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Specimens of skin will be submitted to histology after being obtained by various surgical biopsy procedures, such as the shave, punch, or curettage methods. In general, skin specimens will be oriented so that sections will be taken at an angle perpendicular to the epidermis. Identification of the epidermis is a good first step in deciding correct orientation of most skin specimens. However, since important diagnostic information can very easily be lost with incorrect orientation of skin samples, it is important to verify the specimen type and biopsy type using the accession log, embedding worksheet, or gross description before proceeding. Do NOT merely rely on visual recognition by itself.
|Capillary Blood Collection for Metabolic Testing|
The collection of these specimens requires the same attention to detail as with any phlebotomy procedure. Gather all necessary equipment Be certain to choose a device that punctures the heel to a depth appropriate to the size of the infant. Only use the filter cards provided by your state to collect the specimen. These cards are calibrated to the exact specifications needed for testing of metabolic disorders. An alternate or homemade card must not be used. Put on all necessary personal protective equipment Gloves are always required. Gowns and eye protection may also be required. Positively identify the patient Use two identifiers. The infant who is in the nursery should have an identification band attached to the ankle or wrist. In special care nurseries an alternate form of identification may be used. However, a crib card should never be used as a form of identification. Follow the practice for your facility. Position the infant Be certain that the heel can be easily accessed. Follow all nursery requirements that apply to safe handling of newborns. Warm the heel using an approved warming device Clean the site with alcohol or the approved disinfectant. Allow the site to air dry before proceeding with collection of the specimen. Grasp the heel firmly but not tightly, activate the puncture device, wipe away the first drop of blood, and begin collection of the specimen.Allow the blood to wick onto the card. Completely saturate the circle with one continuous drop of blood. Avoid touching the card to the skin. Apply the blood only to one side of the card. Do not layer the blood by applying a second drop on top of the first. Repeat the procedure to completely fill each circle on the card. Each circle should be completely and uniformly saturated as shown in the bottom image on the right. Follow the policy of your institution or state to determine how many circles must be completely filled. Apply pressure to the puncture site using a sterile gauze Gently raising the infant's leg above the level of the heart will also aid in clotting the puncture site. Bandage according to site-specific policy.
|Challenges for Implementation: Workflow Requirements|
However limited or spacious the available area is, the establishment of a work process that directs the flow of both staff and specimens in a unidirectional flow is essential. Personnel should be educated to begin work in the "clean" area designated for reagent preparation; move on to the area designated for specimen preparation and extraction, and lastly, proceed to the area for amplification and detection.Back and forth movement between these areas in the course of one run of specimens should NOT occur. Each area should have the necessary dedicated equipment to allow for the segregation of activities to their designated areas. Examples include pipette devices, small tabletop centrifuges, water baths, and racks. Gloves should be removed and disposed of before proceeding from one area to the next.
|RhIg-Derived Anti-D Reaction Strength|
As noted, reaction strength can suggest whether anti-D at delivery is likely immune or passive, however, several factors affect RhIg's reaction strength in laboratory tests.Before proceeding, take a moment to think about the following questions. Which reaction strengths are typically seen at delivery from RhIg-derived passive anti-D? Which variables can affect RhIg-derived passive anti-D reaction strengths?
|Mini-Panel Antibody Exclusion|
Below are the results of a mini-panel of red cells specifically chosen to exclude other clinically significant antibodies in the presence of anti-D. Besides an autocontrol, a positive control (Ror) was included to confirm that the mother's plasma containing the probable anti-D was reactive at the time of testing. Recall that the results of the initial antibody screen showed that the possible (unexcluded) antibodies were anti-C, D, E, K, Fyb, Jka, M, s, Leb(with anti-M less likely as a cause of HDFN and anti-Leb not a cause).Antibodies excluded by Screen Cell #3 included anti-c, e, Fya , Jkb, N, S, P1 and anti-Lea.Before proceeding to the next page, assess whether the unexcluded antibodies from the initial antibody screen have been excluded by the mini-panel below using the guidelines in the antibody exclusion protocol.Mini-Panel ResultsCellRhRhesusKellDuffyKiddMNSsPLewisResultsCDEceKkFyaFybJkaJkbMNSsP1LeaLebGel IAT*1rr000+++++0+00++0+S+002rr000++0+0++0++0++S+003r'r+00++0++00++0+00+004r'r+00+++++++++0+++0+05r"r00+++0+0+0+++0+++006r"r00+++0++++++++++0+07Ror0++++0++++++++++0+2+8Auto0* IAT = indirect antiglobulin test All panel cells are negative for low frequency antigens and positive for high frequency antigens unless noted otherwise. All cells are also negative for Cw, Kpa, and Lua.
|Serologic Tests on Newborn|
Based on the results of the mini-panel, the laboratory concluded that only anti-D was present and that it was consistent with administration of RhIg at 28 weeks.Patient A.D. delivered a 5 lb 13 oz female by C. section with serologic test results on cord blood as follows. Well washed cord red cells were used for ABO and Rh(D) typing to remove possible Wharton's jelly.Before proceeding to the next page, evaluate if the infant's ABO and Rh(D) types are valid. You will be asked questions that assess basic knowledge of blood grouping practices and test results for newborns. ABO Forward Group ABO Reverse Group Rh anti-A anti-B A1 cells B cells anti-D* 0 0 NT NT 3+ NT = not tested / * monoclonal IgM anti-D DAT Reagent DAT CC Polyspecific AHG w+ 2+ W+ = microscopic positiveAHG = antihuman globulin serum CC = IgG sensitized cells Note: It is the lab's policy to add IgG sensitized cells to weak antiglobulin test results.
In this case the mother did not require transfusion. For reference, the TS laboratory routinely uses an electronic crossmatch to detect ABO incompatibility for cases where patients do not have unexpected clinically significant antibodies in current antibody screen tests nor a history of clinically significant antibodies. When the laboratory information system (LIS) is down, the lab performs an immediate spin crossmatch.Should transfusion have been needed, these questions arise:1. Does a mother with a detectable passive anti-D due to RhIg qualify for an immediate spin (IS) or electronic crossmatch should transfusion be necessary?The issue also extends to the future:2. Should having a record of passive anti-D that is no longer detectable disqualify a woman from being a candidate for an immediate spin or electronic crossmatch?Before proceeding, consider the policies used in your TS laboratory and which rationales are used to support them.
|Perinatal Testing Programs|
Before proceeding with the case, let's review perinatal testing programs, also called 'Rh prevention programs' since they are designed to prevent HDFN due to anti-D.Perinatal testing programs have two main purposes:1. To detect, at an early stage in pregnancy, the presence of any IgG antibody that could cause HDFN in order to treat the infant as soon as possible.2. To determine which women are candidates for RhIg in order to try to prevent the production of anti-D. [RhIg will be discussed in detail later.]Testing programs include both Rh negative and Rh positive women, but because antibodies other than anti-D only rarely cause HDN, Rh negative females are tested more extensively.
|Proper Patient Identification|
In order to prevent errors that affect specimen quality, the phlebotomist must pay close attention to detail during the entire venipuncture process. All steps of the phlebotomy procedure must be included for every venipuncture. This will help to maintain specimen integrity during the collection, transport, and handling of blood specimensProperly identify the patient every timeThe phlebotomist is responsible for correctly identifying the patient using two unique patient identifiers that include the patient's complete first and last name, medical record or hospital number, and/or date of birth. The patient location or room number, bed tag and chart are not reliable forms of identification and should not be used for patient identification. Every patient must verbalize his/her name to the phlebotomist, if able to do so. It is unacceptable for the phlebotomist to ask the patient to confirm his/her name that was verbalized by the phlebotomist. For example, the phlebotomist should say, "Would you please tell me (or spell) your name and birthdate. " The phlebotomist should NOT say, "Are you Sally Brown, and is your birthdate June 1, 1925?" If this is a hospital inpatient, check the information on the patient's wristband and confirm that the name and hospital number or medical record number matches the patient information on the test order. Never rely on identification attached to a bed, chart or door. NEVER draw a patient whose identity is not established or is in conflict. If there is a discrepancy, the phlebotomist must STOP and seek assistance to have the discrepancy resolved before proceeding with the venipuncture. If this is an outpatient that does not have a wristband, ask the patient (or guardian/caregiver) to state the patient's date of birth. A picture ID, such as a driver's license, can also be used for positive patient identification.
|Case Study Two|
Stop and Think !An 18-year-old male has come to the outpatient clinic for blood work. He tells you that he has not been feeling well for several days, which is obvious from his skin pallor. He also mentions being weak and fatigued. If you are the phlebotomist, what would you do?Consider how you would handle this or a similar situation before proceeding to read the suggested solution on the following page.
|Case Study Three|
Stop and Think ! A pregnant woman who is 28 weeks gestation has come to the blood collection area for a three-hour oral glucose tolerance test to confirm a diagnosis of gestational diabetes. The procedure requires the collection of a fasting blood sample followed by administration of a 100-gram load of glucose, which is administered in an orange-flavored beverage. Blood specimens will then be collected at one, two, and three hours. The woman has finished drinking the beverage, which she had a difficult time finishing, and you instruct her to have a seat in the waiting room until you come get her to have the one-hour post-glucose blood sample collected. After 30 minutes, she comes to tell you that she has just vomited.Consider how you would handle this or a similar situation before proceeding to read the suggested solution on the following page.
|Case Study One|
Stop and Think ! You work in a large hospital that specializes in pediatrics. The policy of the facility is to encourage the parent or guardian to remain in the room during venipuncture to comfort the child. You have taken steps to prepare the child for the venipuncture, but the child starts to cry and becomes combative. The mother says that she does not want the test done. What should you do?Consider how you would handle this or a similar situation before proceeding to read the suggested solution on the following page.
|Follow-up with clinical staff|
The patient's physician was notified that compatible blood was unavailable and that the patient's antibody was still being investigated.When asked whether or not the patient was experiencing a transfusion reaction due to the transfusion of the two unmatched and incompatible O Rh negative RBC, the nurse in the OR stated that the patient was undergoing surgery and completely sedated. A transfusion reaction was not apparent but they would investigate and closely monitor.Hemolytic Transfusion Reactions (HTR)Before proceeding to the next page, make a short list of signs and symptoms associated with immediate hemolytic transfusions reaction and another list associated with delayed hemolytic transfusion reactions.
A standard follow-up to antibody identification is to antigen phenotype: Patient's red cells (expecting them to lack the corresponding antigen) Donor red cells (in this case, those transfused before an antibody was identified, or, more typically, to find suitable antigen-negative donors to crossmatch prior to transfusion).If you had wanted to type the patient for any antigens at this point in the investigation (2-weeks post-transfusion), which specimen would you have used? Think about any antigen typing problems and how to overcome them before proceeding to the next page.