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PETER J. HOWANITZ MD. PROFESSOR, VICE CHAIRMAN & CLINICAL LABORATORY DIRECTOR DEPARTMENT OF PATHOLOGY STATE UNIVERSITY OF NEW YORK Downstate Medical Center Brooklyn , NY, USA [email protected]. INTRODUCTION. Definition & Significance Of Hemolysis Discuss Practice Patterns - PowerPoint PPT Presentation
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1
PETER J. HOWANITZ MD
PROFESSOR, VICE CHAIRMAN & CLINICAL LABORATORY DIRECTOR
DEPARTMENT OF PATHOLOGYSTATE UNIVERSITY OF NEW YORK
Downstate Medical Center Brooklyn , NY, USA
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INTRODUCTION• Definition & Significance Of Hemolysis• Discuss Practice Patterns• Determine Causes• Propose Improvements• Conclusions
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Hemolysis is the disruption of the blood cell membrane with the release of the blood cell
contents into the surrounding fluid.
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SOME IN VIVO HEMOLYSIS CAUSES
• Hemolytic Transfusion Rx, Autoimmune Warm Ab• Hereditary Spherocytosis, G6PD Def, Sickle Cell• Hemolytic Transfusion Rx, Autoimmune Warm Ab• Anti-malarials, Aspirin, Chloramphenicol• Malaria, Clostridia, DIC• Burns, Liver & Renal Disease, PNH• March Hemoglobinuria, Prosthetic Heart Valves
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PHLEBOTOMY RELATED CAUSES
Catheter IV CollectionDrawn From Hematoma
Capillary CollectionPhlebotomy EquipmentPhlebotomy Antiseptic
Tourniquet Time
Lippi….Green et al. Clin Chem Lab Med 2009;47:143
Location of StickNo Mixing In Tube
Vigorous Mixing In TubeTraumatic Draw
Tube Under FillingSyringe Transfer
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PRACTICE PATTERNS OF HEMOLYSIS
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CAP QUALITY PRACTICES COMMITTEE STUDY
Q-Probes FormatCAP Chemistry Resource Committee Assistance
7 CAP Chemistry Survey Participants On-Line Questionnaire
28 Multiple Choice Questions7 “Other, Please List” Questions
846 Participants
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0%
5%
10%
15%
20%
25%
30%
35%
40%36% 35%
15%
4%1%
9%
LABORATORY OVERALL HEMOLYSIS RATE (%)
LABORATORY CATEGORY BASED ON HEMOLYSIS RATE
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PROCEDURES USED FOR HEMOLYSIS ID
Parameter % Yes % No % Unsure
Hemolysis visually graded compared to a picture 40 57 3
Visual grading evaluated by competency assessment 18 73 9
Manual procedures identify hemolysis in difficult cases 8 88 4
Able to send automated hemolysis flags to med record 36 50 14
Used automated result verification primary chem analyzer 32 66 2
Same hemolysis scale all analytes primary chem analyzer 81 14 5
Same hemolysis scale primary chem & IA analyzer 70 23 8
Same hemolysis scale primary & backup chem analyzer 74 19 7
Systematically/regularly monitors hemolyzed specimens 47 46 7
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HEMOLYSIS SCALES USED 710 LABS
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HEMOLYSIS REJECTION PRACTICES
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21/69 MOST COMMONLY USED HEMOLYSIS DESCRIPTIVE TERMS
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USE OF 20 CUTOFF HEMOLYSIS TERMS
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ANALYTE SPECIFIC HEMOLYSIS POLICIES
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ATTEMPTED TO VALIDATE HEMOLYSIS FOR ANALYTES
Any
Potassium
Glucose
LD
0% 5% 10% 15% 20% 25% 30% 35%
30%
29%
24%
23%
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CORRECTIVE ACTION DURING PAST YEAR
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LACK OF SUCCESS IN HEMOLYSIS REDUCTION (N=567)
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PHLEBOTOMY RELATED CAUSES
Catheter IV CollectionDrawn From Hematoma
Capillary CollectionPhlebotomy EquipmentPhlebotomy Antiseptic
Tourniquet Time
Lippi et al. Clin Chem Lab Med 2009;47:143
Location of StickNo Mixing In Tube
Vigorous Mixing In TubeTraumatic Draw
Tube Under FillingSyringe Transfer
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WHOLE BLOOD HEMOLYSIS DETECTION
Not Determined
After analyses stored, visually inspected
After analyses centrifuged, visually inspected
K+ elevated,other tubes evaluated
K+ elevated, centrifuged, visually inspected
0% 10% 20% 30% 40% 50% 60%
56%
10%
21%
3%
3%
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CASE REPORTIsmail et al BMJ 330:949,2005
40 Year Old Woman Admitted –Dx SLE5 Days Vomiting, Diarrhea, Weakness
Hb 8.9 g/dl, WBC 6.1 X109 BUN 87 mg/dl Creatinine 4.8 mg/dl
Blood Smear –Diffuse Fragmented Cells Consistent With Microhemangiopathic Hemolytic Anemia
Potassium Cancelled-Hemolyzed
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CASE REPORT CONTINUEDDx-Hemolytic Uremic Syndrome &
Acute Renal Failure Treated Aggressively, & Planned To
Transfer To Dialysis Next DayCardiac Arrest & Died
POST MORTEM ? KIf Known, Immediate Dialysis?
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RECENT INSTRUMENTATION ADVANCES
• Measure Hemolysis• Download Hemolysis To LIS• Provide Extensive Hemolysis Evaluations• Allow Unique Hemolysis Flag By Analyte• Hemolysis Measurements FDA Approved
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COST OF HEMOLYSIS• $203,037 /Yr• Reduced Hemolysis 19.8% To 4.9%• Singapore General Hospital ED• 200 ‘Lyes & Bun/Day• $18.67/Test
Ong et al Am J Med 2009: 122:1054
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COST OF HEMOLYSIS• ICU/DAY•Hospital Charge/Day
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SAME HEMOLYSIS FLAGS AS LIPEMIA OR ICTERUS
LD Glucose Potassium Other0%
10%
20%
30%
40%
50%
60%
70%
53%58%
61%
37%
54% 55%
64%
36%
Lipemia Icterus
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AIDS FOR IMPROVEMENT
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VALIDITY OF DATA ON CAUSES
• Many Studies By Nursing Personnel• Difficulty In Controlling Variables• Unaware Lab vs Nursing Phlebotomists• Some Data Conflicting• Need For Published Studies
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VENIPUNCTURE VERSUS IV CATHETER
Lowe et al. J Emerg Nurs 2008, 34: 26-32
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FIVE IMPROVEMENT SUGGESTIONS
Do Not Reject Hemolyzed SpecimensDevelop Interdepartmental Team(s)
Choose Instruments That Quantitate HemolysisMonitor & Share Successes With Administration
Select Aids For Improvement
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CONCLUSIONS
• Definition & Significance Of Hemolysis• Discussed Clinical Laboratory Practice
Patterns• Established Causes• Provided Suggestions For Improvements