2. Workflow Benefits of Test-specific thresholds on Sysmex CS analysers
Steve Kitchen, PhD
Lead Clinical Scientist
Sheffield Haemophilia & Thrombosis Centre
Sheffield, UK

3. Causes of errors in laboratory medicine Review of 5 studies
Lab section
Clin Chem
All labs
Primary care
Stat lab
Data period
1 yrs
6 yrs
6 months
3 months
3 yrs
% of samples with errors
0.05
0.1
0.5
0.6
% of errors occurring in pre- analytical phase 32 53 56 68 75
(Bonini, Clin Chem 2002)

4. Causes of sample rejection
Clotted
Under-fill
Labelling
Haemolysis
2010
411
356
(0.6%)
327
119
(0.2%)
2011
439
349
255
247
(0.4%)
2012
204
434
(0.7%)
141
650
(1.1%)
2013
(Accident and emergency)
0.9%
2.6%

5. Are rejected samples replaced?
1077 samples rejected in a 3 month period (2014)
(~3% of all samples)
(48%) not replaced within 24 hours
(including 106 INRs)
(29%) not replaced within 7 days
(including 24 INRs)

6. Haemolysis Plasma Haemoglobin
15 g/l 6 g/l g/l control

7. What level of haemolysis is routinely encountered?
34 consecutive haemolysed samples rejected for visible haemolysis n
Plasma Hb g/l

8. Effect of Haemolysis Freeze/thaw/artificial lysis
Citrated whole blood frozen
Lysed cells added to plasma from same subject
Different mixtures prepared

9. FREEZE/THAW (spiked normal plasma)
1000 mg/dl = 10 g/l

10. FREEZE/THAW (spiked normal plasma)

11. FREEZE/THAW 3

12. Effect of Haemolysis – freeze/thaw/artificial lysis
6 normal subjects
Vacutainer 0.109M trisodium citrate (3.2%)
Whole blood frozen
Lysed cells added to plasma from same subject
12 different mixtures prepared
Mean plasma haemoglobin 0 – 20 g/l (10-15% haemolysis)

15. Haemolysis in real patient samples
Samples with haemolysis that failed local visual inspection assessment (observer variable?)
Free haemoglobin in plasma samples with haemolysis ranged from 0.5 to 9 g/l.
Matched samples from same patients which were
Free of visible haemolysis
Collected within 4 hours of haemolysed sample

17. Samples with > 4 sec difference in APTT with AFS (normal <30
Samples with > 4 sec difference in APTT with AFS (normal <30.5 sec) n= 5/56
Sample
code
Haemolysed APTT (sec)
Clear
Plasma Hb (g/l) 3
35.7
30.8 30 34
38.8 1 33
33.2*
27.2 35
19.3
24.1 41 58 47
0.5
* False abnormal

18. Not significant. Mean difference 0.05

19. False abnormal PT

20. Samples falsely raised above D-Dimer > VTE cut-off (0.5 µg/ml)
Haemolysed
D-Dimer
(µg/ml)
Clear
Plasma Hb
(g/l)
0.95
0.19
0.5
1.53
0.24 1
2.7
0.35
2.98
0.48 5
Potentially unnecessary ultrasounds

23. In Vivo haemolysis (Sickle cell anaemia)

24. HIL check – Sysmex CS series
Checks daughter plasma aliquot at 3 wavelengths
Checks for Haemolysis at 575 nm
Checks for Icterus at 405 nm
Checks for Lipaemia at 660 nm
Flag levels 1 (low) to 5 (high)
Some models - test specific thresholds/flags

25. Haemolysis Conclusions
Level of haemolysis that causes diagnostic errors is variable and test dependant
Effects are not always related to the degree of haemolysis when present
Therefore any in vitro hemolysis – reject for APTT
PT/INR is less affected

26. Tracking for coagulation analysers?
Combined with chemistry samples _ sample numbers, Centrifugation conditions
Detection of Haemolysis and underfilling (visual vs automated
Auto-validation of selected results– automated pre-analytics

27. RHH – Old layout

28. RHH – New layout

29. Work in progress

30. Temporary home!

31. Sample Transport Simplicity and reliability with belt free technology
Sample transport via individually powered CARS
Max. throughput of 6000 tubes / hour
NFC tech for sample
identification
Scalable,
Modular,
Flexible design
Talk through GLP Sample delivery system and benefits
Speed
Efficiency

32. Taking shape

33. Recommendations for flag levels
Test
Flag level
Plasma Hb
APTT – AFS 1
0.4 g/dl
APTT - FSL
DDimer
FXIII
Antithrombin 3
1.8 g/dl
PT /INR Innovin
5 (4 with derived fib)
3.0 (2.4) g/dl
Protein C 5
3.0 g/dl
PT/INR – Thromborel S
Fibrinogen (clauss)
Thrombin Time
Anita Woolley et al poster ISTH 2015

34. Anita Woolley Yuka Tabuchi
Acknowledgements
Anita Woolley
Yuka Tabuchi

35. Wavelengths used for result reporting
Clotting assays except Clauss Fibrinogen
Default = 660nm
Sub-wavelength = 800nm
Clauss Fibrinogen
Default = 405nm
Sub-wavelength = 660nm

36. Wavelength Switching for lipaemic samples
Wavelength switching (to 800 nm) if:
Light level error
Transmitted light error
Turbidity level over error
Slight Coagulation error