Detail PRINCIPLE: Body fluids other than blood and urine will be analyzed according to their site of origin, and the providers specific orders.

Transcription

1 Subject Body Fluid Analysis - Affiliate Index Number Lab-8760 Section Laboratory Subsection Regional/Affiliates Category Departmental Contact Munson, Karen Last Revised 6/28/2017 References Required document for Laboratory Accreditation by the College of American Pathologists (CAP), Centers for Medicare and Medicaid (CMS) and/or COLA. Applicable To Employees of the Gundersen Tri-County Hospital laboratories, Gundersen St. Joseph s Hospital laboratories, Gundersen Boscobel Area Hospital and Clinic laboratories and collection only for Gundersen Palmer Lutheran Hospitals and Clinics laboratories. Detail PRINCIPLE: Body fluids other than blood and urine will be analyzed according to their site of origin, and the providers specific orders. CLINICAL SIGNIFICANCE: The pleural, pericardial and peritoneal cavities normally contain a small amount of serous fluid which lubricates the opposing parietal and visceral membrane surfaces. Inflammation or infections affecting the cavities cause fluid to accumulate. The fluid may be removed to determine if it is an effusion or an exudate, and distinction made possible by protein, cell, or enzyme analysis. Synovial (joint) fluids are fluids that provide lubrication and nourishment for articular cartilage. Examination of the numerical and/or morphological findings in the body fluid are useful in the diagnosis of disease states, such as hemorrhage, malignancy, inflammation, viral, bacterial, and parasitic infections. In pericardial fluid, a leukocyte count of greater than 1000 cells/ul suggests pericarditis. In peritoneal fluid, a leukocyte count exceeding 500 cells/ul with a predominance of neutrophils is suggestive of bacterial peritonitis. Fluid shifts may greatly alter the cell count throughout the cores of the disease. Neutrophils are the predominant leukocyte in about 90% of effusions caused by acute inflammation. Lymphocytes are the predominant leukocyte in about 90% of effusions caused by tuberculosis, neoplasms, and systemic disease. Monocytes are present in increased numbers along with neutrophils and lymphocytes in a variety of disorders. RBC counts are of little diagnostic value but are counted anyway. SPECIMEN: Page 1 of 6

2 1. Patient preparation: N/A' 2. Synovial, pleural, pericardial, peritoneal and any other fluids are obtained by the provider and nursing staff. 3. Minimum volume of fluid is dictated by the testing that is requested by the provider. Collection requirements and handling: 1. An EPIC order will print on laser printer and arrive in the In-Basket for each fluid sent to the lab. Staff will need to collect and receive the order in Beaker for inpatient. Outpatient setting the order will need to be released to the correct encounter, collect and receive. 2. Requirements per test ordered: a. Crystals-plain red-top tube, no gel b. Immunology & Chemistry red-top tube, SST is acceptable. c. Cell count and Differential-lavender tube (EDTA), thoroughly mixed. All specimens must be checked for clots. d. Microbiology-plain red-top tube, no gel e. Referral-check referral website f. Cytology-all remaining fluid should be sent to GL histology department with a copy of the order print-out. 3. Specimen Stability: All fluids should be tested as soon as possible after collection. Cell counts should be tested within 24 hours of collection. All fluids will be stored for seven days in the refrigerator. 4. Criteria for unacceptable specimens: a. Specimens with excess oil, powder or completely clotted should be rejected and test cancelled. Notify physician and department. b. Sub-optimal specimens are handled on a case-by-case basis. If a sample has clots, notify physician and department and verify that the physician does indeed want the counts reported. If physician still requests the count it will be attempted but a comment Clot present, cell count may be inaccurate should be attached to the results. c. Fluids with clusters of WBC s present should have a comment added Clusters of WBC s present, count may be inaccurate. Precautions: All patient specimens should be considered potentially infectious and must be handled with precautions used for human blood as described in CDC recommendations and in compliance with the Federal OSHA Bloodborne Pathogen Standard, 29 CFR part PPE (gloves, lab coat, safety glasses) should be worn when working with body fluids. REAGENTS/MATERIALS: 1. Standard Hematology supplies and stains 2. Normal saline 3. InCyto C-Chip disposable hemacytometer. 4. Disposable pipettes/pipettors 5. Microscope Page 2 of 6

3 6. Gram stain supplies 7. Standard microbiology supplies 8. Vacutainers/sterile ANO2 culture tube EQUIPMENT/INSTRUMENTATION: N/A QUALITY CONTROL: 1. Quality assurance is monitored by Proficiency Testing Surveys. 2. One level of commercial control will be tested, in duplicate, with the first cell count of the day and every 8 hours thereafter in the event of additional cell counts. Record results on log sheet. Implementation PROCEDURE: Cell Count: 1. Cell count should be performed as soon as possible after collection. 2. Check with applicator stick for clots and/or fibrin strands. 3. If specimen is grossly bloody, make a dilution with normal saline. Remember to include dilution factor in cell count calculations. 4. Charge hemacytometer with well mixed specimen. a. Pipette specimen into the sampling area so that it fills by capillary action. b. Be careful not to introduce bubbles into the counting chamber. Page 3 of 6

4 5. Count both WBC & RBC s in all 9 squares on both sides. a. RBC s have distinct outlines with halos and clear center. If crenated they have many fine-pointed projections. b. WBC s are granular. c. Tissue cells are usually large granular cells with irregular outlines. These cells should be included in the nucleated cell count. These cells will be sorted out in the differential. d. If clumps or clusters of cells are present add the comment Clumps of cells present, count may be falsely 6. Average the count on both sides (counts should be within 10%). 7. Add 10% for the total count per mm3. 8. If specimen is visibly bloody or turbid make a dilution using normal saline. Make sure to adjust for your dilution factor when calculating. Page 4 of 6

5 9. Prepare slide for differential and stain and count per manual differential procedure if a differential is requested to be performed on site. WBC s <200 (after calculation): No differential unless specifically ordered by the provider (St. Joseph s and Boscobel). 10. BODY FLUIDS: Differentials to LaCrosse (Tri-County) WBC s<200 (after calculation): No differential unless specifically ordered by the provider WBC s >200 (after calculation): Order a differential to LaCrosse, where a 5 part diff will be done. Fill out a Body Fluid Requisition, and place one small sticker on the form. Order a FLD2 differential only to go to LaCrosse. CALCULATIONS: N/A INTERPRETATION: N/A LIMITATIONS: Culture Procedures: If a culture is requested on a body fluid, the culture should be done from the fluid within the original syringe or an aliquot that was placed in a sterile container or tube. Refer to Body Fluid Culture procedure for specific procedure. Chemistry Procedures: Any chemistry tests that are requested on fluids (other than CSF and urine) will be sent to the Gundersen-Lutheran laboratory. Refer to the specimen requirement web page for specific handling and specimen requirements. Results: Record counts and crystal ID on the CSF/Manual Cell Count worksheet. Save this worksheet in the ESR/RETIC/Fluid Cell Count log book. Page 5 of 6

6 Results will be manually entered in the LIS when completed. A normal knee joint contains up to 4 ml of synovial fluid so retrieval of amounts greater than this would be abnormal. Synovial fluid is usually clear and colorless or a very pale yellow. It is normally viscous as evidenced by a tailing effect when expressing it from a syringe or pipette. Synovial fluid may contain up to 200 WBC/mm 3 and be up to 25% PMN s. Crystals and bacteria are not normally present. There is currently no data as to what numbers and types of cells are present in normal pleural fluid of humans. REVIEW & CHANGES: This document and all attached forms should be reviewed optimally on an annual basis, with 2 years as the maximum review date. Review will be done by the Technical Leader, Supervisor, Manager, Medical Director or designated person. Changes require retyping document or form and review by the Medical Director. REFERENCES: 1. American Journal of Respiratory and Critical Care Medicine, Vol No. 3, MARC NOPPEN, et al, Sept InCyto-C-Chip disposable hemocytometer package insert 3. A Practical Handbook of Joint Fluid Analysis, Gatter; Kean & Febriger, Philadelphia PA, Clinical Diagnosis and Management, Henry; W.B. Saunders, Philadelphia PA, Page 6 of 6