Hemolyzed specimens

[ehwhatsupdoc]

Does your Emergency Department have a high rate of hemolysis in specimens sent to the lab? I currently work as a Clinical Laboratory Technologist and 20-25% of the specimens coming from the ED is hemolized, requiring redraw for K+, LFTs, LDH, and PT, aPTT. The ED seems to think we are causing hemolysis but I believe the real reason is drawing labs with IV starts. If you know of the best ways to minimize hemolysis please let me know. I've heard that if labs must be taken with IV starts it's best to do it from the antecubital region and use a larger bore needle. Having labs redrawn and rerun causes a waste of time and money. It is better to stick the patient twice from the start, one for the IV the other to draw blood with vacutainer set up then it is to stick the patient again 30min to 1 hour later. We only have hemolysis problems with the ED.

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[Angry Birds]

Does your Emergency Department have a high rate of hemolysis in specimens sent to the lab? I currently work as a Clinical Laboratory Technologist and 20-25% of the specimens coming from the ED is hemolized, requiring redraw for K+, LFTs, LDH, and PT, aPTT. The ED seems to think we are causing hemolysis but I believe the real reason is drawing labs with IV starts. If you know of the best ways to minimize hemolysis please let me know. I've heard that if labs must be taken with IV starts it's best to do it from the antecubital region and use a larger bore needle. Having labs redrawn and rerun causes a waste of time and money. It is better to stick the patient twice from the start, one for the IV the other to draw blood with vacutainer set up then it is to stick the patient again 30min to 1 hour later. We only have hemolysis problems with the ED.

1) The four ER's I have worked in have not had this problem.

2) Our patients can be the sickest and without any IV access, and we work under time restraints that other specialties do not. Very often I am grateful that a nurse can get a line at all, and if she does, I'd want labs drawn from it since I am not sure we will be able to get another one due to the patient being too dehydrated, a gomer, etc.

 

[southerndoc]

How are you determining hemolysis is present? We once had a "hemolyzer" in the lab who did visual inspections and deemed labs hemolyzed. About 30% of labs sent to him were "hemolyzed" according to him. He was fired after we demanded the lab confirm they were hemolyzed, which of course only about 5% were.

 

[engineeredout]

Anyone notice that if you call the lab to ask where your results are, like a U/A that is taking two hours to come back, the rest of your labs for the shift end up hemolyzed?

 

[Hair Police]

Hemolyzed = I dropped the tube*

*In the lab tech tongue

 

[mikil100]

I work in an ED as a nurse.

Hemolyzed specimen seem oddly related to the shift I work. Is it the nurses or the lab? Who knows. Some nurses IV skills are certainly worse than others, and I don't have the knowledge of how our labs work to assume it is the labs fault.


I will say that the idea of "sticking the patient twice." is a ridiculous notion. It address the hemolysis problem, possibly. How do you think the patient feels about being poked twice? Not to mention, some patients are extremely difficult sticks. You must remember a large portion of our clientele have had chronic diseases, including IV drug abuse, dialysis, and other factors that greatly limit our options for access.

 

[ehwhatsupdoc]

How are you determining hemolysis is present? We once had a "hemolyzer" in the lab who did visual inspections and deemed labs hemolyzed. About 30% of labs sent to him were "hemolyzed" according to him. He was fired after we demanded the lab confirm they were hemolyzed, which of course only about 5% were.

It's fairly easy to tell if something is hemolyzed, after it is centrifuged the serum should be clear without a red tinge. Our instruments also have a hemolysis index, anything greater than an index of 2-3 is cancelled for certain tests like K+.

 

[ehwhatsupdoc]

I work in an ED as a nurse.

Hemolyzed specimen seem oddly related to the shift I work. Is it the nurses or the lab? Who knows. Some nurses IV skills are certainly worse than others, and I don't have the knowledge of how our labs work to assume it is the labs fault.


I will say that the idea of "sticking the patient twice." is a ridiculous notion. It address the hemolysis problem, possibly. How do you think the patient feels about being poked twice? Not to mention, some patients are extremely difficult sticks. You must remember a large portion of our clientele have had chronic diseases, including IV drug abuse, dialysis, and other factors that greatly limit our options for access.

It really isn't as ridiculous as you think. The IVs are not designed for labs to be drawn.

 

[ehwhatsupdoc]

Hemolyzed = I dropped the tube*

*In the lab tech tongue

Haha, I've also had residents come down to inspect the hemolyzed specimen. I guess some people will always be paranoid. Believe it or not lab professionals strive to do a good job and we have quality measures that go above and beyond many of the other areas of the hospital.

 

[gutonc]

How are you determining hemolysis is present? We once had a "hemolyzer" in the lab who did visual inspections and deemed labs hemolyzed. About 30% of labs sent to him were "hemolyzed" according to him. He was fired after we demanded the lab confirm they were hemolyzed, which of course only about 5% were.

When I was a resident, we had a lab tech that we called "band lady". You knew that she was on because every single CBC came back with a band count, regardless of the total WBC.

WBC 5.5? 15% bands (despite an admission for CHF exacerbation).

ANC of 600 in a chemo patient? Bands 590.

We learned to ignore her and, if necessary, draw a PM CBC when some other tech would be on and would give a more realistic result.

 

[mikil100]

It really isn't as ridiculous as you think. The IVs are not designed for labs to be drawn.

So, you are justifying sticking a patient twice (at least) to obtain a blood sample that will run perfectly fine 90% of the time through an IV?

Lets do a simple risk versus reward analysis

Risks
1) patient is unhappy they're stuck twice "Why are you poking me again, I just got stuck!" (unhappy is putting it mildly for many patients)
2) while low risk, the patient is exposed to more opportunity for infection, thrombophlebitis, and even thrombosis.
3) the added time to the nursing staff, particularly for difficult sticks. Some patients I will end up spending 5-10 minutes looking for, and getting an IV in or blood sample completed, especially if I have to stick more than once.
4) exhaustion of future IV sites.

Reward:
1)Periodically, a blood sample will come back unhemolyzed when it otherwise would have been (maybe)
2)???

I see almost no justification for this. I understand the desire to prevent the issue, as it's frustrating for everyone involved, but I don't think poking the patient more is a realistic expectation.

 

[ehwhatsupdoc]

So, you are justifying sticking a patient twice (at least) to obtain a blood sample that will run perfectly fine 90% of the time through an IV?

Lets do a simple risk versus reward analysis

Risks
1) patient is unhappy they're stuck twice "Why are you poking me again, I just got stuck!" (unhappy is putting it mildly for many patients)
2) while low risk, the patient is exposed to more opportunity for infection, thrombophlebitis, and even thrombosis.
3) the added time to the nursing staff, particularly for difficult sticks. Some patients I will end up spending 5-10 minutes looking for, and getting an IV in or blood sample completed, especially if I have to stick more than once.
4) exhaustion of future IV sites.

Reward:
1)Periodically, a blood sample will come back unhemolyzed when it otherwise would have been (maybe)
2)???

I see almost no justification for this. I understand the desire to prevent the issue, as it's frustrating for everyone involved, but I don't think poking the patient more is a realistic expectation.

I think the solution is better design of IVs. I believe there are vacutainers that were developed to hook up to an IV so blood can be drawn with the initial insertion. It would provide adequate pressure and not lyse RBCs due to shear force.

 

[ehwhatsupdoc]

When I was a resident, we had a lab tech that we called "band lady". You knew that she was on because every single CBC came back with a band count, regardless of the total WBC.

WBC 5.5? 15% bands (despite an admission for CHF exacerbation).

ANC of 600 in a chemo patient? Bands 590.

We learned to ignore her and, if necessary, draw a PM CBC when some other tech would be on and would give a more realistic result.

Its probably because she's reading the diff under 50x and not 100x, also she probably has bad eyesight and can't tell there's segmentation.

 

[mikil100]

I think the solution is better design of IVs. I believe there are vacutainers that were developed to hook up to an IV so blood can be drawn with the initial insertion. It would provide adequate pressure and not lyse RBCs due to shear force.

That would be an excellent solution.