Proficiency TestingResource ManagementLab StaffingTesting Schedules
Slide9Consults
Slide10MUST Consult List
Massive Transfusion Protocols (MTPs)*
Transfusion Reactions*
Urgent Apheresis, e.g.:
Acute Chest Syndrome in Sickle Cell DiseaseThrombotic Thrombocytopenic Purpura
Off-label clotting factor approval*
*You call us (preferred) or we call you
https://
www.turbosquid.com
Slide11“Bad” Consult Example
On a peripheral smear order:“Smear morphology”
“Blood info?”“?”
Clark, William. (2016) Contemporary Practice in Chemical Chemistry, 3
rd
Edition. AACC Press.
Slide12“Good” Consult Example
Indication for testing in chart/lab requestPeripheral smears
Flow cytometryGive clinical context
“I have a question about _____ testing”One-linerHave MR and/or specimen ID
readyGive contact information (full name and number) for follow-upBe as specific as possibleAlways better to call ahead
Especially for Blood Bank and Apheresis
https://
www.arrowheadscientificinc.com
Slide1319Υ-000ΗΕ0000
19Υ-000ΗΕ0000
Slide14General Lab Info and Tips
Ordering, Specimen Handling, and Critical Values
Slide15Slide16Slide17Slide18Slide19Slide20Slide21Lab Tips - Ordering
For:“Missing” OrdersMiscellaneous Orders
Special Send-Out Requests
Order miscellaneous blood/non-blood test and enter into comments:Name of Lab
Name of TestLab ID/Test Code
First Quest
Then
ARUP
Mayo ClinicNMSCannot send to research labs
Slide22Slide23Slide24For other questions about tests
Customer Service Hotline:
203-688-2444
Slide25Lab Tips - Specimen Handling
Send separate specimens to Lab Medicine and Pathology when possibleCoordinate with Lab Medicine and Pathology if shared specimen
Especially if after hoursSend samples in lab-approved containersSend representative samples of larger specimens
If urgent, hand-deliver it to the labAlways better to call ahead
Slide26Critical Values
Regulated at the federal and state levelOrdering provider or other responsible provider must be contacted
The patient name, test name, and value must be repeated by the providerThe provider’s name and contact number must be recorded
If there is a note in the chart with patient name, test name, and value, can be used as surrogate for phone call
Slide27Transfusion Medicine
Platelets, MTPs, Transfusion Reaction Work-Ups, and Apheresis Consults
Slide28Transfusion Medicine - Platelets
Basics1 pool = 1 bag = 4-6 unitsExpire in 5 days
One unit should increase platelet count 5,000-10,000/uL
One pool should increase platelet count 20,000-50,000/uL
Blood Bank ManagementReceived on Day 3~40 units in YNHH Blood BankTurnover ~30 units per day
Slide29Transfusion Medicine - Platelets
Thresholds for platelet transfusion based on AABB and ASCO guidelines and interdisciplinary agreement:
>10,000/uL for bleeding prophylaxis>20,000/uL
for bleeding prophylaxis with fever>25,000/uL for line placement>50,000/
uL for bleeding, invasive procedure, adult lumbar puncture>100,000/uL for neurological bleedContraindicated in HIT and TTP
Slide30Transfusion Medicine - MTPs
What is in an MTP box?6 units RBCs, 6 units plasma, 1 pool platelets (4-6 units)
1:1:1You will be getting a call…To obtain clinical information
To confirm active Type and ScreenDraw before administering blood if possibleTo confirm recent CBC, coagulation studies, and fibrinogen
To receive an estimate of blood product useTo answer whatever questions you might have
Slide31Transfusion Medicine – Transfusion Reactions
Transfusion-associated circulatory overload (TACO)Transfusion-related acute lung injury (TRALI)
Allergic reaction (mild vs. severe)Acute hemolytic transfusion reaction (AHTR)Delayed hemolytic transfusion reaction (DHTR)
Febrile non-hemolytic transfusion reaction (FNHTR)Septic transfusion reactionThese reactions are “dose-dependent”.
Stop the transfusion!
Initiate a reaction
work-up!
Slide32Transfusion Medicine – Transfusion Reactions
Order a “post-transfusion reaction sample” in epic
Pink top tubeWalk the bags and tags back to the blood bankDon’t use the tube system!
Have the following information ready:Clinical historyReaction signs/symptoms
Product(s)Timing of transfusionPre-transfusion medicationPost-transfusion medication
Transfusion Reaction ROS
AMS
Chest pain
DyspneaAbdominal painBack/flank painFevers/chills/rigorsHives/rash/pruritis/edemaInfusion site pain
Slide33Transfusion Medicine – Transfusion Reactions
On the phone we will:Confirm return of bags/tags
Make an initial assessment if possibleRecommend additional laboratory studiesRecommend therapies
Address questions about continued transfusion
In the lab we will:Perform clerical checksAssess for hemolysisRetype the patientRescreen the patient
Assess for antibody binding to red cells (DAT)
Characterize antibody binding to red cells
+/- Culture the product
Perform ancillary testing
Slide34Apheresis
Inpatient consultationsRed cell exchange for ACS in SS disease
Plasma exchange for TTPOrgan rejectionCall in addition to placing consult
We are not contacted by consult call centerTransfusion Fellow will evaluate:Indication
SafetyAccessReach out early to make a planConsider timing of medication that may be removed by apheresis
www.terumobct.com
Slide35Hematology
Peripheral Smears and Special Coagulation Studies
Slide36Slide37Hematology - Peripheral Smear
Considerations for MD smear interpretation
Specific clinical question that requires morphologic interpretationSmear cannot assess functionQuantitation can be assessed with manual differential
E.g. “34 year-old female with rheumatoid arthritis and acute on chronic anemia, ACD vs. iron deficiency”No other clear/confounding etiology
GI bleed and anemiaAcute infection/steroids and leukocytosisTransfusion effects
Laboratory studies are more sensitive and specific
Anemia
Red cell indices, iron studies, reticulocyte indices, B12,
folateHemolysisLDH, haptoglobin, indirect bilirubinThrombocytopeniaReticulated platelet studiesHIT Panel
Slide38Hematology - Special Coagulation Testing
Tube Fill ErrorsClinical ContextMedication Effects
Lupus Anticoagulant TestingTransfusion Effects
Slide39Microbiology
Special Culture Orders, Mixed Cultures, Susceptibility Requests, Stool Pathogen Panel
Slide40Microbiology – Special Culture Orders
Note:
Candida will grow on routine blood cultures
No longer accepting oral/respiratory specimens for
Actinomyces culture
Search “culture” in the lab manual to find special culture orders:
Slide41Microbiology – Special Culture Orders
Call Infection Control and the Lab!
If you suspect a select agent:
Slide42Microbiology – Mixed Cultures
Usually mixture of Gram-positive, Gram-negative, aerobic, and anaerobic organisms
Lab works-up predominating organismsLab checks for individual organisms of clinical importance as per comment
Slide43Microbiology – Susceptibility Requests
Testing is limited by guidelines, methods, equipment, and organism
Guidelines incorporate clinical data to avoid treatment errors based on in vitro results
Courtesy of Dr. David
Peaper
Slide44Microbiology - Stool Pathogen Panel
Included Genera:SalmonellaShigella
CampylobacterSTEC (Shiga Toxin)Yersinia
VibrioCommunity acquired diarrheal organisms
Very low pre-test probability for anyone in the hospital greater than 3 daysWill be cancelled if hospitalized >3 days as per comment
Slide45Slide46Slide47Slide48Slide49Slide50Slide51Chemistry
Body Fluid Testing and Interferences
Slide52Chemistry - Body Fluid Testing
Peritoneal
Pleural
CSF
Surgical Drain
Dialysate
Albumin
Albumin
LDHTotal BilirubinBUNAmylaseAmylase
CreatinineCreatinineLipase
CholesterolAmylaseTotal BilirubinGlucoseLipaseGlucoseLDHLDHTotal ProteinTotal ProteinTriglyceridesTriglyceridesCholesterol
Validated
Analytes
for Body Fluid Testing
Slide53Chemistry - Interferences
Hemolysis (Hemolyzed)
Hyperbilirubinemia (Icteric)Hypertriglyceridemia (Lipemic
)
BiotinHeterophile AntibodiesHuman Anti-Animal Antibodies (HAAA)Human Anti-Mouse Antibodies (HAMA)
Slide54Slide55Summary Slide
Urgent Consults:MTPTransfusion ReactionsApheresis
Off-label factor useWho to call:Customer Service for test information
MHB per service in Amion for Laboratory Medicine questionsApheresis Service for inpatient apheresis consults
Slide56Feedback? Suggestions?
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