pathology_services_handbook_5th_edition_2018

1. Adults : Aerobic and anaerobic culture bottle
Volume : 8-10 mls into each bottle

2. Paediatric : A single blood culture bottle
Volume : 1-3 mls

3. For fungal C&S : Myco F Lytic bottle MICROBIOLOGY
Volume: 1-5 mls into each bottle

4. For TB Blood Culture: Myco F Lytic bottle
Volume: 1-5 mls into each bottle

Method of collection :

Blood culture

1. Prepare all materials required for blood culture taking.
2. Palpate and locate the vein. Apply tourniquet to the extremity.
3. Wear plastic apron. Perform hand hygiene and wear sterile glove.
4. Swab the phlebotomy site in circular motion starting from inside and continue
outwards at a diameter of 3-4 inches using 2% chlorhexidine in 70% alcohol.
5. Allow the site to air dry.
6. If the venipuncture proves difficult and the vein must be palpated again, the site
should be cleansed again.
7. Collect the required amount of the blood using syringe and needle or the
butterfly set.
8. Remove flip-off caps of blood culture vials and wipe the injection port/septum
thoroughly using alcohol swab.
9. Inoculate specified volume of blood into blood culture vials and invert the vials
2-3 times.
10. Label the vials with at least 2 patient identifiers eg: name and identification
number.
11. Keep the inoculated bottle at room temperature in upright position before
sending to the laboratory. Do not refrigerate.

Note:
Blood culture is best taken before giving antibiotics and as close as possible to the
episode of chills or fever.







191

2.2 Cerebrospinal Fluid (CSF)



HTAA, KUANTAN A. Lumbar puncture

1. Position the patient.
2. Procedure should be done under aseptic technique.
3. Disinfect site with 2% chlorhexidine in 70% alcohol.
4. Insert needle with a stylet at L3-L4, L4-L5 or L5-S1 interspace. Upon reaching
the subarachnoid space, remove the stylet and collect 1-2 mls of fluid into each
sterile containers for examination of:
• CSF C&S
• FEME
• Latex Bacterial Antigen /India ink
• AFB
• TB culture
5. The specimen should be sent immediately within 1 hour and handed personally
to bacteriology staff (office hours) and staff counter (after office hours/weekend/
public holidays). Do not store in refrigerator.
6. The request form must be attached with QAP/CSF-1 (TURNAROUND TIME (TAT)
MOTION STUDY OF CEREBROSPINAL FLUID-BACTERIAL MENINGITIS).
7. Always send the most turbid specimen for microbiology analysis.

Note: Before starting procedure, it is compulsory to make appointment with
laboratory staff ( Call ext: 2074 (during office hours), ext: 2069 (after office hours /
weekend/public holidays).


B. Ommaya reservoir fluid or ventricular shunt fluid

1. Clean the reservoir site with antiseptic solution and alcohol prior to removal of
fluid to prevent introduction of infection.
2. Remove 1-2 ml of the Ommaya fluid via the Ommaya reservoir unit or by
collection from the ventricular drain or shunt and place into sterile container
for examination of:
• Culture and sensitivitiy.
• FEME.









192

C. Brain abscess and biopsy sample

1. Aspirated material or biopsy sample collected from lesions must be placed
in a sterile container and sent immediately to the laboratory for aerobic and
anaerobic culture.
2. Do not add formalin. MICROBIOLOGY


2.3 Genital specimens

A. High vaginal swab

1. The specimen is suitable for the diagnosis of candidiasis and other causes of
vaginitis but NOT gonorrhoea in the female.
2. Using a sterile speculum lubricated with sterile normal saline and not antiseptic
cream, swab either from the posterior fornix or lateral wall of the vagina.
3. Inoculate the swab into Stuart transport media and send the specimen to the
laboratory as soon as possible.

B. Endocervical swab

1. This is the best specimen for the diagnosis of gonorrhoea and puerperal sepsis.
2. Under direct vision, gently compress cervix with blades of speculum and use
rotating motion with swab, obtain exudate from the endocervical canal.
3. Inoculate the swab into Stuart transport media.

C. Urethral discharge (Male)

1. Wipe the urethra with a sterile gauze or swab (wet with sterile saline).
2. Collect the exudates with a sterile swab and inoculate into Stuart transport
media.
3. If discharge cannot be obtained by ‘milking’ the urethra, use a sterile swab to
collect material from about 2 cm inside the urethra.
4. Place the swab into Stuart transport media.
5. It is encouraged to send a direct smear of the urethral discharge for gram stain
to look for intracellular gram negative diplococci.

Note: To write relevant clinical history eg: suspect genococcal infection







193

2.4 Indwelling devices

HTAA, KUANTAN Catheters for semi-quantitative culture eg: Hickman catheter, Broviac catheter, arterial,
The acceptable devices are:

umbilical, central line and Swan-Ganz. Foley’s catheter is not acceptable for culture.

1. Clean the skin around the catheter site with alcohol. Let it air dry.
2. Aseptically remove catheter and cut about 5 cm of the distal tip of the catheter
using sterile cutter and directly place into a sterile screw-cap container.
3. Transport directly to the laboratory to prevent drying.


2.5 Mycobacterium: Acid-fast bacilli stain and culture and MTBC & rifampicin
resistance detection by using Gene Xpert MTB/Rif assay

A. Acid-fast bacilli stain

Acceptable specimens:

Sputum/respiratory secretion, bronchial wash, urine, CSF, body fluid/aspirate, gastric
lavage, tissue biopsies and FNAC specimen. Swab and stool are not acceptable.

1. Collect at least sputum samples with at least 1 early morning sputum.
2. Place specimens in sterile container and send to the laboratory.

B. Mycobacterium culture

Acceptable specimens:

Sputum/respiratory secretion, bronchial wash, urine, CSF, body fluid/aspirate, gastric
lavage, tissue biopsies, bone marrow and blood. Swab and stool are not acceptable for
culture.

1. Collect specimen and place in an appropriate container i.e bone marrow and
blood in Myco/F lytic bottle and other specimens in sterile container.
2. Send specimen to the laboratory.







194

C. Mycobacterium tuberculosis complex and rifampicin resistance detection by Gene
Xpert MTB/RIF assay

Indication:

i) Confirmation of diagnosis of MDRTB MICROBIOLOGY

1. Retreatment case (failure/relapsed/defaulter).
2. Contacts of MDRTB and symptomatic.
3. Symptomatic foreigners from heavy burden MDRTB country.
4. HIV patients not responding to primary TB treatment.
5. Smear negative TB not responding to primary TB treatment.
6. Patient suspected of having MDRTB (adult or children).

ii) Diagnosis of TB in special situation
1. Symptomatic paediatric cases.
2. Extrapulmonary TB.

Acceptable specimens:

Sputum, respiratory secretions, bronchial lavage, sterile body fluids/aspirate, CSF and
tissue.

1. Collect appropriate specimens and place in sterile container.
2. Send specimens to the laboratory.
3. Blood-stained sample will be rejected.

Note:
• All cases must be discussed with Chest Physician prior to Gene Xpert ordering.
• Please inform Clinical Microbiologist (Dr. Roesnita or Dr. Nadiyah) before
sending sample to the laboratory.
• Sample for MTB culture need to be send together with gene xpert request
using different sample and form.



2.6 Sterile body fluid C&S (excluding CSF, urine and blood)

1. Clean needle puncture site with 2% chlorhexidine in 70 % alcohol. Let it dry.
2. Aseptically perform percutaneous aspiration to obtain pleural, pericardial,
peritoneal or synovial fluid.
3. Collect fluid into a sterile screw-cap container.
4. For anaerobic culture send specimen immediately to yield better result.

195

2.7 Pus/Tissue/Bone/Swab

A) Pus
HTAA, KUANTAN 1. Perform the procedure with aseptic technique.

2. Clean the surface of the skin with 2% chlorhexidine in 70 % alcohol. Let the slan
antisensis to dry.
3. Aspirate infected material at the deepest portion of the lesion or exudates.

B) Tissue/Bone

1. Clean the area throughly with sterile saline.
2. Remove overlying debris with scalpel and collect biopsy form base or margin of
legion.
3. Send all tissue/bone in sterile container.
4. Do not add formalin.

C) Swab

1. Clean superficial area with sterile saline and remove all superficial exudates
before swabbing.
2. Pre-wet swab stick with sterile saline.
3. Collect sample from base of wound/ulcer using a swab.
4. Place swab in Stuart Transport Medium and transport to the laboratory
immediately.

Note: Swab is an inferior substitute. Therefore, pus/tissue is best specimen to be
taken.


2.8 Respiratory specimens

A. Upper respiratory

1. Nasal swab

Submitted primarily for detection of MRSA carrier

i. Insert a sterile swab into the nose until resistance is met at the level of turbinates
(approximately 1 inch into the nose).
ii. Gently rotate the swab against the nasal mucosa.
iii. Repeat the process on the other side with the same swab.
iv. Place swab in Stuart Transport Media.
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Note:
1. Submitted primarily for detection of MRSA carriers.
2. For other indications, please state relevant clinical history.



2. Pernasal swab/nasopharyngeal swab/aspirate MICROBIOLOGY

This is done to isolate Bordetella pertussis for the diagnosis of pertussis (whooping
cough).

i. A pernasal swab (Dacron or rayon with flexible ultrafine wire shaft) is inserted
through a nostril and advanced along the floor of the nose until it reaches the
nasopharynx.
ii. Leave the swab at the posterior nasopharynx for up to 30 % or until the patient
coughs.
iii. Then, slowly withdrawn the swab with a rotating motion.
iv. For culture, directly inoculate the swab onto Charcoal agar.
v. For PCR, place the Dacron/rayon swab into Stuart Transport Media.

Note:
• To get charcoal agar and Dacron/rayon swab from bacteriology laboratory
before taking sample.
• Write relevant clinical history on the request form eg: suspect pertussis/
whooping cough.
• It is compulsory to inform microbiologist staff of the suspected case before
taking specimen.

2.1 Nasopharyngeal aspirate

a) Vacuum-assisted nasopharyngeal aspirate method

• Attach mucus trap to suction outlet and catheter. Turn on suction and adjust to
suggested pressure.
• Without applying suction, insert catheter into the nose directly posteriorly as
far as nasopharynx.
• Apply suction using a rotating movement, slowly withdrawn catheter.
• Repeating procedure for the second nostril will deliver optimal combined
sample.
• Transport specimen to the laboratory immediately.





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b) Nasopharyngeal wash

• Fill syringe (about 3 ml ) with sterile, non-bacteriostatic saline.
HTAA, KUANTAN • Attach a sterile catheter to syringe tip. Slowly push saline through the tube and
let a drop or two come out of the tip for lubrication.
• The patient’s head should be tilted back with their neck extended to allow for
the pooling of the aspirate in the nasopharynx.
• Insert the catheter straight back along floor of nasal passage until reaching the
posterior wall of the nasopharynx.
• Quickly push and then pull the syringe plunger to inject the saline and withdraw
the fluid.
• Inject aspirated specimen into a sterile container.
• Transport specimen to the laboratory immediately.

Note:
• Wear appropriate PPE eg: gloves, mask and goggles while doing the procedure.
• Write relevant clinical history eg: suspect pertussis/whooping cough.
• Inform microbiologist staff of the suspected case before taking specimen.




3. Throat swab

In the majority of cases, throat swab is obtained to isolate Group A/C/G Streptococcus
which causes pharyngitis and Corynebacterium dipthteriae which causes dipthteria.

i. Depress tongue gently with tongue depressor and rub the sterile swab over
the tonsillar areas and the mucosa on the posterior pharyngeal wall behind the
uvula.
ii. Gently turn the swab so that its whole surface comes in contact with the
inflamed mucosa or lesion.
iii. Avoid touching the oral mucosa or tongue with the swab.
iv. Place the swab in Stuart transport media immediately.

Note:
• Inform microbiologist of any case of suspected diphteria.
• Write relevant clinical history and diagnosis on the request form.








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B.Lower respiratory tract



1. Expectorated sputum
i. Collect the sputum early in the morning, after rinsing the mouth and gargling
with water. MICROBIOLOGY
ii. Instruct the patient to cough deeply and expectorate only sputum and not saliva
into the sterile container.
iii. If delay is anticipated, store the specimen in a refrigerator.



2. Induced sputum

i. Explain procedure and the possible effects to the patient (eg: coughing, dry
mouth, chest tightness, nausea and excess salivation).
ii. Assemble nebuliser equipment and load 20 ml of 3 % hypertonic saline solution
into nebuliser cap.
iii. Connect the assembly to the nebuliser machine.
iv. Turn the machine on. Place the mouthpiece on the patient’s mouth and re-
emphasize on the mouth breathing. (fine mist should be seen through and
patient should experience a salty taste).
v. Allow patient to inhale the hypertonic mist for approximately 5 minutes. Then
instruct patient to take several deep breaths off the nebuliser. If patient does
not initiate coughing spontaneously, ask them to attempt a forced cough.
vi. Person doing this procedure may use gentle chest physiotherapy eg: vibration
and percussion to produce sputum.
vii. The procedure should be stopped when:
• Patient has produced 1-2 ml of sputum for each specimen.
• 15 minutes of nebulisation is reached.
• The patient complains of dyspnoea, chest tightness or wheeze.
viii. Label the sample and write the specimen as induced sputum.


Note:
Sputum induction is used as an aid to the diagnosis of TB in patients who are unable
to spontaneously expectorate adequate sputum specimens.









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3. Tracheal aspirate/ETT Aspirate

i. Aspirate the fluid through tracheostomy tube or ETT
ii. Place aspirated fluid into sterile container
HTAA, KUANTAN 4. Bronchial washing/BAL/Lung Tissue (Biopsy)
iii. Send to laboratory immediately.



i. Place aspirated fluid or tissue acquired from bronchoscopy into sterile container.
ii. Send to laboratory immediately.

2.9 Stool

1. Fresh stool

i. Collect faeces into a sterile container and send to the laboratory immediately.
ii. If the faeces is liquid, the container may be filled to one-third full (excessive
amount will result in spillage when opened).
iii. Enrichment medium i.e., Alkaline Peptone Water for Vibrios and Selenite F
for Salmonella and Shigella can be obtained from the laboratory for bedside
inoculation.

2. Rectal swab

i. Insert a cotton swab into rectum (1 inch beyond anal sphinter) and rotate once.
ii. Place the swab in Cary-Blair transport medium for isolation of enteric pathogen.

Notes :
1. Rectal swab is inferior substitute of fresh stool. It is to be taken if not possible
to obtain faeces.
2. For stool clearance culture in cases of typhoid and cholera, stool should be
sent upon completion of therapy.
















200

2.10 Urine



A. Midstream urine

Male
i. Instruct patient to completely retract foreskin and cleanse penis with soapy MICROBIOLOGY
water and throughly rinse with water.
ii. While holding the foreskin retracted, begin voiding.
iii. Pass the first few milliliters of urine to flush out the bacteria from the urethra,
then collect the midstream portion in a sterile/boric acid container.
iv. Send to the laboratory immediately.

Female
i. Cleanse the periurethral area and perineum with soapy water and thoroughly
rinse with water.
ii. Hold the labia apart during voiding and pass the first few milliliters of urine.
iii. Collect the midstream portion in a sterile/boric acid container.
iv. Send to the laboratory immediately.

Note:
For urine specimen (<20ml), use sterile container and send immediately to he
laboratory. Urine specimen (≥ 20ml), use urine boric acid container, invert the
container to allow proper mixing.


B. Suprapubic aspirate (SPA)

i. Before SPA, the patient should force fluids until bladder is full.
ii. Shave if necessary and disinfect the suprapubic skin overlying the urinary
bladder with 2% chlorhexidine in 70% alcohol.
iii. Aspirate urine from the bladder by using a needle aspiration technique.
iv. Place sample in sterile container and send to the laboratory immediately.
v. Label sample as suprapubic aspirate (SPA).

Note :
SPA is useful in determining urinary infection in adults in which the results from
routine procedures are equivocal but the diagnosis is critical. Also useful for paediatric
when clean-catch urine is difficult to obtain.






201

C) Catheter urine

HTAA, KUANTAN • Clean the sampling port with alcohol swab.
• Clamp the catheter tubing 4-5 cm below the sampling port until sufficient urine
collects.

• Insert needle attached to a syringe into the port using aseptic non touch
technique.
• Aspirate the required amount of uirne and place it in a sterile container.
• Send to the laboratory immediately.

Note:
• Do not collect the urine form the urine bag.
• Do not send urinary catheter tips for culture because tips are invariably
contaminated with urethral organisms.


2.11 Autopsy material

A. Blood

i. Aspirate 10 ml of the right heart blood either through skin and chest wall or
(through unopened heart) from right ventricle after removal of sternum into a
set of blood culture bottle.
ii. Avoid contamination with bacteria from the water faucet and with the enteric
bacteria.




B. Tissue

i. Best collected at an earlier stage before the body is being handled. Decontaminate
the skin or surface of heart or other organ before inserting or cutting out tissue
block.
ii. Collect the tissue and place in sterile container. Large piece is preferred and
accepted because aseptic collection is difficult.
iii. In the laboratory, tissue from suspicious area will cut aseptically and proceed
with culture.







202

II MYCOLOGY



1.1 Skin, hair and nails
Clean cutaneous and scalp lesions with 70% alcohol prior to sampling as this will MICROBIOLOGY
improve the chances of detecting fungus on microscopic examination, as well as
reducing
the likelihood of bacterial contamination of cultures. Prior cleaning is essential if
ointments, creams or powders have been applied to the lesion.


Skin, nails and hairs specimens should be collected into folded squares of paper. Black
paper for skin and nails and white paper for hair.

A. Skin

i. Material should be collected from cutaneous lesions by scraping outwards from
the margin of the lesions with blunt scalpel.


B. Hair
i. Specimen from the scalp should include hair roots, the contents of plugged
follicles and skin scales.
ii. Hair should be plucked from the scalp with forceps or the scalp is brushed with
a plastic hairbrush.

C. Nail

i. Nail specimens should be taken from any discoloured, dystrophic or brittle parts
of the nail.
ii. Specimen should be cut as far back as possible from the edge of the nail and
should include the full thickness of the nail.














203

1.2 Mouth and vagina


i. Swabs from the buccal mucosa should be moistened with sterile water prior to
HTAA, KUANTAN ii. For vaginal infection, swab should be taken from discharge in the vagina and
taking the sample and sent in Stuart transport media.
from the lateral vaginal wall. Swabs to be sent to the laboratory in Stuart
transport media.


1.3 Ear

Scrapings of material from the ear canal are preferred, although swabs can also be
used.



1.4 Ocular specimens

i. Material from patients with suspected fungal infection of the cornea
(keratomycosis) should be collected by scraping the ulcer. The entire base of
the ulcer, as well as the edges should be scraped. Swabs are not suitable for
sampling corneal lesions.
ii. The material is collected directly onto agar plates for culture and to a glass slide
for microscopic examination.


1.5 Blood

Blood culture for fungal is collected in the same manner as for blood culture for bacteria
using Myco/F Lytic culture bottle.
The request for fungal culture should be indicated clearly on the request form.

1.6 Bone marrow

This specimen is helpful for making the diagnosis in a number of deep fungal infection,
including histoplasmosis and cryptococcosis.
3-5 ml aspirated material should be collected and transferred into the Myco/F Lytic
culture bottle.






204

1.7 Cerebrospinal fluid


CSF specimens (1-2 ml) should be collected in a sterile container for microscopy and
culture.



1.8 Pus MICROBIOLOGY
1. Pus from undrained subcutaneous abscesses or sinus tract should be aspirated
with a sterile needle and syringe into sterile container.
2. In grains are visible in the pus as in mycetoma, these must be collected.


Note:
In mycetoma, if the crusts at the opening of the sinus tracts are lifted, grains can
often be found in the pus underneath.



1.9 Tissue
1. If possible, material should be obtained from both the middle and edge of the
lesions.
2. Small cutaneous, subcutaneous or mucosal lesions can often be excised
completely.
3. Tissue specimens should be placed in a sterile container without formalin.


























205

III SEROLOGY


HTAA, KUANTAN 1.0 INTRODUCTION



This section mainly involved in the antibody and antigen detection in the serum.
These comprise of tests in bacteriology, virology, parasitology and immunology.


2.0 METHOD OF BLOOD COLLECTION

i. Draw 3.5 ml of blood into a plain tube with gel serum separator (except for test
eg: PID, HIV PCR (EDTA tube) and AFP (rectal swab)). Please refer Table 1: List of
Test Available and Table 2: List of Test from Refferal Laboratories for reference.
ii. Clot at ambient temperature.
iii. Despatch to the laboratory.

Note :
• Haemolysed, icteric and lipaemic specimens invalidate certain tests. Therefore,
if such specimens received, it will be rejected to ensure that the results are of
clinical value.
• Sufficient volume of serum is crucial as certain tests may need confirmation.
• For request of stool for AFP and PID screening, please contact microbiologist/
serology laboratory (ext: 2075) before sending specimen.


























206

IV PARASITOLOGY



4.1 Blood Film Malaria Parasite (BFMP)
4.1.1 Materials required :


a. Frosted slide MICROBIOLOGY
b. Slide jacket
c. Clean gauze
d. Alcohol (70%)
e. Clean cotton wool
f. Even, flat area to dry slides
g. Sterile Lancet (finger prick) or sterile needle/syringe 3 ml (syringe method)



4.1.2 Method :

a. Clean slides with gauze soaked in alcohol (70 %).Do not use cotton.
b. Dry slides using gauze.
A. Finger prick


i. Select third finger from the thumb (big toe can be used for infants). Never use
thumb, for either children or adults. Massage it to get better blood flow.
ii. Clean finger (or toe) with cotton wool soak in alcohol (70%). Use firm strokes to
remove dirt and oils from the ball of the finger.












iii. Dry the finger with clean cotton wool. Use firm strokes to stimulate blood
circulation.
iv. Puncture the ball of the finger with a sterile lancet using a quick rolling motion.








207

HTAA, KUANTAN








v. Apply gentle pressure to the finger (or toe) and express the first drop of blood.
Wipe it away with dry cotton wool, make sure that no cotton strands remain
thatmight later be mixed with the blood.
vi. Work quickly and handling the slides by the edges, collect the blood.












vii. Allocate 2 cm from one end of the slide for labeling with sticker.
viii. Drop 1 big drop/3 small drops onto slide. This is the thick film.
ix. Space out 1 cm, collect a single drop about the middle of the slide. This is the
thinfilm. Wipe the remaining blood off the finger with cotton wool.
x. Place slide onto a flat surface.













xi. Take another slide to be use as a spreader, put it at an angle of 30-45°, and
touchthe single drop of blood. Allow the blood to run right along the edges.
xii. Firmly push the spreader forward along the slide, keeping it at an angle of 45°.
The edge of the spreader must remain in even contact with the surface of the
other slide while the blood is being collected.



208

xiii. Using the corner of the spreader, make the blood film by joining the dots of MICROBIOLOGY
blood and spread them to make an even, thick film. Never stir the blood. Use
about 3-6 quick strokes. The circular thick film should be about 1 cm in diameter.
xiv. Label the slide. Let the smears dry on an even, flat surface before inserting into
slide jacket to be sent to the laboratory. Do not leave the slide to dry at high
ambient temperature and humidity as it will cause autofixing of the thick slide.
xv. Dispose spreader into sharp bin.


B. Syringe method


i. Follow standard procedure to collect blood, volume required about 1ml.
ii. Carefully remove needle, dispose safely into sharp bin.
iii. Follow the fingerprick method in preparing the thick and thin film.
iv. Dispose spreader & syringe into sharp bin.




4.2 Blood film for microfilaria

i. Collect a big drop of blood by pricking a finger or heel (baby).
ii. Make an oval thick blood film on a clean glass slide (3 x 2 cm).
iii. Dry it in a horizontal position, avoid it from dust or pests.
iv. Send immediately to the laboratory.


Note:
• Microfilaria blood samples must be taken between 10 pm and 2 am as this is
when nocturnal filaria goes into the blood stream.
• For adults, blood should be obtained from the finger while infants from the
heels. Venous blood is acceptable.
• Time specimen is taken must be noted on the request form to avoid rejection.




209

4.3 Stool ova and cyst / FEME

HTAA, KUANTAN A. Specimen collection



i. Collect faeces in a clean wide-mouth container with tight fitting lid. Sample must
be at least 20 ml (liquid) or the size of 2 adults thumbs (solid).
ii. Label the container clearly and properly.
iii. Seal lid properly to avoid spillage during transportation.
iv. Place into biohazard plastic bag, with request form, send to laboratory
immediately.



Note:
• It is recommended that stool sample be sent 3 times (24 hours apart) between
3-10 days period if found negative.
• Make sure sample is not contaminated with water or urine.
• Certain drugs and compounds make the stool specimen unsatisfactory for
testing.
• Specimen must be collected before these substances are administrated or
delay collection until after the effects have passed.
• Substances include : antacids, kaolin, mineral oil and other oily materials, non-
absorbableanti diarrheal preparations ,anti malarial drugs, barium/ bismuth
(7-10 days needed for clearance effect) antibiotics(2-3 weeks) and gallbladder
dyes (3 weeks).

























210

V MOLECULAR



5.1 H1N1 and MERS-CoV test

1. Respiratory specimens including: throat swabs, tracheal aspirates, sputum, MICROBIOLOGY
nasopharyngeal or oropharyngeal aspirates or washes, and nasopharyngeal or
oropharyngeal swabs.
2. Swabs of specimens should be collected only on swabs with a Dacron® tip
and aluminium or plastic shaft. Swabs with calcium alginate or cotton tips and
wooden shafts are not acceptable.
3. Specimens should be transported in 2 ml VTM (Viral Transport Media) in ice to
the laboratory as soon as possible.
4. Other specimen should be placed in sterile container.


5.2 ZIKA Virus Test


Type of samples for investigation of Zika virus:
1) Blood
• 3.5 ml in plain tube with gel separator.

2) Urine
• Minimum 10 ml of urine collected in sterile container.



Note:
• To collect and send both samples for investigation of Zika virus
• Specimens need to be put in biohazard plastic and transport in ice immediately
to laboratory.
• Please consult clinical microbiologist before sending specimens for Zika PCR.
• Investigation of Zika virus for patients with Guillain-Barré syndrome and
microcephaly will be done in IMR (Please refer Table 2: List of Tests to Referral
Laboratories).










211

HTAA, KUANTAN HISTOPATHOLOGY


























































212

1.0 INTRODUCTION





Histopathology Unit is responsible for the processing of tissue specimens surgically
removed from the body, to assist the pathologist in the diagnosis of diseases or the HISTOPATHOLOGY
probable cause of death, as in the case of autopsy specimens.

The co-operation of ward doctors, nurses and the technologists is important in assisting
the pathologist to make a diagnosis. They have to fill the request form properly, ensure
proper collection, labelling and processing of tissue. Hence diagnosis and management
of the patient is prompt with minimal delay.



2.0 SERVICES

Histopathology Unit provides the following services:

i. Routine Histology
ii. Histochemistry
iii. Immunohistochemistry
iv. Frozen section (on appointment basis)
v. Immunofluorescence for renal biopsy and skin biopsy
vi. Clinical autopsy
vii. Muscle biopsy (test will be outsourced to Hospital Kuala Lumpur)

3.0 REQUEST FORM

a. Every specimen should be labeled and accompanied by the Request Form i.e.
PERMOHONAN PATOLOGI ANATOMI ANA/JP/HTAA-01. (Ensure 2 copies : the
original and carbonized together).
b. Additional information required in the request form:
i. Type of specimen and the date specimen taken.
ii. Summary of the history, clinical and operative findings.
iii. Previous HPE report number (if any).
iv. Legible name, signature and stamp of the requesting doctor.
c. The word URGENT should be written on the top of the HPE Form in bold letters
if early result is required.






213

d. Request for frozen section must be made via appointment with Histopathologist
on call and followed by filling the REQUEST FORM FOR INTRAOPERATIVE
HTAA, KUANTAN e. On the day of operation, the fresh specimen should be labeled and accompanied
CONSULTATION / FROZEN SECTION (ANA/JP/HTAA-06) and sending the form to
Histopathology Laboratory at least a day before operation.

by the request form i.e. PERMOHONAN PATOLOGI ANATOMI ANA/JP/HTAA-01
(2 copies) before sending to the laboratory.



4.0 SPECIMEN COLLECTION

a. All tissue specimens for routine histological examination must be preserved
immediately in formalin, i.e 10% Neutral Buffered Formalin (NBF) in a suitable
clean leak proof container.
b. Tissue should be totally submerged in formalin. The volume of formalin should
be at least 10 times the volume of the specimen.
c. The containers used should be of the wide mouthed type for easy removal of
tissue.
d. The tissue container should be appropriate according to the size of the tissue.
Do not put the tissue in plastic bag to prevent leakage unless the tissue is too
big.
e. Screwed cap container/universal bottle should be used for small and tiny tissue
biopsies.
f. All specimen containers should have the same identification details as that
written on the request forms.
g. Specimen for frozen section should be collected fresh and send immediately in
clean empty universal container without any solution.
h. Renal biopsy should be collected in three tissue containers as below :
• One with Phosphate-buffered Saline (PBS) for immunofluorescence test
• One with 10% formalin for routine histology. Do not put specimen in gauze!
• One with glutaraldehyde for Electron Microscopy (EM) study. However, this
test will be done in EM Unit, IIUM Kuantan Pahang.
i. Skin biopsy for immunofluorescence test should be collected in tissue container
containing Phosphate-buffered Saline (PBS).
j. Muscle biopsy (this test will be outsourced to Hospital Kuala Lumpur)
• All requests for muscle biopsy must have prior arrangement with the
patologist concerned or Medical Lab Technologist (MLT) Hospital Kuala
Lumpur at extension 5605 at least one day before the procedure. (Usually
the biceps or quadriceps muscle would suffice in most cases).




214

Important information to be included in the request form are:
• Creatinine kinase level
• LDH
• Contact number of treating clinician relevant hospital fax number

For open muscle biopsy: HISTOPATHOLOGY
• Remove at least one good cylinder of muscle measuring 1.0 x 0.5 x 0.5 mm, the
smallest diameter being the cross-section of the muscle.
• For optimal processing muscle specimen must be wrapped with aluminium foil
and sent fresh in and air tight, dry and clean container.
• The specimen should be transported in a container containing ice or gel ice
(Never use dry ice).
• Do not tie the muscle to stretch it and do not put tissue on gauze.
• Do not put saline or formalin. The laboratory will accept fresh muscle biopsy
specimen up to 6 hours upon removal but please remember that optimal result
requires the specimen to be as fresh as possible.

5.0 SPECIMEN TRANSPORTATION

a. Specimens from the Operation Theatre (OT) should be sent to Histopathology
laboratory before 4:00 pm if possible. Any specimens obtained after 4:00 pm
should be sent on the following day.
b. Specimens from the clinics should be sent immediately to the Histopathology
laboratory.
c. The MLTs who receive the specimens and the HPE request forms must sign the
despatch book.























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6.0 RESULT REPORTING

HTAA, KUANTAN b. URGENT biopsy cases will be ready in 3 working days (exclusion of tissue that
a. The HPE result of non complicated, non urgent biopsies is normally ready in 14
working days.

needs further ancillary test).
c. Longer duration is needed for the following cases :
i. Larger specimens (require longer fixation time).
ii. Bone specimens (need decalcification).
iii. Cases require further ancillary test and regrossing.
iv. Cases require second opinion.
d. All reports must be collected from the Histopathology counter.
e. Reports for cases from certain district Hospitals will be despatched by post.
f. For all cases requiring URGENT reports, please contact Histopathology Unit ;
Tel no. 09-5572862 before referring to the Pathologist.

Report enquiries can be made via extension 2867
Request for a second copy shall be made by using form request of HPE/Cytology Report
(ANA/JP/HTAA-10 Ver. 4/2014). This form is available at Histopathology counter.

INTERDEPARTMENTAL CLINICOPATHOLOGY CONFERENCE

Histopathology Unit conducts clinicopathology conference (CPC) with the major
clinical departments in Hospital Tengku Ampuan Afzan, Kuantan and Hospital Sultan
Ahmad Shah (HOSHAS), Temerloh, Pahang. The schedule for the whole year is issued
before every new year begins. The clinical department concerned is required to
submit the list of patients to be discussed to the Pathologist in charged at least one
week before the schedule date. Enquiries abaout clinicopathology conference should
be communicated directly to the Medical Officer in charge or Pathologist concerned.

TAKING OUT PARAFFIN BLOCKS/SLIDES FROM HISTOPATHOLOGY UNIT

Patients, paraffin blocks and slides are archived in Histopathology Unit. For certain
valid reasons the unit allows the clinician to take diagnostic material (paraffin block/
slide) from the Unit. The following procedure must be followed:










216

a. The request to borrow the diagnostic material must be made by a specialist.
b. The requesting specialist needs to fill up a form PERMOHONAN PEMINJAMAN/
PENGAMBILAN BAHAN DIAGNOSTIK UNIT HISTOPATOLOGI (HKL/JP/HI-BP-01)
(Appendix 6-C).
c. The completely filled form should be submitted to Histopathology counter and
the material can be taken within 3 working days upon submitting the form to HISTOPATHOLOGY
the office.
d. The paraffin block and stained slides must be returned to Histopathology Office
within 1 month.

TAKING OUT TISSUE FROM HISTOPATHOLOGY UNIT

All specimens (tissue) snet to and officially recieved by Histopathology Laboratory
will be kept in the unit up for 3 months after the official report is released. The
Histopathology Unit allows the patient to take their tissue, organ or limb back upon
request. Please follow this procedure:

a. The patient or next kin must make a formal request by filling up a form
PERMOHONAN PENGAMBILAN SPESIMEN/TISU UNIT HISTOPATOLOGI (HKL/
JP/HI-BP-02)(Appendix 6-D).
b. The completed form should be submitted to Histopathology counter.
c. The tissue is released only after the specimen is being examined by the
Pathologist and adequate sampling has been taken for reporting.

REQUEST TO OBTAIN MICROSCOPIC IMAGE FROM HISTOPATHOLOGY UNIT

Microscopic images are not archived as routine but images can be provided upon
request. A request shall be made or endorsed by specialist.
a. For presentation or education:
• The requesting doctor should communicate directly with the Pathologist
concerned.
• A request shall be made by filling up a form i.e Request Form for HPE/
Cytology Image (ANA/JP/HTAA-07 Ver. 1/2013). The completed form
should be submitted to the Histopathology counter.
b. For publication:
• The requesting doctor shall communicating directly with the Pathologist
concerned followed by filling up the request form.
• The abstract of the publication should be provided and the Pathologist
concerned who reported the case should be included as co-author.




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HTAA, KUANTAN CYTOLOGY


























































218

1.0 INTRODUCTION



Cytology is a discipline that involves the morphologic study of cells. It is broadly
divided into exfoliative cytology and aspiration cytology.

Exfoliative cytology involves examination of specimens that contain cells exfoliated CYTOLOGY
from body cavities and surface. It is further subdivided into gynaecological cytology
(Pap/cervical smears) and non-gynaecological cytology (pleural fluid, peritoneal fluid,
cerebrospinal fluid, urine, sputum, brushing, etc).

Aspiration cytology involves examination of cells that are actively obtained by fine
needle aspiration.


2.0 SERVICES

The laboratory service is only available during office hours.
The following types of specimen are processed here:

i. Gynaecology specimen : PAP smears
ii. Non-gynaecology specimen : Body fluids, Sputum, Bronchial Brushings and
Washings, Nipple Secretions, urine, CSF etc.
iii. FNAC (Fine Needle Aspiration Cytology)

Note :
Any procedures that require Rapid On site Examination (ROSE) ie. EBUS TBNA, should
be informed at least one day earlier to cytology lab and/ or pathologist in charge.



3.0 REQUEST FORM

i. Every specimen submitted must be accompanied by a request form (in duplicate).
ii. Fill the form completely including, ie. clinical history, anatomic site, method of
sampling, age of patient, previous therapy, gynaecologic history, findings and
other relevant patient information.
iii. Full identity card numbers and particulars of patient are needed to enable
computerized record keeping system in our laboratory.






219

iv. Details like collection date of specimen, type of examination requested, name of
physician or other authorized person or clinic submitting the specimen should
be written in the form.
HTAA, KUANTAN vi. PAP Smears : Please use PS 1/98 (Pindaan 2007).
v. FNAC & Body Fluids Cytology forms : Please use ANA/JP/HTAA-01/VER.3
(Pindaan 9/9/2015).




4.0 SPECIMENS COLLECTION

4.1 PAP Smears :

i. Specimen to be collected prior to bimanual examination.
ii. No sexual intercourse prior to specimen collection.
iii. Patient should be advised to refrain from douching or using vaginal suppositories
for a period of 24 hours before a specimen is taken.
iv. Avoid collecting specimen during menstrual bleeding.
v. Label a clean glass slide with patient’s name and IC number with pencil on the
frosted end.
vi. DO NOT use lubricant on the speculum.
vii. Place cervical spatula at the external os and rotate through 360 degrees, lightly
o
scraping the squamo – columnar junction.
viii. Smear the material onto the labeled glass slide about as thick as a blood film.
ix. Fix the slide immediately, either by immersing it in a coplin jar containing
95% alcohol for at least 30 minutes or use a spray fixative to prevent cellular
distortion.
x. Air-dry the fixed slide.
xi. Place the slide in a slide mailer and despatch to the cytology laboratory.

Note :
1. If more than one slide is to be placed in the same container, ensure that they
are not placed face to face. After fixing, place the slides in a slide box and send
them to the Cytology Laboratory for processing.
2. Immediate and proper fixation of cellular material is essential for accurate
cytologic interpretation.

Remember :
Use 95% alcohol, available as denatured alcohol / commercial form of industrial
ethanol as a wet fixative.

*TAT for Pap smear is 14 working days. TAT for urgent cases is 7 working days.


220

4.2 Body Fluid :

Specimen is collected into a normal clean plain container.
No fixatives or heparin to be added. Should be brought fresh without delay, within 2
hours to the Cytology Laboratory for immediate processing.

*TAT for body fluid is 14 working days. TAT for urgent cases is 3 working days. CYTOLOGY

Note : Avoid sending Body Fluid specimens on non working days or after office hour.
Cells in a fluid medium must not be permitted to degenerate, as it causes alteration to
cell morphology. If the specimen to be sent after office hour, anticipate refrigeration
o
o
of the specimen at 2 C – 8 C.
4.2.1 Sputum :

Morning specimen is required, before breakfast. Rinse mouth with water. Saliva and
post-nasal discharge should be discarded.

i. Deep cough specimen is required.
ii. Cough into wide mouth receptacle and despatch for immediate processing.

4.2.2 Bronchial Brushings :

Use clean glass slides.Label the slides with patient’s name and IC number. Brushings
should be smeared and fixed immediately in 95% alcohol for a minimum period of 30
minutes.


4.2.3 Aspirates and Washing :

Specimen is collected in a labelled container and sent to the laboratory immediately.

4.2.4 Nipple Secretion :

Specimen should be collected by applying the glass slide directly to the nipple, followed
by immediate fixation (as in PAP smear).









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4.2.5 Urine :

HTAA, KUANTAN voided urine and send immediately to the cytology laboratory. Please state the nature
The patient should void and discard the first morning urine specimen. Collect the next
of urine sample, i.e. voided or via instrumented urine sample.

4.3 FNAC ( Fine Needle Aspiration Cytology) :

For out-patient

Monday – Thursday : 8.30 am – 12.30 pm
(on working days) 2.30 pm – 4.00 pm

Friday : 8.30 am – 12.00 noon
(on working days) 3.00 pm – 4.00 pm

For in–patient

Ambulatory patients as above.

Non Ambulatory patient basis } on appointment
Radiologically guided FNA Call Ext. 2863/2867



Ensure request form, ANA/JP/HTAA-01, (Pindaan 1/7/2003) is in duplicate and has the
following patient information :

i. clinical impression
ii. symptoms
iii. physical findings
iv. any histo/cyto findings done previously
v. patient’s full identity card number















222

Please note that:

i. The request form should be filled legibly, complete with the relevant clinical
history and findings. Every request form must be accompanied by patient
consent form.
ii. Whenever there is more than one lump or swelling present, the clinician should CYTOLOGY
indicate which lump/s or swelling/s to be aspirated.
iii. There is no indication for FNAC in multinodular goiter or diffuse goiter.
iv. Vascular lesions or those of vascular origin are not suitable for FNAC.
v. FNAC for deep seated lesions are performed by radiologist under radiological
guidance on appointment basis.
vi. TAT for FNAC is 14 working days. TAT for urgent cases is 3 working days.



5.0 DESPATCH OF RESULT

a. All results will be despatched directly to the clinics.
b. For ward cases, staff concerned should look for the results in the respective
clinics.
c. Results for District Hospitals and Health Centres will be mailed directly.



6.0 SERVICE AFTER OFFICE HOUR

Specimen for cytological examination is NOT processed after office hour.
Specimen collected outside officer hours should be refrigerated at 2°C - 8°C before
despatched to the cytology laboratory the next day. Refrigeration helps preserving the
cell. DO NOT FREEZE SPECIMEN.





















223

HTAA, KUANTAN TRANSFUSION


























































224

TRANSFUSION


1.0 INTRODUCTION



Transfusion Medicine Unit is divided into two different sections, Blood Donation TRANSFUSION
and Laboratory Section. The laboratory section provides 24 hours services.


2.0 BLOOD DONATION SECTION

The function of this section is for collecting blood from blood donors by :

2.1 Mobile Sessions

These donation groups usually organized by non-government organization, private
companies or from government departments.

2.2 In House (Walk In) Blood Donation

Individual or a group of donors come to the unit to donate blood during office hours or
by appointment.



3.0 LABORATORY SECTION

The function of this section is to ensure that safe blood and appropriate blood products
are provided to the patient. This section is divided into 4 smaller sections.

3.1 Cross Matching Laboratory

It carries out full blood grouping and cross matching in order to ensure compatible
blood is given to patients.

3.2 Immunohaematology Laboratory

A more complex blood serology tests as well as workout for incompatible blood are
being carried out here. List of tests includes:





225

i. Direct Coomb’s test
ii. Indirect Coomb’s test
iii. Antibody screening/Identification
HTAA, KUANTAN 3.3 Components Preparation Laboratory
iv. Red cell phenotyping




This section prepares and stores blood components. The blood components that are
available are whole blood, packed red cells, Fresh Frozen Plasma (FFP), cryoprecipitate
and platelets concentrate.

3.4 Transfusion Microbiology Laboratory

This laboratory offers screening test for all donated blood.
The test includes:-

Hepatitis B : HBsAg and other markers
Hepatitis C : HCV Ag-Ab
Syphilis : RPR, TPPA
Human Immunodeficiency virus (HIV) : HIV Ag-Ab, PA
Nucleic acid testing (NAT) : (outsource to PDN)



4.0 ORDERING OF BLOOD

a. Ordering of blood for transfusion must be done only by the doctor in charge of
the patient requiring transfusion.
b. The Blood Transfusion Request Form (PPDK-5) must be completely filled and
signed by the doctor in charge of the case.
c. All the request for blood and blood component must have an approval from the
blood bank MO oncall.
d. Justified request will be given a code in which must be written on the top of the
request form.

5.0 COLLECTION OF BLOOD SAMPLE

a. All collection for blood samples must be done by a doctor.
b. The doctor must ensure that the blood is withdrawn from the correct patient
by proper patient identification (verbally, wrist band and Bed Head Ticket (BHT).
c. Each specimen tube should be labelled immediately at the bed side after blood
is collected from each patient by the same doctor.


226

Note : DO NOT collect more than one patient sample at a time. This is to prevent
mix-up of samples and the risk of mismatched transfusion being given.



6.0 SPECIMEN COLLECTION AND HANDLING TRANSFUSION

a. Adult and children (patient above 4 months)

i. 4 ml blood specimen in EDTA sample accompanied by one request form.
ii. In cases of massive bleeding when many units of blood/components are
required, more samples and request forms may be needed.
iii. If the patient requires repeated transfusions during the current admission, a
newm blood sample is needed for each request.


b. Infant (less than 4 months of age)

i. Infant blood sample should be accompanied by a sample of the mother’s blood.
ii. 2.5 ml blood sample in EDTA from the infant and 4 ml blood sample in EDTA from
the mother.
iii. Both samples are to be sent to the Blood Bank using one request form.
iv. Blood sample together with completely filled request form (PPDK-5) must be
sent to the Blood Bank without any delay.

Note : Please ensure that the time when the blood is needed for transfusion is stated
on the request form. The request must have the doctor’s signature together with his/
her name clearly written on the form.




7.0 COLLECTION OF BLOOD FOR TRANSFUSION

The blood can be collected from the MLT who is responsible for issuing the blood in
the Blood Bank at any time (24 hours). The blood will be reserved for the patient up to
48 hours from the time the blood is required.










227

8.0 CARE OF BLOOD/BLOOD COMPONENT DURING TRANSPORT AND
STORAGE OF BLOOD IN OPERATION THEATRE/WARD
HTAA, KUANTAN b. Blood must be transported at all times in insulated boxes containing ice-pack to
a. Blood should not be stored in the ward refrigerator BUT should be returned to
the Blood Bank as soon as possible if not transfused.

ensure the temperature of the blood bag remains between 2-8ºC.
c. Blood must never be allowed to remain at room temperature for more than 30
minutes before transfusion.
d. Blood must never be stored in the freezing compartment.
e. For other blood component, please refer to table as stated below:


Whole blood / RBC Platelet Conc. Cryo/LP/FFP
Supply After crossmatch Group specific/ com- Group specific
patible No crossmatching
No crossmatching required
required Should be thawed
Collection Blood box with ice Blood box without ice Blood box with ice
Use As soon as possible (af- Transfuse immediately Transfuse immediately
ter reaching the ward)
Storage +2 C to +6 C Room temperature Should not be stored
o
o
+20 C to +24 C on or kept in the wards
o
o
agitator
Return Return immediately if Return immediately if Return immediately if
not used not used not used
After used Fill up Blood Tag (PPDK Fill up Blood Comp. Tag Fill up Blood Comp. Tag
1) and return togeth- (PPDK 1) and return (PPDK 1) and return
er with empty bag to together with empty together with empty
blood bank as soon as bag to blood bank as bag to blood bank as
possible. soon as possible. soon as possible.

















228

9.0 MONITORING FOR BLOOD TRANSFUSION

a. Ensure the blood collected is for the patient intended (theinfo between blood,
request form and PPDK cardhas to tally)
b. Transfusion process
• Blood must be check JUST BEFORE the transfusion at the bedside, by two TRANSFUSION
clinical staffs.
• Fill in the checklist after checking the blood.
• Ensure patients received the right blood by checking the blood bag against
request form, PPDK card, patient’s wrist band/patient ID and verbal
confirmation with the patient.
• Check each unit the same way just before it is transfused.
• Vital signs (BP, HR, Temp) must be taken before transfusion of each unit.
• Close monitoring for the first 15 minutes, then every half to one hour (if no
complications).
• Avoid transfusion in the evening or nights unless inan emergency situation.
• Document the details of the transfusion (vital signs, blood units transfused,
reactions).
• Complete the PPDK card only after transfusion is finished.
• Fill in the necessary details and sign the card. This can be done by
doctor or staff nurse.
• Return the card with the used blood bag to blood bank (BB).
• Stop the transfusion immediately if the patient shows any reaction. Resume
transfusion only if the reaction is mild and not due to red cell incompatibility,
TRALI and bacterial contamination and the patient benefit from medications
given e.g. antihistamine or antipyretic agents.
• Investigate all reactions.
• Return all used blood bags to Blood Bank – empty or not, and any unused
blood units.
• Should the patient needatransfusionand the blood has been returned, make
a fresh request.

















229

10.0 PATIENTS DETAILS

a. The process of taking and labeling the blood samplemust be done at the bedside,
HTAA, KUANTAN b. The phlebotomist taking the blood sample must ask the patient to state his/her
one patient at a time.
full name and IC number. This information then must be checked against the
wristband and patient’s case notes.


11.0 REQUESTS FOR EMERGENCY BLOOD

In emergency cases, the request form and blood sample must be sent by a doctor to
the blood bank and wait for the blood to be supplied.
In this request, a stamp/chop of ‘EMERGENCY CROSS-MATCHED’ will be placed in
which the doctor must pass a signature before the blood can be supply by blood bank.

Note:
In emergency cross-matched, saline phase cross-matched blood will be supplied in
which limited safety is guaranteed. Full cross-matching will be carried out by the
laboratory. Any incompatibility will be notified to the requesting doctor.



12.0 USED BLOOD OR REMNANTS OF BLOOD

Blood transfusion discontinued for any reason should not be used again and must
be returned to the Blood Bank as soon as possible, together with all the details of the
transfusion and reason for discontinuing the blood transfusion stated on the recipient
card (PPDK 1) attached to the bag. All discontinued blood must be labeled “USED
BLOOD” before returning to the Blood Bank.




















230

13.0 RETURN OF BLOOD BAGS

a. Used blood bags

On completion of blood transfusion, the ward staff must ensure the Recipient Card
(PPDK 1) is filled and returned to the Blood Bank together with the blood bag containing
remnants of the blood transfused at any time. TRANSFUSION

Note : Please ensure the Recipient Card (PPDK 1) is not tainted with blood.

b. Unused blood and Blood Component

All unused blood issued to the ward must be sent back to blood bank immediately
if the transfusion is delayed or cancelled. (<2 hrs).

All unused blood component (platelets, FFP, cryo precipitate) must be send back to
blood bank immediately WITH an explanation letter.

Note: Please practice judicious use of blood and blood component to avoid wastage.




14.0 RESERVATION OF CROSS-MATCHED BLOOD

Blood which has been cross-matched for any patient will be kept in reserve for 48
hours only. In the absence of specific instruction to the medical officer in charge of
Blood Bank, the blood will be returned (released) to the general pool automatically.























231

15.0 TRANSFUSION REACTION


The use of blood even under the best circumstances carries a high risk for the recipient.
HTAA, KUANTAN The commonest risk is transfusion reaction. Examples of these are :

a. Febrile reaction to pyrogens, leucocyte antibodies, platelet antibodies and
minor blood group antibodies.
b. Allergic reactions to plasma constituent.

For patient with repeated history of febrile reaction during transfusion, filtered
blood can be used to prevent similar reactions.


15.1 HAEMOVIGILANCE

Haemovigilance is a set of surveillance procedures covering the whole transfusion
chain ,from the donation of blood and its components to the follow-up of recipients of
transfusions intended to collect and assess information on unexpected or undesirable
effects resulting from the therapeutic use of labile blood products and to prevent the
occurrence or recurrence of such incidents.

The aim of haemovigilance is to increase awareness of the above mentioned situations
and thus raise the level of transfusion quality and safety by means of corrective and
preventive measures.

The haemovigilance system requires cooperation between all the different parties
involved: Blood Bank, the centre responsible for the donation and the blood donors, as
well as those responsible for the preparation, storage and supply of blood components
and the clinical services at the different hospitals where the transfusion will finally take
place.

This system is coordinated by theHaemovigilance coordinating centre at the National
Blood Centre. The functions of this coordinating centre are:


• To collect reports of all adverse events associated with blood transfusion which
includes transfusion reaction, donor reaction and other deviation from the
norm relating to supplies of reagent, equipment , blood bags, etc.
• Analyse the reports submitted.






232

• Prepare and issue annual report which include recommendation for corrective
action to the ministry of health.
• Upon receipt of the “REPORT OF REACTION TO BLOOD OR PLASMA” forms (PPDK
22-Pin. 1/80) by the Hospital Blood Bank, the reporting format for “Adverse
Transfusion Event (Borang X) will be issued to the ward / doctor concerned by
the Hospital Blood Bank. TRANSFUSION
• The “Adverse Transfusion Event” (Borang X) form will be returned in duplicate
to the Hospital Blood Bank and National Blood Centre within one week.
• A copy of this form (Borang X) will be sent to the National Blood Centre, refer to
the flowchart for reporting of adverse transfusion events below:

Flowchart for reporting of adverse transfusion events

Adverse transfusion events































Note:
• Every case of adverse reaction must be reported .
• If the case of adverse reaction involvesa seropositive donor, a look back and
recall procedure must be carried out.
• Identity card number (I/C), donation date must be summitted to Surveillance
Unit , National Blood Centre.


233

16.0 INVESTIGATION OF TRANSFUSION REACTION

This is conducted when a patient develops a transfusion reaction such as febrile or
HTAA, KUANTAN Important : All reactions must be reported immediately.
suspected haemolytic reaction.



The blood bag (with the remaining blood) and giving set (with all attached labels)
should be preserved for culture. Secure it properly to prevent spillage and send
immediately to Blood Bank together with the following forms which must be completely
and accurately filled :

i. PPDK 22-Pin. 1/80 (Report of Reaction To Blood or Plasma)
ii. Borang X (Reporting Format For Adverse Transfusion Event)
iii. PER-PAT 301
iv. HAEM/JP/HTAA/01Ver.2 (Haematology Request Form)

The following samples and forms must be taken stating patient’s name and identifying
data and labeled as Post-transfusion 1 :

i. 8 ml of blood into EDTA tube (4 ml).
ii. 2.5 ml EDTA blood for Full Blood Picture (FBP) by case basis.
iii. 20 ml of urine.

A second set of samples, 24 hours after the reaction should be taken and labeled as
Post-transfusion 2 including:

i. 10 ml of blood in a plain tube.
ii. 2.5 ml EDTA blood for Full Blood Picture (FBP) by case basis.
iii. 20 ml of urine.




17.0 FURTHER INFORMATION

For further information about transfusion, user can refer to Transfusion Practice
Guidelines for Clinicians and Laboratory Personnel by National Blood Bank (3rd Edition
2008) by surfing this link:

http://pdn.gov.my/ms/perkhidmatan/muat-turun/viewcategory/2-panduan-transfusi




234

ACC CLINICAL ACC CLINICAL LABORATORY


LABORATORY




















































235

1.0 INTRODUCTION


HTAA, KUANTAN The ACC Clinical Laboratory at Ambulatory Care Centre (ACC) caters for outpatients

from specialist clinics.

Operating hours: 08:00 am - 05:00 pm (weekdays only).



2.0 SERVICES

The ACC Clinical laboratory offers the following services:

2.1 Biochemistry tests:

i. Glucose
ii. Urea
iii. Serum Electrolytes
iv. Serum Creatinine
v. Urine Dipstick
vi. Urine Pregnancy Test (UPT)

2.2 Haematology tests:

i. Full Blood Count (FBC)
ii. Prothrombin Time/ International Normalised Ratio (PT/INR)
iii. Activated Partial Thromboplastin Time (APTT)

2.3 Microbiology tests:

i. Urine Microscopy

3.0 REQUEST FORM

A standard laboratory form (PER-PAT 301) is used for all categories of tests. The form
should be filled completely and the requesting doctor must sign the form and their
name must be written legibly.







236

4.0 SPECIMEN COLLECTION AND CONTAINER


Please refer to Table 1 : List Of Tests Available At Pathology Department for collection
and container for individual test.



5.0 RECEIPT OF SPECIMEN ACC CLINICAL LABORATORY
All specimens should be sent to ACC Clinical Laboratory during office hour only.



6.0 REPORTING OF RESULT

All results will be given to clinic staffs or to awaiting patients.










































237

HTAA, KUANTAN REFERENCES


























































238

References :
1. Hospital Tengku Ampuan Afzan Pathology Services Handbook 2011.
2. Hospital Kuala Lumpur Pathology Services Handbook 2009.
3. Public Health Laboratories Test Handbook Second Edition 2009.
4. Hospital Sungai Buloh Pathology Services Handbook 2010.
5. IMR Handbook 2010. REFERENCES
6. Transfusion Practice Guidelines For Clinical And Laboratory Personnel (3rd
edition 2008) (PusatDarah Negara).
7. Garcia L.S. (ed), Clinical Microbiology Procedures Handbook 3rd Edition Ameri-
can Society for Microbiology Press Washington D. C.
8. World Health Organization.














































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2018





















































PATHOLOGY SERVICE HANDBOOK
HOSPITAL TENGKU AMPUAN AFZAN







5TH

EDITION