DEPARTMENT OF HAEMATOLOGY HANDBOOK FOR … · Department of Clinical and Laboratory Haematology,...

North Glasgow University Hospitals Division

DEPARTMENT OF

HAEMATOLOGY

HANDBOOK FOR

LABORATORY USERS

Gartnavel General Hospital

Glasgow Royal Infirmary

Stobhill Ambulatory Care Hospital

Western Infirmary

Author: J Wales Authorised by: A Kyle Version No: 10 Active Date: 27th February 2013 Page 2 of 32

CONTENTS

1. Introduction 3

2. The Department 4

3. Using the Service 6

4. Haematology Test Repertoire 11

5. Transfusion Medicine Service 18


1. Introduction

The Department of Clinical and Laboratory Haematology, North Glasgow University Hospitals Division, serves to provide a comprehensive high quality, integrated and cost effective routine and specialist haematology service. This service is provided by laboratories located at Gartnavel General Hospital, Glasgow Royal Infirmary, Stobhill Ambulatory Care Hospital, and Western Infirmary that together, form one of the largest Haematology Departments in the UK.

Quality is fundamental to the service and our well-trained and experienced staff are committed to providing such a service. As defined in the Departmental Quality Policy, the Department shall comply with standards as set by Clinical Pathology Accreditation (UK) Ltd., and is committed to ensuring the needs and requirements of service users by operating a Quality Management System that includes comprehensive internal quality control and external quality assurance to cover the entirety of the Departmental service and test repertoire. Our aspirations to maintain a high quality service are further reflected in our commitment to: � Integrate the organisation � Set quality objectives and plans to meet with requirements as defined in the Departmental Quality Policy

� Manage laboratory specimens, to include collection, transport and handling, in such a way that ensures the correct performance of laboratory examination procedures

� The use of examination procedures that will ensure the highest achievable quality for all tests performed

� Reporting results of examination procedures in ways that are timely, confidential, accurate and clinically useful

� The assessment of user satisfaction and complaints, in addition to internal audit and external audit and assurance, in order to ensure continual quality improvement

� The health, safety and welfare of all staff, and all visitors to the Department

� Staff recruitment, training and development, and retention � The proper procurement and maintenance of equipment and other resources as required for the provision of the service

This Handbook is designed to assist you in using the service, and the Quality Manager welcomes suggestions and comments to ensure that, together, we can provide the best possible service and care for patients. Your compliance with a few simple rules concerning safety, transport, and specimen and request form identification, all outlined within this Handbook, will greatly help us deliver our aims for the best possible service.


2. The Department

2.1 Glasgow Royal Infirmary & Stobhill ACH Postal Address:

Department of Clinical and Laboratory Haematology,

Macewen Building, Royal Infirmary, Castle Street, Glasgow G4 OSF

with satellite Haematology Laboratory, on

1st floor Ambulatory Care Hospital, Stobhill, Glasgow G21 3EW.

2.1.1 Contact Information

URGENT HAEMATOLOGY REQUESTS – TELEPHONE Glasgow Royal - (2)4473 Stobhill ACH - Mon-Fri 9am-5pm only – (1)1469

- Out of hours – (2)4473 URGENT TRANSFUSION MEDICINE REQUESTS – TELEPHONE (2)4666 (From within NHSGG prefix EXT with 2. Out with NHSGG, dial 211 before EXT).

Staff Member EXT FAX E mail

MEDICAL STAFF

Head of Department Secretary

Dr RC Tait

4669 5168

0141 211 4931

[email protected]

Consultant Secretary

Dr L McIlwaine 4492 5125

0141 211 4931

[email protected]

Consultants Secretary

Dr C Bagot 4671 5125

0141 211 4931

[email protected]

Consultants Secretary

Dr AN Parker 5-7144 5-7141

0141 301 7142

[email protected]


Dr G McQuaker 5-7136 5-7141

0141 301 7142

[email protected]


Dr AD Clark 5-7094 5-7140

0141 301 7142

[email protected]


Dr M Leach 5-7736 5-7713

0141 301 7142

[email protected]

Specialist Registrars 4513

Duty Haematologist PAGE 3733

Out of Hours Duty Haematologists

Contact Glasgow Royal Infirmary Switchboard

LABORATORY STAFF

Technical Services Manager Mr A Kyle 4667 0141 211 4931

[email protected] Laboratory Manager Mr G Cameron 4667 [email protected] Quality & Training Manager Mrs J Wales 5548 [email protected]

GENERAL HAEMATOLOGY including HAEMATINICS & HAEMOGLOBINOPATHY

Enquiries & Results 5165

Laboratory 4473 Head BMS Mr G MacVicar 4673 [email protected]

TRANSFUSION MEDICINE

Reception & Dispatch Enquiries & Results

4666 / 4442

Laboratory 5047 Head BMS Mr G Cameron 4667 [email protected]

Transfusion Practitioner Ms L Sinclair Ms J Inglis

4271 [email protected] [email protected]

HAEMOSTASIS & THROMBOSIS


Haemostasis Technical Manager

Mrs C Lawrence

4899

[email protected]

STOBHILL ACH LABORATORY

Senior BMS (1)1469


2.1.2 Laboratory Working Hours

Normal Laboratory Hours - Stobhill ACH Lab

Monday – Friday - 0900 - 1700

Normal Laboratory Hours - GRI

Monday – Friday - 0800 – 1700 hours, Saturdays - 0800 – 1215 hours

For service at all other times and on Public Holidays, see below “Out of Hours”

Out of Hours

[provided from GRI]

A 24-hour shift system operates for the analysis of routine haematology and haemostasis related laboratory requests and the provision of a comprehensive

hospital transfusion medicine service.

2.2 Gartnavel General Hospital and Western Infirmary

Postal Address:


Gartnavel General Hospital, 1053 Great Western Road, Glasgow G12 OXB


Western Infirmary, Dumbarton Road, Glasgow G11 6NT.

2.2.1 Contact Information

URGENT HAEMATOLOGY REQUESTS – TELEPHONE 52366 (Western Infirmary) / 57721 (Gartnavel) URGENT TRANSFUSION REQUESTS – TELEPHONE 52406 (Western Infirmary) / 53360 (Gartnavel)

(From within NHSGG prefix EXT with 5. Out with NHSGG, dial 301 before EXT). Staff Member EXT FAX E mail

MEDICAL STAFF

Head of Department Secretary

Dr T Fitzsimons

7732 7717

0141 211 4931

[email protected]


Dr M Drummond

7734 7712

[email protected]


Dr R Soutar 7733 7715

[email protected]


Dr P McKay 7735 7711

[email protected]


Dr M Leach 7736 7713

[email protected]

Specialist Registrars 7730

Senior House Officers Duty Haematologist Page 5533 Out of Hours Duty Haematologist

Contact Switchboard

LABORATORY STAFF

Technical Services Manager

Mr A Kyle 2406 7727

0141 211 4931

[email protected]

Laboratory Manager Mr G Cameron 24667 [email protected] Quality & Training Manager

Mrs J Wales 25548 [email protected]

GENERAL HAEMATOLOGY & HAEMOSTASIS (Gartnavel Site)

Enquiries & Results 7720 7721

Head BMS Ms K. McIlwaine Ms M. Simms

[email protected] [email protected]

HAEMATOLOGICAL ONCOLOGY (Gartnavel Site)

Principal Scientist Dr M Alcorn 7705 [email protected] CELL MARKERS LABORATORY (Gartnavel Site)


Haemato-oncology Manager

Ms A Doig [email protected] [email protected]

GENERAL HAEMATOLOGY (Western Infirmary Site)

Head BMS Mr R Wyllie 2336 [email protected]

TRANSFUSION MEDICINE (Western Infirmary Site)

Head BMS Mr D Taylor 2406

[email protected] Transfusion Practitioner Ms C Collins 1996 [email protected]


2.2.3 Laboratory Working Hours

Normal Laboratory Hours

Monday – Friday - 0900 - 1700

Monday – Friday - 0800 – 1700 hours, Saturdays - 0800 – 1215 hours

For service at all other times and on Public Holidays, see below “Out of Hours”

Out of Hours

[provided from Western Infirmary]

A 24-hour shift system operates for the analysis of routine haematology and haemostasis related laboratory requests and the provision of a comprehensive hospital transfusion medicine service is available at the Western Infirmary.

Transfusion requests for Gartnavel site are processed by the Scottish National Blood Transfusion service situated on the Gartnavel site

2.3 Department of Haematology – Distribution of Services

Glasgow Royal Infirmary Western Infirmary & Gartnavel Hospital

Stobhill ACH Laboratory

Clinical Haematology

General Haematology

Haematinic Assays

Haemoglobinopathy & Thalassaemia Screening

Core Haemostasis (Coagulation)

Specialist Haemostasis (Bleeding & Thrombotic Disorders)

Haemophilia & Thrombophilia

Hospital Blood Banking

Maternity & Neonatal (Perinatal) Services

On-site anticoagulant control assessment clinics

Clinical Haematology

General Haematology

Haematinic Assays

Core Haemostasis (Coagulation)

Hospital Blood Banking

Immunophenotyping (Cell Markers)

PBSC Processing & Storage


Emergency Core Haematology

[FBC + film, Coagulation Screen]


3. Using the Service

3.1 Clinical Advisory Service

A rota, staffed by both middle grade and consultant staff, operates for clinical advice, authorisation of blood product issue and discussion of laboratory results. Advice can be sought be contacting relevant staff as detailed in this Handbook. Out of Hours, copies of staff rotas, including contact details for Out of Hours Duty Haematologist Staff, are held by the individual Hospital Switchboard Operators.

3.2 Urgent or Emergency Requests and Out of Hours Service

Results of tests requested as urgent or emergency (essential investigations) are normally available (via Telepath, SCI store or Clinical Portal) from ward based computer terminals 60 minutes after receipt of the specimen. For emergency Transfusion Medicine requests, the availability of blood and/or blood components (normally no longer than 60 minutes after the request, or receipt of the specimen) will be telephoned to the requesting clinician, or nominated contact, as soon as blood and or blood components are ready for uplift. Please note that all urgent or emergency requests MUST be arranged by telephoning the laboratory, or out of hours, by telephoning or paging the Out of Hours Biomedical Scientist. Also, the request form MUST specify “Emergency” or “Urgent”; otherwise, the request will be processed as routine.

3.3 Availability of Results

Results for all analyses will be made available to service users via ward / clinic based computer terminals in real time (Telepath, SCI store or Clinical Portal), thus meaning that telephoning for results will NOT save time. To reduce the possibilities of transcription and relay error, service users are instructed to access results, where


available, via ward / clinic based computer terminals. Hard copies (Laboratory Reports), once available, will be delivered daily to the requesting source. The laboratory will telephone grossly abnormal results only. Please note low volume tests are routinely analysed in batches, resulting in such tests being processed less frequently. The Department operates standard operating procedures to ensure compliance with current National legislation, such as the Data Protection Act 1998 (see Section 3.3.2), for the handling and security of patient data. 3.3.1 Laboratory Information System (Computer)

The Laboratory Information System utilises Isoft Telepath Systems software. This is an interlinked database system which records, stores and reports patient details and results. In addition, the system facilitates permitted access of service users to laboratory results. Each permitted user of the system is supplied with a unique password, which allows access to relevant system menus. It is the duty of every user to ensure that their password is not divulged. New users can obtain a password from the IT Department, EXT #650. Accessing Results via SCI Store - https://ggc-scistore.scot.nhs.uk/Storeweb/Home/Login.aspx

If you experience difficulties using SCI Store, contact your IT support team. The IT helpdesk can be contacted on 0845 612 5000 3.3.2 Data Protection Act

The Data Protection Act 1998 is based upon eight enforceable principles: 1. Personal data will be obtained and processed fairly and lawfully 2. Personal data will be held only for specified and lawful purpose and shall not be

further processed in a manner incompatible for those purposes 3. Personal data will be adequate, relevant, and not excessive in relation to the required

purpose 4. Personal data will be accurate, and where required, up-dated 5. Personal data will not be retained longer than is necessary 6. Any individual will be entitled to access any data held in their name 7. Appropriate measures must be taken to ensure against unauthorised or unlawful

processing of data, and against accidental loss or destruction of the data 8. Personal data will not be transferred to sources out with the EU unless adequate

levels of data protection can be assured

3.4 Specimen Collection Information

3.4.1 Collection of Specimens

Please note the following points relevant to collection (or venepuncture) of good quality specimens: � CONFIRM THE IDENTITY of the patient PRIOR to sampling � Never pre-label specimen tubes � Ideally, the patient should be resting for a full five minutes before specimen

collection � Use good quality veins � Never take blood from a drip arm � Do not take samples for coagulation studies from heparinised lines � Avoid prolonged application of the tourniquet both for patient comfort and to avoid

haemolysis � Samples should be filled to the fill line as marked on the bottle. This is essential for

coagulation related tests � Following collection, specimen bottles containing anticoagulant should be inverted

several times to ensure adequate mixing � Following collection, ensure specimen bottle is labelled, as detailed in Section 3.9.2 � Ensure Request Form is labelled, as detailed in Section 3.9.3 and that these details

match those on the specimen bottle (see Section 3.9.1) � Use a safe procedure at all times and dispose of sharps in sharps-boxes provided � Affix a “Danger of Infection” label on specimen tube and request form if appropriate


(see Section 3.9.6) � All specimens and request forms must be secured for transportation in the specimen

compartment of an approved specimen transport bag (affixed to the Request Form) � Specimen tubes or request forms which are blood soiled will not be analysed � Appropriate specimen containers must be used for each laboratory test (see Section

3.4.2) 3.4.2 Blood Venepuncture System A colour-coded specimen container (relating to tube particulars such as type and presence of anticoagulant, and relating to suitability and use for individual laboratory tests) and vacuum assisted venepuncture system (Greiner VacuetteTM) operates throughout NHS GG&C, for the purposes of laboratory specimen collection. Section 5 details the Departmental test repertoire, including the type of specimen container for each laboratory test, also, a comprehensive chart can be found as Appendix 1 of this Handbook. In addition, wall charts and posters detailing the safe use of this system, and the correct container for each test, are posted in most clinical areas throughout the Division. Additional guidance or information regarding the use of the Greiner VacuetteTM system may be obtained by contacting Hospital Head Phlebotomist staff.

3.5 Phlebotomy Services for Wards and Clinics

A dedicated team of trained phlebotomists, covering all acute medical and surgical wards, operates throughout North Glasgow Hospitals. Public Holidays are covered by a limited service, with details available from each Hospital Head Phlebotomist.

3.6 Primary Care - Van & Taxi Specimen Collection Service

Coordinated and managed by hospital Facilities Managers (NOT by the Department of Haematology), a van and taxi specimen collection service operates, often twice per day, for the routine collection and delivery of laboratory specimens and reports between regular service users in General Practice, Primary Care Health Centres, and local Hospitals to the individual laboratories of the Department. All enquiries relating to van and taxi services should be directed to the appropriate hospital Facilities Manager.

3.7 Vacuum Tube Specimen Delivery Systems

Vacuum tube transportation systems operate for the transportation of laboratory specimens at Gartnavel Hospital, Glasgow Royal Infirmary and the Western Infirmary. The following information details individual wards and departments served by these systems: 3.7.1 Gartnavel Hospital

The vacuum tube system at Gartnavel extends to all clinical locations throughout the hospital. 3.7.2 Glasgow Royal Infirmary

A vacuum tube system is operational for the following: � Accident & Emergency � Princess Royal Maternity Unit � Queen Elizabeth Building 3.7.3 Western Infirmary

The vacuum tube system at the Western Infirmary extends to the Beatson Oncology Outpatients Department, Ward G10 and the Clinical Investigation Research Unit (CIRU).

3.8 Hospital Specimen Portering Services

3.8.1 Gartnavel Hospital

Hospital porters uplift specimens from ward areas at different times throughout the day, however, if

the specimen is urgent it should be transported either using the nearest pneumatic tube system or by

calling the emergency blood porter on Ext 53050


3.8.2 Glasgow Royal Infirmary



paging the appropriate blood specimen porter as detailed below Blood Specimen Porter for the transportation of urgent / emergency requests:

Wards / Departments Duty Hours Contact Page No

QEB & Jubilee Building Mon – Friday: 0830 – 1700 Sat & Sun: 0800 - 1600

1509

Princess Royal Maternity Mon – Friday: 24 hour service Sat & Sun: 0800 - 1600

2206

Out with the above hours 1616 Old Building 24 hour service 1616

3.8.3 Western Infirmary



calling the emergency blood porter on Ext 52394 or PAGE 1008

3.9 Specimen & Request Form Labelling Requirements

3.9.1 General Guidelines

The Department will not process specimens that are not clearly identified. In consequence, all specimens and Request Forms sent to the Department MUST be labelled in accordance with the guidelines as detailed in this Handbook, and include: 1. At least three identifiers (from the shaded information provided in Sections 3.9.2

and 3.9.3 below) MUST be provided on both the specimen and Request Form. Also, information on the specimen MUST match the same three identifiers on the Request Form.

2. Re-labelling of specimens and Request Forms is not permitted. 3. Addressograph labels MUST NOT be used on Blood Transfusion specimen bottles but

may be used on Request Forms.

3.9.2 Specimen Labelling Criteria:

� Full Name � Unit Number (if allocated) � Date of Birth

� Gender � Ward / Clinic / Surgery � Date and Time of Sampling � Phlebotomist’s Signature (Mandatory for Blood Transfusion Requests) � Danger of Infection Label, if applicable (see Section 3.9.6)

3.9.3 Request Form Labelling Criteria:

� Full Name � Unit Number (if allocated) � Date of Birth � CHI Number

� Gender � Ward / Clinic / Surgery � Date and Time of Sampling � Clinicians Signature (Mandatory for Blood Transfusion Requests) � Clinician’s Pager or contact Number � Consultant’s Name � Clinical Details, including Diagnosis, relevant Drug Therapy, and Surgical

Procedure (see Section 3.9.7) � Tests or Blood or Blood Products Required (including times for blood and blood

products) � Danger of Infection Label, if applicable (see Section 3.9.6)

3.9.4 IMPORTANT - BLOOD TRANSFUSION SPECIMENS AND REQUEST FORMS In accordance with UK National legislation regarding the safe provision of blood and blood components, and with Departmental policies including guidelines as set by the Hospital Transfusion Committees, North Glasgow University Hospitals Division,

MANDATORY

MANDATORY


compliance with Departmental Specimen and Request Form Labelling Criteria is MANDATORY. As a consequence, the Department will NOT process specimens that are incorrectly labelled. In this event, the requesting clinician shall be contacted by telephone, be informed as to the reasons for discarding the sample, and a fresh specimen shall be requested. � ADDRESSOGRAPH LABELS MUST NOT BE USED ON BLOOD TRANSFUSION SPECIMEN BOTTLES

� ALL BLOOD TRANSFUSION SPECIMEN BOTTLE LABELS MUST BE HAND-WRITTEN AT THE TIME OF VENEPUNCTURE.

3.9.5 Unidentified Patients � Unidentified patients arriving in Accident and Emergency will have a band containing

a series of identical, unique, numbered labels (Casualty or Gate Numbers), affixed to their wrist.

� All laboratory specimens and Request Forms regarding any unidentified patient should be labelled using one of the “unique” numbers as described above. In addition, the term “UNKNOWN MALE” or “UNKNOWN FEMALE” should be recorded onto both the specimen bottle and the Request Form.

� Within the laboratory, the Casualty or Gate Number on the specimen bottle and request form will be entered, with “Unknown Male” (or Female) to the laboratory computer system. To maintain accurate and cumulative laboratory data, further details regarding the unidentified patient, should they be made available, and when cross-identification has been ascertained, will be MERGED to the previously unidentified patient’s electronic file.

3.9.6 Danger of Infection In accordance with UK National legislation (Guidance for Clinical Workers: Protection Against Infection with Blood-Borne Viruses [1998]) and the Control of Infection Policy, North Glasgow University Division: Specimens from patients with known or suspected Blood-Borne Virus Infection must be conspicuously labelled as “DANGER OF INFECTION”. In addition, accompanying Request Forms should be similarly labelled.

As detailed within the Control of Infection Policy, North Glasgow University Division, current policy is that a common label (black print on a yellow background) indicating “DANGER OF INFECTION” be used for all patients known or suspected as Danger of Infection (e.g. HIV, Hepatitis B or C).

3.9.7 Clinical Information To permit the Department to provide the best possible service, clinical information included on the Request Form is essential to allow staff to accurately assess, interpret and validate laboratory results, to accurately monitor drug monitoring such as chemotherapy or anticoagulant therapy, to identify the requirement for further testing or additional analyses, and may prevent unnecessary delays in reporting, unnecessary repeat analyses, and wasting your, and the Department’s time, through having to contact the requesting source. In addition, clinical information, as appropriate, is essential for the safe and effective provision of blood and blood components. Accordingly, service users are instructed to provide appropriate clinical information with all laboratory requests.

3.9.8 Specimens from Mothers & Neonates � Specimen requirements, including those for labelling, of maternal and neonatal

specimens are identical to those detailed throughout Section 3.8 of this Handbook. � Neonates – Capillary specimens from neonates are routinely obtained via heel

stabs. Care must be taken to ensure the specimen is taken from the outer aspect of the heel, that there is no contamination, that undue force is not exerted to prevent haemolysis or contamination / dilution with tissue fluid and that the blood is free flowing and is collected quickly. Appropriate Paediatric Specimen Containers must be used. The volume of blood required is dependent on the test(s) required, and the minimum volume tolerance of laboratory analysers. For FBC analysis, 0.5ml is required as a minimum, though for coagulation related tests, at least 1ml of blood shall be required.


3.10 Posting Specimens to the Department

3.10.1 Sending Specimens by Post The Royal Mail supplies prepaid, single-use mailing containers (Safebox) designed to meet current legislation with regards to posting laboratory specimens. As detailed in Royal Mail guidelines, regardless of container, the following must apply for posted specimens: � The primary container (specimen bottle) shall be leak-proof and shall not contain

more than 500ml. � There shall be absorbent material (e.g. cotton wool, which shall be present in

sufficient quantity to absorb the entire content of the primary container) placed between the primary container and a secondary container.

� The secondary container must be leak-proof. � The secondary packaging shall not contain more than 4 litres (includes the scenario

of multiple primary containers placed into a single secondary container). � Secondary container should be inconspicuously labelled with “Biological Material”,

“Biohazardous Sample”, or similar, and have the laboratory destination address clearly marked.

3.10.2 Procedure Restrictions Patients from whom specimens MUST NOT BE SENT without approval of an Infectious Disease / Control Clinician: � Specimens from patients known or suspected to have SARS. � Specimens from patients with possible or confirmed Viral Haemorrhagic Fever. � Any other hazard category 4 pathogens such as Ebola.

4. Haematology Test Repertoire

4.1 Reference Ranges The Reference Ranges supplied are provided for guidance only, but should be used rather than those quoted in textbooks since methods, instrumentation, and units of measurement may vary from hospital to hospital. The ranges are obtained through analysis of an adult normal population and should not be applied to neonates, children or pregnant women, unless specifically stated for such use. Detailed information and advice on interpretation (see Section 3.1) is always available through contacting the Department.

4.2 Legend for Abbreviations Abbreviation Explanation

NA Not applicable OOH Test available Out of Hours (urgent or emergency request) TAT Target Test Turnaround (or reporting) Time. It is our aim to report at least 90% of tests within this

target time.

4.3 General Haematology Service – Routine Test Repertoire

ANALYTE REQUIRED CONTAINER

REFERENCE RANGE or NORMAL RESULT

OOH TARGET TAT

COMMENTS

BLOOD FILM 1 LAVENDER (4ml) NA √ 24.0 hrs BONE MARROW

BIOPSY NA

CONTACT DUTY HAEMATOLOGIST

ESR 2 LAVENDER (4ml) 1-10 mm √ 3.0 hrs FBC LAVENDER (4ml) SEE SECTION 4.4 √ 1.5 hrs

GLANDULAR FEVER SCREENING TEST

1 LAVENDER (4ml) NEGATIVE √ 3.0hrs

Hb A1c (DCCT aligned)

1 LAVENDER (4ml) 4.0 – 5.9% 24.0 hrs

KLEIHAUER 1 LAVENDER (4ml) NEGATIVE √ 3.0 hrs

MALARIA SCREEN 2 LAVENDER (4ml) NEGATIVE

0% Parasitisation √ 3.0 hrs

OSMOTIC FRAGILITY

GREEN

(Heparin) Immediate MCF 0.4-0.445% Incubated MCF 0.465–0.59%

1 week PHONE REQUEST IN

ADVANCE RETICULOCYTES 1 LAVENDER (4ml) 25 - 100 X 10 9/l √ 2.0 hrs

SICKLEDEX (HbS Screening)

1 LAVENDER (4ml) NEGATIVE √ 2.0 hrs

URINARY HAEMOSIDERIN

PLAIN URINE CONTAINER

NEGATIVE 48.0 hrs


Any requests for additional “Add-On Tests” will be subject to the volume and integrity of the sample. For the above: 1 Indicates Additional Examinations that can be requested within 24hrs of receipt of a FBC Specimen

2 Indicates those tests where a fresh specimen is required for additional requests

4.4 Full Blood Count (FBC)

4.4.1 Differential Leucocyte Count (see also 4.4.2 – Race Variation)

CELL TYPE ABSOLUTE NUMBERS

% OF TOTAL LEUCOCYTES

ADULTS

NEUTROPHILS 2.0 - 7.5 X 109/L 40 - 75 % LYMPHOCYTES 1.5 - 4.0 X 109/L 20 - 45 % MONOCYTES 0.2 - 0.8 X 109/L 2 - 10 % EOSINOPHILS 0.0 - 0.4 X 109/L 1 - 6 % BASOPHILS <0.01 - 0.1 X 109/L < 1 %

CHILDREN (6 YEARS)

NEUTROPHILS 2.0 - 6.0 X 109/L LYMPHOCYTES 5.5 - 8.5 X 109/L MONOCYTES 0.7 - 1.5 X 109/L EOSINOPHILS 0.3 - 0.8 X 109/L BASOPHILS 0.01 - 0.1 X 109/L

4.4.2 Differential Leucocyte Count – Race Variation

Normal racial variation e.g. Afro-Caribbean’s have a lower normal range of neutrophil count than Caucasians: Leucocyte (WBC) Count Neutrophils

Adult African Male 2.8 – 7.2 X 109/L 0.9 - 4.2 X 109/L

Female 3.0 – 7.4 X 109/L 1.3 – 3.7 X 109/L

Adult Afro - Caribbean

Male 3.1 – 9.4 X 109/L 1.2 – 5.6 X 109/L

Female 3.2 – 10.6 X 109/L 1.3 – 7.1 X 109/L

(Blood cells, A Practical Guide, 4th Edition. Barbara Bain)

4.4.3 Full Blood Count (FBC) – excluding neonates ANALYTE REFERENCE RANGE

RBC COUNT MEN 4.5 – 6.5 X 1012/L WOMEN 3.8 - 5.8 X 1012/L CHILDREN, 3 MONTHS 3.2 - 4.8 X 1012/L CHILDREN, 1 YEAR 3.4 - 5.2 X 1012/L CHILDREN, < 10 YEARS 3.8 - 5.6 X 1012/L HAEMOGLOBIN MEN 130 - 180 g/L WOMEN 115 - 160 g/L CHILDREN, 3 MONTHS 95 - 135 g/L CHILDREN, 1 YEAR 105 - 135 g/L CHILDREN, < 10 YEARS 115 - 150 g/L HAEMATOCRIT MEN 0.40 - 0.54 L/L WOMEN 0.37 - 0.47 L/L CHILDREN, 3 MONTHS 0.32 - 0.44 L/L CHILDREN, < 10 YEARS 0.36 - 0.46 L/L LEUCOCYTE (WBC) COUNT MEN AND WOMEN 4.0 - 11.0 X 109/L CHILDREN, 1 YEAR 6.0 - 18.0 X 109/L CHILDREN, < 10 YEARS 4.5 - 14.0 X 109/L MEAN CELL VOLUME (MCV) ADULTS AND CHILDREN 78 - 99 fl MEAN CELL HAEMOGLOBIN (MCH) ADULTS AND CHILDREN 27 - 32 pg MCHC ADULTS AND CHILDREN 310 - 360 g/L PLATELETS ADULTS AND CHILDREN 150 - 400 X 109/L RDW ADULTS AND CHILDREN 11.5- 14.5%


4.5 Haemolytic Screening Service 4.5.1 Haemolytic Screening Tests



OOH TAT COMMENTS

FBC LAVENDER

(4ml)

SEE SECTION 4.4 √ 1.5 hrs BLOOD FILM NA √ 24.0 hrs

RETICULOCYTES 25 - 100 X 10 9/l √ 1.5 hrs Haemoglobin A2 1.8 – 3.4 % 72.0 hrs Haemoglobin F 0.1 – 1.0 % % 24.0 hrs

DIRECT AHG TEST PINK (EDTA) NEGATIVE √ 3.0 hrs SICKLEDEX

(HbS Screening Test) LAVENDER

(4ml) NEGATIVE √ 2.0 hrs

URINARY HAEMOSIDERIN

PLAIN URINE CONTAINER

NEGATIVE 48.0 hrs

4.6 Haemostasis and Thrombosis Service and Test Repertoire The Department provides a wide-ranging, from routine, to a comprehensive analytical laboratory service, for bleeding and thrombotic disorders that includes: � Oral Anticoagulant monitoring services for out-patient and community based clinics � Consultant led clinical advice and test interpretation � Dedicated clinics for bleeding and thrombotic disorders � West of Scotland Comprehensive Care Haemophilia Centre � Patient & family counselling service for genetically inherited bleeding and thrombotic

disorders N.B. Urgent requests will be processed within 24-48 hrs if clinically indicated and on agreement by Haemostasis Consultant Haematologist.



OOH TAT COMMENTS

ROUTINE COAGULATION SCREEN

PROTHROMBIN TIME

PALE BLUE

9 – 13 secs (INR 0.9 – 1.1)

√

2.0 hrs

APTT 27 – 38 secs

(APTT ratio 0.8 – 1.2)

TCT 11 – 15 secs

(TCT ratio 0.8 – 1.2)

FIBRINOGEN 1.5 – 4.0 g/l

D-DIMER (IL-HS) < 243 ng/ml

Negative predictive value of <230 ng/ml for DVT and PE.

INR SEE SECTION 4.7.2 APTT RATIO SEE SECTION 4.7.3

COAGULATION FACTOR ASSAYS

FACTOR II

PALE BLUE (X2)

97 - 141 IU/dL 2 Weeks

FACTOR V 66 - 167 U/ dL FACTOR VII 67 - 153 IU/ dL FACTOR VIII 58 - 152 IU/ dL

1 week Urgent requests in

1 Day FACTOR IX 81 - 157 IU/ dL FACTOR X 79 - 155 IU/ dL

2 Weeks

FACTOR XI 82 - 151 IU/ dL FACTOR XII 59 - 164 U/ dL FACTOR XIII 70 - 140 IU/ dL 4 Weeks

FACTOR VIII COMPLEX ASSAYS

FACTOR VIII PALE BLUE

(x2)

58 - 152 IU/ dL

1 Week

vWF - ANTIGEN 50 – 200 IU/ dL

vWF – RISTOCETIN COFACTOR

50 – 200 IU/ dL

LUPUS ANTICOAGULANT SCREEN

APTT (Lup)

PALE BLUE (X2)

0.81 – 1.20

2 Weeks

APTT (50:50 Lup) 0.89 – 1.13 DRVVT Screen 0.87 – 1.21 DRVVT Confirm 0.81 – 1.08

ACL Antibody (IgG) 1.0 – 13.0 U/mL ACL Antibody (IgM) 1.0 – 10.0 U/mL

THROMBOPHILIA SCREEN

ANTITHROMBIN III

PALE BLUE (X4)

82 - 123 IU/dL

2 Weeks

PROTEIN C 71 - 146 IU/dL

PROTEIN S (Free) Male - 75 - 148 IU/dL

Female – 65 - 137 IU/dL See Note below

Normalised APC Ratio To be determined Normalised APC Ratio

/ FV Def 0.90 – 1.17


PLATELET AGGREGATION STUDIES

PLATELET AGGREGATION

Citrate Tubes Supplied by

Lab

BY ARRANGEMENT

ONLY FIBRINOLYTIC SYSTEM INVESTIGATIONS

FIBRINOLYTIC STUDIES

PALE BLUE (X2)

BY

ARRANGEMENT ONLY

MOLECULAR INVESTIGATIONS

Factor V Leiden PALE BLUE

4 Weeks Prothrombin

G20210A Mutation 3 Weeks

NOTE – Protein S levels may fall below the above Reference Range during pregnancy or use of oral oestrogens.

INVESTIGATION SAMPLING VIABILITY &

ADDITIONAL EXAMINATIONS OTHER REQUIREMENTS

Coagulation Screen Sample (and additional requests) to be received < 4 hours from time of

venepuncture

-

INR -

LMW Heparin (Anti-Xa) Assay*

Sample (and additional requests) to be received < 2 hours from time of

venepuncture

Sample must be taken 3.5 – 4.0 hours post dosage, and type of heparin should be specified

on request form (e.g. LMWH, heparinoid [Orgaran], fondaparinux)

Lupus Anticoagulant Screen -

Thrombophilia Screen -

AT or PC or FPS or APCR-V -

Factor Assay * FV and FVIII assay samples

preferably < 1 hour from time of venepuncture

Intrinsic/Extrinsic Pathway * FV and FVIII assay samples

preferably < 1 hour from time of venepuncture

Inhibitor Screen Sample (and additional requests) to be received < 4 hours from time of

venepuncture

-

Inhibitor Assay * Preferably < 1 hour from time of

venepuncture

Von Willebrand Screen * Sample to be received < 2 hours from

time of venepuncture Samples preferably < 1 hour from

time of venepuncture

Platelet Aggregation Studies ** Sample to be received < 0.5 hour

from time of venepuncture.

10mL citrate tubes will be supplied by laboratory

Do not send in Tube System

* The Department should be notified prior to the dispatch of these samples. ** These investigations must be arranged by contacting the laboratory

Under filled or overfilled samples will be rejected. All bottles must be filled to the correct level and mixed gently by inversion. Avoid frothing and mechanical damage.

4.6.1 Anticoagulation Dosage Assessment Service Departmental anticoagulant clinics are run by a multidisciplinary team including, pharmacists, nurses and haematology Biomedical Scientists. Medical guidance and support is supplied by Consultant Haematology Staff. Patients are referred directly to the clinic on discharge from hospital and from outpatient clinics. Clinics operate in all Glasgow Hospitals and can facilitate out-patient initiation of warfarin if required. Clinic Staff are responsible for interpreting INR results, patient counselling and advising on dosage adjustment using computerised dosage support (DAWN AC). The computer programme also functions as a clinic management system and retains patient’s records. In addition, the system provides useful data for benchmarking and audit.


4.6.2 Oral Anticoagulant Monitoring and Control Indications for oral anticoagulant, the usual INR and the usual duration of anticoagulation are outlined below:

INDICATIONS FOR WARFARIN TARGET INR (Range) DURATION

Atrial Fibrillation / Paroxysmal AF 2.5 (2.0 – 3.0) Lifelong

Cardioversion 2.5 (2.0 – 3.0) >3 weeks before, >4 weeks after.

Proximal DVT 2.5 (2.0 – 3.0) 6 months Isolated calf vein thrombosis 2.5 (2.0 – 3.0) 3 months Post op calf vein thrombosis 2.5 (2.0 – 3.0) 6 weeks Pulmonary embolism 2.5 (2.0 – 3.0) 6 months Recurrent DVT / PTE (on warfarin) 3.5 (3.0 – 4.0) Consider Lifelong Recurrent DVT / PTE (off warfarin) 2.5 (2.0 – 3.0) Consider Lifelong Dilated cardiomyopathy 2.5 (2.0 – 3.0) Lifelong Mechanical Mitral Valve Replacement 3.0 (2.5 – 3.5) Lifelong Mechanical Aortic Valve Replacement 2.5 (2.0 – 3.0) Lifelong Tissue Valve Replacement 2.5 (2.0 – 3.0) 3 months

4.6.3 Therapeutic (full treatment dose) Heparin Range


THERAPEUTIC RANGE OOH TAT COMMENTS

APTT RATIO

PALE BLUE

IV Unfractionated Heparin 1.8 – 2.8

√ 2 hrs

ANTI Xa Low Molecular Weight Heparin peak level 3-4 hours post dose 0.5 – 1.0 (varies with indication)

N/A 24 hrs

See NOTE below Please indicate which specific anticoagulant is being used.

ANTI Xa Heparinoid

0.5 – 0.8 (varies with indication) N/A 24 hrs

Please indicate which specific anticoagulant is being used.

NOTE - Monitoring not normally required, but discuss with Haematology Medical Staff if circumstances are unusual, e.g. thrombosis in pregnancy, renal failure, obese patients. In these cases, Low Molecular Weight Heparin activity can be assayed using Anti Factor Xa activity.

4.7 Haematinic Assays Service


REFERENCE RANGE & RESULT INTERPRETATION

OOH TAT COMMENTS

SERUM FERRITIN

GEL YELLOW Normal 10 - 275 ng/mL N/A 3 days

SERUM B12 GEL YELLOW Normal 200 - 900 pg/mL N/A 3 days

SERUM FOLATE GEL YELLOW Normal 3.1 – 20.0 ng/mL N/A 3 days

RBC FOLATE LAVENDER (EDTA)

Normal 100 - 600 ng/mL N/A 1 week

4.8 Haematological Oncology Service The West of Scotland Regional Bone Marrow Transplantation Service provides a comprehensive clinical Haemato-Oncology service. Laboratory support, by laboratories located at the Gartnavel General site, includes the provision of the following: � Immunophenotyping (cell marker) service, including the flow cytometric assessment,

incorporating multi-parameter cell sorting, of haematological malignancies. In addition, the cell marker service includes tests for the screening of Paroxysmal Nocturnal Haemoglobinuria, quantitation of CD34+ cells, and the immunophenotypic analysis of leukaemia and lymphoma (EDTA, Lavender Specimen)

� Bone Marrow Transplantation Laboratory Service, incorporating procedures for the harvesting and processing of allogeneic bone marrow and peripheral blood stem cell collections (sibling donor and matched unrelated donor); the cryopreservation and storage of bone marrow, peripheral blood stem cells, umbilical cord bloods and donor lymphocyte infusions. Additional testing includes the resolution of blood samples into myeloid and lymphoid populations for subsequent analysis of chimaerism post allogeneic transplantation.


� Further testing includes Cell Culture Studies, including Committed Progenitor Assays

(CFU-Mix, CFU-GM and BFU-E), and quantification of stem cells by long term culture-initiating cell (LTC-IC) assay.


REFERENCE RANGE & RESULT INTERPRETATION

OOH TAT COMMENTS

CD34 LAVENDER (EDTA)

N/A N/A 1.5 Hours

LEUKAEMIA/ LYMPHOMA

LAVENDER (EDTA)

N/A N/A

Urgent sample - 1 day

Non urgent sample - 3 days

PNH LAVENDER (EDTA)

N/A N/A 1 days

4.9 Perinatal Haematology Service The Department provides a comprehensive antenatal and postnatal haematology laboratory service that includes � Haematology service and blood group serology service for hospital and community

based antenatal clinics � Antibody screening, identification and quantification � Routine postnatal haematology screening � Paediatric haematology screening � Routine and specialist haemostasis screening service including the investigation of

bleeding and thrombotic disorders In addition to the laboratory service, the Department provides full clinical support that includes: � Consultant led interpretation and advice � Consultant led clinical support for ante and postnatal mothers with haematological

disorders 4.10 Key Factors Affecting the Performance of Haematology Analyses There are many physiological and physical factors (including the effects of anticoagulants, effects of storage, and the effects of delayed analysis) known to affect the collection & handling of blood, and hence, the performance of Haematology Analyses -to detail all such factors is beyond the scope of this Handbook. Where required, specific advice can be sought by contacting the Department. Generally, however, the following factors can be considered as fundamental for all laboratory tests: � Good quality venepuncture � Appropriate type of tube for specimen is essential � Appropriately filled specimen tubes (fill lines indicated on specimen bottles) � Timely arrival at the Haematology laboratory


4.11 Referred Analyses The following tests can be referred to external testing laboratories:

Tests Referred

Specimen

Referral Laboratory

Accreditation Status

Fibrinogen Gene EDTA Whole Blood

Molecular Diagnostics Section, Dept of Clinical Pathology, Queens Medical Centre,

Nottingham University Hospitals NHS Trust

Nottingham

CPA Accredited

Factor V Gene EDTA Whole Blood

Molecular Genetis Unit Reference Centre for Thrombotic and

Haemostatic Disorders 1st Floor, North Wing St Thomas’ Hospital

Westminster Bridge Rd London

CPA Accredited

Factor VIII & IX Genes

EDTA Whole Blood

Department Of Haematology, 15 Little France Crescent,

Old Dalkeith Road, Edinburgh

CPA Accredited

Factor XI Gene EDTA Whole Blood

Sheffield Molecular Genetics Service, Sheffield Children’s NHS Foundation Trust,

Western Bank Sheffield

CPA Accredited

Thrombophilia Genes

Antithrombin,

Protein C, Protein S Genes

EDTA Whole Blood

Sheffield Molecular Genetics Service, Sheffield Children’s NHS Foundation Trust,

Western Bank Sheffield

CPA Accredited

VWF Multimers & Gene

Citrated Plasma and

EDTA Whole Blood

Molecular Haematology Dept of Clinical Laboratory Haematology,

The Children’s Hospital, Steelhouse Lane,

Birmingham B4 6NH

CPA Accredited


5. Transfusion Medicine Service

The Department, on all Hospital sites, operates a comprehensive 24hour / seven day Transfusion Medicine Service. This section serves as a brief descriptor of the service provided, and the means to use and access this service. Detailed and comprehensive information relating to transfusion medicine practice is available in the Divisional Blood Transfusion Policy (see Section 5.4). This document is routinely distributed to all Hospital based clinical areas, and can be accessed electronically at www.ngt.org.uk/transfusion. In addition, copies can be obtained by contacting the Transfusion Practitioners or the Quality Manager. 5.1 Hospital Blood Banks & the Transfusion Medicine Service - Introduction The Transfusion Medicine Service for North Glasgow University Hospitals is provided by the respective Hospital Blood Banks, with transfusion practice overseen on each site by a site-based Hospital Transfusion Committee. This is a multi-disciplinary group whose existence is mandated by the Scottish Executive. This Hospital-based Committee arrangement part explains the minor differences in Transfusion Practice that may be encountered across North Glasgow. The Overarching Transfusion Committee (including representatives from all Hospital Sites) part serves to standardise transfusion medicine practice where safe, appropriate, and practical, across NHS GG&C 5.2 Specimen Collection & Blood or Blood Component Ordering ALL requests for blood and or blood components (with the exception of urgent or emergency telephone requests) must be made on a fully completed Blood Transfusion Request Form and accompanied by a hand written, signed blood transfusion specimen (where appropriate).

Blood and or Blood Components can be issued ONLY against adequately identified specimens and request Forms, as outlined in Section 3.9 of this Handbook.

5.2.1 Telephone Requesting of Blood & Blood Components

In certain circumstances, a blood sample may not be required by the Hospital Blood Bank, e.g. when Albumin, an Immunoglobulin Product, or a Coagulation Factor Concentrate is being requested, or, the scenario whereby additional units of blood (to a previously arranged X-Match Request) are required, or when it is appropriate to convert a Group & Save Request to an X-Match (see below).

5.2.2 URGENT & EMERGENCY REQUESTS

Urgent or Emergency Requests MUST always be telephoned to the Hospital Blood Bank:

On-site Off-site

GARTNAVEL HOSPITAL (Transfusion request handled by SBTS)

357-7802

GLASGOW ROYAL INFIRMARY 24666 211 - 4666

WESTERN INFIRMARY 52406 211 – 2406

5.3 Transfusion Medicine Test Repertoire

TEST / PROCEDURE SPECIMEN CONTAINER

Group & Save

PINK (6ml EDTA) X-Matching Direct Coombs (DAHGT) Test Blood Group Phenotyping HIT Screen (referred to SNBTS)

5.3.1 Group & Save (Group, Antibody Screen & Save)

This consists of an ABO and Rhesus (D) Blood Grouping, a screen for clinically significant antibodies and the subsequent storage of plasma to permit X-matching of blood should this become necessary during the subsequent 5 day period.


5.3.2 X-Match (Crossmatch) Procedure This should be requested ONLY if it is certain, or very likely, that a patient will require blood transfusion. If an X-Match is requested to cover a surgical procedure then the date and time of this should be clearly indicated on the Request Form. Requests for surgical cases, ideally, should be sent to Blood Bank at least 24 hours before the procedure is to be carried out. Requests for X-Matching for surgical cases should comply with the maximum surgical blood order schedule (MSBOS). The Hospital Transfusion Committee(s) has agreed this schedule. It is designed to maximize the use of available bloodstocks, whilst at the same time minimise blood wastage. The maximum Surgical Blood Order Schedule is printed in Appendix 3 for reference. 5.3.2.1 Known Antibodies If the patient has a record of previous antibodies the requesting doctor should indicate this on the request form. This can save time in locating supplies of blood for X-Matching against the patient should transfusion become necessary. 5.3.2.2 Special Blood Requirements Certain patients, e.g. severely immuno-compromised patients, may have special transfusion requirements, such as a requirement for CMV Negative and or irradiated blood, etc. Such special requirements MUST be clearly indicated in the designated section of the Request Form. CMV Negative and or Irradiated blood and blood products must be ordered from the Regional Transfusion Centre, hence, for non-urgent cases, blood and blood components should be ordered the day before they are required to allow scheduled delivery. Alternatively, blood and blood components required urgently must be transported from the Transfusion Centre by taxi. 5.4 Blood Transfusion Policy Detailed and comprehensive information relating to transfusion medicine practice is available in the Divisional Blood Transfusion Policy. This document is routinely distributed to all Hospital based clinical areas, and can be accessed electronically at www.ngt.org.uk/transfusion. In addition, copies can be obtained by contacting the Transfusion Practitioners or the Quality Manager. Information provided by the Blood Transfusion Policy includes: � Release, Collection, Transport & Storage of Blood

I. Procedures for the labelling of blood (Compatibility Label) including mandatory procedural information relating to completion and return of the “blue section” of the Compatibility Label in order to allow unambiguous traceability of the fate of the unit of blood (EU Blood Directives 2002/98/EC, and 2004/33/EC).

II. Procedures and forms for the collection of blood (and blood components) from hospital blood banks and satellite blood fridges.

III. Procedures for the transportation of blood, and procedures for the maintenance and monitoring of temperature (the “cold chain”), of blood & blood components prior to transfusion.

IV. Procedures for the use of satellite fridges for the storage of blood. (BLOOD MUST ONLY BE STORED IN DESIGNATED BLOOD STORAGE FRIDGES)

V. Procedures for blood that arrives with a patient from “another” hospital.

� Administration of Blood (& Blood Components)

I. Procedures and forms for the “Prescription of Blood” (and blood components). II. Procedures for the “Bedside Checking Procedure”. III. Observation procedures for patients receiving transfusion. IV. Procedures and forms to be followed at the completion of transfusion.

� Issue of Blood for Major Bleeding Episodes & Un-Crossmatched Blood

Full procedural information for the issue of blood (and blood components) for Major Bleeding Episodes (Major Haemorrhage Policy & Procedures) is provided.

In addition, information relating to the storage, availability and use of screened Group O Negative blood stock (Un-Crossmatched Blood) is provided. Such stock is


used ONLY where there is no time to provide X-Matched units. NOTE – this stock blood may not be suitable for patients having allo-antibodies - Please discuss with Blood Bank Staff if allo-antibodies are known to be present.

� Blood Components

The term blood component is used for all therapeutic materials derived from blood and includes both cellular blood components (such as platelets) and plasma related components and fractions (such as Fresh Frozen Plasma, Albumin Solution, etc).

The Blood Transfusion Policy details all blood components held by the Department, and the procedural information and forms, etc, to be used for the ordering and administration of blood components.

5.5 Blood Transfusion Reactions

Acute haemolytic reactions are generally accompanied by an acute deterioration in the patient’s condition and may be associated with rigors, chest pain, loin pain, abdominal pain, dyspnoea, shock, hypotension, oliguria, and in all cases, haemoglobinuria. If a transfusion reaction is suspected: 1. Stop the transfusion immediately, 2. Inform the Haematology Registrar on-call by telephone of the suspected reaction, 3. Take a post transfusion sample from the patient and send it to the Blood Bank with

a completed Blood Transfusion Request Form marked with ‘Post Transfusion Sample’. Additional samples may be requested by the Haematologist.

4. Fill in a “Transfusion Reaction Form” with details of the suspected reaction and return this with the pack and label to the Blood Bank for analysis.

5. Finally, liaise with the Blood Bank to arrange for the patient’s transfusion needs. Investigation of suspected transfusion reactions is time consuming and will inevitably cause a delay in supplying blood while the investigation is completed. In urgent cases advice on the immediate transfusion strategy should be sought from Consultant Haematologist staff.

5.6 Key Factors Affecting the Performance of Blood Transfusion Requests

See Section 4.10.

5.7 Referred Analyses

See Section 4.11. The following analyses are routinely sent to laboratories of the Scottish Regional Transfusion Service, Shelley Road, Gartnavel Hospital, Glasgow. 1. Anti-D and anti-c quantitation 2. Unidentified Antibody Investigations 3. Difficult X-Match Requests (where screened blood is required) 4. Platelet Antibody Investigations 5. Foeto-Maternal Haemorrhage Screen (Flow Cytometric Assessment) Investigation 6. HIT antibody assessment

5.8 Referred Analyses

The following tests can be referred to external testing laboratories: Antibody Screening &

Identification, X-Matching,

HLA & Platelet Antibody Screening & Identification,

HIT Screening, FMH estimation by Flow

Cytometry

EDTA Whole Blood

West of Scotland Blood Transfusion Centre, AT Gartnavel Hospital,

25 Shelley Road, Glasgow

CPA Accredited

Foetal DNA Testing EDTA Whole Blood

(2x7ml) North & East Scotland Regional Blood

Transfusion Centre, Foresterhill Road,

Aberdeen

CPA Accredited Anti-Neutrophil Antibodies EDTA Whole Blood

Malaria Testing Confirmation

EDTA Whole Blood

Malaria Reference Laboratory London School of Hygiene and Tropical

Medicine, Keppel (Gower) Street, London

CPA Accredited

Plasma Viscosity EDTA Whole Blood Haematology Department, Southern General Hospital,

Glasgow CPA Accredited


6. Guidelines for Test Requesting & the Interpretation of Results

It is useful to know how best to interpret an abnormality identified on an initial full blood count. Sometimes the cause is obvious when information about the patient’s clinical condition, medication, treatment, etc. is known. The following serves as a brief guide. The possible causes of each laboratory abnormality are listed below. The commoner causes appear first with less common causes shown in brackets. If you are at all unsure as to how to proceed, please contact the Department.

6.1 Anaemia MICROCYTIC ANAEMIA (MCV < 80fl)

Iron deficiency Thalassaemia Anaemia of chronic disease Lead poisoning (rare) Congenital Sideroblastic anaemia (rare)

MACROCYTIC ANAEMIA MCV > 100fl)

Liver disease including alcohol excess Vitamin B12 or folate deficiency Hypothyroidism Reticulocytosis Haemochromatosis Myeloma Drugs e.g. hydroxycarbamide, azathioprine

NORMOCYTIC ANAEMIA (MCV 80 – 100FL)

Active bleeding Anaemia of chronic disease Secondary to: � Chronic infection � Inflammatory disease � Malignancy � Chronic organ failure

6.2 Polycythaemia

WITH NORMAL WBC AND PLATELET COUNT

Dehydration Lifestyle e.g. alcohol, smoking, stress, obesity Chronic hypoxia e.g. cardiac or pulmonary disease (Ectopic erythropoietin) (Myeloproliferative disorder)

WITH RAISED WBC AND PLATELET COUNT

Myeloproliferative disorder (Primary Polycythaemia)

6.3 Leucocytosis

NEUTROPHILIA

Bacterial Infection Steroid therapy Post operative Tissue Necrosis / infarction Inflammatory disorders e.g. vasculitis, rheumatoid, Malignancy


LYMPHOCYTOSIS

Viral infection Acute stress e.g. head injury, seizure, myocardial infarction Post splenectomy Lymphoproliferative disorders

MONOCYTOSIS

Bacterial infection Atypical infection Post splenectomy Leukaemia’s

Malignancy

EOSINOPHILIA

Asthma or eczema Drugs Vasculitis Parasitic infection

Carcinoma / Hodgkins disease

BASOPHILIA

Myeloid disorders Myxoedema Ulcerative colitis

6.4 Leucopenia

NEUTROPENIA LYMPHOPENIA

Viral infection Drugs e.g. carbimazole, septrin. Chemotherapy Radiotherapy Rheumatoid arthritis or Sjogren’s syndrome Acute or chronic leukaemia’s

Drugs especially steroid therapy Autoimmune disorders HIV infection (Cong immunodeficiency)

6.5 Pancytopenia

B12 or Folate deficiency

Post chemotherapy/radiotherapy Hypersplenism Bone marrow infiltration- carcinoma, leukaemia, lymphoma, fibrosis Drugs

Aplastic anaemia

6.6 Thrombocytosis

Chronic infection

Chronic inflammatory disorders Malignancy Post splenectomy Myeloproliferative disorders

Iron Deficiency

6.7 Thrombocytopenia

� Platelet clumping in EDTA (spurious) � Alcohol excess


� Chronic liver disease � Drugs � Immune thrombocytopenia � Hypersplenism � Massive transfusion � Disseminated Intravascular Coagulation � Haemolytic Uraemic Syndrome/Thrombotic Thrombocytopenic Purpura

6.8 Notable Blood Film Morphology Comments

The morphologist will often suggest further relevant investigations as part of the assessment of the case. In other situations particular features are identified but a specific unifying explanation may not be readily apparent. The following are common terms used to describe blood cell morphology together with their clinical associations:

RBC Feature Clinical Association

Target cells Liver disease, iron deficiency, thalassaemia Hypochromia Iron deficiency, thalassaemia Polychromasia Reticulocytosis Spherocytes Haemolytic anaemia, Hereditary Spherocytosis Pencil cells Iron deficiency Teardrop cells Marrow fibrosis/infiltration Basophilic stippling Dyserythropoiesis Oval macrocytes B12 or folate deficiency Red cell fragments Microangiopathy Howell Jolly bodies Hyposplenism Pappenheimer bodies Failure iron utilisation Acanthocytes/crenated cells Hyposplenism, metabolic disorders Dimorphic red cells Recent transfusion, treated haematinic deficiency

WBC Feature Clinical Association

Toxic neutrophil granulation Bacterial infection Myeloid left shift Bacterial infection Hypersegmented neutrophils B12 or folate deficiency Hypogranular neutrophils Myelodysplasia Activated/atypical lymphocytes Viral infection Blasts present Leukaemias/lymphomas/marrow infiltration/severe

sepsis General Terms Clinical Association

Leucoerythroblastic film Bone marrow stress or infiltration Rouleaux Inflammation/infection/excess globulins Agglutinates on film Cold agglutinins present

6.9 Commonly Encountered Problems

6.9.1 Mild Thrombocytopenia and Neutropenia 5% of healthy individuals will have blood indices that lie out with the normal range. Patients who are found to have an isolated mild reduction in platelet count(100-150) or neutrophil count (1.0-1.5) and are otherwise well may not immediately require referral to Haematology for further investigation. A repeat FBC & blood film is suggested in 2-3 weeks. Platelet clumping is an EDTA induced artefactual cause of a low platelet count. Sending a Lithium Heparin or Citrate specimen may be useful for obtaining a more accurate count in these cases. Pathology is more likely when the neutrophils are < 1.0 or platelets < 100 (unless clumped). Possible causes: � Haematinic Deficiency � Drug related � Normal racial variation e.g. Afro-Caribbeans have a lower normal range of neutrophil

count than Caucasians � Viral infection � Marrow infiltration/hypoplasia � Hypersplenism Worrying features: � Neutrophils <0.5 x 109/l or platelets <50 x 109/l � Weight loss, fever, anorexia � Hepatosplenomegaly/Lymphadenopathy � Reduction of other blood counts


Consider abnormal values in their clinical context – if you have any concerns or queries please discuss with your local Haematology Department. 6.9.2 Lymphocytosis Slight lymphocytosis (4-10 x109/l) is a common finding and may be associated with viral infection and other reactive conditions. Repeat FBC and blood film is suggested in 4-6 weeks. If lymphocytosis is confirmed, in general, cell markers will be done on that sample or suggested on a follow up sample. Cell marker analysis allows identification of early lymphoproliferative disorders. Assessment of lymphocytosis should include examination for lymphadenopathy, hepatosplenomegaly and symptoms of lymphoproliferative disease (ie any sudden weight loss, fatigue, itch). 6.9.3 Polycythaemia The Haematocrit or packed cell volume is the indicator for polycythaemia Patients with a persistent, unexplained elevation of Haematocrit - >0.54 in males or >0.48 in females (for at least 2 months and on at least 2 separate occasions) should be referred to Haematology for assessment. Secondary Polycythaemia is much more common than the primary disease. Causes are related to Smoking, Chronic lung disease or Renal disease (polycystic kidneys, renal tumours).

6.10 Interpretation of Abnormal Clotting Screen Results

Analyte Possible Causes

Prolonged Prothrombin Time (PT)

Liver disease, Warfarin therapy,

Vitamin K deficiency, DIC,

Massive blood loss, Factor deficiency.

Prolonged Activated Partial Thromboplastin Time (APTT)

Liver disease, Heparin therapy,

DIC, Lupus Inhibitor,

Massive blood loss, Factor deficiency.

Prolonged Thrombin Clotting Time (TCT) Heparin therapy,

DIC, Fibrinogen defect / deficiency.

Low Fibrinogen

Consumptive coagulopathy, DIC,

Fibrinogen defect, Liver disease,

Massive blood loss,

6.11 Assessing B12 Status

The B12 assay is a frequently requested test, generating many results out with the reference range and thus reported as abnormal. Determining the relevance and appropriate management of these results has been highlighted as an area of concern by many GPs locally. Vitamin B12 deficiency - as defined by serum vitamin B12 levels below the reference range on two separate occasions a month apart - is a common finding; however the identification of significant pathology either underlying or secondary to this deficiency is not. Our aim is to provide a simple means of assessing and replacing vitamin B12 which will ensure adequate treatment of those with severe deficiency or underlying disease whilst minimising the treatment and investigative burden of the many minor deficiencies. As there is little evidence that population screening for vitamin B12 deficiency is of benefit, the assay should be reserved for those with signs or symptoms which suggest that B12 deficiency is likely – a list of indications is attached. If on initial haematinic assay, the serum vitamin B12 level is reduced a repeat serum vitamin B12 assay should be requested approximately one month after this initial test. Testing for the presence of Parietal Cell (PC) and Intrinsic Factor (IF) antibodies should be requested in addition at this stage. PC and IF antibody testing is undertaken by the Immunology Laboratory. The absence of Parietal Cell antibodies virtually rules out a diagnosis of pernicious anaemia (PA). On the other hand, IF antibody positivity is strongly predictive for pernicious anaemia and should be considered diagnostic unless


clinical features suggest otherwise. However, IF antibody is only present in 50% of cases of PA. The Schilling Test is not required in any but the most difficult diagnostic cases. No specific level is considered a threshold for major deficiency though the lower the serum vitamin B12 level the more likely clinical symptoms or macrocytosis will be present. The level at which clinically significant deficiency occurs is particularly variable in the elderly and indeed vitamin B12 deficiency is frequent in the elderly (65+). Most causes of vitamin B12 deficiency apart from PA and malabsorption will respond to oral vitamin B12 replacement (see below) and this can be used as a screening test. A patient responding to oral therapy could then either continue oral replacement or use an IM preparation but would not need further investigation. Hospital referral should be reserved for those with severe symptoms or in whom standard investigations fail to clarify the cause of a clinically significant deficiency. A flow diagram follows to guide investigation and vitamin B12 replacement (see Section 6.13). Food-Cobalamin Malabsorption Many patients with vitamin B12 deficiency have a negative Parietal cell and Intrinsic factor antibody screen. Recently the syndrome of Food-Cobalamin Malabsorption has been described. In this syndrome the absorption of vitamin B12 bound to food is impaired but the absorption of free vitamin B12 such as in oral vitamin B12 supplements, is normal. This appears to be related to altered acid levels in the stomach. It is common in the elderly and in those taking antacid therapies. A full list of causes is appended. The advent of food cobalamin syndrome as a diagnosis suggests a greater role for oral vitamin B12 in diagnosis and replacement therapy. It is suggested that between 125 and 250µg of oral cobalamin daily should be sufficient in dietary deficiency or food-cobalamin malabsorption. The only licensed formulation available at present is Cytagon containing 50µg cyanocobalamin. A trial of oral vitamin B12 should consist of Cytagon 250µg daily for 2 months. Predisposing Factors for Food Cobalamin Malabsorption � Atrophic gastritis, chronic H. pylori infection � Microbial proliferation, AIDS � Long term ingestion of antacids or biguanides � Chronic alcoholism � Gastrectomy, gastric bypass surgery � Pancreatic exocrine failure � Idiopathic (age related) Oral Contraception, Pregnancy and HRT Oestrogen containing OCP, HRT use and pregnancy lower serum vitamin B12 levels without causing tissue deficiency or macrocytosis. Therefore it is generally not helpful to check serum vitamin B12 in females taking the Combined OCP or HRT unless there is a clinical indication such as described above. It is hoped that this approach will allow a diagnosis to be made in Primary Care in the majority of patients and that unnecessary investigation can be avoided

6.12 Indications for requesting Vitamin B12 Assay

� Macrocytosis (MCV ≥ 100fl) Note: Liver disease, alcohol and hypothyroidism should also be considered as possible causes of a macrocytosis.

� Unexplained neurological signs and symptoms. E.g. Peripheral neuropathy, visual loss and dementia.

� Severe depression (especially in the elderly) � GI symptoms.

E.g. Glossitis, abnormal taste, surgery or radiotherapy to stomach/small bowel, malabsorption or unexplained diarrhoea.

� Vegan Diet (long term) � Hypothyroidism

Remember, there is a high incidence of hypothyroidism in patients with PA. Notes 6.12.1 Tiredness is not an indication for serum vitamin B12 assay.


6.12.2 Serum vitamin B12 assays should not be performed as first line in any routine

haematological screen, References � Vitamin B12 (cobalamin) deficiency in elderly patients. Andrès,E. CMAJ 2004; 171

(3) 251-9 � Current concepts in cobalamin deficiency. Carmel, R. Annu. Rev. Med. 2000;

51:357–375 � Serum folate and Vitamin B12 levels in women using modern oral contraceptives

(OC) containing 20 µg ethinyl estradiol. Sϋtterlin M. Eur J O&G and RB. 2003; 107: 57-61

� Oral Contraceptives Can Cause Falsely Low Vitamin B12 Levels. Gardyn, J. Acta Haematol 2000;104:22–24

6.13 Recommended Action on Obtaining Abnormal B12 Result Note: Patients in whom B12 deficiency is part of a wider malabsorptive disorder or who have associated bowel symptoms should be referred to Gastroenterology in the first instance and should not follow this schematic.

6.14 Assessing Fe Status

DIAGNOSIS OF IDA

1. Establish state of iron deficiency � FBC and film � Assess Red Cell Indices � Microcytic, hypochromic red cells � Serum Ferritin � Most useful initial test in all patients with anaemia and in determining a diagnosis

of IDA. � Normal range 15-300 mg/l in male; 14-200 mg/l in premenopausal female � As a general rule, it is low in IDA and normal or elevated in patients with anaemia

of chronic disease (ACD). � Ferritin is an acute phase protein e.g. raised in infection, inflammation, malignancy

etc. A normal ferritin does not exclude IDA in the presence of inflammation.

Low B12 Result*

IF antibody positive (i.e. PA)

PC positive and IF antibody negative (i.e.

possible PA)**

Diagnose Pernicious Anaemia Treat with IM B12 indefinitely

Yearly TFT check

Either treat as PA or Commence oral B12 trial

(250mcg Cytagon for 2 months)**

B12 normalised on oral B12

B12 remains low on oral B12

Make dietary adjustments or continue with B12

supplementation as suits patient

No diagnosis achieved Hospital referral may be

appropriate; for many of these patients (particularly elderly) it is appropriate to manage as PA in

the community with IM B12.

Macrocytic anaemia or

Neurological symptoms

Commence IM B12, and consider hospital referral if

IF antibody negative

Normal MCV and

asymptomatic

PC & IF negative (i.e.

not PA)†

Diagnose dietary deficiency or Food Cobalamin malabsorption


� Serum Iron and Transferrin saturations are labile measurements and not reliable indicators of low iron stores (Serum Iron can be low in anaemia of chronic disease).

� Microcytic Anaemia alone is not sufficient to diagnose iron deficiency especially in elderly patients. 20 % of elderly patients with a MCV of <75 fl will not be iron deficient

� In patients with anaemia and MCV >95 fl there is a low probability of iron deficiency and other causes should be looked for initially.

2. Identify its cause � Blood Loss is the most common cause of IDA in adults � Pre menopausal females – menstrual blood loss – consider GI investigation if GI

symptoms; positive FOB; family history suggestive of colorectal cancer. � Adult males and post menopausal females - complete GI investigation is required � However complete GI work up will fail to identify source of blood loss in 35-40% of

cases � Other causes – malabsorption e.g. celiac; dietary (rare)

3. Treatment The most effective treatment for IDA is oral iron supplementation. If there is no ongoing blood loss one would expect Hb to rise by 1.5-2g/l per month. If no response to oral iron – consider: � lack of compliance � continuing blood loss � malabsorption � may also get poor response if active infection; renal or hepatic disease; malignancy

etc If intolerant of Ferrous Sulphate (65mg iron), try a reduced dose, Ferrous Gluconate (35mg iron) or by taking with food. If unable to tolerate oral iron, discuss with haematology for consideration of Intravenous iron therapy. This must be administered in hospital setting with full resuscitation facilities available. Intramuscular iron is no longer indicated. Once Hb level has returned to normal range, continue iron treatment for 3 months to replenish body stores. (Minimum of 6 months) IRON OVERLOAD Hereditary Haemochromatosis (HH) refers mainly to conditions of iron overload associated with mutations of the HFE gene. It has autosomal recessive inheritance and siblings have 1 in 4 risk. Transferrin saturation can be a useful screening test of iron accumulation. Values of >55% in men and >50% in women is in keeping with iron overload. Ferritin is also a useful marker of iron overload, but falsely elevated results can be secondary to inflammation or release of tissue ferritin by liver damage/necrosis. Levels of ferritin of >500 are more in keeping with HH. (Renal patients on dialysis are an exception and often have very high ferritin values). Patient may also have a family history of HH. In patients with elevated ferritin who may have HH, samples for genetic testing for HFE mutation can be sent directly to biochemistry by GP surgery (2 EDTA tubes). Haemochromatosis patients are often managed by gastroenterology.

6.15 Significance of the ESR Measurement in Clinical Medicine

The Erythrocyte Sedimentation Rate (ESR) is a widely used non specific test, but clinically useful in disorders associated with an increased production of acute-phase proteins. Upper limits of normal are shown in the tables below:

Men aged (years) ESR (mm/1hr) Upper limit (mm/1hr) 17-50 4 ± 3 10 51-60 6 ± 3 12 >60 6 ± 4 14

Women aged (years) ESR (mm/1hr) Upper limit (mm/1hr)

17-50 6 ± 3 12 51-60 9 ± 5 19 >60 10 ± 5 20

(Reference: Practical Haematology 6th Edition Dacie & Lewis)


The widely used rule for calculating normal maximum ESR values in adults (98% confidence limit), is given by a formula devised in 1983.

Age (in years) + 10 (if female) ESR (mm/hr) ≤ 2 (Reference: Simple Rule for Calculating Normal ESR. Miller A, Green M, Robinson D (1983), Br Med J (Clin

Res Ed) 286 (6361): PMID 6402065).

Elevated levels may be caused by a variety of situations both physiological and pathological. In pregnancy, the ESR is increased from about the 3rd month and returns to normal by the 3rd - 4th week post partum. The vast majority of acute or chronic infections and most neoplastic and degenerative diseases are associated with changes in plasma proteins and an elevated ESR. A raised ESR should always prompt appropriate clinical assessment of the patient. It is worth noting that the ESR may take some weeks to fall even after the cause has been treated. Follow up testing is useful in monitoring chronic inflammatory conditions such as rheumatoid arthritis and temporal arteritis.

6.16 Haemoglobinopathy screening Guidance

To provide clinically relevant parameters in the diagnosis of abnormal haemoglobins and other significant haemoglobinopathies Indicators for Haemoglobinopathy Screening Clinical Criteria

� Symptoms, signs or X-ray suggestive of sickle cell disease, Beta Thalassaemia Major or any other haemoglobinopathy

� Relatives of an individual known to have a haemoglobinopathy

� All pregnant women of non north European extraction should routinely be screened at booking visit and ferritin checked also. (Hospital antenatal check)

� Partners of women of child bearing age who have been diagnosed with a haemoglobinopathy / trait.

� As pre pregnancy screen for couples / individuals of black African or black American races. 20% are carriers for sickle cell disease.

Laboratory Criteria In the case of a positive Haemoglobinopathy screen in a non pregnant patient, a repeat sample may be requested for confirmation. The GP may be asked to obtain consent for referral for genetic counselling (which will be carried out by the Institute of Medical Genetics at RHSC, Yorkhill), or asked to refer patient directly to the genetic counselling service. If a positive Haemoglobinopathy screen is identified in a pregnant patient this will be dealt with urgently by the Haematologists, who will contact the antenatal clinic and request testing of the child’s father (unless already tested), repeat sample from the patient and suggest referral for genetic counselling. Further information on carrier diagnosis, risk assessment and information leaflets is available at www.chime.ucl.ac.uk/ApoGI/. It is essential that information on family origin is supplied in order to provide interpretation of the result.

6.17 Investigation of Malaria

Malaria is a parasitic disease found in tropical and subtropical regions. It is caused by protozoa of the genus Plasmodium. Four species of this protozoa cause malaria in humans, P.vivax, P.ovale, P.malariae and P.falciparum. Of these infections P.vivax, P.ovale & P.malariae can cause severe illness, but P.falciparum can cause a much more serious illness which can be fatal. Thus, P.falciparum infection must be identified urgently. P.vivax and P.ovale are responsible for relapsing malaria, which can occur up to 12 or 18 months after initial infection. Early presentation of malaria is flu like symptoms followed, after about a day, by fever. Symptoms take at least 6 days after mosquito bite to appear, but can take over a year,


depending on the species. Thrombocytopenia is a common finding, particularly in P.falciparum infections and should prompt urgent testing. Malaria must be diagnosed without delay in order to institute appropriate treatment. Malaria is found in most continents outside Europe, North America & Australia. P.falciparum is found most commonly in Africa and South East Asia.

IT IS VERY HELPFUL IF THE COUNTRY RECENTLY VISITED IS LISTED - This can aid diagnosis and as some areas are known to have drug resistance, this knowledge is advantageous if treatment is required. NHS Scotland has a useful website where information regarding malarious areas can be checked – http://www.fitfortravel.scot.nhs.uk/destinations/maps/worldmap.htm Laboratory investigation of malaria requires an EDTA (full blood count) tube. It is preferable that the laboratory receives the sample the same day as it is taken. Two investigations are performed – Malaria antigen screening test and a blood film examination for parasites. In all cases where malaria is confirmed, the result will be telephoned to the requesting source by Haematology medical staff.

6.18 Outreach Anticoagulant Therapy and Guidance

The Glasgow Anticoagulation Service offers clinics Monday to Friday 9am-4.30pm for the monitoring of warfarin therapy. The clinics are organised as morning and afternoon sessions throughout the city. These clinics are run on an appointment only basis. If an existing patient requires an urgent appointment then either the patient or clinician can contact one of the anticoagulation offices to request this. North Glasgow - 0141 201 3536/211 2011 South Glasgow - 0141 201 5946/5711 New patient referrals can often be made directly to the service, preferably using a Glasgow Anticoagulant Service Referral Form (accessed via Haematology pages on staffnet or a standard hospital referral form). Patients will usually be appointed within 1-2 weeks. If a patient is to commence warfarin in the community, we would prefer this to be deferred until the patient has attended the anticoagulant clinic. If a patient has started on a new medication, or has an existing one altered, an early appointment should be arranged with the anticoagulation clinic. The guidelines for these appointments are: � Medications with known or suspected interactions – Patient should be seen within 4-7

days � Medications with no known interactions – Patient should be seen within 14 days. When to take an INR If a patient complains of minor bleeding, unexplained bruising, or symptoms suggestive of possible internal bleeding a venous sample of blood for urgent INR should be sent to the lab. If the patient’s INR is >4, then the patient should be advised to omit warfarin for 1-2 days and to make an appointment for the earliest anticoagulant clinic. The patient should also be informed to seek further advice (or attend A&E) if there is any clinical deterioration. If a patient is actively bleeding or has had significant trauma, particularly to the head (with any neurological signs or symptoms), then the patient should be advised to attend the A&E Department immediately.


APPENDIX 1 Greiner Vacuette Venepuncture System


APPENDIX 2 - MAXIMUM SURGICAL BLOOD ORDERING SCHEDULE (MSBOS) GENERAL SURGERY UNITS ORTHOPAEDICS UNITS

Hepatectomy Oesophagectomy Total/partial gastrectomy Oesophageal gastrectomy Pancreatectomy – partial Whipple Adrenalectomy Cholecystectomy Splenectomy Gastrostomy, ileostomy, colostomy Anti-reflux surgery/hiatus hernia repair Hellers myotomy Mastectomy Thyroidectomy – partial/total Parathyroidectomy Oesophageal dilation Liver biopsy Renal biopsy

4 4 4 4 4 2 Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S

Revision hip/knee/shoulder Prosthesis (more if clinical indicated) Fixation pelvic/acetabular fracture (more if requested) Spinal fusion Internal fixation of femur Arthroplasty-total knee or shoulder Total hip (if clinical indication*) Total elbow Removal of hip pin or femoral nail Fixation fractured neck of femur Laminectomy Internal fixation-tibia Hemiarthioplasty for fractured neck of femur Osteotomy/bone biopsy (except upper femur*) Bone graft from iliac crest – 1 side (Bilateral*)

3 3 2 Gp & S Gp & S Gp & S (2*) Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S (2*) Gp & S (2*)

VASCULAR SURGERY UNITS CARDIO-THORACIC SURGERY UNITS

Thoracic or thoraco-abdominal aneurysm Ruptured aneurysms Aorto-illiac bypass Infra-renal aortic operations Redo infra-inguinal operations Amputation of leg Sympathectomy Groin procedure Carotid endarterectomy Femoro-popiteal bypass Femoral crossover graft

6 or as req’d 6 or as req’d 4 4 2 Gp & S Gp & S Gp & S Gp & S Gp & S Gp & S

Open heart operations – CABG, AVR MVR Redo open heart operations Closed heart surgery Major Thoracic-lobectomy/pneumonectomy Intermediate thoracic-bronch / mediastin-oscopy Video assisted thoracoscopic procedures Open pleural / lung biopsy Sternal rewiring

2 3 4 2 3 Gp & S Gp & S Gp & S Gp & S

COLO-RECTAL SURGERY UNITS HEAD AND NECK UNITS

Rectum-pouch resection / excision etc. Intra-abdominal colectomy – large cancer Intra-abdominal-colectomy Rectopexy

2 2 Gp & S Gp & S

Major H-N procedures – laryngectomy etc Major plastic reconstructions Other major H-N procedures

2 (ask surgeon) Gp & S

UROLOGY UNITS OBSTETRICS & GYNAECOLOGY UNITS

Radical nephrectomy

Partial nephrectomy

Cystectomy

2

2

2

Pelvic Exenteration

Placenta Praevia type 3 & 4

Wertheim’s Operation

6

4

2


Radical prostatectomy

Simple nephrectomy

Open pyelolithotomy

Cytoplasty, including clams

Continent diversion

Retropubic or transvesical

prostatectomy

TURP (in retention*)

Percutaneous pyelolithotomy

Pyeloplasty

Ureterolithotomy

Re-implant ureter inc.

transureteroureterostomy

Urethral suspension (inc.

birch, MMK and stamey)

Ileal conduit

TURT

Bladder diverticulectomy

Ureteroscopy and/or stone

extraction

Suprapubic lithotomy

2

1

1

1

1

1

Gp & S (2*)

Gp & S

Gp & S

Gp & S

Gp & S

Gp & S

Gp & S

Gp & S

Gp & S

None

None

Hysterectomy + pelvic

lymphadenectomy

APH / PPH

Hydatidiform Mole

Placenta Praevia / retained

Oophorectomy (radical)

Vulvecomy (radical)

Hysterectomy; abdominal or

vaginal – extended

Hysterectomy; abdominal or

vaginal – simple

LSCS (assuming Hb > 10.5)

ERPC / D&C

Termination of pregnancy

2

2 (variable)

2

2

2

Gp & S

Gp & S

Gp & S

Gp & S

Gp & S

Gp & S

PLASTIC SURGERY UNITS DENTAL UNITS

Breast surgery Pedicled tissue transfer (lat dorsi) Immediate or delayed Free tissue transfer (diep) delayed Free tissue transfer (diep) immediate Implant surgery Reduction / mastopexy Other procedures inc. trauma Free Tissue transfer / replantation Minor procedures (inc. cosmetic) Burns If > 50% surface area (then as guided by Hb)

Gp & S Gp & S 2 Gp & S Gp & S 1 Gp & S 2

Trauma and reconstructions

2

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