Haematology & Blood Transfusion Laboratory Handbook

Transcription

1 Title: Haematology & Blood Transfusion Laboratory Handbook Code: Authors: Version: Document Category: Authorised By: Authorised On: Review On: Location Of Copy: Section: Date Time Of Last Update: Date Time Printed: Document Status: Ou Name: Haematology/Blood Transfusion/Clinical Chemistry Chris Brammer and Marie Hughes 5.0 Haematology & Transfusion Sheila Kowalczyk 30-Jun Jun-2016 Intranet All Haematology, Chemistry & Transfusion Locations 30-Jun :53 30-Jun :53 Authorised Department of Haematology, Blood Transfusion & Clinical Chemistry

2 Department of Haematology and Blood Transfusion Laboratory Handbook Section Contents 1 Introduction, Location & Telephone Numbers 2 General Comments and Clinical Guidelines 3 Laboratory Opening Hours and Emergency Service 4 Request Forms 5 Specimen Tubes 6 Blood Transfusion 7 Obstetric Haematology 8 Thrombophilia investigation and testing 8.1 Anticoagulation and warfarin induction 9 Table of Haematology Tests, Turnaround Times and Reference Ranges 9.1 Sample Type and Container Guide 9.2 Guide to notes in Table of Tests 9.3 Turnaround Times 9.4 Reference Ranges for Full Blood Count and White Cell Differential 10 Reference Lab Addresses 11 Haematology Tests Special Precautions 12 Haematology Tests Time Limit for adding Additional Request 13 Screening for Malaria and other blood borne parasites 14 Requesting and interpreting Haematinics tests (B12, Folate, Iron studies) 15 Screening for Thalassaemia and Haemoglobinopathies 16 Investigation of Hereditary Spherocytosis Page 1 of 41

3 1. INTRODUCTION, LOCATION AND TELEPHONE NUMBERS We provide a service to all hospitals and General Practitioners in the area and receive about 2000 specimens each day. The laboratory is located on the second floor as shown on the following floor plan: Page 2 of 41

4 CONSULTANTS Dr. C. Brammer ext (external ) Dr. R.F. Neilson ext (external ) Dr. M. Hughes ext (external ) Dr R. Boulton-Jones ext (external ) Secretary ext (external ) For urgent clinical queries Consultant Haematologist can be contacted on Mon-Fri 9am 5pm. The on-call Haematologist can be contacted via hospital switchboard out with these hours. Non-urgent clinical or laboratory queries should be directed to the departmental mailbox which will be reviewed daily Monday to Friday. address: SENIOR LABORATORY STAFF Mrs Sheila Kowalczyk BMS 4 ext (external ) Mrs Mandy Dawson BMS 3 ext (external ) Mrs Gillian Lowe BMS 3 ext (external ) Mr Mark Gilmour Quality Manager ext (external ) Page 3 of 41

5 LABORATORY NUMBERS Laboratory Emergency Pager out of hours 1777 (to page dial and follow instructions, from outside FVRH phone switchboard and ask to page) Specimen Reception Routine Enquiries ext (external ) Specimen Reception Emergency Requests ext (external ) Haematology Laboratory ext (external ) Transfusion Laboratory ext (external ) Transfusion Practitioner ext (external ) FORTH VALLEY ROYAL SWITCHBOARD: Page 4 of 41

6 2. GENERAL COMMENTS AND CLINCIAL GUIDELINES CHI Number Please ensure that specimens and request forms are both adequately labelled so that they can be matched up without error and the result sent to the appropriate destination. If you do not use the CHI number, we may not be able to link earlier results to the same patient and the result may not match to the patient when the result processes into SCI Store. If you have access to laboratory results electronically they may not be available to you. Clinical Details Relevant clinical details help us to be more helpful to you. It is rarely possible, for example, to interpret blood film morphology without some knowledge of the clinical situation. A comment such as routine is not any help. The Consultant Haematologists are always willing to discuss problems and to give advice. Clinical Guidelines Relevant Clinical Guidelines are available on the Forth Valley Intranet at the following link by selecting Haematology and Transfusion Service. The handbooks for all laboratory departments are found by selecting Laboratories through the Clinical Guidelines page or by using the Departments A-Z option from the Intranet home page. Page 5 of 41

7 3. LABORATORY OPENING HOURS AND EMERGENCY SERVICE LABORATORY OPENING HOURS HAEMATOLOGY AND BLOOD TRANSFUSION Monday to Friday 08:40 17:00 (Normal Service) Monday to Friday 17:00-08:40 (Reduced 24 hour service) Saturday and Sunday all day (Reduced 24 hour service) Public Holidays Reduced service (details issued via staff comms) SPECIMEN RECEPTION OPENING HOURS Monday to Friday 08:45-20:00 Saturday and Sunday and 09:00-17:00 Out of hours: The department operates a shift system for Haematology and Blood Transfusion, and the duty BMS should be contacted through the switchboard or internal page number EMERGENCY SERVICE When sending urgent samples please notify the Laboratory in advance on the numbers below: Monday to Friday 08:45-20:00 and Saturday and Sunday and 09:00-17:00: Phone specimen reception on ( ) or the laboratory number as in section 1. At all other times contact the duty BMS by paging 1777 or phone the laboratory number. From outside the hospital phone switchboard on and ask for page Page 6 of 41

8 4. REQUEST FORMS 1. Haematology: The front sheet (Red on White) of the multi-layer request form is for Haematology but not Blood Transfusion. If your request is for other departments also you MUST write firmly with a ballpoint pen and if address labels are used, attach them to all relevant pages. If you do take labels from the patient s notes check that they refer to the right patient. Haematology request form requirements are: Surname and forename, date of birth and / or CHI number must be provided use the CHI number whenever possible as this assists matching results to previous result for the patient Name and address of requestor is required in order that reports can be directed appropriately or can be found on SCI store using the search facility (consultants name should be clearly identified in full). Date and time of specimen and person who bled the patient should be recorded Useful clinical details should be provided Note that bar-coded addressograph labels should be used on request forms whenever possible 2. Blood Transfusion: (Blue on White): All requests for blood or blood products including group and save procedures and Anti-D requests. Please refer to the NHS Forth Valley Blood Transfusion Protocol for request form and sample labelling requirements (use link in section 6). Page 7 of 41

9 3. Direct Order Comms: The DartOCM system is being implemented across Forth Valley in The system will not be used for Blood Transfusion. Training will be provided to requestors before moving on to the system. Any requests that can t be generated through DartOCM must comply with 4.1 above. 5. SPECIMEN TUBES Specimens are taken by the Becton Dickinson system. Under or overfilling may lead to invalid results. All anti-coagulated specimens should be mixed gently by repeated inversion, not shaken. Becton Dickinson distributes charts with information on which bottles to use for which test, order of draw and mixing requirements. Charts are available through the practice development team. DO NOT pre-label bottles as this can lead to misidentification errors. Sample bottles should be labelled at the bedside by the person taking blood and initialled by them. A list of tests performed and the type of specimen tube required is in section 9. Please ensure that separate bottles are sent for haematology and clinical chemistry tests. Addressograph labels are acceptable on Haematology sample bottles but under no circumstances will they be accepted for blood transfusion work or ante-natal grouping. This practice has been shown to increase the likelihood of misidentification. For blood transfusion or ante-natal blood group samples: Bar-coded addressograph labels are not accepted on samples for transfusion testing or ante natal grouping. The minimum identification requirements are detailed in the Blood Transfusion protocol which is found at the link in section 6. Page 8 of 41

10 For Haematology samples the following information is required: Minimum identification required on the sample is: o Surname o Forename o Date of birth and / or CHI number In addition there should be the name of requestor and requesting location, the date and time the sample is taken and the signature of the person who bled the patient. The details on the sample and request form must match. Failure to provide the correct details may result in the sample being rejected and a repeat required. A bar-coded addressograph label is preferred. Place the label on the bottle so that the level of blood in the bottle can still be seen. When emergency tests are required for unidentified patients a casualty number should be used and as much other information e.g. unknown male / unknown female. The laboratory cannot process specimens that are not clearly identified. Note that for requests generated via direct order comms DartOCM barcoded sample labels are printed for each bottle required. Training will be provided for requestors before moving on to the system during Any requests that can t be generated through DartOCM must be comply with the above. Page 9 of 41

11 Precautions for High Risk Specimens: All samples and request forms which are known to be or suspected may be high risk e.g. hepatitis, HIV or other group 3 or 4 agent such as Dengue fever must be labelled with a high risk sticker. The laboratory must be informed in advance if a sample is suspected of containing any high risk agent other than hepatitis or HIV e.g. Dengue fever. See section 11 for further information on special precautions required for high risk samples. 6. BLOOD TRANSFUSION The NHS Forth Valley Blood Transfusion Protocol details the procedures adopted by this organisation to maximise transfusion safety and is based on national guidelines. Please use the link below to the Forth Valley Intranet Clinical Guidelines page and search for Transfusion Service guidelines. Alternatively from the intranet home page under main menu select Departments A-Z, select Laboratories and click on the link to Blood Transfusion. Page 10 of 41

12 7. OBSTETRIC HAEMATOLOGY ANTI-D IMMUNOGLOBULIN Indications for Administration: 1. All Rhesus negative women as soon as possible after, or at least within 72 hours of, delivery of a Rhesus D positive infant, when the post delivery maternal venous blood specimen contains no detectable anti-rhesus D antibody. Advice should be sought if other antibodies are present. 2. All pregnant Rhesus negative women with no Rhesus D antibody on record, to be given as soon as possible after, or at least within 72 hours of, the following potential sensitising episodes: Miscarriage; complete, incomplete or threatened at > 12/40; Persistent PV bleeding at any stage of pregnancy Termination of pregnancy Amniocentesis, chorionic villus biopsy and cordocentesis Anti-partum Haemorrhage External cephalic Version Abdominal trauma (sharp/blunt, open/closed) at >12/40 Ectopic pregnancy Evacuation of molar pregnancy Intrauterine death and stillbirth In-utero therapeutic interventions (transfusion, surgery, insertion of shunts, laser) Delivery normal, instrumental or Caesarean section Page 11 of 41

13 Dosage and Administration: 250 units (50 µg) intramuscularly up to 20 weeks gestation. 500 units (100 µg) intramuscularly after 20 weeks gestation. Timing of administration of anti-d To be given preferably within 24 hours of the potential sensitising incident, and in no case later than 72 hours. However, in the case of accidental omission, Anti-D should still be given up to 7 days after the incident. The preferred site of injection is the deltoid muscle. Injections should be given every 6 weeks if there is continued ante partum bleeding. NB In the case of Intrauterine death, it should be noted that the diagnosis of IUD is the sensitising event rather than delivery and hence anti-d Ig should be issued for administration within 72h of diagnosis. Prophylactic anti-d programme A programme for administration during pregnancy of prophylactic Anti-D to suitable Rh(D) Negative women is now in place. Women are offered a dose of 1500 IU Prophylactic Anti-D at 30 weeks. To request Prophylactic Anti-D on this programme send the request to the transfusion laboratory with the 28 weeks grouping sample, stating on the Transfusion Request Form when and where the Anti-D is required, the dose required and that it is to be administered as part of the programme. If a sensitising episode occurs at any stage of pregnancy to a patient who is on the Anti-D Prophylactic Programme, they must be tested in the same way as patients who are not on the programme as above. Anti-D will be issued if appropriate and a Kleihauer test will be performed if the event is after 20 weeks Page 12 of 41

14 Kleihauer Tests This measures the quantity of feto-maternal transplacental haemorrhage (FMH) for calculation of any additional dose of Anti-D that may be necessary in nonsensitised Rh(D) Negative patients. A specimen of maternal blood in 4 ml EDTA (FBC Tube) for a Kleihauer test in addition to the 6 ml EDTA grouping sample is required in the following circumstances: Instrumentation at any gestation Within 2hrs after delivery Any potentially sensitising event after 20 weeks gestation (as above) Following a large transplacental bleed (as below) For any FMH > 4 ml an appropriate supplementary dose of anti-d immunoglobulin must be given immediately. A repeat estimation of the FMH should be carried out 48 h following the initial anti D injection. Page 13 of 41

15 Further Points to Remember 1. THE COMMONEST CAUSE OF SENSITISATION TO THE RHESUS D ANTIGEN IS FAILURE TO ADMINISTER ANTI-D IN APPROPRIATE CASES. 2. Particular vigilance is necessary in cases of abortion, whether therapeutic or spontaneous; threatened, complete or incomplete, where stay in hospital is brief. Results must be telephoned as a matter of urgency and staff trained to act properly on them. There must be close liaison between the laboratory, the clinical units and the primary care teams. 3. Where threatened or complete abortion occurs at home, the General Practitioner must ascertain whether anti-d is necessary. 4. Anti-D given to the mother antenatally is not harmful to the baby. 5. Passively administered anti-d may be detected up to 6 weeks after administration, and occasionally up to 6 months. 6. If antibody is not detectable at delivery, further administration of immunoglobulin is necessary whether or not the mother was given a prophylactic dose antenatally. 7. If there is any doubt about whether to give anti-d, advice may be obtained from the Blood Transfusion Laboratory or from Consultant Haematologist. 8. Seek advice when any other antibody is present. 9. Additional doses of anti-d immunoglobulin, when recommended should be administered in multiple muscular sites to avoid local reactions. Page 14 of 41

16 8. THROMBOPHILIA INVESTIGATION AND TESTING Information on thrombophilia testing is available as a Haematology Clinical Guideline on the Forth Valley intranet. The Clinical Guideline provides advice on testing in the following conditions: Acute VTE (DVT+/- PE) Venous thrombosis of Upper Limb/Eye/Venous Sinus of Brain/Intra-abdominal Veins Coronary, cerebral and peripheral arterial thrombosis Woman being considered for HRT/COCP Prevention of VTE in hospitalised patient Relatives of patients with a history of VTE Children Tests Available and Sample Requirements: The following tests comprise the thrombophilia screen: Antithrombin Assay Protein C assay Protein S assay (Total & Free) Lupus anticoagulant and anticardiolipin assays Modified activated protein C sensitivity Prothrombin G20210A mutation APC:SR ratio as marker for Factor V Leiden Genetic analysis for Factor V Leiden will only be undertaken if the APC:SR is abnormal. Page 15 of 41

17 Samples required for a thrombophilia screen are: 4 x citrate samples (blue topped tubes) Requests for thrombophilia testing MUST include full patient and family history details and drug therapy, especially oral contraceptive use or HRT, where appropriate. All requests will be vetted by a Haematology Consultant. Incomplete or clinically inappropriate requests will be rejected and the requesting clinician informed. In all cases, if there is a doubt about who and when to test please contact a consultant haematologist to discuss prior to sending the samples. 8.1 ANTICOAGULATION AND WARFARIN INDUCTION For information on anticoagulation and warfarin induction refer to the Haematology Clinical Guidelines on the FV intranet. Page 16 of 41

18 9. TABLE OF HAEMATOLOGY TESTS, TURNAROUND TIMES AND REFERENCE RANGES 9.1 Table of tests analysed - Refer to sections 9.2 and 9.3 for guides to notes and bottle / container type Test Anti-nuclear antibodies Bone marrow Coagulation Screen (PT, APTT and fibrinogen) D-Dimer for coagulopathy (not for detecting thrombosis) Direct anti-globulin test (Coombs test) Transfusion EDTA and request form required (pink top bottle with hand written details) Notes Bottle / Container type Vol. (ml) Reference range where applicable (adult unless otherwise stated) Reference laboratory Expected turnaround time for results SST 7 Less than 1/64 Tested locally 2 weeks * - - Tested locally 72 hours 1 Citrate 4 PT +APPT controls reported with results fibrinogen g/l Tested locally 12 hours 3 Citrate 4 <0.5mg/l Tested locally 12 hours EDTA 4 positive in up to 5% of normal controls Tested locally 12 hours Page 17 of 41

19 Test Erythrocyte sedimentation rate (ESR) Notes Bottle / Container type 1 EDTA 4 Full Blood Count (FBC) EDTA 4 Haematinics: Serum B12 Serum ferritin 5 SST 7 Serum folate Vol. (ml) Reference range where applicable (adult unless otherwise stated) Men 0-5mm in 1 hour Women 0-7mm in 1hour see later tables for reference ranges Reference laboratory Tested locally Tested locally Expected turnaround time for results 12 hours 8 hours 2, 5 SST ng/l Tested locally 72 hours Age male ug/l female ug/l Age 45+ male ug/l female ug/l Tested locally 72 hours 5 SST ug/l Tested locally 72 hours Page 18 of 41

20 Test Haemoglobin electrophoresis (See section 12) Hb A2 (HPLC) Hb F (HPLC) Notes Bottle / Container type HbA1c (HPLC) 5 EDTA 4 Haemosiderin Haptoglobin Infectious Mononucleosis test Intrinsic factor antibody Vol. (ml) Reference range where applicable (adult unless otherwise stated) Reference laboratory 5 EDTA 4 Tested locally 1 week Expected turnaround time for results 5 EDTA % Tested locally 3 working days 5 EDTA % Tested locally 3 working days Target range for good diabetic control is mmol/mol (IFCC units) Tested locally 48 hours 6 Universal 20 Tested locally 1 week SST g/l Tested locally 4 weeks SST or EDTA 7 or 4 Tested locally 48 hours 7 SST 7 Tested locally 2 weeks Page 19 of 41

21 Test Notes Bottle / Container type INR 1 Citrate 4 Kleihauer Malarial screen (and other blood borne parasites (thick and thin film and plasmodium antigen test) Reticulocytes Rheumatoid factor Sickle test Vol. (ml) Reference range where applicable (adult unless otherwise stated) Target INR range is dependent on reason for anticoagulation. Refer to Haematology clinical guidelines on intranet. Reference laboratory Tested locally Expected turnaround time for results 12 hours EDTA 4 See section 7 Tested locally 48 hours EDTA 4 See section 10 Tested locally antigen test 12 hours films 24 hours EDTA x10 9 /l Tested locally 4 hours SST 7 Tested locally 72 hours 9 EDTA 4 Tested locally 24 hours Page 20 of 41

22 Test Acetyl choline receptor antibodies Adrenal Antibodies Allergy testing (RAST) allergens must be specified Alpha-NMDA receptor antibodies Anti-Mitochondrial antibodies Anti-Neutrophil cytoplasmic antibodies Anti-neural antibodies (e.g. anti-hu, Yo) Aquaporin-4-antibodies REFERRED TESTS - see section 10 for list of reference laboratories Notes Bottle / Container type Vol. (ml) Reference range where applicable (adult unless otherwise stated) Reference laboratory Expected turnaround time for results ** SST 7 <0.1nmol/l xiv 4 weeks ** SST 7 vii 4 weeks ** SST 7 vii 6 weeks ** SST 7 xv 4 weeks ** SST 7 vii 4 weeks ** SST 7 vii 4 weeks ** SST 7 xiv 4 weeks ** SST 7 xv 4 weeks Page 21 of 41

23 Test Notes Bottle / Container type Anti-neutrophil antibodies ** Auto-antibodies (DNA binding, ENA, AMA, SMA, Ro, La, TTG, Gastric parietal cell, skin, smooth muscle, glomerular basement membrane, cardiac, MPO, Scl70/Jo1,) Anti-musk Bcr-abl pcr Cell marker analysis Coagulation factor assay EDTA, SST Vol. (ml) 20, 10 Reference range where applicable (adult unless otherwise stated) Reference laboratory i Expected turnaround time for results 4 weeks 10, ** SST 7 vii 4 weeks ** SST 1 xv 4 weeks ** EDTA 4 ii 2 weeks ** EDTA 4 iii 2 weeks ** Citrate 4 iv 1 week Page 22 of 41

24 Test Notes Bottle / Container type Vol. (ml) Reference range where applicable (adult unless otherwise stated) Reference laboratory Expected turnaround time for results Complement ** SST 7 vii 4 weeks C iu C iu Factor B iu C1esterase inhibitor iu CH50 Cytogenetics Erythropoietin ** Glutamic acid decarboxylase antibodies Ganglioside antibodies G-6-PD Genetics ** Genetic 5 ix 4 weeks SST, EDTA 7, mu/ml v 4 weeks ** SST 5 xiii 4 weeks ** SST 2 xiv 4 weeks ** EDTA iu/ghb at 37oC xvii 2 weeks ** EDTA 4 ix 4 weeks Page 23 of 41

25 Test Haemoglobin DNA screening Hereditary Spherocytosis H.I.T. screen (anti-pf4) HLA-DR, HLA B27 Insulin antibodies Islet cell antibodies JAK 2 PCR Lupus anticoagulant Lymphocyte phenotyping/subsets Notes Bottle / Container type Vol. (ml) Reference range where applicable (adult unless otherwise stated) Reference laboratory Expected turnaround time for results ** EDTA 4 xii 4 weeks ** EDTA 4 iii 4 weeks ** SST 2 vi 4 weeks ** EDTA 10 viii 4 weeks ** SST 7 xviii 4 weeks ** SST 1 xiii 4 weeks ** EDTA 4 ii 4 weeks 8, ** Citrate 16 iv 2 weeks ** EDTA 4 vii 4 weeks Page 24 of 41

26 Test Mast cell tryptase Neutrophil function ** Notes Bottle / Container type Vol. (ml) Reference range where applicable (adult unless otherwise stated) Reference laboratory Expected turnaround time for results ** EDTA ug/l vii 4 weeks EDTA from patient and a healthy control Thrombophilia screen ** 4 x Citrate 16 Thyroid Peroxidase antibodies Thyrotropin receptor antibody 4 vii 4 weeks See section 11 Requests screened by Haematology Consultant iv 2 weeks ** SST 7 xvi 4 weeks ** SST 3 - xvi 4 weeks Page 25 of 41

27 Test Tissue transglutaminase Tissue typing Plasma Viscosity Voltage gated Ca + channel antibodies Warfarin assay Notes Bottle / Container type Vol. (ml) Reference range where applicable (adult unless otherwise stated) Reference laboratory Expected turnaround time for results ** SST 7 vii 4 weeks ** EDTA 20 - viii 4 weeks ** EDTA xix 48 hours ** SST 1 - xx 6 weeks 4, ** SST 2 - x 2 weeks The list above is not exhaustive so if the test required is not listed phone the laboratory for advice. Requests for New Tests: If a new test not previously provided is required a New Test Request Form must be completed, signed off by a General Manager and submitted to the Laboratory Service Manager for approval. The form is available from laboratory senior staff (contact details in section 1). Approval must be obtained in advance of sending a sample for a new test or testing will not be carried out. Page 26 of 41

28 9.1 Sample type and container guide Note that the bottle cap colour of paediatric bottles may not match that of the adult bottle Bottle / Container Code SST Citrate EDTA Heparin Universal Genetic Description serum separation tube citrate for coagulation Potassium EDTA Heparin urine use plain universal container Marrow transport media kept at 2-8oC Colour of bottle cap yellow (gold) red (paediatric) light blue (adult) green (paediatric) purple (Haematology) pink (Transfusion) pink/lilac (Paediatric) green white contact department Page 27 of 41

29 9.2 Guide to Notes from test table above Notes * ** Description By arrangement with lab Referred elsewhere. Must be in laboratory before Thursday 12 midday Specimen tube must not be under or overfilled Do not test following B12 injection D-dimers may be raised in presence of thrombosis, disseminated intravascular coagulation, inflammation, infection, underlying malignancy recent surgery. The sensitivity of the laboratory test currently only allow assessment of coagulopathy. Testing for underlying thrombosis requires lithium heparin sample and is not performed by the laboratory but is available as a point of care test in other hospital departments. Sample should be taken pre-dose Must be requested PRE-TRANSFUSION Early morning sterile urine sample Must be sent before starting cobalamin treatment as test disrupted by hi levels of serum B12 Samples should arrive in laboratory no later than 2pm A positive test must be followed by haemoglobin electrophoresis to distinguish between heterozygote and homozygote Please specify which are of clinical interest Page 28 of 41

30 9.3 Turnaround Times: For urgent tests contact the laboratory as in section 3 Urgent Full Blood Count and Coagulation: results within 2 hours from receipt of sample If other tests are required urgently contact laboratory staff See table of tests for routine turnaround times Results are available in SCI Store between minutes after completion in the laboratory. 9.4 Reference ranges NORMAL RANGES FULL BLOOD COUNT ADULTS MEN WOMEN White Cell Count (x10 9 /l) Red Cell Count(x10 12 /l) Haemoglobin (g/l) Packed Cell Volume Mean Cell Volume (fl) Mean Cell Haemoglobin (pg) MCH Concentration (g/dl) Platelet Count (x10 9 /l) CHILDREN BIRTH 1 YEAR 6 10 WBC (x10 9.l) Hb (g/l) Page 29 of 41

31 DIFFERENTIAL WHITE CELL COUNT (as absolute counts, x 10 9 /l) 1 year 6 10 Adult Neutrophils Lymphocytes Monocytes Eosinophils Basophils (Data extracted from Haematology, W J Williams et al., 3rd edition, 1983, McGraw Hill) Reference ranges for other tests are shown in the table of tests. Reference ranges are provided on reports from referral laboratories. Page 30 of 41

32 10. REFERENCE LABORATORY ADDRESSES i. NHSBT Filton (Bristol) 500 North Bristol Park Northway Filton Bristol BS34 7QH ii. iii. iv. Department of Molecular Haematology Southern General Hospital Govan Road Glasgow /9409 Department of Haematology Gartnavel General Hospital 2 nd Floor Laboratory Building 21 Shelly Road Glasgow G12 0XL Tel Department of Haematology Glasgow Royal Infirmary 82 Castle Street Glasgow G4 OSF v. SAS Erythropoietin Laboratory Department of Clinical Biochemistry King s College hospital Denmark Hill London SE5 9RS vi. Scottish National Blood Transfusion Service Shelley Road Gartnavel General Hospital Great Western Road Glasgow Page 31 of 41

33 vii. viii. ix. Immunology laboratory 1 st floor Laboratory medicine and facilities management building Southern General Hospital Govan Road Glasgow G51 4TF Tel Histocompatibility and immunogenetics Tissue typing service Gartnavel hospital Glasgow West of Scotland genetic services Level 2b, Laboratory medicine and facilities Management Building. Southern General Hospital Glasgow G51 4TF Tel x. Department of Clinical Chemistry Queens Medical Centre Nottingham NG7 2UH Ex xi. xii Deleted National Haemoglobinopathy reference laboratory Molecular Haematology Level 4 John Radcliffe Hospital Oxford OX3 9DU Telephone Page 32 of 41

34 xiii xiv xv xvi xvii xviii Protein reference unit Department of Immunology Northern General Hospital Herries Road PO BOX 894 Sheffield S5 7YT Tel Department of Neuro-Immunology Southern General Hospital 1345 Govan Road Glasgow G51 4TF Immunology laboratory John Radcliffe Hospital Headley Way, Headington Oxford, Oxfordshire OX3 9DU Department of Biochemistry Glasgow Royal Infirmary Alexandra Parade Glasgow Department of Haematology Edinburgh Royal infirmary 51 Little France Crescent Edinburgh, EH16 4SA SAS peptide hormone section Clinical laboratory Royal Surrey County Hospital Egerton Road Guildford Surrey GU2 7XX Tel ext 4696 Page 33 of 41

35 xix xx Haematology Department South Laboratory Victoria Hospital Kirkcaldy Fife KY2 5AH Tel ext Immunology Department Churchill Hospital Headington Oxford OX3 7LJ Tel Page 34 of 41

36 11. SPECIAL PRECAUTIONS: The Haematology and Blood Transfusion laboratories are containment level 2 facilities. This means that there is a limited capacity to test samples containing biological agents categorised as group 3 by the Advisory Committee on Dangerous Pathogens. The Advisory Committee prepare the Approved List of Biological Agents for the Health & Safety Executive. A Biological Agent is categorised by: The likelihood it will cause disease or toxicity in humans How likely it is that the infection would spread to the community The availability of any prophylaxis or treatment (includes vaccines) Hepatitis and HIV, although group 3 agents, are officially approved to be tested in a level 2 facility provided the necessary containment and safety precautions are taken. It is therefore extremely important to identify high risk samples or potentially high risk samples to all staff involved by applying high risk stickers to sample and request form. Group 3 Biological Agents a. All known high risk samples must be clearly labelled as such on the sample and form. b. All samples suspected of containing group 3 biological agents other than hepatitis and HIV must be notified to the laboratory in advance. Only limited testing on other group 3 pathogens may be available e.g. malaria antigen test. Further advice can be sought from the Consultant Microbiologist. Group 4 Biological Agents a) Do not send samples suspected of containing group 4 biological agents to the laboratory other than after a risk assessment has been carried out by the clinician in charge of the patient and after consultation with the Consultant Microbiologist. Page 35 of 41

37 Other Special Precautions a) There are no other special precautions required other than the requirements noted in the table of tests. 12 TIME LIMIT FOR REQUESTING ADDITIONAL REQUESTS: Coagulation: 2 hours from venesection Full Blood Count: 4 hours from venesection Clotted samples, e.g. haematinics: 24 hours Transfusion: Contact the transfusion laboratory for advice Referred tests: Contact the referral laboratory for advice Page 36 of 41

38 13. SCREENING FOR MALARIA AND OTHER BLOOD BORNE PARASITES If a diagnosis of malaria is suspected, the gold standard diagnostic test is a thick blood film for detection of parasites, accompanied by a thin film for species identification and estimation of parasitaemia. Thick and/or thin films may also detect other blood borne parasites, such as microfilaria or trypanosomes. For specific diagnostic and clinical advice, please contact a consultant haematologist and/or infectious disease specialist. If malaria is suspected: a) Send 4ml blood in EDTA (FBC sample) urgently to the haematology laboratory samples should ideally arrive in the laboratory within 2 hours of venepuncture (lengthy exposure to anticoagulant may significantly diminish the likelihood of detecting parasites). b) The request form must clearly state that malaria is suspected, and include travel history which should be as specific as possible. This is likely to significantly aid species identification. c) A thick film and a thin film will be prepared and examined. d) In addition, a rapid malarial antigen detection test (for Plasmodium spp.) will be performed to complement microscopy. Outside of normal working hours, this may be reported before a blood film has been examined. Please note that a negative antigen test must be confirmed by microscopy, and, if clinical suspicion is high, a negative antigen test alone must not be relied upon to fully exclude malaria. e) If the initial thick film proves negative, yet clinical suspicion remains high, send two further consecutive daily samples for malaria screening. Three negative thick films make a diagnosis of malaria unlikely. Page 37 of 41

39 14. REQUESTING AND INTERPRETING HAEMATINIC TESTS (B12, FOLATE, IRON STUDIES) Serum B12 and Folate assay a) Tests for serum vitamin B12, serum folate levels and serum ferritin are frequently requested for the initial investigation of anaemia, or microcytosis / macrocytosis in the absence of anaemia. In addition, a serum B12 assay is included in the list of screening tests in a number of neurological and psychiatric conditions, and ferritin is used as a marker of whole body iron levels in patients with (suspected and confirmed) haemochromatosis. Interpretation of results can be problematic. b) For information on B12 and folate requesting and interpretation refer to the Haematology clinical guideline B12 and Folate: Practical Guide which can be found on the Forth Valley Intranet at the following link: Iron studies a) Serum Ferritin is the usual test for iron deficiency. b) The normal range is different for women of childbearing age compared to men and postmenopausal women, but it is debatable whether this is a real physiological difference or simply reflects a high incidence of iron deficiency in the population of women from whom the normal range is derived. c) In general, a serum ferritin <12µg/L is diagnostic of iron deficiency, and if <30µg/L is highly suggestive. Interpretation should be in the context of the FBC (MCH, MCV and blood film features). d) Ferritin is an acute phase reactant, so may be normal even in the presence of iron deficiency if there is intercurrent infection, inflammation or neoplasia. A rough guide might be to interpret a ferritin of <100µg/L with caution in the presence of intercurrent illness, as iron deficiency cannot be excluded. Again, haematological parameters are likely to help. e) A high serum Ferritin (>300µ/l) may indicate iron overload, but such a finding is common in hospitalised patients and others with intercurrent illness. Page 38 of 41

40 f) A better guide to iron overload is the Transferrin Saturation (calculated from serum iron x100 divided by TIBC see Chemistry handbook), which, if over 55% (men) or 50% (women) warrants further investigation. g) Serum iron and TIBC are generally unreliable tests for diagnosing iron deficiency. Page 39 of 41

41 15. SCREENING FOR THALASSAEMIA AND HAEMOGLOBINOPATHIES Indications for screening for thalassaemia and/or haemoglobinopathies include: Investigation of a hypochromic blood picture in the absence of iron deficiency Investigation of anaemia in a patient of non-northern European ancestry Screening in an individual with a family history of thalassaemia or haemoglobinopathy Antenatal screening Identification of Sickle haemoglobin prior to surgery in patients from ethnic Groups with a high incidence of Sickle Cell Disease. When requesting thalassaemia and/or haemoglobinopathy screening please include the following clinical information: a. Ethnic origin of the patient (as precisely as possible). b. Whether or not there is a family history of thalassaemia/haemoglobinopathy, with details of diagnosis if available. c. Please state clearly if the test is for antenatal screening purposes (pregnant woman or partner). d. Reason for request. This information will help direct laboratory tests, which in general will include: a. FBC and blood film examination b. Serum ferritin if MCH is subnormal. c. High Pressure Liquid Chromatography (HPLC) for HbA2, HbF and variant haemoglobins. d. Further analysis by gel electropheresis or DNA testing dependent on HPLC. Further samples may be requested from the patient. Page 40 of 41

42 16. INVESTIGATION OF HEREDITARY SPHEROCYTOSIS Based on BCSH Guidelines a) Although the diagnosis of HS is often made in childhood and young adult life, it may be diagnosed at any time of life including old age. Diagnostic testing a) Newly diagnosed patients with a family history of HS, typical clinical features and laboratory investigations (spherocytes on blood film, raised MCHC, increase in reticulocytes, negative DCT) do not require any additional tests. b) If there is no family history AIHA should be excluded. c) If the diagnosis is equivocal the EMA (Eosin-5-maleimide) binding test has a high predictive value for HS. d) This is a flow cytometry test performed at Gartnavel Hospital using an EDTA sample. Testing should be discussed with a haematology consultant and the correct request form obtained. e) Gel electrophoresis analysis of erythrocyte membranes is the method of choice for diagnosis of atypical cases. Page 41 of 41