Clinical Specimen Review: Plasma vs Serum
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Questions and Answers

What diseases can cause conjugated bilirubinemia? (Select all that apply)

  • Cirrhosis (correct)
  • Bile duct obstruction (correct)
  • Viral hepatitis (correct)
  • Pancreatic cancer (correct)

    • What does a positive bilirubin result indicate?

    Jaundice, liver disease, hemolytic disorder, or bile duct obstruction.

    Where is CSF produced?

    In the choroid plexuses of the subarachnoid space.

    Xanthochromic CSF indicates presence of RBC degradation products from old bleeding.

    <p>True</p> Signup and view all the answers

    Define albumin index.

    <p>CSF albumin (mg/dL) / serum albumin (g/dL)</p> Signup and view all the answers

    Match the body fluid tests to their respective body fluids:

    <p>Cerebrospinal fluid = CSF glucose and lactate tests Serous fluids = Thoracentesis, pericardiocentesis, paracentesis</p> Signup and view all the answers

    What results would indicate bacterial meningitis? (Select all that apply)

    <p>Positive gram stain and cultures</p> Signup and view all the answers

    Describe three factors controlling formation of serous fluid.

    <p>Hydrostatic pressure, colloidal (oncotic) pressure, and permeability of blood vessels.</p> Signup and view all the answers

    What is the lifespan of an RBC?

    <p>120 days</p> Signup and view all the answers

    What is the function of platelets?

    <p>Active in plasma hemostasis and blood coagulation.</p> Signup and view all the answers

    Kidney failure is usually associated with anemia.

    <p>True</p> Signup and view all the answers

    What is the most sensitive test for iron deficiency?

    <p>Serum iron study, Ferritin values</p> Signup and view all the answers

    If a patient with IDA receives iron therapy, what test should be ordered to check effectiveness?

    <p>Reticulocyte count</p> Signup and view all the answers

    What are the changes on CBC and WBC morphology when a patient has a bacterial infection?

    <p>Granulocytosis, left shift, increased immature neutrophils (bandemia), toxic granulation, vacuolization, Dohle body</p> Signup and view all the answers

    What coagulation factors are inhibited by coumadin? What is the mechanism?

    <p>Factors II, VII, IX, X</p> Signup and view all the answers

    What are the causes, pathophysiology, and lab profiles of DIC?

    <p>Causes: sepsis, tumors, immune disorders, snake/insect bites, drugs. Pathological activation of coagulation pathways. Lab findings: prolonged APTT, PT, and TT; decreased fibrinogen and platelet count; increased FDP and D-dimer.</p> Signup and view all the answers

    What is the value of normal INR?

    <p>&lt; 1.1</p> Signup and view all the answers

    What is the ideal range of INR for a patient with A-fib taking coumadin?

    <p>2.0 – 3.0</p> Signup and view all the answers

    What are the clinical consequences of VWF deficiency?

    <p>Increased breakdown of factor VIII, impaired platelet function, prolonged APTT, decreased factor VIII, increased bleeding time</p> Signup and view all the answers

    What does prolonged bleeding time indicate?

    <p>VWF deficiency</p> Signup and view all the answers

    What are the indications of using washed RBCs?

    <p>Reduce anaphylactic reactions in patients with IgA deficiency, remove excess K to prevent post-transfusion hyperkalemia in pediatric patients</p> Signup and view all the answers

    What are the specific therapeutic purposes of using packed RBCs?

    <p>Increase O2 carrying capacity</p> Signup and view all the answers

    One packed RBC is expected to increase Hgb by ____.

    <p>1 g/dL Hgb and 3% Hct</p> Signup and view all the answers

    How is platelet product stored?

    <p>Only in room temperature; never frozen/refrigerated</p> Signup and view all the answers

    APTT normal and PT prolonged indicates intrinsic pathway deficiency.

    <p>False</p> Signup and view all the answers

    What should be included in a pretransfusion test?

    <p>All of the above</p> Signup and view all the answers

    Explain the purpose of the direct and indirect antiglobulin tests.

    <p>DAT checks for antibody-coated RBCs; IAT identifies antibodies against potential donor RBCs.</p> Signup and view all the answers

    What are the requirements of the RBC product?

    <p>Crossmatch performed by: cordocentesis, unit blood type compatible to baby; Requirements: &lt; 7 days old, sickle cell negative, CMV negative, O = best.</p> Signup and view all the answers

    Describe the pathophysiology of hemolytic disease of the newborn (HDN).

    <p>Erythroblastosis fetalis is the hemolytic anemia in babies due to maternal antibodies binding to baby's RBCs, leading to RBC destruction. Symptoms include jaundice, enlarged spleen/liver, increased retic value, nRBCs, and indirect bilirubin. Hydrops fetalis occurs with severe anemia leading to cardiac failure and generalized edema. Kernicterus is the build-up of unconjugated bilirubin in the brain.</p> Signup and view all the answers

    What is the management approach for preventing hemolytic disease of the newborn?

    <p>Prevent production of anti-D antibody by the mother using RhIG (RhoGAM).</p> Signup and view all the answers

    Describe the test used to detect fetomaternal hemorrhage.

    <p>Kleihauer-Berke (KB) staining detects fetal RBCs in the mother’s circulation and quantifies the severity of FMH by percentage.</p> Signup and view all the answers

    Who are the candidates for Rh Immune Globulin injection?

    <p>Mothers, females of childbearing age that are D negative, and males under 16 years that are Rh-.</p> Signup and view all the answers

    Who will develop anaphylactic reaction after IVIG infusion?

    <p>Patients who are IgA deficient.</p> Signup and view all the answers

    Describe the plans to monitor pregnancy if the mom is Rh negative, fetus is not the first pregnancy, and there are anti-D antibodies in the mom’s serum.

    <p>Amniotic fluid analysis to evaluate bilirubin levels, Color Doppler for middle cerebral artery peak to assess hemodynamic changes from anemia, and cordocentesis to test for H&amp;H, bilirubin, blood type, DAT, and antigen phenotype.</p> Signup and view all the answers

    If there is evidence that the fetus is developing hemolysis and anemia, what are the treatment plans?

    <p>IVIG to protect fetal RBCs, intrauterine transfusion to treat severe anemia, and phototherapy to reduce bilirubin toxicity.</p> Signup and view all the answers

    What are the differences between plasma and serum?

    <p>Plasma is the liquid portion of centrifuged anticoagulated blood, making up ~55% of the sample. Serum is the liquid portion of centrifuged coagulated blood, which is plasma minus coagulation factors.</p> Signup and view all the answers

    Arterial blood is _____ red and contains _____ hemoglobin.

    <p>bright, oxygenated</p> Signup and view all the answers

    Why is arterial blood used to measure O2 partial pressure?

    <p>It tells you how much O2 is being delivered, indicating the level of oxygenation.</p> Signup and view all the answers

    What is universal safety precaution?

    <p>Rules that assume all patients are infectious for blood-borne pathogens.</p> Signup and view all the answers

    What is the genus, species, and strain of Escherichia (E.) coli O157H7?

    <p>Genus = Escherichia (E.), Species = coli, Strain = O157H7.</p> Signup and view all the answers

    Compare Gram positive and Gram negative bacteria.

    <p>Gram positive bacteria have a thick layer of peptidoglycan and stain purple; Gram negative bacteria have a thin layer and stain pink.</p> Signup and view all the answers

    Why is Mycobacterium tuberculosis resistant to Gram stain?

    <p>It is resistant due to high lipid and wax content in its cell walls.</p> Signup and view all the answers

    What stain can be used to detect Cryptococcus in the CSF?

    <p>India ink stain.</p> Signup and view all the answers

    What are the complications of empiric antibiotic treatment?

    <p>Selection of drug resistant bacteria, elimination of normal flora leading to conditions like C-diff colitis and fungal infections.</p> Signup and view all the answers

    Define pathogen, opportunistic pathogen, and iatrogenic infection.

    <p>Pathogen: can cause disease in a susceptible host; Opportunistic pathogen: normal flora that cause infection when conditions change; Iatrogenic infection: result of medical treatment.</p> Signup and view all the answers

    What are common virulence factors of bacteria?

    <p>Capsules, toxins, adhesive fimbriae.</p> Signup and view all the answers

    How does protein A help bacteria resist phagocytosis?

    <p>Protein A binds to the Fc region of antibodies, preventing macrophages from effectively binding to and engulfing the bacteria.</p> Signup and view all the answers

    Compare endotoxin with exotoxin.

    <p>Endotoxins are heat stable and produced by Gram negative bacteria; exotoxins are proteins secreted by bacteria with specific effects.</p> Signup and view all the answers

    Define bacteremia and septicemia.

    <p>Bacteremia: viable bacteria in the blood; septicemia: bacteremia with clinical signs of bacterial invasion and toxin production.</p> Signup and view all the answers

    Describe how to correctly collect a sample for blood culture.

    <p>Perform new venipuncture, clean the skin well, and collect 20 mL from three different punctures.</p> Signup and view all the answers

    What is the specimen of choice for wound culture?

    <p>Wound biopsy.</p> Signup and view all the answers

    What is the most common cause of gastroenteritis in children in the US?

    <p>Rotavirus.</p> Signup and view all the answers

    Describe tests used to diagnose Syphilis.

    <p>Serology tests such as RPR for screening and FTA-ABS for confirmation.</p> Signup and view all the answers

    What is the preferred collection method for urine tests?

    <p>Midstream 'clean catch' collection.</p> Signup and view all the answers

    How many colony counts of pure culture can be considered positive?

    <p>75,000 or higher.</p> Signup and view all the answers

    Describe the three forces that determine glomerular filtration.

    <p>Hydrostatic pressure, oncotic pressure, and shield of negativity.</p> Signup and view all the answers

    Define renal threshold of glucose.

    <p>Concentration of glucose in the plasma above which it will exceed the transport maximum and be passed in the urine, typically $160-180 mg/dL$.</p> Signup and view all the answers

    What can cause positive glucose in urine?

    <p>Plasma concentration exceeds renal threshold due to conditions such as diabetes mellitus.</p> Signup and view all the answers

    What kind of bilirubin can urinalysis detect?

    <p>Conjugated bilirubin.</p> Signup and view all the answers

    Study Notes

    Clinical Specimen Review

    • Plasma: Liquid portion of centrifuged anticoagulated blood, constitutes ~55% of the sample.
    • Serum: Liquid portion of centrifuged coagulated blood, lacks coagulation factors.

    Arterial vs. Venous Blood

    • Arterial Blood: Bright red, oxygenated hemoglobin, higher O2 content, used for measuring O2 partial pressure; essential for determining oxygen delivery.
    • Venous Blood: Dark red, deoxygenated hemoglobin, lower O2 content, higher CO2 content.

    Universal Safety Precaution

    • Introduced by CDC in 1988, assumes all patients may carry blood-borne pathogens.
    • Important pathogens include Hepatitis B, Hepatitis C, HIV, and CoV.
    • Requires safety measures during phlebotomy, e.g., gloves, protective clothing; no recapping of needles.

    Microbiology Review

    • Escherichia coli O157H7:
      • Genus: Escherichia
      • Species: coli
      • Strain: O157H7.

    Gram Staining

    • Gram Positive Bacteria: Thick peptidoglycan layer traps crystal violet, stains purple.
    • Gram Negative Bacteria: Thin peptidoglycan layer loses primary stain; takes up counterstain (safranin), appears pink.

    Mycobacterium tuberculosis

    • Resists Gram staining due to high lipid content in cell walls.
    • Detectable with acid-fast stains (Carbolfuschsin).

    Cryptococcus Detection

    • Identified in CSF using India ink stain, a negative stain highlighting yeast capsules.

    Complications of Empiric Antibiotic Treatment

    • Causes selection of drug-resistant bacteria.
    • May lead to dysregulation of normal flora, resulting in C. difficile colitis, fungal infections, and coagulopathy.

    Definitions

    • Pathogen: Causes disease in susceptible hosts.
    • Opportunistic Pathogen: Usually non-pathogenic pathogens that cause infection when normal flora balance is disrupted or immunity is compromised.
    • Iatrogenic Infection: Infections resulting from medical interventions.
    • Virulence: Measurement of a microorganism's ability to cause disease.

    Common Virulence Factors

    • Resisting Phagocytosis: Mechanisms including capsules and protein A, which prevent immune clearance.
    • Adhesion to Target Cells: Fimbriae and pili enhance bacterial colonization.
    • Invasion Factors: Enzymes like streptokinase and hyaluronidase facilitate tissue breakdown and bacterial spread.
    • Toxins: Classified as endotoxins (Gram-negative cell wall components, heat stable) and exotoxins (secreted proteins with specific cellular effects).

    Bacteremia vs. Septicemia

    • Bacteremia: Presence of viable bacteria in blood, may be transient.
    • Septicemia: Bacteremia with clinical signs of infection and toxin production, requiring urgent treatment.

    Blood Culture Collection

    • Venipuncture is necessary; avoid drawing from existing lines.
    • Clean the skin thoroughly to prevent contamination.
    • Ideal collection volume is 60 mL from three sites, split into aerobic and anaerobic bottles.

    Wound Infection Management

    • Wound biopsy is the preferred specimen for culture.
    • Surgical care and drainage are crucial for treating wound infections; antibiotics act as supplementary therapy.

    Gastroenteritis in Children

    • Rotavirus is the leading cause of gastroenteritis in the U.S.

    Diagnostic Tests by Pathogens

    • C. difficile: Stool cultures, toxin detection assays, antigen detection, and molecular tests.
    • Helicobacter pylori: Endoscopic biopsy, non-invasive tests like antibody detection and urea breath test.
    • Rotavirus: Rapid immunoassays and molecular tests, such as RT-PCR.

    Bacterial Meningitis

    • CSF analysis shows increased protein and decreased glucose levels.
    • Non-focal neural signs; urgent initiation of empirical antibiotic treatment is critical.

    Syphilis Testing

    • Screening: Non-treponemal tests (RPR, VDRL) detect antibodies to damaged cells.
    • Confirmatory: Treponemal tests (FTA-ABS, TP-PA, MHA-TP) detect specific antibodies against Treponema.

    Urine Tests

    • Midstream clean-catch collection is preferred for routine testing.
    • Positive cultures (≥75,000 colony counts) indicate infection.

    Glomerular Filtration

    • Influenced by hydrostatic pressure, oncotic pressure, and the shield of negativity from the basement membrane.

    Hematuria vs. Hemoglobinuria

    • Hematuria: Red and cloudy urine with intact RBCs, indicating renal or genitourinary disorders.
    • Hemoglobinuria: Red and clear urine without intact RBCs, usually due to hemolysis.

    Conditions Associated with Proteinuria

    • Often linked to glomerular diseases (glomerulonephritis, nephrotic syndrome) or tubular impairments.

    Positive Glucose in Urine

    • Indicates glucose levels exceeding renal threshold (160-180 mg/dL) or impaired tubular reabsorption (e.g., Fanconi syndrome).

    Bilirubin in Urinalysis

    • Detects conjugated bilirubin, which may indicate liver dysfunction or hemolytic disorders.### Conjugated Bilirubinemia and Urine Analysis
    • Conjugated bilirubinemia can result from viral hepatitis, cirrhosis, bile duct obstruction, and pancreatic cancer.
    • Positive urine bilirubin indicates jaundice due to liver disease, hemolytic disorders, or bile duct obstruction.
    • Urinary bilirubin and urobilinogen levels differentiate between:
      • Bile duct obstruction: + bilirubin, - urobilinogen
      • Liver damage: + bilirubin, + urobilinogen
      • Hemolytic disease: - bilirubin, + urobilinogen.

    Microscopic Urine Examination

    • Normal urine contains cells (RBCs, WBCs, epithelial), crystals, and casts.
    • RBC presence indicates glomerular membrane damage or vascular injury; may lead to macroscopic or microscopic hematuria.
    • WBC increase suggests pyuria, with neutrophils indicating bacterial infection and eosinophils pointing to drug-induced interstitial nephritis.
    • Cast types include:
      • RBC casts: indicative of glomerular diseases.
      • WBC casts: signify upper UTI or pyelonephritis, often with associated bacteria.
      • Waxy casts: linked to renal failure; appear dark pink.
      • Broad casts: indicate tubular damage due to extreme urine stasis.

    Urine Crystals and Clinical Significance

    • Crystals such as uric acid, calcium oxalate, triple phosphate, cystine, cholesterol, and bilirubin may indicate various conditions.
    • Uric acid crystals relate to leukemia/Gout.
    • Calcium oxalate indicates renal calculi.
    • Triple phosphate points to UTI caused by urea-splitting bacteria.
    • Cystine crystals signify cystinuria.
    • Cholesterol crystals associated with nephrotic syndrome or lipiduria.

    Cerebrospinal Fluid (CSF) Production

    • CSF is produced in the choroid plexuses of the subarachnoid space.
    • Xanthochromic CSF indicates old bleeding through the presence of RBC degradation products.
    • Bloody CSF can differentiate between traumatic collection (1st tube most blood) and subarachnoid hemorrhage (SAH) with even distribution across tubes.

    Albumin and IgG Index

    • Albumin index helps assess blood-brain barrier integrity, with values < 9 indicating intact BBB.
    • IgG index > 0.7 suggests CNS disease due to internal IgG production.

    Body Fluid Testing Procedures

    • Common tests for CSF include glucose and lactate tests, while serous fluids typically involve thoracentesis, pericardiocentesis, and paracentesis.
    • Transudate arises from systemic diseases causing fluid filtration, while exudate is related to vascular damage from inflammation or malignancies.

    Hematology Overview

    • Plasma is the liquid portion of blood containing proteins and electrolytes, while serum is the fluid after coagulation, devoid of clotting factors.
    • Buffy coat contains WBCs and platelets, layered above RBCs in blood samples.

    Hematopoiesis and Regulation

    • Lymphoid progenitor cells produce T and B lymphocytes; common myeloid progenitors yield granulocytes and monocytes.
    • Erythropoietin (EPO), released from kidneys, regulates RBC production in response to hypoxia.

    Anemia Overview

    • Anemia is the decrease in blood's capacity to transport oxygen, defined by hemoglobin levels < 13 gm/dL in males and < 12 gm/dL in females.
    • Adaptations to anemia include increased RBC production through EPO stimulation.
    • Causes of anemia include iron deficiency, megaloblastic anemia, chronic inflammation, acute/chronic blood loss, and hemolysis.

    Iron Deficiency Anemia (IDA)

    • Serum iron and ferritin levels are key indicators, with decreased ferritin being the earliest sign of IDA.
    • Reticulocyte count is crucial to assess effectiveness of iron therapy.

    Bacterial Infection and CBC Changes

    • Severe bacterial infections show granulocytosis and increased neutrophils, especially band forms.
    • Morphological changes in neutrophils include toxic granulation and vacuolization.

    Immune Response Indicators

    • Lymphocytosis indicates viral infections, while eosinophilia suggests parasitic infections.

    Coagulation Factor Inhibition

    • Coumadin inhibits specific coagulation factors to manage clotting disorders.### Vitamin K and Coagulation Factors
    • Vitamin K-dependent factors include II, VII, IX, and X; antagonizing vitamin K inhibits coagulation.

    Coagulation Pathways

    • Intrinsic Pathway Initiation

      • Triggered by endothelial damage; does not require penetrating injury.
      • Activation of factor XII occurs upon exposure of negatively charged subendothelial tissue.
      • Involves factors XII, XI, IX, VIII, calcium ions, and platelets.
      • APTT is used as a test; results in activation of factor X.

    • Extrinsic Pathway Initiation

      • Initiated by penetrating blood vessel injury.
      • Tissue factor (factor III) is the key initiator.
      • PT is the testing method; results also in activation of factor X.

    Factor Deficiencies Impacting APTT and PT

    • Prolonged APTT

      • Associated with deficiencies in intrinsic and common pathways: factors XII, XI, IX, VIII, X, II, and I.

    • Prolonged PT

      • Linked with deficiencies in extrinsic and common pathways: factors VII, X, II, and I.

    INR Values

    • Normal INR value is less than 1.1.
    • Ideal INR range for Atrial Fibrillation patients on Coumadin is 2.0 – 3.0; for those with mechanical heart valves, 2.5 – 3.5.

    D-Dimer Formation

    • D-dimer is formed when factor XIII cross-links fibrin monomers, leading to a stable fibrin mesh with blood cells.

    D-Dimer Test

    • A positive D-dimer test indicates the presence of a clot.

    Prolonged TT Causes

    • Can indicate fibrinogen disorders, heparin administration, or increased fibrin degradation products.

    Heparin vs. Coumadin

    • Heparin

      • Administered subcutaneously or intravenously; effective only in inpatient settings.
      • Inhibits the common coagulation pathway; monitored using APTT test.

    • Coumadin (Warfarin)

      • Oral medication for outpatient management.
      • Inhibits factors II, VII, IX, and X; inactive in vitro but effective in vivo.
      • Monitored using PT and INR tests.

    Laboratory Profiles in Coagulation Disorders

    • FDP+ and D-dimer+

      • Indicates formation of a clot (DIC).

    • FDP+ and D-dimer-

      • No clot formation; indicates secondary fibrinolysis with plasmin cleaving fibrinogen.

    Thrombolytics in Stroke and MI

    • Urokinase and streptokinase function similarly to tissue plasminogen activator (tPA), dissolving clots by converting plasminogen to plasmin.

    Disseminated Intravascular Coagulation (DIC)

    • Causes

      • Triggered by sepsis, tumors, immune disorders, drug reactions, snake/insect bites.

    • Pathophysiology

      • Unregulated activation of coagulation pathways leads to fibrin deposition and consumption of coagulation factors, resulting in bleeding.

    • Lab Findings

      • Prolonged APTT, PT, and TT; decreased fibrinogen and platelet count; increased FDP and D-dimer.

    • Treatment for DIC

      • Address underlying disease; administer heparin or recombinant protein C to manage coagulation; replace consumed factors with plasma and platelets; use antifibrinolytics for hyperfibrinolysis.

    Hemophilia A

    • Inherited deficiency of factor VIII leads to prolonged APTT with normal PT and TT.
    • Treatment Options
      • Cryoprecipitate, recombinant factor VIII, Hemlibra (emicizumab), Desmopressin.

    Von Willebrand Factor (VWF) Deficiency

    • Results in factor VIII breakdown and impaired platelet function, leading to increased bleeding time.
    • Lab findings mirror hemophilia A with prolonged APTT, normal PT and TT, and decreased factor VIII levels.

    Blood Component Therapeutics

    • Packed RBCs: Increase oxygen carrying capacity.
    • Plasma: Restores hemostasis and volume.
    • Platelets: Necessary for hemostasis.
    • Granulocytes: Boost neutrophil count to combat infection.
    • Cryoprecipitate: Treats fibrinogen deficiency and various bleeding disorders.

    Transfusion Guidelines

    • Massive transfusion defined as replacing ≥10 units or total blood volume within 24 hours.
    • Rh-negative patients: Only administer Rh-negative PRBCs, especially females of childbearing age.

    Direct and Indirect Antiglobulin Tests

    • DAT

      • Detects antibodies attached to RBCs; significant for conditions like HDN and HTR.

    • IAT

      • Tests recipient's blood for antibodies against donor RBC antigens.

    Rh Immune Globulin (RhoGAM)

    • Administered to Rh-negative mothers at 28 weeks and post-delivery if the baby is Rh-positive, preventing antibody production against Rh antigens.

    Monitoring Pregnancies with Rh-Negative Mothers

    • Regular assessments of bilirubin in amniotic fluid; utilize Doppler ultrasound for hemodynamic changes in fetal blood flow; conduct cordocentesis for blood analysis.

    Treatment for Fetal Hemolysis

    • Administer IVIG to protect fetal RBCs and consider intrauterine transfusions for severe anemia.

    Hemolytic Disease of the Newborn (HDN)

    • Results from maternal antibodies attacking fetal RBCs; leads to conditions like erythroblastosis fetalis and kernicterus.
    • Management involves RhIG to prevent maternal sensitization and other supportive therapies.

    Fetomaternal Hemorrhage Detection

    • Kleihauer-Betke staining identifies fetal RBCs in maternal circulation, quantifying the extent of FMH to guide RhoGAM administration.

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