Meet the Consultants: Lab Medicine

Meet the Consultants: Lab Medicine

Laboratory Medicine and Anatomic Pathology Chemistry/Immunology Autopsy Microbiology/Virology Cytology Transfusion Medicine Apheresis Blood Bank Surgical Pathology Bone and Soft Tissue Breast Pathology Dermatopathology Genitourinary GI and Liver Gynecologic Head, Neck & Endocrine Hematology/Flow Cytometry Tumor Profiling Hematopathology Molecular Diagnosis Bioinformatics Medical Renal Neuropathology Ophthalmic Pediatric Thoracic

55 Park Street 6th Floor: Microbiology Virology 5th Floor Processing Chemistry Hematology Other Locations: NP 8 Apheresis Clinic Sample Delivery 4th Floor Hematopathology Immunology Flow Cytometry Special Chemistry 3rd Floor Blood Bank Stem Cell Lab Bags and Tags for Transfusion Reactions

Service Duties Patient Care Sign-Out Critical Values Approval of Off-Label Use of Clotting Factors Consultation Laboratory Management CLIA Regulations Evidence-Based Practice Protocols QC/QA/QI Proficiency Testing Resource Management Lab Staffing Testing Schedules

Consults

MUST Consult List Massive Transfusion Protocols (MTPs)* Transfusion Reactions* Urgent Apheresis, e.g.: Acute Chest Syndrome in Sickle Cell Disease Thrombotic Thrombocytopenic Purpura Off-label clotting factor approval* *You call us (preferred) or we call you https://www.turbosquid.com

“Bad” Consult Example On a peripheral smear order: “Smear morphology” “Blood info?” “?” Clark, William. (2016) Contemporary Practice in Chemical Chemistry, 3 rd Edition. AACC Press.

“Good” Consult Example Indication for testing in chart/lab request Peripheral smears Flow cytometry Give clinical context “I have a question about testing” One-liner Have MR and/or specimen ID ready Give contact information (full name and number) for follow-up Be as specific as possible Always better to call ahead Especially for Blood Bank and Apheresis https://www.arrowheadscientificinc.com

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General Lab Info and Tips Ordering, Specimen Handling, and Critical Values

Lab Tips - Ordering For: “Missing” Orders Miscellaneous Orders Special Send-Out Requests First Quest Then ARUP Mayo Clinic NMS Cannot send to research labs Order miscellaneous blood/nonblood test and enter into comments: Name of Lab Name of Test Lab ID/Test Code

For other questions about tests Customer Service Hotline: 203-688-2444

Lab Tips - Specimen Handling Send separate specimens to Lab Medicine and Pathology when possible Coordinate with Lab Medicine and Pathology if shared specimen Especially if after hours Send samples in lab-approved containers Send representative samples of larger specimens If urgent, hand-deliver it to the lab Always better to call ahead

Critical Values Regulated at the federal and state level Ordering provider or other responsible provider must be contacted The patient name, test name, and value must be repeated by the provider The provider’s name and contact number must be recorded If there is a note in the chart with patient name, test name, and value, can be used as surrogate for phone call

Transfusion Medicine Platelets, MTPs, Transfusion Reaction Work-Ups, and Apheresis Consults

Transfusion Medicine - Platelets Basics 1 pool 1 bag 4-6 units Expire in 5 days One unit should increase platelet count 5,000-10,000/uL One pool should increase platelet count 20,000-50,000/uL Blood Bank Management Received on Day 3 40 units in YNHH Blood Bank Turnover 30 units per day

Transfusion Medicine - Platelets Thresholds for platelet transfusion based on AABB and ASCO guidelines and interdisciplinary agreement: 10,000/uL for bleeding prophylaxis 20,000/uL for bleeding prophylaxis with fever 25,000/uL for line placement 50,000/uL for bleeding, invasive procedure, adult lumbar puncture 100,000/uL for neurological bleed Contraindicated in HIT and TTP

Transfusion Medicine - MTPs What is in an MTP box? 6 units RBCs, 6 units plasma, 1 pool platelets (4-6 units) 1:1:1 You will be getting a call To obtain clinical information To confirm active Type and Screen Draw before administering blood if possible To confirm recent CBC, coagulation studies, and fibrinogen To receive an estimate of blood product use To answer whatever questions you might have

Transfusion Medicine – Transfusion Reactions Transfusion-associated circulatory overload (TACO) Transfusion-related acute lung injury (TRALI) Allergic reaction (mild vs. severe) Acute hemolytic transfusion reaction (AHTR) Delayed hemolytic transfusion reaction (DHTR) Febrile non-hemolytic transfusion reaction (FNHTR) Septic transfusion reaction Initiate a Stop the reaction transfusion! work-up! These reactions are “dose-dependent”.

Transfusion Medicine – Transfusion Reactions Order a “post-transfusion reaction sample” in epic Pink top tube Walk the bags and tags back to the blood bank Don’t use the tube system! Have the following information ready: Clinical history Reaction signs/symptoms Product(s) Timing of transfusion Pre-transfusion medication Post-transfusion medication Transfusion Reaction ROS AMS Chest pain Dyspnea Abdominal pain Back/flank pain Fevers/chills/rigors Hives/rash/pruritis/edema Infusion site pain

Transfusion Medicine – Transfusion Reactions On the phone we will: Confirm return of bags/tags Make an initial assessment if possible Recommend additional laboratory studies Recommend therapies Address questions about continued transfusion In the lab we will: Perform clerical checks Assess for hemolysis Retype the patient Rescreen the patient Assess for antibody binding to red cells (DAT) Characterize antibody binding to red cells /- Culture the product Perform ancillary testing

Apheresis Inpatient consultations Red cell exchange for ACS in SS disease Plasma exchange for TTP Organ rejection Call in addition to placing consult We are not contacted by consult call center Transfusion Fellow will evaluate: Indication Safety Access Reach out early to make a plan Consider timing of medication that may be removed by apheresis www.terumobct.com

Hematology Peripheral Smears and Special Coagulation Studies

Hematology - Peripheral Smear Considerations for MD smear interpretation Specific clinical question that requires morphologic interpretation Smear cannot assess function Quantitation can be assessed with manual differential E.g. “34 year-old female with rheumatoid arthritis and acute on chronic anemia, ACD vs. iron deficiency” No other clear/confounding etiology GI bleed and anemia Acute infection/steroids and leukocytosis Transfusion effects Laboratory studies are more sensitive and specific Anemia Red cell indices, iron studies, reticulocyte indices, B12, folate Hemolysis LDH, haptoglobin, indirect bilirubin Thrombocytopenia Reticulated platelet studies HIT Panel

Hematology - Special Coagulation Testing Tube Fill Errors Clinical Context Medication Effects Lupus Anticoagulant Testing Transfusion Effects

Microbiology Special Culture Orders, Mixed Cultures, Susceptibility Requests, Stool Pathogen Panel

Microbiology – Special Culture Orders Search “culture” in the lab manual to find special culture orders: Note: Candida will grow on routine blood cultures No longer accepting oral/respiratory specimens for Actinomyces culture

Microbiology – Special Culture Orders If you suspect a select agent: Call Infection Control and the Lab!

Microbiology – Mixed Cultures Usually mixture of Gram-positive, Gram-negative, aerobic, and anaerobic organisms Lab works-up predominating organisms Lab checks for individual organisms of clinical importance as per comment

Microbiology – Susceptibility Requests Testing is limited by guidelines, methods, equipment, and organism Guidelines incorporate clinical data to avoid treatment errors based on in vitro results Courtesy of Dr. David Peaper

Microbiology - Stool Pathogen Panel Included Genera: Salmonella Shigella Campylobacter STEC (Shiga Toxin) Yersinia Vibrio Community acquired diarrheal organisms Very low pre-test probability for anyone in the hospital greater than 3 days Will be cancelled if hospitalized 3 days as per comment

Chemistry Body Fluid Testing and Interferences

Chemistry - Body Fluid Testing Validated Analytes for Body Fluid Testing Peritoneal Pleural CSF Surgical Drain Dialysate Albumin Albumin LDH Total Bilirubin BUN Amylase Amylase Creatinine Creatinine Lipase Cholesterol Amylase Total Bilirubin Glucose Lipase Glucose LDH LDH Total Protein Total Protein Triglycerides Triglycerides Cholesterol

Chemistry - Interferences Hemolysis (Hemolyzed) Biotin Hyperbilirubinemia (Icteric) Heterophile Antibodies Hypertriglyceridemia (Lipemic) Human Anti-Animal Antibodies (HAAA) Human Anti-Mouse Antibodies (HAMA)

Summary Slide Urgent Consults: MTP Transfusion Reactions Apheresis Off-label factor use Who to call: Customer Service for test information MHB per service in Amion for Laboratory Medicine questions Apheresis Service for inpatient apheresis consults

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