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1
Pathology Services Handbook 2021
Hospital Sungai Buloh
2
Foreword
Pathology services play an important role in diagnostic
services and acts as part of crucial steps in the diagnosis,
prognosis and management of a disease. It is in line with our
hospital vision in which to provide world class patient care
including research and educational programs. I would like to
thank all the working committee of Pathology Department for
their commitment in preparing this 6th Edition of the HSgB
Pathology Services Handbook 2021. We hope that this will be
a great help and useful reference for clinicians and laboratory
staff requiring this service.
Kind Regards,
Dr Kuldip Kaur A/P Prem Singh
Hospital Director
Hospital Sungai Buloh
3
Preface
Pathology take pride in providing superior quality pathology
service to the medical profession. In the light of this, we
always strive to ensure our service users were well informed
of the preanalytical requirements for the tests offered. This
new edition of Pathology Handbook has added new tests,
specimen handling requirement for infectious diseases,
reviewed test schedule and turnaround time, and easy format
to ease user navigation. Though this handbook is mainly for
clinicians, it is also relevant for lab members and trainees
who needs to know the preanalytical requirements as well
as quick reference for tests. We welcome your feedback
regarding this publication and please feel free to contact the
laboratory with comments or criticism. We hope that you will
find this user–friendly reference guide very useful.
Kind Regards,
Dr Afifah Hj Hassan
Senior Consultant Pathologist &
Head of Pathology Department
Hospital Sungai Buloh
4
Contents General Information
Our Location 7
Scope of Service 8
List of Referral Labs 8
Operating Hours 9
Complaints & Concerns 9
Type of Request 10
Specimen Registration 12
Specimen Collection 13
Unmanaged Specimen 14
Specimen Transportation 16
Specimen Rejection Criteria 17
Result Reporting & Tracing 23
Tracing Outsource Results 24
Critical Result Notification 27
Lab Directory 29
Requesting Test During LIS Downtime 30
Sending for Covid-19 Specimen 32
Test offered during Covid-19 Outbreak 33
Requesting for Covid-19 RTK (Rapid Test Kit) Antigen 35
Chemical Pathology
Introduction 36
List of factors affecting tests results 37
Uncertainty of Measurements 38
Specimen Collection Chart 39
List of Tests (in–house) and Reference Interval 42
Therapeutic Drug Monitoring (TDM) Range 54
List of Tests (outsourced) 55
5
List of Request Forms 63
Patient Information Sheet for Glucose Tolerance Test (GTT) 64
Patient Instructions for the Collection of Mid–Stream Urine 65
Patient Instructions for the Collection of 24–Hour Urine 66
Medical Microbiology
Introduction 67
Specimen Collection Chart 67
Specific Collection Guideline 71
List of Test (in-house) 83
List of Test (outsourced) 92
List of Request Forms 101
Haematology
Introduction 102
Pre- Analytical Variables in Haematology Testing 103
Measurement of Uncertainty 104
Specimen Collection Chart 105
List of Tests (in–house) and Reference Interval 108
List of Tests (Outsourced) 111
List of Request Forms 121
Full Blood Count Reference Interval 124
Transfusion Medicine
Introduction 125
List of Test & Turn Around Time (TAT) 125
Blood Transfusion Procedures 126
Specimen Collection Chart 141
List of Request Forms 142
Histopathology & Cytology
Histopathology Procedures 143
Cytology Procedures 146
Tracing Histopathology & Cytology Results 150
6
Specimen Collection Chart 152
List of Tests (outsourced) 153
List of Request Forms 154
PLEASE NOTE: Information is subject to change without notice. For latest and most up-
to-date information, always refer online at https://hsgbuloh.moh.gov.my
7
Our Location Department of Pathology, Hospital Sungai Buloh provides medical laboratory
diagnostic and consultation services to the entire clinical services in the hospital
and external health facilities. The Department is located at Level 1, Block B of the
hospital, next to the Radiology Department.
All specimens in our lab were received at the Central Receiving Area (CRA) which
serves as the common centralized counter for the department, except for Blood
Transfusion services, where they have a separate reception counter adjacent to
the CRA. In CRA we checks, barcodes, sorts and process all specimens before
they are sent to specific laboratories for analysis. Here, we also supply special
containers or preservatives for certain tests.
Central Reception Area
8
Scope of Service
The scope of services offered including those that were outsourced are listed as follows:
Unit Scope of Services
Medical Microbiology Serology, Virology, Immunology, Bacteriology, Parasitology and Mycology
Chemical Pathology Routine Chemistry, Endocrine & Metabolic, Cardiac Markers, Tumour Markers, TDM, Toxicology, Dynamic Function Test, Special Proteins and Proteomics
Haematology Haemostasis, General and Specialised Haematology
Transfusion Medicine Supply of blood products and components.
Immunohematology tests will be outsourced to PDN
Histopathology & Cytology
Outsourced to Hospital Selayang, Hospital Kuala Lumpur, IMR and UiTM Sungai Buloh
List of Referral Labs Where tests cannot be performed in–house, we outsource the tests to various
referral labs. Please refer to respective unit section for the list of tests
outsourced. The labs were selected based on certain criteria to ensure quality is
maintained. The list of our referral labs include:
i. Institute of Medical Research (IMR)
ii. Hospital Kuala Lumpur (HKL)
iii. Pusat Darah Negara (PDN)
iv. Hospital Putrajaya
v. Hospital Selayang
vi. Hospital Ampang
vii. Chemistry Department of Malaysia
viii. UiTM Sg Buloh
ix. Makmal Kesihatan Awam Kebangsaan (MKAK) Sungai Buloh
9
Operating Hours
Internal specimens
Monday to Friday 8:00 am – 4:30 pm (for all tests offered)
Saturday After office hours tests only – Refer to Section Type
of Request Sunday & Public Holidays
External specimens
Monday to Friday 8:00 am – 4:30 pm (for all tests offered)
Saturday Urgent tests only – Refer to Section Type of Request
Sunday & Public Holidays
Complaints & Concerns Users wishing to raise a concern, make a complaint or compliment the
department may do so by scanning the QR code below and fill up the details:
If users need to discuss further, please contact the Quality Manager or Head of
Unit. Please refer to the Lab Directory section for contact details.
10
Type of Request
The scope of tests were grouped into 4 categories as follows:
Tests offered as urgent
Tests offered after office hour
Tests by batches / schedule
Tests by appointment
MICROBIOLOGY
• AFB stain
• BFMP
• Cryptococcal antigen
• CSF Bacterial antigen
• Microfilaria (Blood film)
• Stool for ova & cyst
• Stool for microscopy examination
• Infective screening (Needle Stick Injury case)
• Merscov–PCR
• AFB stain
• BFMP
• Cryptococcal antigen
• CSF Bacterial antigen
• Microfilaria (Blood film)
• Stool for ova & cyst
• Stool for microscopy examination
• All culture & sensitivity
• Molecular
• Serology
Refer to Section Microbiology
CHEMICAL PATHOLOGY
• BUSE
• Creatinine
• Bilirubin
• ALT
• ALP
• AST
• LDH
• Amylase
• Calcium
• Ammonia
• Lactate
• CSF Biochemistry
• hs–Troponin I
• Urine Paraquat
• Acetaminophen
• Salicylate
• BUSE
• Creatinine
• Serum Bilirubin
• ALT
• ALP
• AST
• LDH
• Amylase
• Calcium
• Ammonia
• Lactate
• CSF Biochemistry
• hs–Troponin I
• Urine Paraquat
• Acetaminophen
• Salicylate
• FSH, LH, Progesterone, Oestradiol, Testosterone (Tuesday)
• Tumour markers (Thursday)
• Iron, Transferrin, Folate, B12 (Wednesday & Friday)
11
Tests offered as urgent
Tests offered after office hour
Tests by batches / schedule
Tests by appointment
HEMATOLOGY
• FBC
• FBP
• PT
• APTT
• Fibrinogen
• D–Dimer
• FBC
• FBP
• PT
• APTT
• Fibrinogen
• ESR
• G6PD Screening
• D–Dimer
• Hb Analysis
• Bone Marrow Aspiration
• Bone Marrow Trephine Biopsy
• Kleihauer test
• Mixing Test
TRANSFUSION SERVICES
• First stage Crossmatch
• Antibody Identification (send to PDN)
• GSH
• GXM
• Antibody Identification (send to PDN)
• Phenotype Blood for Thalassemia Patient
• Rhesus Negative for Elective OT Cases
• Rare phenotype blood (Anti–JK3, etc.)
HISTOPATHOLOGY AND CYTOLOGY (OUTSOURCED)
• Unstained slides (for special staining, etc.)
12
Specimen Registration All tests can be requested through CA (Clinical Access) in Hospital Information
System (HIS). Clinical summary and diagnosis in the clinical comment must be
clearly entered and abbreviations are discouraged.
For specimens which need to accompany by request form, all the necessary
information listed below MUST be filled in completely:
a. Patient’s identification data (Name, I/C or passport number, hospital number,
age and gender)
b. Relevant clinical summary and diagnosis
c. History of administration of drug, where relevant
d. Ward or clinic and hospital’s official rubber stamp
e. Name of test requested
f. Type of specimen and anatomic site of origin, where appropriate
g. Special timing of specimen collected, where indicated
h. Doctor’s name and signature
Incomplete form filling may delay the specimen processing which subsequently
delay the final report
13
Specimen Collection Correct containers for each specimen or test requested must be ensured at all time.
Correct labelling of all specimens is essential as per MS ISO 15189 requirements.
Patient name, hospital number and test name are the minimal requirements on the
specimen. This must be clearly written or available on the printed barcode.
All specimen containers for each patient should be put in one biohazard plastic bag.
For test that were outsourced, the biohazard bag should be stapled together with
the accompanied request form.
Barcoding of samples
The Chemical Pathology lab has started implementing full automation starting
April 2021. Hence, with the sample track system, all tubes were changed to 5 ml
to allow the system to read the barcode on the sample. See details below on how
to stick the barcode on the sample. Failure to adhere to this will result in delayed
anlysis
3 cm dari atas tiub
2.5 cm dari bawah tiub
14
Unmanaged Specimen For all tests ordered in the CA, it must be managed (specimen collection and
despatch) prior sending to the lab as unmanaged specimen could not be
recognized in the lab and therefore impossible to register in our Laboratory
Information System (LIS).
LIS system prompt on Unmanaged Samples
All these unmanaged specimens will be
retained for a certain period to allow for the
wards to manage it. After a certain period, if
the samples were still not managed, it will be
discarded as the specimens are no longer
suitable for analysis. It is very important that
the requester in the wards and clinics to
ensure that all samples are managed
before sending to the lab.
15
How to Manage Samples
1. Click Place Order
2. Select Record Collection
3. Select Record Dispatch
16
Specimen Transportation All specimens must be packed appropriately before sending to the laboratory.
Where indicated, use dry ice instead of wet ice. All specimens must be sent to
laboratory immediately via porter or pneumatic tube with exception for some tests.
Tests or specimen that need to be sent manually includes:
i. Histopathology & Cytology
ii. Blood C&S
iii. Blood Gases
iv. 24–hour urine
v. Ammonia & Lactate
vi. Transfusion Reactions Workout
vii. Blood & Blood product
viii. ESR tube
ix. Specimen in Sterile Urine Container
x. CSF Bijou Bottle
17
Specimen Rejection Criteria Samples that do not meet criteria will be rejected. All rejection shall be informed by phone or via rejection slip to notify.
1. Counter
All specimen will be screened at the counter upon receipt, before sent to each respective Unit to be processed or analysed. Below is the list of rejection criteria at the counter:
1. Order cancelled by doctor
2. Unreadable barcode (please refer to table below for examples)
3. Tests which cannot be shared in one container received in one container
4. Test not offered
5. Temporarily no reagent
6. Tube cracked/broken while spinning
7. Empty container received
8. Specimen leakage
9. Specimen not in ice (ammonia & lactate)
10. Delayed in sending blood more than 2 hours
11. Unmanaged specimen more than 1 hour
12. Need separated barcode
13. Improper barcode labelling
14. Mislabelling of specimen
15. Double sticker of different ID
16. Wrong container / tube
17. Tube/container not labelled
18. No request form attached
19. Wrong request form
20. Wrong test request
21. Test requested not stated in the form
22. No requesting Dr's name/not clear
23. Incomplete request form
24. SYSTEM House Cleaning
18
Causes of unreadable barcode
Barcode issues
Poor distribution of ink on this
test tube barcode label has
resulted in some white spots
within the bar elements, which
may lead to readability issues.
Please contact Unit IT if this
happens.
Barcode were paste
horizontally or slanted which
cannot be read by the
instrument.
Barcode were pasted on the
cap and impossible to read
Barcode were pasted
overlapped and impossible to
read
19
In the respective unit, the specimen and test will be screened again. Rejection can be done before the specimen are processed, while its being processed and after it has been processed. The rejection criteria differs according to test in the Unit:
2. Chemical Pathology
1. Duplicate order
2. Blood clotted
3. Insufficient sample
4. Contaminated specimen
5. Specimen leakage
6. Blood haemolysed
7. Empty container received
8. No sample received
9. Mucoid specimen
10. Lipemic sample received
11. Icteric sample received
12. Unsuitable sample for analysis
13. CSF heavy blood stained
14. Urine pH >4 for 24 hrs urine metanephrine
15. Total urine volume for 24 hrs urine metanephrine < 750ml
16. HbA1C requested less than 3 months from previous request
17. Urine pH >4 for 24h urine catecholamine
18. No clinical indication
19. No clinical history/patient diagnosis
20. Delayed in sending ABG more than 30 mins
21. Specimen not in ice (ammonia & lactate)
22. Delayed in sending blood more than 2 hours
23. Need separated barcode
24. Test not offered
25. Temporarily no reagent
26. Order cancelled by doctor
27. Interface down
28. SYSTEM House Cleaning
20
3. Hematology
1. Duplicate order
2. Blood clotted
3. Delayed in sending FBC more than 2 hrs
4. Delayed in sending FBP more than 4 hrs
5. Delayed in sending PT/APTT more than 2 hrs
6. CD4/CD8 – less than 4 months
7. Insufficient sample
8. Icteric serum received
9. Lipemic sample received
10. Blood haemolysed
11. Unsuitable sample for analysis
12. Wrong tube/container
13. No clinical indication
14. No clinical history/patient diagnosis
15. Temporarily no reagent
16. No MO code
17. No request form attached
18. Incomplete request form
19. Order cancelled by doctor
20. Interface down
21. SYSTEM House Cleaning
3. Transfusion Medicine
1. Duplicate order
2. Blood clotted
3. No MO code
4. Improper barcode labelling
5. Need separated barcode
6. Insufficient sample (less than 3mls)
7. Blood haemolysed
8. Lipemic sample received
9. Wrong tube/container
10. Unsuitable sample for analysis
11. Post transfusion sample
12. No clinical indication
21
13. No clinical history/patient diagnosis
14. Test not done (empty blood bag received)
15. Incorrect information
16. No request form attached
17. Incomplete request form
18. Order cancelled by doctor
19. SYSTEM House Cleaning
4. Microbiology
1. Duplicate order
2. Mislabelling of specimen
3. Blood clotted
4. Delayed in sending blood more than 2 hrs
5. Delayed in sending urine C&S more than 2 hrs
6. Insufficient sample
7. Lipemic blood received
8. Blood haemolysed
9. CSF heavy blood stained
10. Salivary specimen
11. Contaminated specimen
12. Unsuitable sample for analysis
13. Test not offered
14. Temporarily no reagent
15. No thin film received
16. No thick film received
17. Need separate barcode
18. Earlier BFMP positive
19. Earlier AFB positive
20. Wrong test request
21. No clinical indication
22. No clinical history/patient diagnosis
23. No request form attached
24. Wrong request form
25. Incomplete request form
26. Wrong container/transport medium
27. No sample received
28. Empty container received
29. Incorrect information
22
30. Wrong order at receiving counter
31. Order cancelled by doctor
32. SYSTEM House Cleaning
4. Outsource
1. Duplicate order
2. Insufficient formalin
3. Improper barcode labelling
4. Mislabelling of specimen
5. Wrong test request
6. No clinical indication
7. No clinical history/patient diagnosis
8. Order cancelled by doctor
9. No request form attached
10. No request form attached
11. Wrong request form
12. Incomplete request form
13. No specialist signature on request form
14. Incorrect information
15. Order cancelled by doctor
16. SYSTEM House Cleaning
23
Result Reporting & Tracing
Result Reporting
All results requested via the CA can be viewed in the HIS. For outsourced tests,
results can be viewed in specific outsourced folder. For external results, results will
be printed out and send to the respective institution by post or dispatch via porter.
Result Tracing
Any inquiry regarding result, kindly call the RESPECTIVE unit i.e. Chemical
Pathology, Microbiology, Haematology, Transfusion Medicine and Histopathology
/ Cytology. Refer to the Lab Directory
Result tracing will only be entertained if the result has exceeded its turnaround time
(TAT). Please refer to each tests’ TAT in respective unit section
24
Tracing Outsource Results
1. Copy the unique number as stated in the eHIS system (refer picture below)
2. Go to MY COMPUTER PUBLIC FOLDER ‘OUTSOURCE PATHOLOGY RESULTS’ folder
25
3. Click ‘Search’ ‘All Files and Folder’
4. Paste the copied number in the column as shown below.
26
5. List of result/s (PDF form) will be shown
27
Critical Result Notification All critical limit results shall be informed to respective ward or clinic once the result is ready. Refer to list below for the critical limits that shall be informed.
Test Critical Limit
Lower Limit Upper Limit
ADULT
Potassium < 2.8 mmol/L > 6.0 mmol/L
Sodium < 125 mmol/L > 155 mmol/L
Calcium < 1.5 mmol/L > 3.0 mmol/L
Hemoglobin < 6.0 g/dL > 19.0 g/dL
Hematocrit < 0.2 > 0.6
Platelet < 20 X 103 / µL > 1000 X 103 / µL
PEDIATRIC
Potassium < 2.8 mmol/L > 6.0 mmol/L
Sodium < 125 mmol/L > 155 mmol/L
Calcium < 1.7 mmol/L >3.1 mmol/L
Ammonia - >100 µmol/L
Bilirubin - > 300 µmol/L
Hemoglobin < 7.0 g/dL > 20.0 g/dL
Hematocrit < 0.20 > 0.40
Platelet < 50 X 103 / µL > 1000 X 103 / µL
WBC < 2.0 X 103 / µL > 50 X 103 / µL
NEONATES
Hemoglobin < 8.0 g/dL > 22.0 g/dL
Hematocrit < 0.25 > 0.70
Reference: Pekeliling KPK KKM Bil 3/2016: Penambahbaikan Malaysian Patient Safety Goals No 8: To improve clinical communication by implementing critical value programme
28
Critical Value Notification Policy
1. Only first time critical value will be reported
2. The authorised receiver shall only be:
a. Specialist
b. Medical Officer
c. Postgraduate Medical Officer
d. Nurse (SN & JM)
3. Result shall be reported according to the location specified on the form/
request. It is the responsibility of the requester to inform the subsequent ward
where the patient was transferred
4. If location is not specified, result shall not be informed
5. The first person who receives the notification shall accept and take the call
even though the patient is not under his/her care. The same applies in the event
the patient has transferred to other location.
6. The waiting time shall be until the ringing ends. Lab shall make second attempt
after 5 to 10 minutes after the first call. Only 2 call attempts shall be made for
each notification
29
Lab Directory
Staff / Location Position / Unit Ext. Number
Pathology Fax Number Admin 03-61562645
Clerk / General Office Admin 2100 / 2103
Dr Afifah Haji Hassan Head of Department 4236
Dr Tuan Suhaila Tuan Soh Clinical Microbiologist 2130
Dr Adilahtul Bushro Clinical Microbiologist / QM I 2140
Dr Nur Izati Clinical Microbiologist 2149
Dr Nur Hanani Clinical Microbiologist 2149
Dr Idimaz Hajar Clinical Microbiologist 2162
Dr Syarifah Khairul Atikah Chemical Pathologist 7020
Dr Firdaus Mashuri Haematologist / QM II 7020
Dr Nor Khairina Haematologist 2150
Dr Sarojini Transfusionist 2150
Medical Officers’ Room MO 2141 / 2147
Scientific Officers’ Room Biochemist / Microbiologist 2108 / 2109 / 2110
Senior MLT –
2111 / 2114 / 2115
Counter Receiving Area (CRA) – 2121
Microbiology Lab Culture & Sensitivity 2128 / 2129
Parasitology 2127
Mycology 2136
Molecular (PCR / Viral Load) 2131
Serology / Virology 2139 / 2148
Media 2132
Chemical Pathology Lab Routine Chemistry & HbA1c 2119
Haematology Lab Routine Test & BMT 2116
FBP / MO in charge 2117
G6PD / CD4 / CD8 2152
Blood Transfusion Lab Blood Bank Lab 2154
MO in charge 2151
Outsource & HPE MO in charge 2122
30
Requesting Test During LIS Downtime
LIS Downtime is a condition where the LIS in the lab cannot be used to perform the
lab processes that was LIS–assisted. All samples will need to be registered,
barcoded, processes and validated manually. Since the processes are laborious,
only limited samples are able to be processed during downtime. The test which can
be requested during downtime is listed below.
Unit 8 a.m. – 5 p.m. 5 p.m. – 8 a.m. Including Saturday, Sunday and
Public holiday
Medical Microbiology
All tests • Cultures
• Serology & Virology
• NS1 Antigen
• Dengue rapid
• Organ transplant
• Needle Stick Injury (NSI)
• BFMP
• AFB
Chemical Pathology
All tests
Note: Batch tests will still be run according to its schedule
• BUSE
• Creatinine
• ABG
• Amylase
• Lactate
• Ammonia
• Calcium
• Bilirubin
Haematology • FBC
• PT/APTT
• Fibrinogen
• G6PD
• FBC
• PT/APTT
• Fibrinogen
Note: For other tests, kindly call
MO/Specialist to request
Blood Transfusion Service
• GSH
• GXM
• Antibody Identification
• GSH
• GXM
• Antibody Identification
Histopathology & Cytology
All tests None
31
LIS Downtime Procedure
After 30 mins of downtime, IT will activate Business Continuity Plan (BCP) manual form
Send all samples using Per-Pat 301 form (3 copy);
regardless barcode has already been generated or not, with exception for transfusion; use GXM manual form
Note:
• Send separate Per-Pat 301 form for each unit’s test
• All outsourced samples (without barcode/not registered) during downtime are advised to hold from sending to the lab until system recover to avoid problem
Fill up Per-Pat 301 form with all the following details:
Patient’s identification data (Name, I/C or passport number, hospital number, age and gender)
Relevant clinical summary and diagnosis
History of administration of drug, where relevant
Ward or clinic and hospital’s official rubber stamp
Name of test requested
Type of specimen and anatomic site of origin, where appropriate
Special timing of specimen collected, where indicated
Doctor’s name and signature
Note: Please ensure LOCATION is specified as result will be dispatched according to location
Note:
Collect the hard copy results at the counter
• Please expect delay in TAT as all processes were done manually
• We do not encourage tracing during downtime as all manpower will be mobilised for manual work processes
32
Sending Covid-19 Specimen General workflow for Covid-19 samples
DO’S DON’TS
1. Collect Specimen
Note: For Paediatrics (< 8 yrs.)
FBC & G6PD, use elevated
EDTA Paediatric microtainer
DO NOT open the tube cap
(loose cap will cause spillage during
centrifugation)
DO NOT use normal paediatric
microtainer
2. Label Specimen
DO NOT wrap the
tube with gauze/ plaster
3. Put into double biohazard plastics
For Hematology & Biochemistry DO NOT put into cylinder
tube Cylinder tube can ONLY be used for Microbiology
4. Put the biohazard plastic into polystyrene box
Note:
• Hematology and biochemistry samples from multiple patients can share the same polystyrene box.
• For Microbiology samples, use separate polystyrene box
5. Label the box with patients’ stickers
Note: Ensure barcodes on box matches the samples
6. Seal the box and send by to the lab by porter.
Note: DO NOT use pneumatic tube for Covid-19 samples
33
Test Offered During Covid-19 Outbreak
Unit Tests Specific Requirements
Medical Microbiology
All tests None
Chemical Pathology
All test EXCEPT:
• HbA1c – will be suspended (in eHIS)
• Batch test (hormones, tumour marker)
• Serum / urine osmolality
• 24 hours urine chemistries
• 24 hours urine protein will be advised for Urine PCI
• Ferritin for Routine monitoring (from haemodialysis unit and Thalassemia clinic)
Procalcitonin Daily
Ferritin Daily
ABG Will be done at POCT location
Test to be OUTSOURCED:
• Digoxin (Hospital Selayang)
• Urine myoglobin (IMR)
Haematology FBC • Send Paediatric samples in Elevated K2EDTA microtainer (Pierceable cap)
G6PD • Daily (9 am)
PT/APTT • Received once patients getting ill
FBP (Full Blood Picture) • By appointment with Haematologist
• (Urgent cases only; To rule out hemolysis, Acute Leukemia)
D-dimer • Daily
• Ordered by Specialists only
Fibrinogen • Done together with D-Dimer
34
• Use derived method
CD4/CD8 • Not indicated
Blood Transfusion Service
As usual
Histopathology & Cytology
As usual
35
Requesting for Covid-19 RTK (Rapid Test Kit) Antigen
Inform MO Covid at 2128 / 2129 (8 a.m. to 5 p.m.) or MO on-call Microbiology (after office hours)
Wear appropriate PPE
Swab using NPS without VTM
Order in system: Test: Covid-19 Antigen Type of Specimen: NPS without VTM Form: PER-PAT-301
Send to Microbiology Lab with triple packaging
36
Chemical Pathology
Introduction
The unit offers a full service, including: General Biochemistry, Hormones, Anaemia
Profiles, Tumour Markers, HbA1C, Urine analyses, Therapeutic Drug Monitoring,
Special Protein & Immunology, hs–Troponin I and Osmometry. List of tests and
specimen requirements for each test is described in the Chemical Pathology list of
tests section.
All analytes are monitored by extensive external assurance schemes including
RIQAS and EQAS. A full programme of internal quality assurance also operates.
All reports issued to clinicians are reviewed by the chemical pathologist, medical
officers, clinical biochemist and medical lab technologists; and clinical interpretation
are provided by the chemical pathologist when appropriate. All critical abnormal
results are communicated to clinical staff.
The laboratory has expertise to advise users concerning the selection and
installation of instruments for point of care testing. The laboratory manages POCT
through the Hospital POCT Committee. Quality Performance monitoring (IQC and
EQA) and audit is conducted by the lab regularly.
Analytical / biological factors affecting the performance of tests
There are many factors which may cause an interference in the performance of a
test including physiological aspects such as age and sex of the patient, whether
patient is supine or erect, fasting or non–fasting. In general reference ranges will
allow for these factors. The table below indicates some common analytical factors
which can cause an interference, but the list is by no means exhaustive.
37
List of factors affecting tests results
Factors Precautions
Hemolysis Avoid shaking blood tubes which may cause trauma to the red cells (for tubes containing anti-coagulant, gently invert the tubes 3 times immediately on collection).
Never inject a syringe needle into the vacutainer to empty the syringe.
Avoid extremes of temperature. Hemolysis badly affects, potassium, folate, bilirubin, AST, ALT, LDH, CK, Mg, PO4
Contamination Avoid taking blood from the arm where an IV infusion has been set up, which can cause a dilution effect of most analytes also depending on the infusion may increase glucose, sodium and potassium levels.
Avoid decanting blood from one tube to another. Blood requiring K+EDTA preservative must be taken after samples for Chemistry tests (serum separator tubes, SST). K+EDTA will badly affect potassium, calcium, ALP
Venous Constriction Avoid a tourniquet where possible or at least keep its use to a minimum. Constriction can badly affect calcium, lactate, electrolytes, proteins
Icterus Icterus can badly affect Creatinine, Cholesterol, Ammonia, Triglycerides
Lipaemia Lipaemia can badly affect sodium, Ammonia, ALT, AST, Salicylate
Drugs It is not possible to list all the drugs that may cause interference in analysis. Advice can be obtained from the Clinical laboratory staff if required
Delay in transit of specimens (more than 4 hr)
Delays in transit can cause significant changes in analyte concentrations. The most commonly affected analyte is potassium, but others could also be affected
Incorrect specimen received Ensure the correct blood collecting tube is used to take the sample.
38
Uncertainty of Measurements
Biochemical tests are subject to a degree of uncertainty in their measurement. This
may be due to a variety of factors including:
Biological variation within individuals
Analytical measurement imprecision
Pre–analytical factors
Please contact the Chemical Pathology Unit if you wish to know or discuss the
uncertainty values for each analyte measured in the laboratory
39
Collection Chart – Chemical Pathology
Tube / Container Sample/Tube Description
Common Use Special Instruction
Adult
Serum / SST Gel
Clinical Chemistry:
Routine Biochemistry analysis.
Special Protein & Immunology:
C3, C4, hs–CRP, RF, ASOT
Anaemia Profiles: Iron, Transferrin, Ferritin & Folate, B12
Mix sample gently 8 – 10 times
Then stand for 15 mins before centrifuging
Paeds
Hs–Trop I Tumour Markers Hormones
Adult
Paeds
Whole blood / K2EDTA
HbA1c (Glycosylated Haemoglobin)
Mix sample gently 8 – 10 times
40
Tube / Container Sample/Tube Description
Common Use Special Instruction
Adult
Paeds
Plasma / Sodium fluoride
Clinical Chemistry:
Glucose testing, GTT Mix well gently.
Please specify if fasting or non–fasting and any glucose load given to patient
Lithium Heparin Specialised test (Outsourced):
Plasma Amino acid
Mix sample gently 8 - 10 times
Heparinised syringe
Blood Gases Mix Well. Please send samples in slurry ice water
41
Tube/Container Tube Description
Common Use Special Instruction
Bijou sterile bottle
CSF biochemistry and body fluids biochemistry
Please ensure cap is tight and secure
Sterile urine container
Urine and other body fluids biochemistry
Please ensure cap is tight and secure
Dried blood spot NA NA
24 hr urine sterile container
24 hr urine chemistries Additives will be added by lab staff depending on the test requested
42
List of Test (in–house) & Reference Interval
Test Sample Container
TAT Reference Interval Remarks
Acetaminophen Plain tube 2 hrs Therapeutic level 9.98 – 19.95 ug/mL
Toxic level >15 ug/mL
Alanine Transaminases (ALT/ SGPT)
Plain tube / Heparinised
4 hrs 10 – 49 U/L
Albumin Plain tube / Heparinised
4 hrs 32 – 48 g/L
Albumin to Creatinine ratio, strip
Spot urine in Sterile urine container
4 hrs < 3.4 mg/mmol
Alkaline phosphatase (ALP)
Plain tube / Heparinised
4 hrs 46 – 116 U/L
Alpha Fetoprotein (AFP) Plain tube 5 working days
< 8.1 ng/mL Run every Thursday
Ammonia EDTA 60 mins 11 – 32 μmol/L (adults) Send in ice
Amylase, serum Plain tube / Heparinised
4 hrs 30 – 118 U/L
Amylase, urine (Diastase)
Sterile urine container
4 hrs ≤ 650 U/L
Anti–streptolysin ‘O’ Titre (ASOT)
Plain tube / Heparinised
4 hrs Children preschool
≤100.0 IU/mL Children school age ≤ 250.0 IU/mL Adult
≤ 200.0 IU/mL
Aspartate Transaminase (AST)
Plain tube/ Heparinised
4 hrs 34 U/L
Beta HCG (Quantitative) Plain tube 60 mins Non-pregnant females
1.5 – 4.2 mIU/mL
Bilirubin, direct Plain tube / Heparinised
4 hrs ≤ 5 μmol/L
Bilirubin, total Plain tube / Heparinised
4 hrs 0 – 1 day <137 μmol/L 1 – 2 days <205 μmol/L 3 – 5 days <274 μmol/L
> 5 days – 60 years 5 – 21 μmol/L 60 – 90 years
43
Test Sample Container
TAT Reference Interval Remarks
3 –19 μmol/L > 90 years
3 – 15 μmol/L
Blood Gases (Arterial / Venous)
Heparinised syringe
60 mins pH
7.35 – 7.45 pCO2 35 – 45 mmHg Base Excess –2.0 – +2.0 mmol/L Actual Bicarbonate 22.0 – 28.0 mmol/L Total CO2 22.0 – 28.0 mmol/L pO2 80 – 100 mmHg Oxygen Saturation
95.0 – 98.0 %
Send in slurry ice
Body fluids biochemistry (pleural / peritoneal / synovial)
Sterile urine container
4 hrs Reference interval for body fluids are not available
Calcium, serum Plain tube 4 hrs 2.08 – 2.65 mmol/L
Calcium, urine 24 hr 24 hr urine container
4 hrs 2.50 – 7.50 mmol/day
Cancer Antigen (CA125) Plain tube 5 working days
<35 U/mL Run every Thursday
Carbamazepine Plain tube without gel
60 mins Therapeutic level 16.9 – 50.8 μmol/L
Carbohydrate Antigen (CA19–9)
Plain tube 5 working days
<37 U/mL Run every Thursday
Carcinoembryonic Antigen (CEA)
Plain tube 5 working days
<5 ng/mL Run every Thursday
Chloride, 24 hr urine 24 hr urine container
4 hrs 110 – 250 mmol/day
Chloride, serum Plain tube 4 hrs 98 – 107 mmol/L
Cholesterol, total Plain tube 4 hrs Risk level Desirable < 5.2 mmol/L Borderline 5.2 – 6.1 mmol/L High
≥ 6.2 mmol/L
Complement C3 Plain tube 4 hrs Newborns
0.60 – 1.10 g/L 3 months
44
Test Sample Container
TAT Reference Interval Remarks
0.70 – 1.20 g/L 6 months
0.70 – 1.40 g/L
Complement C4 Plain tube 4 hrs 0.12 – 0.36 g/L
Cortisol, serum Plain tube 4 hrs Morning (7 – 9 am)
145.4 – 619.4 nmol/L Afternoon (3 – 5 pm) 94.9 – 462.4 nmol/L
Cortisol, urine 24 hr 24 hr urine container
4 hrs 57.7 – 806.8 nmol/day
C–Reactive protein, high sensitive
Plain tube 4 hrs <1.0 mg/dL
Creatine kinase (CK) Plain tube 4 hrs Males 46 – 171 U/L Females 34 – 145 U/L
Creatinine Plain tube / Heparinised
4 hrs Males 62 – 115 μmol/L Females 49 – 90 μmol/L
Creatinine clearance 24 hr urine container & Plain tube
4 hrs
Creatinine, urine 24 hr 24 hr urine container
4 hrs Males
8.4 – 22 mmol/day Females 5.3 – 15.9 mmol/day
CSF Protein Sterile urine container / Bijou container
60 mins 0.08 – 0.32 g/L
CSF Chloride Sterile urine container / Bijou container
60 mins 116 – 130 mmol/L
CSF Glucose Sterile urine container / Bijou container
60 mins Adult 2.2 – 3.9 mmol/L Infant / child 3.3 – 4.4 mmol/L
Concurren t Random
Blood Sugar
(RBS) test
CSF Lactate Fluoride Oxalate
60 mins 1.2 – 2.1 mmol/L
Estradiol Plain tube 5 working days
Adult Reference Interval Run every Tuesday
45
Test Sample Container
TAT Reference Interval Remarks
Female
Follicular Phase 71.6 – 529.2 pmol/L Luteal Phase 240.8 – 786.1 pmol/L Mid luteal phase 234.5 – 1309.1 pmol/L Post–menopausal
ND – 118.2 pmol/L Male ND – 146.1 pmol/L
Pediatric Reference Interval
Female 2 – 3 years
<43.3 – 106.8 pmol/L 4 – 9 years <43.3 – 160.3 pmol/L 10 – 11 years
<43.3 – 644.5 pmol/L 12 – 21 years 59.1 – 874.6 pmol/L
Male 2 – 3 years <43.3 – 188.6 pmol/L 4 – 9 years
<43.3 – 97.1 pmol/L 10 – 13 years <43.3 – 134.4 pmol/L 14 – 21 years
<43.3 – 179.5 pmol/L
Ferritin Plain tube 4 hrs Males
22 – 322 ng/mL Females 10 – 291 ng/mL
Folate Plain tube 3 working days
Deficient 0.79 – 7.63 nmol/L Indeterminate 7.64 – 12.19 nmol/L Normal 12.19 – 46.4 nmol/L
Run every Wednesda
y
46
Test Sample Container
TAT Reference Interval Remarks
Follicle–stimulating hormone (FSH)
Plain tube 5 working days
Adult Reference Interval
Female Follicular phase
2.5 – 10.2 IU/L Mid cycle Peak
3.4 – 33.4 IU/L Luteal phase 1.5 – 9.1 IU/L Pregnant
<0.3 IU/L Post–Menopausal 23.0 – 116.3 IU/L
Male 13 – 70 years 1.4 – 18.1 IU/L
Pediatric Reference Interval
Female 2 – 3 years 1.3 – 5.0 IU/L 4 – 9 years 0.5 – 5.0 IU/L 10 – 11 years 1.4 – 9.3 IU/L 12 – 21 years 2.2 – 10.1 IU/L
Male 2 – 3 years <0.3 – 1.3 IU/L 4 – 9 years 0.4 – 2.0 IU/L 10 – 13 years 0.4 – 4.6 IU/L 14 – 21 years
1.4 – 7.5 IU/L
Run every Tuesday
Gentamicin Plain tube 4 hrs Peak level 8.64 – 21.6 μmol/L
Globulins, qualitative Plain tube 4 hrs
Glucose tolerance test Fluoride Oxalate
Fasting <6.1 mmol/L 2 hours post prandial <7.8 mmol/L
Please mix well
47
Test Sample Container
TAT Reference Interval Remarks
Glucose, 2 hr post prandial
Fluoride Oxalate
4 hrs <7.8 mmol/L Please mix well
Glucose, fasting Fluoride Oxalate
4 hrs <6.1 mmol/L Please mix well
Glucose, random Fluoride Oxalate
4 hrs <11.1 mmol/L Adults 4.1 – 5.9 mmol/L Newborn 2.2 – 3.3 mmol/L Newborn (1 day) 2.8 – 4.4 mmol/L Child 3.3 – 5.6 mmol/L
Please mix well
Glucose, urine 4 hrs < 2.8 mmol/day
Hemoglobin A1c EDTA 5 working days
Normal < 5.6 % Prediabetes 5.6 – 6.2 % Diabetes > 6.3 %
High density lipoprotein cholesterol (HDL-C)
Plain tube 4 hrs <1.03 mmol/L
Interleukin-6 (IL6) Plain tube 24 hours
2.7 - <4.4 pg/mL
Iron Plain tube 3 working days
Male
11.6 – 31.3 μmol/L Female 9.0 – 30.4 μmol/L
Run every Wednesda y & Friday
Lactate Dehydrogenase Plain tube / Heparinised
4 hrs 120 – 246 U/L
Lactate, plasma Fluoride Oxalate
60 mins 0.50 – 2.20 mmol/L Send in ice
Low density lipoprotein cholesterol (LDL–C)
Plain tube 4 hrs <3.0 mmol/L
Luteinising Hormone (LH) Plain tube 5 working days
Adult Reference Interval
Female Follicular phase
1.9 – 12.5 IU/L Mid cycle Peak 8.7 – 76.3 IU/L Luteal phase 0.5 – 16.9 IU/L
Pregnant <0.1 – 1.5 IU/L
Run every Tuesday
48
Test Sample Container
TAT Reference Interval Remarks
Post–Menopausal 7.9 – 53.8 IU/L
Male 20 – 70 years 1.5 – 9.3 IU/L >70 years 3.1 – 34.6 IU/L Children <0.1 – 6.0 IU/L
Pediatric Reference Interval
Female 2 – 3 years <0.07 IU/L 4 – 9 years < 0.07 – 0.2 IU/L 10 – 12 years <0.07 – 11.8 IU/L 13 – 21 years
1.0 – 52.2 IU/L
Male 2 – 3 years
<0.07 IU/L 10 – 13 years <0.07 – 2.9 IU/L 14 – 21 years
1.0 – 7.1 IU/L
Magnesium Plain tube / Heparinised
4 hrs 0.66 – 1.07 mmol/L
Magnesium, 24 hr Urine 24 hr urine container
4 hrs 0.99 – 10.45 mmol/day
Osmolality, serum Plain tube 4 hrs 270 – 295 mOsm/kg
Osmolality, urine Sterile urine container
4 hrs 300 – 900 mOsm/kg
Paraquat, urine Sterile urine container
4 hrs Negative
pH, urine Sterile urine container
60 mins 4.5 – 7.5
Phenytoin Plain tube 4 hrs Peak level 39.6 – 79.2 μmol/L
49
Test Sample Container
TAT Reference Interval Remarks
Phosphate Inorganic Plain tube / Heparinised
4 hrs 0.78 – 1.65 mmol/L
Phosphate Inorganic, 24 hr urine
24 hr urine container
4 hrs 12.9 – 42.0 mmol/day (on restricted diet)
Potassium Plain tube/ Heparinised
2 hrs 3.5 – 5.1 mmol/L
Potassium, spot urine Sterile urine container
2 hrs
Potassium, urine 24 hr 24 hr urine container
2 hrs 25 – 125 mmol/day
Procalcitonin Plain tube 60 mins < 0.05 ng/mL
Progesterone Plain tube 5 working days
Males
0.89 – 3.88 nmol/L
Females 12 years
<0.67 – 5.53 nmol/L 13 – 21 years <0.67 – 39.43 nmol/L Follicular Phase
ND – 4.45 nmol/L Luteal Phase
10.62 – 81.28 nmol/L Mid luteal phase 14.12 – 89.14 nmol/L Post–menopausal
ND – 2.32 nmol/L
Pregnant 1st trimester 35.68 – 286.2 nmol/L 2nd trimester 81.25 – 284.29 nmol/L
3rd trimester 153.91 – 1343.55 nmol/L
Run every Tuesday
Prolactin Plain tube 5 working days
Adult Reference Interval
Females Non pregnant 59 – 619 mIU/L Pregnant 206 – 4420 mIU/L Post–menopausal 36 – 430 mIU/L Males
Run every Tuesday
50
Test Sample Container
TAT Reference Interval Remarks
45 – 375 mIU/L Pediatric Reference Interval
Females
2 – 3 years 65.7 – 332.8 mIU/L 4 – 9 years 66.6 – 334.1 mIU/L 10 – 16 years
75.0 – 386.7 mIU/L 17 – 21 years 89.9 – 489.7 mIU/L
Males 2 – 3 years 76.3 – 606.3 mIU/L 4 – 9 years
95.4 – 382.2 mIU/L 10 – 16 years 67.8 – 284.9 mIU/L 17 – 21 years
115.1 – 326.7 mIU/L
Prostate Specific Antigen, total
Plain tube 5 working days
<4 ng/mL Run every Thursday
Protein total, serum Plain tube / Heparinised
4 hrs 57 – 82 g/L
Protein, 24 hr urine 24 hr urine container
4 hrs 0.01 – 0.14 g/L
At rest 0.05 – 0.08 g/day After intense exercise 0.25 g/day
Rheumatoid factor (RF) Plain tube / Heparinised
4 hrs < 14 IU/mL
Salicylate Plain tube 4 hrs Toxic level >300 mg/L
Sodium Plain tube / Heparinised
4 hrs 136 – 145 mmol/L
Sodium, spot urine Sterile urine container
20 mmol/L
Sodium, 24 hr urine 24 hr urine container
4 hrs 40 – 220 mmol/L/24 hr
51
Test Sample Container
TAT Reference Interval Remarks
Testosterone Plain tube 5 working days
Adult Reference Interval
Male 21 – 49 years 5.72 – 26.14 nmol/L 50 – 89 years
3.00 – 27.35 nmol/L
Female Pre–menopause 0.42 – 2.06 nmol/L Post–menopause <0.24 – 1.70 nmol/L
Pediatric Reference Interval
Males 2 – 10 years <0.24 – 0.90 nmol/L 11 years <0.24 – 11.85 nmol/L 12 years <0.24 – 19.52 nmol/L 13 years 0.32 – 19.53 nmol/L 14 years 0.81 – 25.76 nmol/L 15 years 5.00 – 29.20 nmol/L 16 – 20 years
4.10 – 32.92 nmol/L
Females 2 – 10 years
<0.24 – 3.76 nmol/L 11 – 15 years <0.24 – 1.68 nmol/L 16 – 20 years
0.61 – 1.75 nmol/L
Run every Tuesday
Thyroid Stimulating Hormone (TSH)
Plain tube 24 hrs 1 – 23 months
0.87 – 6.15 mIU/L 2 – 12 years 0.67 – 4.16 mIU/L 13 – 20 years
0.48 – 4.17 mIU/L
Thyroxine, free (FT4) Plain tube 24 hrs Infants 1 – 23 month
12.1 – 18.6 pmol/L
52
Test Sample Container
TAT Reference Interval Remarks
Children 2 – 12 years 11.1 – 18.1 pmol/L Adult: 13 – 20 years 10.7 – 18.4 pmol/L
Transferrin Plain tube 3 working days
Males 2.15 – 3.65 g/L Females 2.50 – 3.80 g/L
Run every Wednesda y & Friday
Triglycerides, total Plain tube 4 hrs Normal 1.70 mmol/L
Borderline high 1.70 – 2.25 mmol/L High 2.26 – 5.64 mmol/L Very high ≥2.26 – 5.64 mmol/L
Tri–Iodothyronine free (FT3)
Plain tube 24 hrs Adult 3.5 – 6.5 pmol/L Infants 1 – 23 months 5.1 – 8.0 pmol/L Children 2 – 12 years 5.1 – 7.4 pmol/L
Troponin I, high–sensitive
Plain tube 60 mins Female < 38.64 pg/mL Male < 53.53 pg/mL
Urea Plain tube / Heparinised
4 hrs 3.2 – 8.2 mmol/L
Urea, 24 hr urine 24 hr urine container
4 hrs 0.43 – 0.71 mol/24 hr
Uric Acid Plain tube / Heparinised
4 hrs Male
220 – 547 μmol/L Female
184 – 464 μmol/L
Uric Acid, urine 24 hr 24 hr urine container
4 hrs 1.48 – 4.43 mmol/24 hr
Valproic acid Plain tube 4 hrs Therapeutic level 346 – 693 μmol/L
Vancomycin Plain tube 4 hrs Peak 12.4 – 17.9 µmol/L Trough 3.5 – 6.9 µmol/L
Vitamin B12 Plain tube 3 working days
Normal 156 – 672 pmol/L Deficient
Run every Wednesda y & Friday
53
Test Sample Container
TAT Reference Interval Remarks
24 – 181 pmol/L
Note:
• All tests were run daily, otherwise specified
• TAT for samples received from Klinik Kesihatan and other hospital is 5 working days and
10 working days for batch testing
• Reference interval that were not based on clinical decision limit are set according to the
methodology and equipment used. Therefore, it could vary between hospital.
• Reference interval for all outsourced test will follow the ranges specified by the perform
site/location.
54
Therapeutic Drug Monitoring (TDM) Range
Test Dosing umol/l mg/l
Amikacin Multiple Dosing
Peak Adult 34-51 20-30
Paeds
Trough Adult <17 <10
Paeds 3.4-8.5 2-5
Single Daily Dosing
Peak Adult 102 60
Paeds 34-51 20-30
Trough Adult <1.71 <1
Paeds 3.4-8.5 2-5
Gentamicin Multiple Dosing
Peak Adult 10.5-21 5-10
Paeds 10.5-25 5-12
Trough Adult <4.2 <2
Paeds <2.1 <1
Single Daily Dosing
Peak Adult 21-42 10-20
Paeds 11-25 5-12
Trough Adult < 2.1 <1
Paeds
Vancomycin Peak 17.3-27.6 25-40
Trough Non-complicated infection
6.9-10.4 10-15
Complicated Infection 10.4-13.8 15-20
Paediatric & neonates 6.9-13.8 10-20
Continuous Infection 10.4-17.3 15-25
Digoxin CHF 0.64-1.15 nmol/L 0.5-0.9 ng/ml
AF 1-2.5 nmol/L 0.8-2 ng/ml
Theophylline Apnoea / Bradycardia in neonates
27.75-55.5 5-10
Asthma / COAD 55.5-111 10-20
Valproic Acid Epilepsy 347-693 50-100
Psychiatry Disorder 347-866 50-125
Phenobarbitone Epilepsy 65-172 15-40
Refractory status epilepticus >302 (up to 431) >70 (up to 100)
Phenytoin 40-80 10-20
Carbamazepine 17-51 4-12
Reference:
1. Clinical Pharmacokinetics Pharmacy Handbook, Pharmaceutical Service Division, MOH, 2015 2. Basic Clinical Pharmacokinetic (Winter) 2004 3. Drug Doses, Frank Shann 16th Edition 2014 4. Drug Information Handbook 10th Edition 2003
55
List of Test (outsourced)
Please refer to website below for the latest list of tests offered by each referral lab:
1. HOSPITAL KUALA LUMPUR (GENERAL) http://www.hkl.gov.my/index.php/services/clinical-department?id=%20158
2. CHEMICAL PATHOLOGY, HKL http://www.hkl.gov.my/content/2020/Patologi/Unit%20Patologi%20Kimia/Chemical%20Pathology_ENGLISH.pdf
3. CORE LAB, HKL http://www.hkl.gov.my/content/2020/Patologi/Unit%20Makmal%20Teras/Core%20Laboratory%20Unit_BI.pdf
4. CLINICAL TOXICOLOGY, HKL http://www.hkl.gov.my/content/2020/Patologi/Unit%20Toksikologi/Toaxicology%20Unit_BI.pdf
5. HOSPITAL AMPANG https://hampg.moh.gov.my/images/DokumenJabatan/Patologi/Handbook_of_Pathology_Services_2017_5th_Edition.pdf
6. INSTITUTE MEDICAL RESEARCH (IMR) https://www.imr.gov.my/testlist
Test Perform Site / Referral Lab
Sample/ Container
Volume TAT (Working
days)
Forms / Special
Requirement
Adrenocorticotrophic Hormone
Chemical Pathology, HKL
Plain tube 3 ml 5 days PER–PAT 301
Aldosterone Endocrine Unit, Hospital Putrajaya
EDTA 4 ml 30 days PER–PAT 301
Alpha–1–Acid Glycoprotein
Unit Patologi Kimia, Hospital Ampang
Plain tube 3 ml 7 days PER–PAT 301
Alpha-1-antitrypsin Quantitation
Special Protein Unit, IMR (03-26162669 /2731)
Plain tube 3 ml 7 days Request Form for Multiple Myeloma and Specific Proteins
Alpha 1-Antitrypsin Deficiency (SERPINA1)
Molecular Diagnostic, IMR (03-26162540)
EDTA 1-2x2.5ml blood EDTA or dried blood spots
3 months
Request Form for Molecular Diagnostic Services Must have specialist Signature
By consultation only
56
Test Perform Site / Referral Lab
Sample/ Container
Volume TAT (Working
days)
Forms / Special
Requirement
Amino Acid (plasma) (for Amino acid disorders)
Biochemistry Unit, IMR (03-2616 2640 / 2649)
Lithium heparin (Send in ice)
2 ml 15 days Special Form (IEM Request Form)
Amino Acid (CSF) (for Amino acid disorders)
Biochemistry Unit, IMR (03–26162627 / 2498)
Sterile container
1 ml 15 days Special Form (IEM Request Form) Must send together with plasma
Amino Acid (Urine) (for Amino acid disorders)
Biochemistry Unit, IMR (03–26162792 / 2498)
Sterile container (Send in ice)
2 ml 15 days Special Form (IEM Request Form) After consultation only
Amikacin Chemical Pathology, Hospital Selayang
Plain tube 3 ml 3 days TDM Form
Anti-Mullerian Hormone Assay
Endocrine Unit, IMR (03-26162636 / 2644 / 2645)
Plain tube 2-3 ml 14 days PER–PAT 301 to be REQUESTED ONLY by O&G Specialist from Infertility Clinics/OBG clinics.
Anti–Thyroglobulin (anti-TG)
Chemical Pathology, Hospital Selayang
Plain tube 3 ml 7 days PER–PAT 301 Please provide relevant history & latest TFT result
Anti–thyroid Peroxidase (anti-TPO)
Chemical Pathology, Hospital Selayang
Plain tube 3 ml 7 days PER–PAT 301 Please provide relevant history & latest TFT result
57
Test Perform Site / Referral Lab
Sample/ Container
Volume TAT (Working
days)
Forms / Special
Requirement
Beta–2 Microglobulin Chemical Pathology, Hospital Ampang
Plain tube 3 ml/ 20 ml
7 days PER–PAT 301
Caeruloplasmin Chemical Pathology, HKL
Plain tube 3 ml 5 days PER–PAT 301
Cancer Antigen 15–3 (CA 15–3)
Clinical Toxicology, HKL
EDTA 3 ml 2 days PER–PAT 301
Carnitine Free & Total Biochemistry Unit, IMR (03–26162792 / 2498)
EDTA 2 ml 5 days PER–PAT 301
Cholinesterase Chemical Pathology, Hospital Selayang
Plain tube 3 ml 2 days PER–PAT 301
Copper, 24H urine Toxicology & Pharmacology Unit, IMR (03-26162626)
24H urine container
5 ml
14 days
PER–PAT 301 Samples must be collected using an appropriate container, free of heavy metal or trace elements
Copper, Serum Toxicology & Pharmacology Unit, IMR (03-26162626)
Plain tube 1-3 ml
C–Peptide Chemical Pathology, HKL
Plain tube 3 ml 5 days PER–PAT 301
By Appointment
Metanephrines, 24 hr Urine
Endocrine Unit, Hospital Putrajaya
24H urine container * Acidify with 10 ml of 25% HCl
- 30 days PER–PAT 301 Must have specialist signature
Cyclosporine Clinical Toxicology, HKL
EDTA 3 ml 5 days TDM Form
Dehydroepiandrostero ne Sulphate (DHEA–S)
Chemical Pathology, HKL
Plain tube 3 ml 10 days PER–PAT 301 Once a week
Panel Diabetes antibodies: Anti- Glutamic Acid Decarboxylase (GAD),
Endocrine Unit, IMR 03-26162636
Plain tube 3 ml 14 days PER–PAT 301 To be requested ONLY by endocrinologist / general physician
58
Test Perform Site / Referral Lab
Sample/ Container
Volume TAT (Working
days)
Forms / Special
Requirement
Anti-Insulinoma- associated Antigen 2 (IA2) & Anti Islet Cells (ICA)
/ Family medicine specialist (for hospital without in house endocrinologist)
Digoxin Chemical Pathology, Hospital Selayang
Plain tube 3 ml 5 days TDM Form
Fructosamine Chemical Pathology, Hospital Ampang
Plain tube 3 ml 7 days PER–PAT 301
Gamma Glutamyl Transpeptidase (GGT)
Chemical Pathology, Hospital Selayang
Plain tube 3 ml 5 days PER–PAT 301
Galactosemia Screening (Total Galactose & Galactose–1–Uridyl Transferase), blood spot
Biochemistry Unit, IMR (03–26162791 / 2498)
Dried blood spot (DBS) on Whatman 903 Filter paper
3 circles of DBS
5 days Special Form (IEM Request Form)
Growth Hormone (Somatotropin)
Chemical Pathology, HKL
Plain tube 3 ml 10 days PER–PAT 301 Once a week
Haptoglobin Chemical Pathology, HKL
Plain tube 3 ml 5 days PER–PAT 301 Once a week
Immunoglobulin A (IgA)
Makmal Protein, Hospital Ampang
Plain tube 3 ml 7 days PER–PAT 301
Immunoglobulin G (IgG)
Makmal Protein, Hospital Ampang
Plain tube 3 ml 7 days PER–PAT 301
Immunoglobulin M (IgM)
Makmal Protein, Hospital Ampang
Plain tube 3 ml 7 days PER–PAT 301
Immunoglobulin E (IgE) – Total
Allergy Unit, IMR (03–26162587 / 2804 / 2789)
Plain tube 0.5 ml / 3 ml
5 days PER–PAT 301
Immunoglobulin E (IgE) – Specific (per– allergen)
Allergy Unit, IMR (03–26162587 / 2804 / 2789)
Plain tube 0.5 ml / 3 ml
5 days PER–PAT 301 Send immediately to the lab
Insulin Chemical Pathology, HKL
Plain tube 3 ml 10 days PER–PAT 301 Once a week
59
Test Perform Site / Referral Lab
Sample/ Container
Volume TAT (Working
days)
Forms / Special
Requirement
Insulin–like Growth Factor I (IGF–1)
Endocrine Unit, Hospital Putrajaya
Plain tube 3 ml 21 days PER–PAT 301
Inborn Error Metabolism (IEM) screening, blood spot
Unit Biokimia, IMR (03–26162792 / 2498)
Dried blood spot (DBS) on Whatmann 903 Filter paper
3 circles of DBS
3 days Special Form (IEM Request Form)
Inborn Error Metabolism (IEM) Screening, Urine
Biochemistry Unit, IMR (03–26162796 / 2498)
Sterile container
2 ml 10 days Special Form (IEM Request Form)
Lead MKAK EDTA 2 ml 14 days Send at ambient temperature If > 3hrs, keep sample cooled & Protect from freezing
Lithium Core Lab, HKL Plain tube 3.5 ml 1 day PER–PAT 301
Mercury, Urine MKAK Sterile container
15 ml 4 – 6 weeks
Daily
Mucopolysaccharide (GAGs / HRE) Urine
Biochemistry Unit, IMR (03–26162627 / 2498)
Sterile container (1st Morning Urine)
5 ml 10 days Special Form (IEM Request Form)
Methotrexate (MXT) Clinical Toxicology, HKL
Plain tube 3 ml 5 days PER–PAT 301 Daily (office hrs)
Mycophenolic acid Clinical Toxicology, HKL
EDTA 3 ml 1 day TDM Form Every Thursday
Organic Acid, Urine Biochemistry Unit, IMR (03–26162594 / 2792)
Sterile container (Send in ice)
5 ml 5 days Special Form (IEM Request Form)
Transport FROZEN, easily destroyed by heat
60
Test Perform Site / Referral Lab
Sample/ Container
Volume TAT (Working
days)
Forms / Special
Requirement
Orotic Acid, Urine Biochemistry Unit, IMR
Sterile container (Send in ice)
5 ml 5 days Special Form (IEM Request Form)
Parathyroid Hormone (PTH 1–84)
Chemical Pathology, HKL
EDTA (Send in ice)
3 ml 5 days PER–PAT 301 Please provide relevant history and latest calcium and ALP result
To be REQUESTED ONLY by endocrinologi st/general physician/Fam ily medicine specialist (for hospital without in house endocrinologi st)
Porphyrin / porphobilinogen / Uroporphobilinogen Urine
Biochemistry Unit, IMR (03–26162627 / 2498)
Sterile container
5 ml 15 days Special Form (IEM Request Form)
Protect from light, easily destroyed by light
61
Test Perform Site / Referral Lab
Sample/ Container
Volume TAT (Working
days)
Forms / Special
Requirement
Progesterone, 17–OH
Endocrine Unit, IMR (03–26162645)
Plain tube 3 ml 20 days PER–PAT 301 Keep FROZEN or within 2– 8’C during transportation
Protein Electrophoresis (Serum / Urine)
Makmal Protein, Hospital Ampang
Plain tube/ 24 hour urine container
3 ml / 20 ml
– PER–PAT 301 Must send serum & urine together
Protein Electrophoresis CSF (CSF Oligoclonal Band)
Makmal Protein, Hospital Ampang
Bijou bottle 1–2 ml 21 days PER–PAT 301 Must send CSF & Serum together
CSF must be FROZEN immediately after collection
CSF (frozen) and serum (at 2–8’C) must reach lab not more than 7 days after collection
Phenobarbital Chemical Pathology, Hospital Selayang
Plain tube 3 ml 5 days TDM Form
Prostate Specific Antigen (PSA), Free
Chemical Pathology, HKL
Plain tube 3 ml – PER–PAT 301
Renin Endocrine Unit, Hospital Putrajaya
EDTA 3 ml 30 days PER–PAT 301 Must have specialist signature
Sirolimus Clinical Toxicology, HKL
EDTA 3 ml 1 day TDM Form
Succinyl acetone, urine Biochemistry Unit, IMR
Sterile container
2 ml 15 days IEM Request Form
62
Test Perform Site / Referral Lab
Sample/ Container
Volume TAT (Working
days)
Forms / Special
Requirement
03-26162640/ 2511
Tacrolimus Clinical Toxicology, HKL
EDTA 3 ml 5 days TDM Form
Theophylline Clinical Toxicology, HKL
Plain tube 3 ml 5 days TDM Form
Total Homocysteine, Plasma
Biochemistry Unit, IMR
EDTA 2 ml 10 days IEM Request Form
Separate plasma immediately
Thyroglobulin Chemical Pathology, HKL
Plain tube 3 ml 20 days PER–PAT 301 Please provide relevant history and latest TFT result
Thyroid Stimulating Hormone Receptor Antibody (anti-TSHR)
Chemical Pathology, HKL
Plain tube 3 ml 14 days PER–PAT 301
Please provide relevant history and latest TFT result
Urine Myoglobin & Haemoglobin
Biochemistry Unit, IMR (03–26162627 / 2498)
Sterile container
5 ml 5 days Special Form (IEM Request Form)
Urine Tetra glucoside Biochemistry Unit, IMR
Sterile container
15 ml 4 weeks PER–PAT 301
Urine Oligosaccharide Biochemistry Unit, IMR (03–26162791 / 2498)
Sterile container / 1st Morning Urine
5 ml 15 days Special Form (IEM Request Form)
Vitamin D Level Chemical Pathology, Hospital Putrajaya
Plain tube 3 ml 2 – 4 weeks
PER–PAT 301 Must have specialist signature
63
List of Request Forms – Chemical Pathology
FORMS CODE DESCRIPTION
General PER-PAT Form PER-PAT 301 For other tests
Molecular Diagnostics Services Request Form
IMR/SDC/UMDP/MOLDX/ REQUEST FORM
IMR
Multiple Myeloma and Specific Proteins Request Form
IMR/SDC/UMDP/PROTEIN/R EQUEST FORM
IMR
Inborn Error Metabolism (IEM) Request Form
IMR/SDC/BC/FORM-RQ IMR
Primary Immunodeficiency (PID) Request Form
IMR/AIRC/PID/RF For PID Quantitation of Immunoglobulin & Complement IMR
Borang Permintaan Ujian Pengesanan Dadah Dalam Air Kencing
- HKL
Therapeutic Drug Monitoring Request Form
TDM FORM (dari Jabatan Farmasi)
Biochemistry Unit, Hospital Selayang and Toxicology Unit, HKL
*All request forms can be downloaded from the P:\borang-borang\borang pathology
*For latest IMR forms (Diagnostic Services Forms), can refer website : https://www.imr.gov.my/en/services-menu/menu-specific-request-form
64
Patient Information Sheet for Glucose Tolerance Test (GTT)
Purpose of Test:
Used in the diagnosis of Diabetes Mellitus
Preparation for the Test:
1. You should have an unrestricted diet containing at least 150g of carbohydrates
per day over the three (3) days preceding the test.
2. You should fast (no food or energy supplying substance) for at least eight hrs
prior to the test (but no longer than 16 hrs). Water is permitted during this period
and during the test procedure.
Test Procedure:
1. All tests are preferably done in the morning because of variations in sugar levels
during the course of the day.
2. On arrival, a fasting blood is collected.
3. Following this, you will be given a glucose (sugar) drink. You should drink all the
liquid over a period of no more than five (5) mins.
4. Blood sample is collected after 60 mins (1 hour), and 120 mins (2 hrs) from the
start of you drinking the glucose drink.
Note:
1. You should not have the test if you are ill or if you are known to have diabetes
mellitus.
2. Smoking is not permitted during the fasting period and throughout the duration
of the collection procedure.
3. Any form of exercise (walking) during the test period should be avoided.
65
Patient Instructions for the Collection of Mid- Stream Urine
General Information:
If your doctor suspects you have a bladder infection, a carefully collected and tested
Urine sample is an important part of the assessment.
Method of Collection
1. You will be given a supply of tissues and a sterile plastic container with a Yellow
Top.
2. Wash your hands before you collect the sample.
3. Wet a tissue and wash the tip of your penis. Uncircumcised patients should
retract the foreskin.
4. Dry the tip of your penis with a tissue.
5. Pass the first part of Urine into the toilet without stopping. The middle portion
is passed into the sterile Yellow Top container. The container should be at least
¼ full.
6. Void the final part of Urine into the toilet.
Note:
A. When you handle the Yellow Top container, it is important that you don’t touch
the inside of the container as this may introduce unwanted germs which will
complicate testing.
B. If the specimen is to be collected at home, store the specimen in the refrigerator
(not freezer)
66
Patient Instructions for the Collection of 24-Hour Urine
1. Empty bladder into toilet after 6:00am on the morning of the
commencement of the test (this specimen is not to be collected into the
24-Hour Sterile urine container)
2. Record on the 24-Hour Sterile urine container the time and date you
passed the Urine.
3. Collect all Urine over the next 24 hrs directly into the 24-Hour Sterile urine
container provided.
4. The 24-Hour Sterile urine container should at all times be stored in the
refrigerator.
67
Medical Microbiology
Introduction
The Microbiology Unit is a full service laboratory offering diagnostic, consultative,
training, research and development services in diagnostic bacteriology, virology,
mycology, parasitology, serology and mycobacteriology. Services also include
tests for screening and monitoring of diseases. The laboratory also participates in
hospital wide infection control activities in relation to surveillance, control and
prevention of nosocomial infections.
Collection Chart – Medical Microbiology
Tube / Container Sample/Tube
Description Common Use Special Instruction
Adult Serum / SST Gel
Serology tests Mix sample gently 8 – 10 times
Then stand for 15 mins before centrifuging
Paeds
68
Tube / Container Sample/Tube Description
Common Use Special Instruction
Adult Whole blood / Molecular test: Mix sample gently
K2EDTA For blood PCR such as HIV viral load, Hep B viral load, Hep C viral, etc.
8 – 10 times
Paeds
Amies Transport Media
Swab sample for culture
High vaginal swab, eye, ear, nasal swab, etc.
Viral Transport Media (VTM) and
Dacron swab
Swab sample for viral/bacterial PCR (throat swab, nasopharyngeal swab)
For Rapid Test Kit (RTK) Antigen for Covid, no need VTM
Bijou sterile bottle
For fluid sample (CSF, pleural fluid, peritoneal fluid, etc.)
Please ensure cap is tight and secure
DO NOT STORE IN THE REFRIGERATOR
69
Tube / Container Sample/Tube Description
Common Use Special Instruction
Sterile urine container
Urine and other body fluids biochemistry
Please ensure cap is tight and secure
DO NOT ADD FORMALIN FOR TISSUE CULTURE
Stool Container NA DO NOT CONTAMINATE STOOL WITH URINE
Sputum cup
Blood culture bottle (Aerobic/
Anaerobic)
Mix with swirling method
DO NOT STORE IN THE REFRIGERATOR
Adult
Paeds
70
Myco F/ Lytic bottle
Mix with swirling method
DO NOT STORE IN THE REFRIGERATOR
71
Specific Collection Guideline - Microbiology
1. Bacteriology
Autopsy material Blood
i. Aspirate 10 ml of right heart blood from right heart either
through skin and chest wall or (through unopened heart) from
right ventricle after removal of sternum into a set of blood
culture broths or a sterile tube.
ii. Avoid contamination with bacteria from the water faucet and
with enteric bacteria.
Tissue
i. Best collected before the body is being handled at an earlier
stage
ii. Decontaminate the skin or sear surface of heart or other
organ before inserting needle or cutting out tissue block
iii. Collect the tissue and placed in a sterile container. Large
piece is preferred (because aseptic collection is difficult).
In the laboratory, 1 cm cube will be aseptically cut from the
suspicious area including some normal tissue for processing
Blood cultures An automated blood culture system with different types of
bottles according to age is used:
i. Adults: Aerobic and anaerobic culture bottle
Volume: 3 – 10 ml each bottle
ii. Pediatric: A single pediatric blood culture bottle
Volume: 0.5 – 5 ml
iii. Fungal C&S: Mycobacteria/Yeast/Fungi blood culture bottle
Volume: 1-5 ml
iv. TB Blood Culture: Mycobacteria/Yeast/Fungi blood culture
bottle
Volume: 1-5 ml
Note: In the suspicion of catheter-related bacteremia, blood
drawn from both the line and peripheral vein is indicated
Bone marrow
aspirate
1 – 2 ml of aspirate is required and to be inoculated directly into
the bottles.
72
1. Bacteriology
i. Before venipuncture, the skin must be carefully disinfected
with alcoholic antiseptic
ii. Clean the tops of the bottle with alcohol
iii. Inoculate the specified volume of blood / bone marrow
aspirate into each bottle
iv. Do not store the specimens in the refrigerator
Cerebrospinal
Fluid (CSF)
i. Collect 3 – 4 ml of CSF into sterile Bijoux bottles for the
examination of:
a. microscopy and culture for bacterial (Cryptococcus and
mycobacterium if indicated)
b. bacterial antigen
ii. Send the specimen immediately to the laboratory
iii. Do not store in the refrigerator
Clostridium
difficile culture
and toxin
detection
i. Collect fresh stool in a sterile container. Specimens collected
in formalin or swabs are not acceptable
ii. Transport to the laboratory immediately
Genital samples High vaginal swabs
i. This is suitable for the diagnosis of candidiasis and other
causes of vaginitis but NOT gonorrhea in the female
ii. Using a sterile speculum lubricated with sterile normal saline
and not antiseptic cream, swab either from the posterior fornix
or the lateral wall of the vagina
iii. Inoculate the swab into Amies transport media and send the
specimen to the laboratory as soon as possible
Endocervical swab
i. This is the best specimen for the diagnosis of gonorrhea and
puerperal sepsis
ii. Under direct vision, gently compress cervix with blades of
speculum and use a rotating motion with swab, obtain
exudates from the endocervical canal
iii. Inoculate the swab into Amies transport media
73
1. Bacteriology
Urethral discharge (Male)
i. Wipe the urethra with a sterile gauze or swab
ii. Collect the exudates with a sterile swab and inoculate into
Amies transport media
iii. If discharge cannot be obtained by ‘milking’ the urethra, use a
sterile swab to collect material from about 2 cm inside the
urethra
iv. Place the swab into Amies transport media
Mycobacterium:
Acid-fast bacilli
stains and culture
Acceptable specimens:
Respiratory secretions, urine, CSF, body fluids, whole blood and
tissue biopsies. Swab specimens are NOT acceptable.
i. Collect in a sterile container
ii. Collect a minimum of 3 early morning sputum or urine
specimens in successive 24-hour period
iii. Place whole blood, body fluids and CSF into a manufacturer
TB culture bottle
Pus/ Swabs/
Tissue
i. Send pus if available, in a sterile universal container
ii. Swab is an inferior substitute and should be sent in an Amies
transport medium.
iii. Send all tissues for culture in a sterile container. Do not add
formalin to the specimen
Note:
A ‘dry’ swab may fail to yield organisms in smear and culture
Surface swabs of deeply infected lesions (e.g.; sinus tracks from
osteomyelitis, pressure sores) usually grow surface contaminants
like coliforms and pseudomonas.
Respiratory
specimens
Nasal swab
i. Commonly done for screening of MRSA carriage
ii. Moisten a swab with sterile saline
iii. Swab both the anterior nares and insert the swab into the
nose and gently rotate against the nasal mucosa
74
1. Bacteriology
Throat swab
i. In the majority of cases, throat swabs are obtained to recover
Group A Streptococcus (Streptococcus pyogenes) which
causes pharyngitis.
ii. Ask the patient to open his mouth widely. Gently depress the
tongue with a tongue depressor and rub the sterile swab over
the tonsillar areas and the mucosa on the posterior
pharyngeal wall behind the uvula.
iii. Gently turn the swab so that its whole surface comes in
contact with the inflamed mucosa or lesion
iv. Avoid touching the oral mucosa or tongue with the swab
v. Place the swab in Amies transport medium immediately
Swab from mouth, gums and oral cavity
i. Rinse mouth with water before sampling
ii. Using a sterile swab, rub into areas of exudation or
inflammation and place into Amies transport medium
Sputum
i. Collect the sputum early in the morning, after a deep cough
or after a session of physiotherapy. If tuberculosis is
suspected, send 3 consecutive specimens (1 specimen per-
day).
ii. Ask the patient to cough deeply and spit directly into a sterile
universal container
iii. The material expectorated should be secretions from the
bronchi and not merely saliva from the mouth
iv. If delay is anticipated, store the sample in a refrigerator
Bronchial alveolar lavage (BAL) / brushings / biopsies
i. Place the specimen which is obtained via bronchoscopy into
a sterile container
ii. Send the specimen to the laboratory immediately
Stool i. Collect faeces into a sterile / clean wide-mouth screw-capped
plastic container.
ii. If the faeces is liquid, the container may be filled to one-third
full (excessive amount will result in spillage when opened)
75
1. Bacteriology
iii. Enrichment medium i.e., Alkaline peptone for Vibrios and
Selenite F for Salmonella can be obtained from the laboratory
for bedside inoculation
Note:
• Rectal swab is a poor second-best alternative to faeces. If it is
not possible to obtain faeces, collect a specimen by inserting
a cotton swab into the rectum
• For stool clearance culture in cases of typhoid, stool should
only be sent upon completion of therapy
Urine Midstream urine Male patients
Note:
When culture for tubercle bacilli is
required, collect at least 50 ml of
early morning midstream urine on
3 consecutive mornings into
sterile containers
i. Withdraw the prepuce
and cleanse the glans
penis with soapy water
and thoroughly rinse with
water
ii. Pass the first few
millimeters of urine to
flush out the bacteria
from the urethra,
iii. Collect the mid-stream
portion in a sterile
universal container and
close it tightly
Female patients
i. Clean the peri-urethral
area and perineum with
soapy water and
thoroughly rinse with
water.
ii. Hold the labia apart
during voiding and pass
the first few millimeters of
urine.
iii. Collect the midstream
portion in a sterile
container and close it
tightly
76
1. Bacteriology
Catheterized urine
i. Catheter urine specimens should be taken by aseptic
puncture of the catheter conduit and syringe out into a sterile
container
ii. Urine from catheter bags is generally unsuitable for culture
Note:
Culturing urinary catheter tips is a waste of time because the
catheter tips are invariably contaminated with urethral organisms
Bladder urine
i. This is obtained via suprapubic aspiration or cystoscopically
ii. Urine is collected in a sterile container
2. Mycology
Skin, nails and
hair
General Note:
• Clean cutaneous and scalp lesions with 70% alcohol prior to
sampling as this will 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 hair specimens should be collected into folded
squares of paper or directly onto an agar plate
Skin
• Material should be collected from cutaneous lesions by
scraping outwards from the margin of the lesion with the edge
of a glass microscope slide or a blunt scalpel
Hair
Specimen from the scalp should include hair roots, the
contents of plugged follicles and skin scales.
Hairs should be plucked from the scalp with forceps or the
scalp is brushed with a plastic hairbrush and collected onto
an agar plate
77
2. Mycology
Nail
Nail specimens should be taken from any discolored,
dystrophic or brittle parts of the nail
Specimen should be cut as far back as possible from the
edge of the nail and should include the full thickness of the
nail
Mouth • Swabs from the buccal mucosa should be moistened with
sterile water prior to taking the sample and sent in Amies
transport medium
Ear • Scrapings of material from the ear canal are to be preferred,
although swabs can also be used
Ocular specimens 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 scrapped. (Swabs are not suitable for sampling
corneal lesions)
The material is collected directly onto agar plates for culture
and to a glass slide for microscopic examination
Blood Blood culture for fungal is collected in the same manner as for
blood culture for bacterial using a manufacturer fungal bottle
The request for fungal culture should be indicated clearly on
the request form and a total of two weeks incubation will be
carried out
Bone marrow This specimen is helpful for making the diagnosis in a number
of deep fungal infections, including histoplasmosis and
cryptococcosis.
1 – 5 ml of aspirated material should be collected and
transferred into a manufacturer blood culture bottle
Cerebrospinal
fluid • CSF specimens (3 – 5 ml) should be collected in a sterile
container for microscopy and culture
Pus Pus from undrained subcutaneous abscesses or sinus tracts
should be collected with a sterile needle and syringe
78
2. Mycology
If grains are visible in the pus (as in mycetoma), these must
be collected. In mycetoma, if the crusts at the opening of the
sinus tracts are lifted, grains can often be found in the pus
underneath
Tissue If possible, material should be obtained from both the middle
and edge of the lesions
Small cutaneous, subcutaneous or mucosal lesions can often
be excised completely
Tissue specimens should be placed in a sterile container
without formalin
Vagina • For vaginal infections, swabs should be taken from discharge
in the vagina and from the lateral vaginal walls. The swabs
should be sent to the laboratory in transport medium
3. Serology
Blood Method of collection:
i. Draw 3 – 5 ml of blood into a Plain tube with gel without
anticoagulants.
ii. Clot at ambient temperature.
iii. Dispatch to the laboratory within 4 hours of collection for
serum separation by centrifugation
Note:
Haemolysed, icteric or lipaemic specimens invalidate certain
tests. If such specimens are received, the samples will be rejected
to assure that results are of clinical value
Cerebrospinal
fluid
Method of collection:
i. CSF specimens (3-4 ml) should be collected in a sterile
container
Note:
Blood stained specimens invalidate certain tests.
If such specimens are received, the samples will be rejected to
assure that results are of clinical value
79
Urine Method of collection:
i. Urine specimens should be collected in a sterile container for
antigen test
4. Virology
Blood i. Collect 3 – 5 ml blood in Plain tube (without anticoagulant)
ii. Clot at room temperature for 10 min and sent to laboratory
Serum i. Follow procedure as for blood collection above, and spin the
collected blood by centrifuge at 3,000 rpm for 10 minutes
ii. Aliquot the serum into sterile container if necessary, for
outsource sample
5. Special Diagnostic Test for Transplant
ELISA - based
tests
i. Collect 3 – 5 ml blood in Plain tube (without the anticoagulant)
ii. Clot at room temperature for 10 minutes.
iii. Sent to laboratory immediately
iv. Spin the blood by centrifuge at 3,000 rpm for 10 minutes to
obtain serum
6. MOLECULAR
Viral Genome Detection using polymerase chain reaction (PCR) method
Blood i. Collect 3 – 5 ml of blood into EDTA tube
ii. Sent directly to laboratory within 4 hours after being taken
CSF i. Collect minimum of 0.3 ml of CSF into a sterile Bijoux bottle
ii. Packed in ice for transport
iii. Sent directly to laboratory within 2 hours after being taken
Tissue Biopsy i. If possible, sample should consist of both the middle and the
edge section of the tissue
ii. Small sample of minimum roughly 0.3 cm size is appropriate
80
iii. Place tissue in an empty sterile container and do not add
formalin into the specimen
iv. Sent directly to laboratory within 2 hours after being taken
Ocular specimens i. Specimens from patients with suspected infection of cornea
(ocular fluids) should be collected properly. Take a minimum
of 0.3 ml of sample
ii. Place specimen into an empty sterile Bijoux bottle
iii. Sent directly to Virology Lab within 2 hours after collection
Vesicles fluids i. Collect a minimum of 0.3 ml of sample using a sterile needle
by puncturing the lesion
ii. Place specimen into an empty sterile Bijoux bottle
iii. Sent directly to laboratory in ice within 2 hours after collection
Bone Marrow i. Collect a minimum of 0.3 ml of the aspirated sample
ii. Place specimen into an empty sterile Bijoux bottle
iii. Send directly to laboratory within 2 hours after collection
Respiratory
specimen
i. Nasopharyngeal / Oropharyngeal swab to be sent in Viral
Transport Medium (VTM), packed in ice using triple layer
packaging and send to lab immediately. Must ensure the
temperature is maintained between 2 – 8°C throughout
transport.
ii. Sputum / Tracheal aspirate need to send in sterile container,
packed with ice using triple layer packaging and send to lab
immediately. Must ensure the temperature is maintained
between 2 – 8°C throughout transport
7. HIV RNA , HCV RNA & HBV DNA Genome Detection (Quantitative assay
by PCR method)
Blood i. Collect 10 ml of blood into an EDTA bottle
ii. Sample should reach the laboratory within 2 hours upon
collection of the sample from the patient
81
8. Viral Isolation
Blood i. Sample should be taken as early as possible
ii. Collect aseptically 5 – 10 ml of blood (3 – 5 ml for children)
iii. Chill the blood and send it to the lab as soon as possible
Brain tissue for
viral diagnosis
i. Remove portions, about 1.5 cm cube, of various parts of the
brain and the upper spinal cord with as little contamination as
possible
ii. Place tissue in a sterile container and transport in ice as soon
as possible
CSF i. Aseptically collect 1 – 3 ml into a sterile container
ii. Keep the specimen chilled at all time
Vesicular lesion i. Unroofed a fresh vesicular lesion using sterile needle and
swab the base of the vesicle with sterile swab lesion preferred
rayon or Dacron plastic shafted swab to obtained cells for
sampling
ii. Place swab lesion into VTM bottle
iii. Sent directly to laboratory in ice within 2 hours after collection
Conjunctival
scraping
i. Collect the scraping in a screw-capped test tube containing
Viral Transport Media (VTM), which is available in the lab
ii. Keep it chilled at all times
Eye swab i. Firmly rub the lesion with a sterile swab, which has been
moistened with nutrient broth, or sterile distilled water
ii. Put the swab in a screw-capped test tube containing Viral
Transport Media (VTM), which is available in the laboratory
Note:
DO NOT moisten swab with normal saline
Throat swab i. Put the patient at a sitting position. Ask the patient to tilt the
head slightly and open the mouth
ii. Depress the tongue with tongue depressor. Use a sweeping
motion to swab the posterior pharyngeal wall and tonsillar
pillars. Have the subject say “aah” to elevate the uvula.
Note: Use sterile Dacron or rayon swab with plastic shaft.
DO NOT use calcium alginate or cotton swabs or ones
with wooden sticks
82
8. Viral Isolation
iii. Avoid swabbing the soft palate and do not touch the tongue
with the swab tip. (N.B. This procedure can induce the gag
reflex)
iv. Place the swab immediately into a viral transport media and
break applicator sticks off near the tip to permit tightening of
the cap
v. Transport on wet ice
Nasopharyngeal
swab
i. Insert a flexible, fine shafted polyester swab into the nostril
and back to the nasopharynx
ii. The swab should be slid straight into the nostril with the
patient’s head held slightly back
iii. The swab is inserted following the base of the nostril towards
the auditory pit and will need to be inserted at least 5 – 6 cm
in adults to ensure that it reaches the posterior pharynx
Note: DO NOT use rigid shafted swabs for this sampling
method – a flexible shafted swab is essential
iv. Leave the swab in place for a few seconds. Withdraw slowly
with a rotating. Use a different swab for the other nostril
v. Put the tip of swab into vial containing VTM and breaking
applicator’ stick. Close the vial and seal
Nasopharyngeal
aspirate (NPA)
i. Patient must sit comfortably, and the head tilted slightly
backward. Instill 1 – 1.5 ml of sterile, physiological saline (pH
7.0) into one nostril
ii. Flush 3 cc syringe with 2 – 3 ml of saline. Insert the syringe
into the nostril parallel to the palate. Flush in and out few
times
iii. Aspirate nasopharyngeal secretions and collect specimens in
sterile container. Transport on wet ice.
iv. If nasopharyngeal wash is not feasible, please do throat swab
83
List of Test (in-house):
1. Bacteriology & Mycology Section
TEST CONTAINER SPECIMEN VOLUME TAT
Antibiotic sensitivity testing
Not Applicable
Not Applicable
Not Applicable
3 – 4 days (positive culture)
Aspirate culture & sensitivity
Sterile Container Aspirate Not Applicable
1 – 5 days (negative culture)
3 – 4 days (positive culture)
Blood culture & sensitivity (aerobic)
Aerobic sterile container
Blood 3-10 ml 1 – 5 days (negative culture)
3 – 4 days (positive culture)
Blood culture & sensitivity (anaerobic)
Anaerobic sterile container
Blood 3-10 ml 1 – 5 days (negative culture)
3 – 4 days (positive culture)
Body Fluids culture & sensitivity
Sterile container Body Fluid Not Applicable
1 – 5 days (negative culture)
3 – 4 days (positive culture)
Bronchial aspirate culture & sensitivity
Sterile Container Bronchial Alveolar Lavage
Not Applicable
1 – 5 days (negative culture)
3 – 4 days (positive culture)
Cerebrospinal fluid culture & sensitivity
Sterile Tube CSF 3 ml 1 – 5 days (negative culture)
3 – 4 days (positive culture)
Clostridium difficile toxin
Sterile container Stool 3 ml/ peanut size
1 – 2 days
Cryptococcal antigen Sterile Container CSF 2 ml 2 hours
CSF Bacterial Antigen Sterile Tube CSF 3 ml 1 hour
Ear swab culture & sensitivity
Amies TM Pus Not Applicable
1 – 5 days (negative culture)
3 – 4 days (positive culture)
84
TEST CONTAINER SPECIMEN VOLUME TAT
Fungal Blood culture & sensitivity
Fungal Blood Container
Blood 5 ml 3 – 21 days
Fungal culture & sensitivity
Sterile Container Tissue Not Applicable
3 – 21 days
Genital culture & sensitivity
Amies Pus Not Applicable
1 – 5 days (negative culture)
3 – 4 days (positive culture)
Modified Ziehl-Neelsen for Cryptosporidium
Sterile Container Stool 5 ml 1 day
MTB Gene Xpert / RIF Sterile bottle Sputum, CSF,
broncho- alveolar lavage and tracheal aspirate
Not applicable
24 hours
Nasal swabs culture & sensitivity
Amies TM Swab Not Applicable
1 – 5 days (negative culture)
3 – 4 days (positive culture)
Peritoneal Fluid culture & sensitivity
Sterile Container Peritoneal fluid
> 1 ml 1 – 5 days (negative culture)
3 – 4 days (positive culture)
Pus culture & sensitivity (aerobic)
Amies TM Anaerobic
Pus 3 ml 1 – 5 days (negative culture)
3 – 4 days (positive culture)
Pus culture & sensitivity (anaerobic)
Sterile Container Pus 3 ml 1 – 5 days (negative culture)
3 – 4 days (positive culture)
Rectal Swab culture & sensitivity
Sterile Container Rectal swab Not Applicable
1 – 5 days (negative culture)
3 – 4 days (positive culture)
Respiratory culture & sensitivity
Amies TM Sputum Not Applicable
1 – 5 days (negative culture)
3 – 4 days (positive culture)
85
TEST CONTAINER SPECIMEN VOLUME TAT
Rotavirus Antigen Sterile container Stool 3 ml / peanut size
1 – 2 days
Stool culture & sensitivity
Sterile Container Stool 3 ml 1 – 5 days (negative culture)
3 – 4 days (positive culture)
Stool for Clostridium difficile culture & sensitivity
Sterile Container Stool 3 ml 1 – 5 days (negative culture)
3 – 4 days (positive culture)
2. Parasitology Section
TEST CONTAINER SPECIMEN VOLUME TAT
Blood Film Malaria parasites (BFMP)
Thick/thin film Blood Smear 2 hours
Cryptosporidium (Modified Acid Fast Stain)
Sterile Container
Stool 3 ml 1 day
Isospora belli (Modified Acid Fast Stain)
Sterile Container
Stool 3 ml 1 day
Microfilaria (Blood film) Thick / thin film Blood (Preferred mid- night sample)
Smear 2 hours
Microsporidium (Modified Trichrome Stain)
Sterile Container
Stool Peanut size 1 day
Stool for ova & cyst Sterile Container
Stool ¾ of container volume
4 hours
Stool microscopy examination
Plain Container Stool ¾ of container volume
4 hours
86
BFMP (Blood Film Malaria Parasite)
Good quality of BFMP slide:
Completely dry
Label with patient name/SB Number/date
Thick smear: Size 1-2cm diameter
Able to read newspaper through it
Thin smear: Rounded end
87
Thick / Thin Blood Film Malaria Parasite
88
3. Molecular Section
TEST CONTAINER SPECIMEN VOLUME TAT
BK Virus Genome Detection (Quantitative)
EDTA tube / Sterile container
Blood / Urine 5 ml 1 – 2 days
CMV-DNA Genome Detection (Qualitative & Quantitative)
EDTA tube / Sterile Bijoux bottle
Blood / CSF/ BAL 5 ml / min 0.3 ml
1 – 2 days
COVID-19 Genome Detection
VTM/Sterile bottle
Nasopharyngeal swab / oropharyngeal swab / tracheal aspirate / Nasopharyngeal aspirate
Not applicable
24
hours
EBV DNA Genome Detection (qualitative & quantitative)
EDTA tube Blood / CSF / TISSUE
5 ml 1 – 2
days
HBV DNA Genome Detection (quantitative)
EDTA tube Blood 5 ml 1 – 2 days
HCV RNA Genome Detection (quantitative)
EDTA tube Blood 5 ml 1 – 2 days
HIV RNA Genome Detection (quantitative)
EDTA tube Blood 10 ml 1 – 2 days
HSV I & II DNA Genome Detection
EDTA tube / Sterile Bijoux bottle
Blood / CSF Vesicle fluids
5 ml 1 – 2 days
Influenzae A, Influenzae B, RSV
VTM Nasopharyngeal Swab / Oropharyngeal Swab
Not applicable
1 – 2 days
Meningoencephalitis Panel (i.e. Mumps virus, Measles virus Human enterovirus, Parechovirus, HSV 1, HSV 2, VZV, EBV, CMV, Human Herpes Virus 6, Human Herpes Virus 7, Human Herpes Virus 8, Listeria monocytogenes, S. aureus, H. influenzae, Streptococcus pneumoniae, Streptococcus agalactiae, N. meningitides Borrelia burdorferi/Borr
Sterile Bijoux bottle
CSF 0.5 - 2 ml 1 – 2 days
89
TEST CONTAINER SPECIMEN VOLUME TAT
E. coli K, Cryptococcus neuformans, Cryptococcus gattii
MERS Coronavirus Genome Detection
Dacron swab (for swab only) / Sterile bottle
Sputum, throat swab, bronchoalveolar lavage, tracheal aspirate, nasopharyngeal aspirate, and tissue from lung biopsy
Not applicable
24 hours
MTB/RIF Gene Xpert Ultra
Sterile bottle Sputum, CSF, bronchoalveolar lavage and tracheal aspirate
Not applicable
24 hours
Respiratory Pathogen Panel (i.e. Influenza A, Influenza A H1, Influenza A H3, Influenza B, Respiratory Syncytial Virus A, Respiratory Syncytial Virus B, Coronavirus 229E ,Coronavirus OC43, Coronavirus NL63, Coronavirus HKU1, Human Metapneumovirus, Rhinovirus/Enterovirus, Adenovirus, Parainfluenza 1, Parainfluenza 2, Parainfluenza 3, Parainfluenza 4, Human Bocavirus, Chlamydophila pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila
Sterile Container
Nasopharyngeal aspirate, bronchoalveolar lavage (BAL) and tracheal aspirates
2 ml 1 – 2 days
VZV DNA Genome Detection (qualitative)
EDTA tube Blood / CSF Vesicle fluids
5 ml 1 – 2 days
ZIKA Genome Detection Plain tube/EDTA / Sterile Bijoux bottle / Sterile container
Serum/plasma CSF/Urine
0.5 - 3 ml 1 – 2 days
90
4. Serology / Virology Section
TEST CONTAINER SPECIMEN VOLUME TAT
Anti-double stranded DNA Plain tube Blood 5 ml 1 – 2 days
Anti-HB core IgM Plain tube Blood 3 – 5 ml 1 – 2 days
Anti-HB core Total Plain tube Blood 3 – 5 ml 1 – 2 days
Anti-HBe Plain tube Blood 3 – 5 ml 1 – 2 days
Anti-HBs Plain tube Blood 3 – 5 ml 1 – 2 days
Anti-Mycoplasma pneumonia IgM
Plain tube Blood 5 ml 1 – 2 days
Anti-nuclear antibodies Plain tube Blood 5 ml 1 – 2 days
Aspergillus antigen Plain tube Blood / BAL 3 ml / BAL 1-3 ml
1 – 2 days
Cytomegalovirus IgG Plain tube Blood 3 – 5 ml 1 – 2 days
Cytomegalovirus IgM Plain tube Blood 3 – 5 ml 1 – 2 days
Dengue-IgG ELISA Plain tube Blood 3 – 5 ml 1 – 2 days
Dengue-IgM ELISA Plain tube Blood 3 – 5 ml 1 – 2 days
Dengue NS1 Antigen (Rapid) Plain tube Blood 3 – 5 ml 1 – 2 days
Epstein-Barr Virus IgG Plain tube Blood 3 – 5 ml 1 – 2 days
Epstein-Barr Virus IgM Plain tube Blood 3 – 5 ml 1 – 2 days
Extractable Nuclear Antigen- Anti Jo1
Plain tube Blood 5 ml 1 – 2 days
Extractable Nuclear Antigen- Scl 70
Plain tube Blood 5 ml 1 – 2 days
Extractable Nuclear Antigen- Sm
Plain tube Blood 5 ml 1 – 2 days
Extractable Nuclear Antigen- RNP
Plain tube Blood 5 ml 1 – 2 days
Extractable Nuclear Antigen- SSA/ Ro
Plain tube Blood 5 ml 1 – 2 days
Extractable Nuclear Antigen- SSB/ La
Plain tube Blood 5 ml 1 – 2 days
Hanta Virus IgM Plain tube Blood 3 – 5 ml 1 – 2 days
HAV Antibody IgM Plain tube Blood 3 – 5 ml 1 – 2 days
HBe Antigen Plain tube Blood 3 – 5 ml 1 – 2 days
HBs Antigen Plain tube Blood 3 – 5 ml 1 – 2 days
HCV-Antibody Plain tube Blood 3 – 5 ml 1 – 2 days
HIV-Antibody Confirmatory Immunoblot
Plain tube Blood 3 – 5 ml 1 – 2 days
91
TEST CONTAINER SPECIMEN VOLUME TAT
HIV-Antigen & Antibody Plain tube Blood 3 – 5 ml 1 – 2 days
HIV-Particle Agglutination. Plain tube Blood 3 – 5 ml 1 – 2 days
HSV I-IgG Plain tube Blood 3 – 5 ml 1 – 2 days
HSV I-IgM Plain tube Blood 3 – 5 ml 1 – 2 days
HSV II-IgG Plain tube Blood 3 – 5 ml 1 – 2 days
HSV II-IgM Plain tube Blood 3 – 5 ml 1 – 2 days
HTLV I & II-Ab Screen ELISA Plain tube Blood 3 – 5 ml 1 – 2 days
Indirect Immunoperoxidase for Rickettsia (IIP)
Plain tube Blood 5 ml 1 – 2 days
Legionella Antigen Detection Sterile Container
Urine 5 ml 1 – 2 days
Leptospira Antibody IgM Plain tube Blood 5 ml 1 – 2 days
Measles-IgG Plain tube Blood 3 – 5 ml 1 – 2 days
Mumps-IgG Plain tube Blood 3 – 5 ml 1 – 2 days
Mumps-IgM Plain tube Blood 3 – 5 ml 1 – 2 days
Parvovirus B19-IgG Plain tube Blood 3 – 5 ml 1 – 2 days
Parvovirus B19-IgM Plain tube Blood 3 – 5 ml 1 – 2 days
Rapid Plasma Reagin (Syphilis)
Plain tube Blood 5 ml 1 – 2 days
Rubella-IgG Plain tube Blood 3 – 5 ml 1 – 2 days
Rubella-IgM Plain tube Blood 3 – 5 ml 1 – 2 days
Toxoplasma gondii-IgG Plain tube Blood 3 – 5 ml 1 – 2 days
Toxoplasma gondii-IgM Plain tube Blood 3 – 5 ml 1 – 2 days
Treponema Pallidum Particle
Agglutination Plain tube Blood 3-5 ml 1 – 2 days
Varicella Zoster Virus-IgM Plain tube Blood 3 – 5 ml 1 – 2 days
92
List of Test (outsourced) Test Perform
Site Container Sample Volume TAT
(Working days)
Schedule
Allergy Testing (Screening)
Microbiology, HKL
Plain Tube Blood 5 ml 5 days Daily (Office Hour)
Allergy Testing (Specific)
Microbiology, HKL
Plain Tube Blood 5 ml 5 days Daily (Office Hour)
Anti- Acetylcholine Receptor
Immunology, IMR
Plain Tube Blood 5 ml 14 days Daily (Office Hour)
Anti- Phospholipid Antibody
Microbiology, H. Selayang
Plain Tube Blood 5 ml 1 week Daily (Office Hour)
Anti-Neutrophil Cytoplasmic ANCA
Microbiology, H. Selayang
Plain Tube Blood 5 ml 1 week Daily (Office Hour)
Anti- Mitochondrial Antibody (AMA)
Microbiology, H. Selayang
Plain Tube Blood 5 ml 1 week Daily (Office Hour)
Anti- Thyroglobulin Antibody
Microbiology, H. Selayang
Plain Tube Blood 5 ml 1 week Daily (Office Hour)
Anti-Glomerular Baseline Antibody
Immunology, IMR
Plain Tube Blood 5 ml 14 days Daily (Office Hour)
Panel Tissue Antibodies: Anti-Gastric Parietal Cell Antibody (APC), Anti Mitochondrial Antibodies, Anti Smooth Muscle
Immunology, IMR
Plain Tube Blood 5 ml 14 days Daily (Office Hour)
Anti-Liver Kidney Microsome Ab (LKM)
Microbiology, H. Selayang
Plain Tube Blood 5 ml 14 days Daily (Office Hour)
Anti-Intrinsic Microbiology, H. Selayang
Plain Tube Blood 5 ml 1 week Daily (Office Hour)
Anti-Aquaporin 4 Immunology, IMR
Plain Tube/ Bijou bottle
Blood/ CSF
5 ml 10 days Daily (Office Hour)
93
Test Perform Site
Container Sample Volume TAT (Working
days)
Schedule
Burkholderia pseudomallei Antibody IgM
Bacteriology, IMR
Plain Tube Blood 2 – 3 ml 5 days Daily (Office Hour)
Bordetella pertussis PCR
Bacteriology, IMR
For nasophary- ngeal aspirates, use sterile container
For swab, use Dacron swab in Stuart's transport media
Do not use calcium alginate or cotton swab
NPA/ Swab
Transport in ice
1 – 2 ml 5 days Daily (Office Hour)
HLA Antibody Test Panel Reactive Antibody (PRA)/Donor Specific Antibody (DSA)
Immunology, IMR
Plain Tube Blood 10 ml 4 weeks Appointment is not required. For transplant recipient only (screening test)
Human Leukocyte Antigens (HLA) Crossmatch (Complement Dependent Cytotoxicity)
Immunology, IMR
Sodium Heparin (donor),
Plain Tube (patient)
Blood Donor: 18 ml
Patient:
5 ml
10 days For solid
organ
transplantati
on
Active by appointment only. Please call 03- 26162581
Human Leukocyte Antigens (HLA) Crossmatch (Flow Cytometry)
Immunology, IMR
Sodium Heparin (donor),
Plain tube (patient)
Blood Donor: 18 ml
Patient:
5 ml
10 days For solid
organ
transplantati
on
Active by
appointment
only. Please
call 03-
26162581
94
Test Perform Site
Container Sample Volume TAT (Working
days)
Schedule
Human Leukocyte Antigens (HLA) Typing Class I (Loci A, B and C) - low/medium resolution (SSO/SSP-PCR)
Immunology, IMR
2 K2EDTA tubes
Blood 6 ml 10 days Active by appointment only
Please call 03-2616258
Human Leukocyte Antigens (HLA) Typing Class II(Loci DR,DQ) - Low/medium resolution (SSO/SSP-PCR)
Immunology, IMR
2 K2EDTA tubes
Blood 6 ml 10 days Active by appointment only
Please call 03-2616258
Human Leukocyte Antigens (HLA) Typing Class I and II (Loci A, B and DR) - Medium/High Resolution (SSO-PCR)
Immunology, IMR
2 K2EDTA tubes
Blood 6 ml 10 days Active by appointment only
Please call 03-2616258
Human Leukocyte Antigens (HLA) Typing Class I and II (Loci A, B, C, DR and DQ) - high resolution (SSO-PCR) per loci
Immunology, IMR
2 K2EDTA tubes
Blood 6 ml 10 days Active by appointment only
Please call 03-2616258
Human Leukocyte Antigens (HLA) Typing for Disease Association (HLA B27/B57:01/ B15:02)
Immunology, IMR
2 K2EDTA tubes
Blood 6 ml 10 days Active by appointment only Transport condition: Room Temperature (WITHOUT ICE).
Please call 03-2616258
95
Test Perform Site
Container Sample Volume TAT (Working
days)
Schedule
Human Leukocyte Antigens (HLA) Typing Class I and II (Loci A, B, C, DR & DQ) - low resolution (PCR)
Immunology, IMR
2 K2EDTA tubes
Blood 6 ml 10 days Active by appointment only.
Please call 03-2616258
Chikungunya Virus IgM / IgG
Makmal Kesihatan Awam Kebangsaan, Sg Buloh
Plain Tube Blood 1-3 ml 2 weeks Daily (Office Hour)
Chikungunya Genome Detection
Virologi, IMR Plain Tube Blood 5 ml 2 weeks Daily (Office Hour)
Dengue Genotyping (Qualitative)
Makmal Kesihatan Awam Kebangsaan, Sg Buloh
Plain sterile tube
Blood Blood: 5 ml
CSF: minimum 0.3ml
3 weeks Daily (Office Hour)
Sterile Bijoux bottle
CSF
Sterile container
Tissue
Diabetes Mellitus Autoantibodies: Anti-Glutamic Acid Decarboxylase (GAD), Anti-Insulinoma- Associated Antigen 2 (IA2) & Anti-Islet Cells (ICA)
Immunology, IMR
Plain Tube Blood 5 ml 2 weeks Daily (Office Hour)
Enterovirus Genome Detection
Virology, IMR
Sterile plain container
Stool/ BAL/ sputum
Pleural fluid
CSF
Stool:
>5 g or pea size
Pleural fluid:
1 – 3 ml
CSF:
1 – 3 ml
2 weeks By appointment
Reach lab within 12 hours after collection
96
Test Perform Site
Container Sample Volume TAT (Working
days)
Schedule
VTM (Swab)
Serum
Rectal swab
Throat
swab
Vesical swab
Ulcer
swab
Organ biopsies
Serum: 3 – 5 ml
Enterovirus Virus Culture
Virology, IMR
Sterile plain container
VTM (Swab)
Stool/ BAL/ sputum
Pleural fluid
CSF
Serum
Rectal swab
Throat swab
Vesical
swab
Ulcer
swab
Organ biopsies
Stool: 5 g or pea size
Pleural fluid: 1 – 3 ml
CSF: 1 – 3 ml
Serum: 3 – 5 ml
4 – 6 weeks
Daily (Office Hour)
HIV Genome Detection for babies (0-18 months)
Virology, IMR
EDTA Blood 5 ml 2 weeks For newborn cases
97
Test Perform Site
Container Sample Volume TAT (Working
days)
Schedule
Interferon Gamma Releasing Assay (IGRA)
Makmal Kesihatan Awam Kebangsaan
Special bottle from MKAK
Blood 5 ml (1 ml per tube)
4 weeks Please contact MKAK for collection tubes and special instruction. By appointment ONLY through MKAK's Clinical Microbiologist
Japanese encephalitis serology
Makmal Kesihatan Awam Kebangsaan
Plain tube
Bijou Bottle
Blood
CSF
1 – 3 ml 7 days Samples should be collected within 5 days of illness
Japanese encephalitis PCR
Virology, IMR
Plain Tube
Sterile container
Sterile containers containing VTM
Blood
CSF
Organ biopsies
1 – 3 ml 2 weeks Daily (Office Hour)
Leptospira PCR Microbiology, IMR
EDTA
Sterile container
Blood
Sterile body fluid
Tissue
5 ml 2 weeks Send before start antibiotic
Daily (Office Hour)
Leptospiral Micro- agglutination Titer (LeptoMAT)
Microbiology, IMR
Plain Tube Blood 5 ml 1 week Daily (Office Hour)
Mycobacterium C&S
Makmal Kesihatan Awam Kebangsaan
Sterile plain container
Sputum
Tissue
CSF
Pus
Body
fluids
CSF/ fluid/ Pus: 1 – 2 ml
7 weeks Daily (Office Hour)
98
Test Perform Site
Container Sample Volume TAT (Working
days)
Schedule
Mycobacterium TB Genome Detection
Microbiology, IMR
Sterile plain container
Sputum
Tissue
CSF
Pus
Body
fluids
CSF/ fluid/ Pus:
1 – 2 ml
2 weeks Daily (Office Hour)
Measles IgM Makmal Kesihatan Awam Kebangsaan
Plain Tube Blood 1-3 ml 1 week Daily (Office Hour)
Measles Viral Culture
Makmal Kesihatan Awam Kebangsaan
Sterile plain container
VTM
Urine
NPA
Tracheal aspirate Throat swab
Urine: 10 ml
NPA/TA: 1 ml
3 weeks Daily (Office Hour)
Measles RT- PCR
Makmal Kesihatan Awam Kebangsaan
Sterile plain container
VTM
Urine
NPA
Tracheal aspirate Throat swab
Urine:
10 ml
NPA/TA: 1 ml
1 week
Daily (Office Hour)
Nipah IgG Virologi, IMR Plain Tube
Sterile container
Blood
CSF
1-3 ml 2 – 4 weeks
Daily (Office Hour)
Nipah IgM Virology, IMR
Plain Tube Sterile container
Blood
CSF
1-3 ml 2 – 4 weeks
Daily (Office Hour)
Nipah Virus PCR
Virology, IMR
Leak-proof sterile container
Serum
CSF
Serum/ CSF:
2 – 3ml
2 weeks Daily (Office Hour)
99
Test Perform Site
Container Sample Volume TAT (Working
days)
Schedule
Blood
Organ biopsies
Blood: 5 ml
Organ: 1.5 cm cube
Parvo VirusB19 DNA Detection
Makmal Kesihatan Awam Kebangsaan
Plain Tube
Sterile plain container
Blood
CSF
Serum: 5 ml
CSF: 1 ml
1 week
Daily (Office Hour)
Polio virus / Acute Flaccid Paralysis (AFP)
Virology, IMR
Sterile plain container
VTM
Stool
CSF
Throat swab Rectal swab
Stool: 5 g or pea size
CSF: 1 – 2 ml
4 – 6 weeks
Daily (Office Hour)
Rubella Viral culture
Makmal Kesihatan Awam Kebangsaan
Sterile plain container
VTM
Urine
NPA
Throat swab Tracheal aspirate
Urine:
10 ml
NPA/TA: 1 -3 ml
4 weeks Daily (Office Hour)
Viral Culture Makmal Kesihatan Awam Kebangsaan
Sterile bottle CSF
BAL
NPA
Vesicle fluid
Stool
Tissue
CSF: 1 – 3 ml
Others: Not applicable
4 – 6 weeks
Daily (Office Hour)
100
Test Perform Site
Container Sample Volume TAT (Working
days)
Schedule
Viral Culture Virology, IMR
VTM bottle Throat swab
Nasal swab
Rectal swab
Lesion swab
Not applicable
4 – 6 weeks
Daily (Office Hour)
101
List of Request Forms – Microbiology
FORMS CODE DESCRIPTION
General PER-PAT Form PER-PAT 301 For other tests
Autoimmune Request Form - IMR
Acute Flaccid Paralysis Case Investigation Form
AFP Case Investigation Form IMR AFP Case
HIV PCR Request Form (Baby)
IMR/Viro/HIV/2 IMR/VIRUS/NARL2
IMR
HIV Genotyping Resistance Testing IMR/Viro/HIV/24 IMR
Bacteriology request Form IMR/BACT/FORM/SMIS/01 IMR
Ricketsia request Form IMR/IDRC/BACT/RICK/02 IMR
Brucella Request Form IMR/IDRC/BACT/BRUCE/01 IMR
Leptospira Request Form IMR/IDRC/BACT/LEPTO/01 IMR
TB Request Form TBIS 20C All TB samples
Viability & Sensitivity Antibiotic Mycobacterium leprae Request Form
MKAK-BPU-K03 MKAK
Dengue dan Flavivirus Request Form MKAK-BPU-02 (rev_Nov_2015)
MKAK
Measles Request Form MSLF:01/2004 MKAK
MKAK Lab Request Form MKAK-BPU-U01 For MKAK viral identification
HLA Crossmatch Test Request Form (Living Donor)
IMR/AIRC/TI/RF-1 IMR
HLA Typing Test Request Form IMR/AIRC/TI/RF-2 IMR
HLA Typing Test Request Form (Disease Association)
IMR/AIRC/TI/RF-3 IMR
HLA Antibody Test Request Form IMR/AIRC/TI/RF-4 IMR
HLA Crossmatch Test Request Form (Deceased Donor)
IMR/AIRC/TI/RF-5 IMR
*All request forms can be downloaded from the P:\borang-borang\borang pathology
102
Haematology
Introduction
The unit provides basic and specialized Haematology testing. The tests offered are
stated in the Haematology list of tests section
All analytes are monitored by both internal and external quality assurance
programmes to ensure reliability. Reports issued to clinicians are reviewed by the
Haematologist, Medical Officers, Clinical Biochemist and Medical Lab
Technologists; and clinical interpretation is provided by the Haematologist/ Medical
Officers when appropriate.
The laboratory has expertise to advise users concerning the selection and
installation of instruments for point of care testing. The laboratory manages POCT
through the Hospital POCT Committee. Quality Performance monitoring (IQC and
EQA) and audit is conducted by the lab regularly.
103
Pre-Analytical Variables in Haematology Testing
The table below shows common factors that are known to interfere with
Haematology testing.
Factors Precautions
Hemolysis Hemolysis affects certain FBC parameters and coagulation tests
Allow alcohol to dry completely when it is used for skin sterilization prior to venipuncture
Never inject a syringe needle into the vacutainer to empty the syringe.
Samples should be mixed thoroughly but gently immediately after collection. Vigorous shaking causes red cells to rupture.
Avoid extremes of temperature. Never place a blood tube directly on ice as this may cause hemolysis
Contamination Avoid taking blood from the arm where an IV infusion has been set up. It can cause a dilution effect of most analytes.
Avoid decanting blood from one tube to another even if the tubes contain the same anticoagulant. Follow the recommended order of draw to avoid contamination.
e.g. Blood requiring K+EDTA preservative must be taken after samples for coagulation tests to avoid the possibility of falsely prolonged PT/ APTT or low fibrinogen results.
Icterus Icterus affects Coagulation tests
Lipaemia Lipaemia affects Hemoglobin, MCH, MCHC and Coagulation tests
Delay in transit of specimens (> 4 hours)
Delays in transit affects coagulation testing and cause Platelet, RBC and WBC cell degradation
Inadequate filling of
blood collection tubes
Improper ratio of blood to anticoagulant causes prolonged PT and APTT result.
Hematocrit level > 55% Improper ratio of blood to anticoagulant causes prolonged PT and APTT result. Please contact lab for further information
Improper specimen
storage/ transport
Specimens not stored or transported according to recommended temperature may cause aberrant results. e.g. CD4/CD8 Enumeration should be sent at room temperature not cold temperature (2- 8 °C)
104
Uncertainty of Measurements
Haematology tests are subject to a degree of uncertainty in their measurements.
This may be due to a variety of factors including:
Biological variation within individuals
Analytical measurement imprecision
Pre–analytical factors
Please contact the Haematology Unit if you wish to know or discuss the uncertainty
values for analytes measured in the laboratory
105
Specimen Collection Chart – Haematology
Tube / Container Sample/Tube Description
Common Use Special Instructions
Adult
Whole blood / K2EDTA
Routine Haematology:
Full Blood Count Full Blood Picture Retic Count G6PD Screening
Specialised test:
CD4/ CD8 Hb Analysis
Specialised test (Outsourced):
G6PD Assay DNA Analysis
Mix sample gently 8 - 10 times
Paeds
3.2% Sodium Citrate Coagulation test Mix sample gently 3 - 4 times
Must be filled until the marked indicator
106
Tube / Container Sample/Tube Description
Common Use Special Instructions
3.8% Sodium Citrate (ESR tube)
ESR Fill within the 2 markers
Mix sample gently 8 - 10 times
Lithium Heparin Specialised test (Outsourced):
Chromosome Analysis / Cytogenetic for Genetic Disease
Mix sample gently 8 - 10 times
Sodium Heparin
Specialised test (Outsourced):
Cytogenetic for Leukemia (Blood & Bone Marrow Aspiration)
Mix sample gently 8 - 10 times
SST Gel (Plain tube)
Specialised test (Outsourced):
Serum Erythropoietin
Mix sample gently 5 - 6 times
107
Tube / Container Sample/Tube Description
Common Use Special Instructions
Plain tube (without Gel)
Specialised test (Outsourced): Platelet Antibody Screening
Mix sample gently 5 - 6 times
Sterile urine container with added formalin
Specialised test (Outsourced):
Bone marrow trephine biopsy
Please ensure cap is tight and secure
108
List of Test (in–house) & Reference Interval
Test Sample Container/ Volume
TAT Reference Interval
Remarks
Activated 3.2 % Sodium Urgent: 60 mins 25.1 - 36.5 secs Send immediately Partial Citrate Routine: 90 after collection Thrombin Time Paeds: 1.8 ml mins
(APTT) Adult: 2.7 ml
Bone Marrow Aspiration
Slide smear Urgent: 1 day Routine: 7 days
- By appointment
Bone Marrow Trephine Biopsy
Sterile urine container with 10% formalin
20 working days
By appointment
Bone Marrow biopsy 1.5cm
CD4/CD8 EDTA 2 ml 3 working days CD4+ cells: Mon- Thurs:
Enumeration 24-48 % 8am - 5pm 358-1279 Fri & Eve of PH: cells/µL External: 11 am Internal: 12 pm CD8+ cells:
15-38 % External: Send within 268-925 cells/µL 12 hours from blood collection without CD3+ cells: ice 56-81 %
831-2240
cells/µL
D-Dimer 3.2 % Sodium Citrate Paeds: 1.8 ml Adult: 2.7 ml
Urgent: 90 mins Routine: 3 working days
<500 ng/ ml Run twice a week (Tues & Fri)
MO Code required
Office hours: Hematology MO
After office hours: On-call MO
Erythrocyte ESR tube 3 hrs Men (mm/ hr):
Sedimentation (Sodium Citrate 17- 50 years: < Rate (ESR) 3.8 %): 1.3 ml 10
51-60 years: ≤ 12 61-70 years: ≤ 14
> 70 years: ≤ 30
109
Test Sample Container/ Volume
TAT Reference Interval
Remarks
Women (mm/ hr): 17- 50 years: ≤ 12 51-60 years: ≤ 19 61-70 years: ≤ 20 > 70 years: ≤ 35
Reference: Dacie & Lewis 12th Edition
Fibrinogen 3.2 % Sodium Citrate Paeds: 1.8 ml Adult: 2.7 ml
90 mins 276-471 mg/ dL
Full Blood EDTA Urgent: 45 mins Refer table:
Count Paeds: 0.5 ml Routine: 2 hrs Full Blood Count Adult: 2 ml Reference
Interval
Full Blood Picture
EDTA Paeds: 0.5 ml Adult: 2 ml
Urgent: 1 day Routine: 5 days
Please call MO for urgent FBP
MO code required after office hours
G6PD screening
EDTA 2 ml 1 day Batch test performed twice daily (8 am & 3 pm)
(Peripheral/ cord blood)
3 months post transfusion
Do not send during hemolytic crisis
Haemoglobin (Hb) Analysis
EDTA Paeds: 0.5 ml Adult: 2 ml
6 weeks Hb A (%): 96.8-97.85
Run once a week (Thursday)
Hb F (%): <2 years: <5 <12 years: 2-3 Adult: < 1
Send immediately at Room Temperature
3 months post
transfusion Hb A2(%):
2.2-3.2
Please exclude IDA before sending
Reference: - Standardization
110
Test Sample Container/ Volume
TAT Reference Interval
Remarks
National Hematology Workshop Langkawi, 2015
- Thalassemia Carrier Diagnosis in Malaysia, Dr Elizabeth George, 1998
For family screening, details of index case must be clearly stated
Kleihauer test EDTA Paeds: 0.5 ml Adult: 2 ml
3 days By appointment
Please provide cord blood sample as control
Mixing test 3.2 % Sodium Citrate 2.7 ml (2 tubes)
1 day By appointment
Prothrombin Time (PT)/ International normalized ratio (INR)
3.2 % Sodium Citrate Paeds: 1.8 ml Adult: 2.7 ml
Urgent: 60 mins Routine: 90 mins
9.4-12.5 secs Send immediately after collection
Reticulocyte count
EDTA Paeds: 0.5 ml Adult: 2 ml
2 hrs 0.5-2.5% Reference: Dacie & Lewis 12th Edition
Note:
• All tests are run daily, unless otherwise specified
• Reference intervals are set according to the methodology and equipment used,
unless otherwise specified. Any changes made will be notified.
111
List of Test (Outsourced)
Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
ADAMTS-13 Clinical Hematology Lab, Hospital Ampang
3.2% Sodium citrate
Blood 1 tube
*Collect until indicated mark
4 - 6 weeks
• By appointment
• Fresh specimen
Request form: Hospital Ampang Special Hematology Lab Requisition form
Anti-Xa Clinical Hematology Lab, Hospital Ampang
3.2% Sodium citrate
Blood 1 tube
*Collect until indicated mark
7 working days
• Send immediately to lab
• By Appointment
Request form: Hospital Ampang Special Hematology Lab Requisition Form
Chromosome analysis (for genetic disease)
Cytogenetics Unit, WCH KL (ext. 2711)
Lithium heparin
Blood 4 ml 60 working days
• By appointment
• Fresh specimen
• Send to HSgB lab Mon-Wed only
• Samples must reach before 9 am
• Do not send on PH and eve of PH.
Request form: Cytogenetics Request Form
Chromosome Analysis for Leukaemia / Cytogenetic
Clinical Hematology Lab, Hospital Ampang
Sterile transport medium with heparin
Bone Marrow
Minimum 1-2 ml
30 working days
• Appointment with haematologist, Hospital Ampang
• Fresh specimen
• Send to HSgB lab Mon-Wed only
• Samples must reach before 9 am
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Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
• Do not send on PH and eve of PH.
Request form: Hospital Ampang Special Hematology Lab Requisition Form
Cytogenetic FISH
Clinical Hematology Lab, Hospital Ampang
Sterile transport medium with heparin
BMA Minimum 1-2 ml
18 working days *Case to case basis
• Appointment with haematologist, Hospital Ampang
• Fresh specimen
• Send to HSgB lab Mon-Wed only
• Samples must reach before 9 am
• Do not send on PH and eve of PH.
Request form: Hospital Ampang Special Hematology Lab Requisition Form
2 tubes of sodium Heparin (2.5ml in each tube)
Blood Minimum 5 ml
Coagulation: • Factor
Assay • VWF test
Haemostasis Unit, PDN
3.2% Sodium citrate
Specimen: Blood
> 1 year: 2.7 mL x 5 tubes
≤ 1 year: 2.7 mL x 2 tubes
20 working days
• Send immediately to lab
Request form: PDN Haematology/ Serology Request Form
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Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
Dihydrorhoda- mine test (DHR)
AIRC Unit, IMR (ext. 2587)
Lithium heparin (without gel)
Blood 2 ml 15 working days
• By appointment
• Fresh specimen
• Send to HSgB lab Mon-Wed only
• Samples must reach before 9 am
• Do not send on PH and eve of PH.
• Send additional 2mL blood from unrelated healthy person’s blood as control
Request form: AIRC IMR PID Request Form
DNA Analysis- Alpha Thalassemia
Hematology Unit, HKL (ext. 5746/ 5748)
EDTA Blood Adult: 2 mL
Paeds: 0.5 mL
90 working days
Must attach:
• Hb Analysis Report
• latest FBC result (< 3 months)
• Detailed history on index case for family screening
Request form:
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Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
DNA analysis of Thalassemia Syndromes & Haemoglobinopathy’ s Request Form (Latest version)
DNA Analysis- Beta Thalassemia
Hematology Unit, HKL
HKL (ext. 5746/ 5748)
EDTA Blood Adult: 2 mL
Paeds: 0.5 mL
90 working days
Must attach:
• Hb Analysis Report
• latest FBC result (< 3 months)
Patient < 12 years Must send:
• Patient’s sample
• Parent’s sample (Ordered in THIS)
• Parent’s Hb Analysis report
• Parent’s FBC result (3 months)
Request form: DNA analysis of Thalassemia Syndromes & Haemoglobinopathy’ s Request Form (Latest version)
Erythropoietin (sEPO)
Clinical Hematology Lab, Hospital Ampang
Plain tube Blood 3.5 ml 6-12 weeks
• By appointment
• Fresh sample
Request form: Hospital Ampang Special Hematology Lab Requisition Form
G6PD Quantitative Assay
Hematolog y Unit, WCH KL (Ext 2169)
EDTA Blood Adult: 2 mL
Paeds: 0.5 mL
25 working days
• By appointment
• Send to HSgB lab Mon-Wed only
• Samples must reach before 9 am
• Do not send on PH and eve of PH.
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Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
• Provide detailed
patient’s history with previous G6PD screening result
NOTE:
• Do not send during haemolytic crisis
• Send 3 months post transfusion
Request form: PER–PAT 301
Immunopheno -typing (IPT) Leukemia / Lymphoma
Hematology Unit, WCH, KL
EDTA Blood / Bone marrow
2 ml x 2 tubes
21 working days
• Fresh sample
• Send to HSgB lab Mon-Wed only before 9 am.
• Do not send on PH and eve of PH.
Request form: PER–PAT 301
Lymphocyte Proliferation Test
AIRC Unit, IMR (ext. 2587)
Sodium Heparin
Blood 2 ml 15 working days
• By appointment
• Fresh specimen
• Send to HSgB lab Mon-Wed only
• Samples must reach before 9 am
• Do not send on PH and eve of PH
• Send additional 2mL blood from unrelated healthy person’s blood as control
Request form: AIRC IMR PID Request Form
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Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
Molecular Analysis for Leukaemia
Clinical Hematology Lab, Hospital Ampang
EDTA Blood
Minimum 5 ml
4 weeks
• Fresh sample
• Send to HSgB lab Mon-Wed only
• Samples must reach before 9 am
• Do not send on PH and eve of PH
Request form: Hospital Ampang Special Hematology Lab Requisition form
Bone marrow
Minimum 1-2 ml
Molecular BCR/ABL 1
Clinical Hematology Lab, Hospital Ampang
EDTA Blood
Minimum 5 ml (2.5 ml x 2 tubes)
4 weeks
• Fresh sample
• Send to HSgB lab Mon-Wed only
• Samples must reach before 9 am
• Do not send on PH and eve of PH.
Request form: Hospital Ampang Special Hematology Lab Requisition form
Bone marrow
Minimum 1-2 ml
Molecular Genetic Test
Unit of Molecular Diagnostics and Protein (UMDP), IMR KL
Specimen requirements are according to cases. Please refer to Request Form for Molecular Diagnostic Services or call IMR (03-26162540/2590) for details
3 months
• All cases must be referred to and endorsed by a Clinical Geneticist before sending specimens
Request form: Request Form for Molecular Diagnostics Services
Molecular JAK 2
Clinical Hematology Lab, Hospital Ampang
EDTA Blood / Bone marrow
2 ml x 2 tubes
8 weeks
• Send to HSgB lab Mon-Wed only
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Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
• Samples must
reach before 9 am
• Do not send on PH and eve of PH.
Request form: Hospital Ampang Special Hematology Lab Requisition form
Osmotic Fragility Test
Hematology Unit, HKL (ext. 6549)
Lithium heparin (without gel)
Blood 2 ml x 2 tubes
15 working days
• By appointment
• Inform HSgB Lab before requesting
• Fresh sample required
• Send additional 2 mL healthy person’s blood as control
NOTE: 3 months post transfusion Request form: PER–PAT 301
Platelet Aggregation Test
Hemostasis Unit, PDN
- - - - • By appointment
• Patient to go directly to PDN
PID Lymphocytes (T & B Cell) Subset Enumeration
Measurement of :
1. Total T cells (CD3)
2. T helper cells (CD4)
3. Cytotoxic T cells (CD8)
4. B cells
AIRC Unit, NIH (ext. 8386)
EDTA Blood 2 ml 10 working days
• By appointment
basis
• Send to HSgB lab on every working Mondays and Thursdays only
• Samples must reach HSgB lab before 9 am
• Do not send on PH and eve of PH
• Please call (2122 / 2152) if there is any
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(CD19) 5. Natural
Killer cells
delay/ cancellation.
Request form: IMR PID Request Form
PID Immunoglobulin and complement Measurement of IgA, IgM, IgG, IgE*, C3 and C4.
Plain Blood 5 ml
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Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
Platelet Antibody Screening
Makmal Platelet Antibodi, PDN
EDTA & Plain tube (without gel)
Specimen: Blood Baby: - Patient: 2mL EDTA x 5 tubes
- Father’s blood: 2mL EDTA x 5 tubes
- Mother’s blood: 2mL EDTA x 5 tubes & 10mL plain tube
Adult:
2mL EDTA x 5 tubes & 10mL plain tube
20 working days
• By appointment with PDN Specialist on-call
• Register test for patient only. Write down parent’s details (Name and IC no.) on the sample tube
Request form: PDN Haematology/ Serology Request Form
PNH (Paroxysmal Nocturnal Hemoglobinuria)
Hematology Unit, WCH, KL
EDTA Blood 2 ml x 2 tubes
25 working days
• Fresh sample
• Send to HSgB Lab Mon-Wed only
• Samples must reach before 9 am
• Do not send on PH and eve of PH.
Request form: PER–PAT 301
Thrombophilia Screening:
• Lupus anticoagulant (LA)
• Activated Protein C Resistance
• Anti-
cardiolipin
• Anti-B2 Glycoprotein 1
Hemostasis Unit, PDN
3.2% Sodium citrate
Specimen: Blood
Adult:
6-7 tubes (15 ml)
Paeds 1- 12 years: 4-5 tubes (10 ml)
Paeds ≤ 1 year: 2-3 tubes (5 ml)
2 weeks
• Send immediately to lab (within 4 hours collection
• Please follow the PDN guidelines (Available in Public Folder)
Not indicated for:
• during acute episodes of thrombosis and pregnancy
• patients who had provoked VTE
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Test Perform Site / Referral Lab
Sample/ Container
Specimen Volume TAT Special Requirement/ Forms
• Antithrombin activity
• Protein C & S Activity
• Antiphospho- lipid Antibody
Patients on anticoagulants should be discontinued as below:
• Warfarin: suggest sending 2 weeks after discontinuation
• UFH & LMWH: suggest sending 24 hours post dose.
Request form: PDN Haematology / Serology Request Form
Note:
• All tests require freshly collected samples to be sent to the lab immediately with the exception
of DNA Analysis for Alpha and Beta Thalassemia. DNA Analysis specimen may be stored at
2- 8°C prior to sending.
• Appointments should be made with the respective referral labs and the appointment date
stated on the request form. If the given date is not within our lab’s appointed schedule (E.g.
G6PD Quantitative Assay- Mon- Wed), kindly inform us prior to sample collection for further
arrangement.
• Refer to the request forms for additional sampling guidelines.
• Reference interval for all outsourced test will follow the ranges specified by the perform site/
location.
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List of Request Forms - Hematology
FORMS CODE DESCRIPTION
Borang Permohonan Ujian Perkhidmatan Patologi
PER-PAT 301 General form
Cytogenetic Request Form for Peripheral Blood Samples
HKL/GE/TPM/N-1-(1) Chromosome Analysis for genetic disorder (WCH,KL)
DNA Analysis for Thalassemia Syndromes & Haemoglobinopathies Form
IMR/CaRC/HAEM/22/220 3/03(1)/REQForm
DNA Analysis test (Alpha : HKL, Beta : IMR)
Hospital Ampang Special Haematology Requisition Form
Hem-RQ19 Version 2 Clinical Haematology Lab, Hospital Ampang
Hematology/Serology Request Form
PDN/H/QP-01/01 PDN
Molecular Diagnostics Services Request Form
IMR/SDC/UMDP/MOLDX/ REQUEST FORM
IMR
Primary Immunodeficiency (PID) Request Form
IMR/AIRC/PID/RF For PID Quantitation of Immunoglobulin & Complement IMR
*All request forms can be downloaded from the P:\Borang-borang\Borang pathology
122
Full Blood Count Reference Interval
TEST REFERENCE INTERVAL REFERENCE
Haemoglobin (g/dL) Male < 60 Years 13.5 - 17.4 Ambayya et al. (2014)
Male > 60 Years 11.8 - 16.9
Female 11.6 - 15.1
0 Days 14.0 - 22.0 Dacie & Lewis 12th Edition
3 - 6 Months 11.1 - 14.1
1 Years 11.1 - 14.1
2 - 6 Years 11.0 - 14.0
6 - 12 Years 11.5 - 15.5
Haematocrit (%) Male < 60 Years 40.1 - 50.6 Ambayya et al. (2014)
Male > 60 Years 35.7 - 48.9
Female 35.1 - 44.9
0 Days 0.45 - 0.75 Dacie & Lewis 12th Edition
3 - 6 Months 0.30 - 0.40
1 Years 0.30 - 0.38
2 - 6 Years 0.34 - 0.40
6 - 12 Years 0.35 - 0.45
MCV (fL) Adult 80.6 - 95.5 Ambayya et al. (2014)
0 Days 100 - 120 Dacie & Lewis 12th Edition
3 - 6 Months 68 - 84
1 Years 72 - 84
2 - 6 Years 75 - 87
6 - 12 Years 77 - 95
MCH (pg) Adult 26.9 - 32.3 Ambayya et al. (2014)
0 Days 31 - 37 Dacie & Lewis 12th Edition
3 - 6 Months 24 - 30
1 Years 25 - 29
2 - 6 Years 24 - 30
6 - 12 Years 25 - 33
MCHC (g/dL) Adult 31.9 - 35.3 Ambayya et al. (2014)
0 Days 30.0 - 36.0 Dacie & Lewis 12th Edition
3 - 6 Months 30.0 - 36.0
1 Years 32.0 - 36.0
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TEST REFERENCE INTERVAL REFERENCE
2 - 6 Years 31.0 - 37.0
6 - 12 Years 31.0 - 37.0
RBC (x 10^12/ L) Male < 60 Years 4.53 - 5.95 Ambayya et al. (2014)
Male > 60 Years 3.86 - 5.62
Female 3.87 - 5.21
0 Days 5.0 - 7.0 Dacie & Lewis 12th Edition
3 - 6 Months 4.1 - 5.3
1 Years 3.9 - 5.1
2 - 6 Years 4.0 - 5.2
6 - 12 Years 4.0 - 5.2
RDW-SD (fL) Adult 37.5 - 48.1 Ambayya et al. (2014)
RDW-CV (%) Adult 12.0 - 14.8 Ambayya et al. (2014)
Platelets (x 10^9/ L) Male 142 - 350 Ambayya et al. (2014)
Female 171 - 399
0 Days 100 - 450 Dacie & Lewis 12th Edition
3 - 6 Months 200 - 550
1 Years 200 - 550
2 - 6 Years 200 - 490
6 - 12 Years 170 - 450
WBC (x 10^9/ L) Adult 4.1 - 11.4 Ambayya et al. (2014)
0 Days 10.0 - 26.0 Dacie & Lewis 12th Edition
3 - 6 Months 6.0 - 18.0
1 Years 6.0 - 16.0
2 - 6 Years 5.0 - 15.0
6 - 12 Years 5.0 - 13.0
Neutrophils (x 10^9/ L) Adult 3.9 - 7.1 Ambayya et al. (2014)
0 Days 4.0 - 14.0 Dacie & Lewis 12th Edition
3 - 6 Months 1.0 - 6.0
1 Years 1.0 - 7.0
2 - 6 Years 1.5 - 8.0
6 - 12 Years 2.0 - 8.0
Lymphocytes (x 10^9/ L) Adult 1.8- 4.8 Ambayya et al. (2014)
0 Days 3.0 - 8.0 Dacie & Lewis 12th Edition
3 - 6 Months 4.0 - 12.0
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TEST REFERENCE INTERVAL REFERENCE
1 Years 3.5 - 11.0
2 - 6 Years 6.0 - 9.0
6 - 12 Years 1.0 - 5.0
Monocytes (x 10^9/ L) Adult 0.4 - 1.1 Ambayya et al. (2014)
0 Days 0.5 - 2.0 Dacie & Lewis 12th Edition
3 - 6 Months 0.2 - 1.2
1 - 12 Years 0.2 - 1.0
Eosinophils (x 10^9/ L) Adult 0.0 - 0.9 Ambayya et al. (2014)
0 Days - 12 Years
0.1 - 1.0 Dacie & Lewis 12th Edition
Basophils (x 10^9/ L) Adult 0.0 - 0.9 Ambayya et al. (2014)
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Transfusion Medicine
Introduction
The blood transfusion service plays a role by ensuring a reliable and adequate
supply of safe and effective blood products. It encompasses transfusion laboratory
testing, clinical transfusion consultation, transfusion audit and monitoring of
transfusion reaction. The unit will ensure that the correct blood is given and that
any adverse reactions are dealt with promptly and efficiently
List of Test & Turn Around Time (TAT)
Test TAT
Group, Screen and Crossmatch (GXM) 2 hours
Urgent Full crossmatch (uGXM) 45 mins
Group, Screen and Hold (GSH) 2 hours
GSH convert to GXM 1 hour
Urgent GSH convert GXM (cGXM) 45 mins
Immediate spin phase/ 1st Stage GXM < 30 mins
Blood components If blood group known: Platelets 10 mins
If blood group unknown: Platelets 20 – 30 mins
Fresh Frozen Plasma, Cryoprecipitate
and Cryosupernatant 20 – 30 mins
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Blood Transfusion Procedures
The decision to transfuse should be made based on clinical judgment. The benefit
and risk must be assessed, and alternative therapy should consider. Blood
transfusion carries various risks to the health of the patient including transmission
of infectious disease agents (HIV, Hepatitis, and Syphilis), transfusion reaction and
even risk of transfusing wrong blood, which may be fatal. Process and procedure
should be in place to ensure patient safety. Blood transfusion should be avoided
after office hours except in emergency situation.
1. Consent for Transfusion
The decision to transfuse and consent should be made at advance with patient,
parent or guardian before any planned transfusion. Patient planned for transfusion
must be informed on indication, benefits, potential risk and alternatives to the
transfusion therapy. The patient should be given opportunity to ask questions. The
discussion between clinician and patient should be documented in patient’s health
records and does not require the signature of the patient.
The consent form needs to be signed by the patient before the transfusion. If the
patient is unable to give written consent, a responsible family member must be
asked to do so. In an emergency and if no family member available, when the
need for transfusion leaves no time for written consent, the decision shall be made
by two fully registered medical practitioners, note in patient’s health record and
this information should be provided to patient or family member of the patient after
transfusion.
2. Blood Ordering and Sampling
The process of taking and labelling blood samples must be done in one process
at the bedside, one patient only at any one time. The requesting doctor shall be
responsible to ensure:
i. Use own personnel log in HIS
ii. Place order on correct patient’s chart
iii. Print the specimen label, collect sample and label it
iv. Fill in the blood requesting form
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3. Patient Identification
Accurate identification of patients at all stages of the blood transfusion process is
essential. Confirm patient’s name and identification by:
i. Asking the patient to state his/her full name
ii. Read the wristband.
iii. Check the patient’s information on clinical notes and printed specimen label.
The unconscious patients MUST be identified by the information given on the
wristband. If the patient is unconscious and unknown, it is acceptable to use
“Unknown” with the Medical record number, which is assigned to the patient on
arrival. This number must be used to identify this patient until full and correct
personal details are available.
4. Labelling of Sample
i. Labelling must be done at patient’s bedside immediately after blood taking by
the person who takes the blood.
ii. Never label 2 or more patient’s sample at the same time.
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5. Blood Requesting Form
Prescribing blood and blood products is the responsibility of the doctor managing
the patient. The request form and request through the THIS system should be
complete.
The relevant patient information should include:
i. Patient’s details: Name, IC number, hospital registration number
ii. Current working diagnosis
iii. Indication for transfusion
iv. Previous transfusion history
v. Patient’s consultant name
vi. Blood group if known
vii. Latest haemoglobin level
viii. The test required (GSH /GXM/ABO grouping/ /DCT)
ix. The quantity of blood bags requested
The request form should be signed by the requesting doctor and his/her name
should be stamped or written clearly in block letters.
6. Receiving Request
The blood sample for GXM or GSH shall be sent to the blood bank either:
i. Walk in at counter blood bank
ii. Via pneumatic tube system (115)
Blood bank personnel must ensure that the request form is properly filled, and the
corresponding samples are correctly labelled before accepting the request.
129
7. Pre-Transfusion Testing
Tests Remarks
ABO Grouping ABO grouping will be carried out on all requests for blood and blood component using the test tube or gel card method
Rh Typing Rh D typing will be carried out on all requests for blood and blood component using the tube or gel card method
Antibody Screening • Mandatory request for all transfusion
• Antibody screening done by gel card method
Antibody Identification • Antibody identification shall be carried out whenever the antibody screening test is positive, and/or incompatible cross match detected.
• In the event of incompatible cross match in a life- threatening situation, more time and blood should be cross match to find units that are fully compatible.
• In non-urgent situation, sample will be sent to PDN for antibody identification and supply of compatible
Group, Screen and Hold (GSH)
• Performed for cases where probability of transfusion is low
• Comprises of ABO blood grouping, Rh typing and antibody screening.
• Patient’s sample will be retained in blood bank for 48 hours.
• If transfusion required, the sample will be converted to cross matched.
• After 48 hours a fresh new sample is required for cross match.
• GSH will not be carried out at night after 9pm, except bleeding case and cases from emergency department.
Group and Cross matching (GXM)
• Performed for cases where probability of transfusion is high.
• Comprises of ABO grouping, Rh typing, antibody screening and cross matching.
• Cross matched blood units will be kept in reserved for 48 hours before blood collection.
• The samples should reach the blood bank before 5 pm
• Medical officer blood bank approval (MO code) required for blood sample processing after 5 pm
Direct coomb’s test (DCT)
• Performed if cross match not compatible (for recipient and donor)
• Investigation for transfusion reaction
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8. Blood Samples
A blood sample is required prior to a transfusion to ensure compatibility of blood
groups between donor and recipient and to screen patients for atypical red cell
antibodies which can potentially cause reactions.
Requirement for blood samples for pre-transfusion testing:
Blood sample for red cells (GSH /GXM)
i. 3 ml – 5 ml blood in EDTA tube
ii. If no previous ABO blood grouping record in the system, 2nd sample
for ABO blood grouping required.
iii. Completed blood bank request form
Blood sample for blood components
i. 3 ml – 5 ml blood in EDTA tube for blood component required.
ii. If no previous ABO blood grouping record in the system, 2nd sample
for ABO blood grouping required.
iii. If patient had received a transfusion of blood within the previous 3
months and the procedure was without any complications, a new
blood sample need NOT accompany requests for more blood
components. Only barcode for components required.
iv. Completed blood requesting form for each product one form as per
barcode.
Blood sample for infant less than 6 months old (GXM)
i. The Infant’s blood sample should be accompanied by a sample of the
mother’s blood sample.
ii. If the maternal blood is unavailable, 3 ml infant’s blood is required for
testing.
iii. 1 – 1.5ml infant blood in EDTA tube
iv. 3 ml – 5 ml mother’s blood in EDTA tube
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v. To fill in request blood form for each sample (infant and mother).
vi. Generate barcode under paedy bag request for infant and mother
sample.
vii. 2nd sample for ABO grouping required if no previous record available
in system (for baby and mother).
Blood sample for infant more than 6 months old (GSH/GXM)
i. 3 ml – 5 ml infant blood in EDTA tube
ii. One completed blood request form
iii. 2nd sample for ABO grouping required if no previous record available
in system.
Blood sample for antibody identification
If antibody screening test is positive and/or incompatible cross-match
detected, antibody identification should be performed. Referral to a
reference Laboratory may be necessary for definite identification.
Ward/ Clinician
i. 10ml of blood in EDTA tube
ii. 10ml blood in plain tube.
iii. Completed blood request form
Blood Bank
i. Provide the reference laboratory with initial laboratory findings
ii. Consult reference laboratory’s Specialist/Medical Officer before
sending the sample
Blood sample for elective transfusion and surgery (GSH/GXM)
Blood sample requirements:
i. Should be sent during office hours
ii. One day prior to blood is required (24 hours)
132
iii. Request based on hospital maximum surgical blood ordering
schedules (MSBOS)
iv. GSH and GSH converting to GXM for elective operation will be
performed only during office hour.
v. Blood bank MO code is required after 5 pm
vi. 3 ml – 5 ml EDTA tube (1st sample)
vii. 2nd sample for ABO grouping as required
viii. Completed blood requesting form
Blood sample for emergency transfusion (GXM)
All emergency requests shall be followed by a phone call to alert the blood
bank staff to facilitate the process. The clinician / House officer in charge
shall send sample directly to blood bank and wait until the blood is ready
for collection.
i. 3 ml – 5 ml in EDTA tube
ii. Completed blood requesting form
Second blood sample for ABO grouping confirmation.
Second blood sample for ABO grouping confirmation is a must for patient
who has no record of his ABO blood group in the system/ first time GSH
or GXM.
i. 3ml-5ml in EDTA tube
ii. Should be collected at different time of the 1st blood sample collection
Blood sample for transfusion reaction workout
i. Order placed under post transfusion reaction profile 1 panel
ii. Order post transfusion reaction profile 2 panel for post 24 hours
iii. 3ml of venous blood sample collected in EDTA tube
iv. Additional blood for FBP, biochemistry (bilirubin, renal profile) and
screening for those suspected haemolytic transfusion reactions.
v. 20 cc of urine sample for haemoglobinuria.
133
vi. The remaining blood bag (partially transfused blood or unused blood
bag) and tubing set without needle (closing it securely)
vii. Completed transfusion reaction form.
Massive Transfusion Protocol (MTP)
i. MTP activation decision should be made by attending specialist
ii. Clinical co-coordinator appointed by the attending specialist to
activate the MTP
iii. Inform blood bank and provide full required information
iv. Inform blood bank medical officer
v. Ensure sufficient blood sample in EDTA tube, completed blood
requirement forms and manage the sample before sending to blood
bank.
vi. Ensure the sample reaches the blood bank on time to avoid delay.
vii. Deactivate MTP
viii. Send completed tracking form to blood bank once MTP deactivated.
Form available in Public folder Massive Transfusion Protocol (MTP)
tracking form.
134
9. Rejection of Samples
The blood sample will be rejected in the following cases:
i. Duplicate order
ii. Blood clotted
iii. No MO code
iv. Improper barcode labelling
v. Need separated barcode
vi. Insufficient sample (less than 3mls)
vii. Blood haemolysed
viii. Lipemic sample received
ix. Wrong tube/container
x. Unsuitable sample for analysis
xi. Post transfusion sample
xii. No clinical indication
xiii. No clinical history/patient diagnosis
xiv. Test not done (empty blood bag received)
xv. Incorrect information
xvi. No request form attached
xvii. Incomplete request form
Note: Exceptions are made only in life threatening situations after consulting and
obtaining the approval of the laboratory personnel.
10. Unmanaged Blood Sample
i. Unmanaged blood sample will not be able to register in blood bank
system
ii. It will be kept for 1 hour at blood bank counter awaiting ward personnel
to manage.
iii. If the sample has been managed within the 1 hour, the sample shall be
accepted to run the test.
iv. If the status of sample is still unmanaged after 1 hour, the sample will be
discarded without any notice.
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11. Selection of Red Cells for Transfusion
For routine transfusion, packed red cells should be used in preference to whole
blood.
i. Red blood cell products should be of the same ABO and Rh D type as the
patient whenever possible.
ii. The choice of red cells for infant less than 4 months of age is Group O Rh
positive pack red cells (paedy-bag).
12. Transfusion in Special Circumstances
Emergency un-crossmatched blood group O (safe O)
i. In life threatening situation, clinician shall choose to transfuse group
O Rh (D) Positive buffy coat poor packed cell or pack cell for
resuscitation which made available in Emergency Department (ED)
and Operation Theatre (OT).
ii. Decisions to transfuse un-crossmatched safe group O blood must only
be made after the responsible clinician has fully assessed the patient's
condition. The decision should not be made in haste.
iii. The requesting doctor must state the reasons for such a decision on
the request form/ clinical note/patient’s chart in THIS and sign it.
iv. Pre transfusion blood sample must be collected before the
transfusion.
v. Pre transfusion sample and the completed empty safe O bag should
be sent to blood bank immediately for ABO blood grouping and
crossmatch.
vi. Replacement of used safe O bag will be done once unit consumption
completed by the respective department/clinician in the system.
Saline phase crossmatched blood (1st stage)
i. Transfusion of ABO-matched red cell is preferable to uncrossmatched
group O Rh positive packed cell.
ii. Red cell transfusion needed urgently but not as immediate where the
patient’s lives are in immediate danger.
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iii. Emergency cross-match is done by saline phase at room temperature
and shall be available in 20 minutes. Full cross-match shall continue
after the blood is issued and any incompatibility detected shall be
informed immediately to the requesting clinician.
13. Issue, Collection & Returned Unused Blood and
Blood Component
i. Blood bank staff shall ensure that correct blood and blood component is
being issued.
ii. The date and time of issue and collection shall be recorded by the blood
bank personnel.
iii. The record shall include the details of the person issuing and the person
collecting the blood or blood product.
iv. The person collecting the blood shall provide a documentary proof of the
patient identity (blood collection slip or barcode label).
v. The person collecting the blood shall ensure that correct blood and blood
component has been supplied to him/her before leaving the blood bank
counter.
vi. Issued blood shall be transfused without undue delay.
vii. The prepared blood and blood component shall be kept in blood
refrigerators in blood bank at appropriate temperature.
viii. Collect blood bag only if required for immediate transfusion.
ix. Transportation shall be carried out in an appropriate temperature.
x. The ward shall maintain the blood at appropriate temperatures and
condition until they are used or returned to the blood bank immediately
xi. The ward shall return untransfused blood immediately to blood bank.
xii. The ward shall inform the blood bank if any of the untransfused blood
returned has not complied with the storage or transportation temperature.
xiii. Untransfused blood that returned shall be discarded unless it is kept in an
appropriate condition and temperature.
xiv. The returned of unused blood shall be kept until the next stock check
following day (8 am and 2 pm).
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14. Return of Used Blood Bags
i. The ward shall be responsible to return used blood bags and completed
compatibility card within 24 hours.
ii. Unit consumption shall be completed in ward prior to return of the used
empty bag.
iii. The empty used bag and the completed compatibility card will be kept in
blood bank for 7 days.
15. Administration of Blood Product
Confirm the patient’s name and identification by asking the patient or
relative to and by checking:
i. The patient’s note
ii. Compatibility card
iii. Request form.
iv. Wristband
Check the expiry date of blood or blood component.
Record the blood transfusion detail in patient’s note
i. Type of product transfused
ii. Product barcode number
iii. Date of transfusion
iv. Volume transfused
v. Time transfusion started and ended.
vi. Adverse transfusion reaction, if any
The patient shall be closely observed and monitored during the
transfusion.
Parameters to be monitored shall include:
i. Blood pressure and pulse rate
ii. Temperature
iii. Clinical features of acute transfusion reactions
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16. Storage, Transportation and Duration for Transfusion of Blood Components
BLOOD COMPONENTS
Red cells (all types of red cells)
Platelets Thawed Plasma
Thawed Cryoprecipitate/ Cryosupernatant
STORAGE 2 - 6ºC 20 - 24ºC Shall be issued once the product is thawed
Shall be issued once the product is thawed
TRANSPORTATION 2 - 10ºC Should be kept at 20 - 24ºC.
NEVER put
platelets in refrigerator
2 - 10ºC 20 - 24ºC (thawed product)
TRANSPORT BOXES
Insulated box with coolant pack. Direct contact with coolant shall be AVOIDED
Insulated box WITHOUT ICE
Insulated box with coolant pack. Direct contact with coolant shall be AVOIDED
Insulated box WITHOUT ICE
DURATION BEFORE TRANSFUSION
30 minutes after removing the packs from blood refrigerator
Start as soon as the pack is received from the blood bank
As soon as the thawed pack is received from the blood bank
As soon as the thawed pack is received from the blood bank
DURATION DURING TRANSFUSION
SHOULD NOT
more than 4 hours to completion to avoid risk of bacterial contamination
SHOULD NOT be
more than 30 minutes
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17. Transfusion Reaction
All Transfusion Reactions shall be investigated, reported and managed
accordingly.
To facilitate investigation of an adverse transfusion reaction, the following
shall be carries out:
i. Blood samples in EDTA shall be taken for:
a) Repeat ABO/Regrouping
b) Repeat crossmatching
c) Direct and indirect antihuman globulin test (Combs’ test)
d) Urine examination for hemoglobin and red cells
*Refer section 8.9 for details on specimen collection
ii. In addition, for case suspected of haemolytic transfusion reactions,
further investigation should include full blood picture (FBP), liver
function test (LFT) and lactate dehydrogenase (LDH).
iii. These specimens shall be accompanied by a request form for
investigation of transfusion reaction.
iv. The remaining blood bag (partially transfused blood or unused blood
bag) and tubing set (closing it securely) should be returned to blood
bank with all attached labels.
v. If the patient needs further transfusion, new crossmatch will be
performed with fresh new samples.
18. Transfusion Record
i. All record of transfusion request shall be kept in blood bank and on the THIS
system, including those cases of screen and hold.
ii. Document the details of the transfusion including blood unit transfused in the
system / PPDK card.
iii. Return all used blood bag to blood bank - empty or not, and any unused units
together with completed PPDK card.
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19. Rare Blood Group
Rh(D) negative blood group:
i. To follow the own hospital procedure on managing RhD negative cases
ii. Minimal stock available in blood bank (only for emergency use)
iii. In elective cases, blood bank shall be informed at least one week prior to the
procedure that may require transfusion.
iv. This notification is essential to allow the blood bank enough time to source for
the required blood.
v. In emergency situation, where ABO group specific RhD negative blood is not
available in time, blood bank may issue, in order of preference:
a) Group O RhD negative blood, or
b) ABO group specific RhD positive blood, only if the patient does not have
pre-formed anti D.
c) This shall be done only after discussing with and agreed by the treating
clinician.
vi. In case of patient with a rare blood group ample notice should be provided to
blood bank so that appropriate arrangement can be made. At least one week
notice should be given prior to the operation to facilitate procurement of
sufficient compatible blood units and for screening of family members
(phenotype the siblings).
141
Collection Chart – Transfusion Medicine
Tube / Container Sample/Tube Description
Common Use Special Instruction
Plain tube without gel
Antibody identification Mix sample gently 5 times
Adult EDTA GSH, GXM, Antibody identification
Mix sample gently 8 – 10 times
Paeds
Sterile urine container
For Urine Hb – Transfusion reaction case
Please ensure cap is tight and secure
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List of Request Forms – Transfusion Medicine
FORMS CODE DESCRIPTION
General PER-PAT Form PER-PAT 301 For other tests
Borang Pemohonan Transfusi Darah
WJD011379-PNMB., K.L.
For GSH, GXM, Antibody Identification
Borang Laporan Reaksi kepada Darah atau Komponen Darah
BTS/TR/2/2016 For Transfusion Reaction Report
Permohonan Rujukan Ujian Immunohematologi
PDN/IH/QP-01/04 For Antibody Identification PDN
Permohonan Rujukan Ujian Platelet Immunologi
PDN/IH/QP-03/03 PDN
Borang Persetujuan Pemindahan Darah atau Komponen Darah (Consent Form)
BTS/TC/2/2016 Consent form for patient
Worksheet for Investigation of Transfusion Reaction
BTS/TRW/2/2016 For pathology staff
(transfusion unit)
Reporting Form for Transfusion-Related Adverse Event
BTS/HV/3/2016 For pathology staff (transfusion unit)
*All request forms can be downloaded from the P:\borang-borang\borang pathology
143
Histopathology *All histopathology and cytology samples will be outsourced to respective referral laboratory [to refer table List of Test (Outsourced)]
1. List of Services
i. Surgically and non-surgically removed tissue
ii. Frozen section
Histopathology Procedures
2. General procedure for Submission of Specimen
All specimens for routine histological examination are to be fixed in 10%
formalin in suitable leak-proof container. The volume of formalin used is
at least 10 times the specimen to be fixed.
Seal every specimen securely to avoid leakage and pack with proper
plastic to avoid damage during transport.
Register and label the specimen with the patient’s name, registration
number and the site of origin of the specimen.
PLEASE ENSURE THE SAME IDENTIFICATION as written on the
request forms (3 copies of PER-PAT 301 forms).
Every specimen must be accompanied by a completed request form
giving full particulars of the patient including relevant clinical history,
diagnosis and previous histopathology reports if any. Clearly indicates
the ward / clinic where the sample was taken. Also, include name of
doctor in charge (especially the specialist in charge), for contact if there
is any inquiry.
144
Stick the hospital barcode at the right hand side corner of all 3 copies of
the PER-PAT 301 forms. For urgent request, please mark as “URGENT”
on the request form.
3. Specimen Collection and Preparation
The specimens should be fixed in the usual manner. DO NOT put large
specimen in small containers as this would prevent proper fixation of the
tissue and also distort the specimen.
For adequacy of surgical excision in malignant neoplasm, the margins
must be marked accordingly by sutures or by diagrammatic
representation of the excised specimen.
Specimen for immunofluorescence (IMF), enzyme histochemistry studies
are to be sent fresh without fixative in the closed containers or in gauze
moistened with normal saline to prevent drying.
For immunofluorescence specimen are sent in phosphate buffered saline
(PBS) to prevent drying.
Specimen for routine histological and immunofluorescence should be
sent directly to receiving counter.
IMF received after office hour will be frozen and send to respective
hospital during office hour.
All histopathology samples are sent to Hospital Selayang, Hospital UiTM,
Sg Buloh and Hospital Kuala Lumpur daily except on Saturday, Sunday
and Public holiday. As for stomatology, the samples are sent to IMR
4. Frozen Section
The tissues for frozen section are to be sent fresh without formalin or in
gauze moister by normal saline to prevent drying.
Frozen section can only be requested by the specialist treating the patient
by making an appointment with the histopathology’s on-call (Hospital
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UiTM, Sg Buloh or Hospital Selayang) and pathology laboratory (ext.
2122, MO Outsource) at least ONE DAY earlier before sending sample
to the lab.
All cases scheduled for frozen section examination are best placed first
in the operating list. No frozen sections are available after office hours.
Please inform the lab when:
a) The patient is wheeled into the operating room
b) The frozen section specimen is on the way to the lab
c) The frozen section examination is cancel
The lab has to make an arrangement for the hospital transport.
The doctor must send the specimen immediately to the laboratory with
the request form. Transport arrangement will be made by Pathology
Department and Pathology PPK will send the sample to respective
laboratory.
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Cytology *All histopathology and cytology samples will be outsourced to respective referral
laboratory [to refer table List of Test (Outsourced)]
1. List of Services
Exfoliative cytopathology - involves examination of specimens which
contain exfoliated cells. The usual specimens received are cervical
smears, sputum, urine, pleural fluid, peritoneal fluid and washings of
various sites.
i. Gynaecologic – pap smear
ii. Non gynaecologic – body fluids
Aspiration cytopathology - involves examination of cells that are
obtained by fine needle aspiration and brushings.
i. Fine needle aspiration
ii. Brushings
Cytology Procedures
2. General procedure for Submission of Specimen
All specimens for cytological examination should be put in clean
universal leak – proof containers.
All specimens should have the same identification as that written on the
request forms.
The form must be completely filled including the clinical history to avoid
rejection of specimen.
Pap smear slide should be placed in a slide mailer before being
dispatched to the laboratory.
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Specimen for cytological examination should be sent directly to the lab to
be sent to cytological laboratory, Hospital Selayang.
Specimens collected after office hours should be refrigerated at 4C
before being dispatched to the cytology laboratory the next day.
Refrigeration helps in preserving the cell.
DO NOT FREEZE SPECIMEN.
3. Specimen Collection and Preparation
Gynaecologic cytology
DO NOT use lubricant on the speculum. Place cervical spatula
at the external os and rotate through 360 degrees, lightly scraping the
squamo-columnar junction.
Smear the material onto a clean, labelled glass slide about as
thick as a blood film.
Immediately place the slide in 95% alcohol for at least 15
minutes. If more than one slide is to be placed in the same container,
ensure that they are not placed face to face.
Sputum
(Specimen must be collected on three consecutive days)
Instruct the patient to empty the mouth of all saliva immediately
after waking up in the morning.
The patient should then cough deeply and collect the resulting
sputum in the container supplied.
The specimen must be sent immediately to the laboratory.
Do not forget to collect a similar specimen on the next two days.
The specimen container should be labeled according to day
specimen is collected.
148
Urine
The patient should void and discard the first morning specimen.
Do not send overnight urine sample as most of the cells in this sample
are degenerated.
Collect the next voided urine and send it immediately to the
laboratory.
Body fluids
(Pleural fluid, ascitic fluid, cerebrospinal fluid, pericardial fluid, etc)
Specimens are collected in clean containers and dispatched
immediately to the laboratory.
Vesicle fluid
Prepare two thin smears on clean glass slides
Air-dry the slides. Air- drying is done by putting the slide in a
vertical position on a slide rack or placed horizontally on a table top and
letting the smear dry. This usually takes 10 minutes to 15 minutes.
Place the slides in a slide mailer and send to the laboratory for
Giemsa staining.
Fine Needle Aspiration Cytology (FNAC)
The FNAC clinic is conducted twice a week at the surgical
outpatient department (SOPD) and once a week at the ENT clinic.
Tuesday and Thursday : 9.00 am (SOPD)
Tuesday : 2.00 pm (ENT)
Wednesday : 9.00 am (Radiology)
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Appointment requests for FNAC should be ordered only by the
medical officer / specialist. The request forms should be filled legibly,
complete with the clinical history and findings. Whenever there is more
than one lump or swelling present, the clinician should indicate which
lump/s or swelling/s to be aspirated. The clinician requesting the FNAC
procedure should have his/her name clearly written on the request form
so that they would be able to be contacted if there is any query.
Indications for FNAC
a) Breast cancer cases to confirm diagnosis.
b) Suspicious lesions to exclude breast cancer.
c) Solitary cold nodule in a thyroid gland.
d) Suspicious lesions such as salivary gland tumours and
subcutaneous nodules.
Please note that:
a) Breast and thyroid cyst may be aspirated by the surgeon and
material sent for cytologic examination.
b) There is no indication for FNAC in multinodular goitre or
diffuse goiter.
c) Vascular lesions or those of vascular origin should not be
sent for FNAC.
d) Radiologist under radiological guidance on appointment
basis performs FNAC for deep-seated lesions.
4. Collection of reports
All histopathology and cytology results are entered in LIS using report’s
unique number.
Clinician must use that unique number to view the results.
All results are available in ‘Public’ folder ‘Histo Cyto Patologi’
(which is accredited to selected clinician only).
Please refer diagram below, to see the instruction on how to view the
results.
150
Tracing Histopathology & Cytology Results
1. Copy the unique number as stated in the eHIS system (eg: SP-20-xxxx SBxxxxxxxx)
2. Go to MY COMPUTER PUBLIC FOLDER ‘Histo Cyto Patologi’ Folder
151
3. Click ‘Search’ ‘All Files and Folder’
4. Paste the copied number in the column provided
5. List of result/s (PDF form) will be shown
152
Collection Chart – Histology & Cytology
Tube / Container Sample/Tube Description
Common Use Special Instruction
Sterile container with 10% formalin (for Histopathology specimen)
without formalin (for Cytology specimen)
-
Disposable container
For surgical specimen
-
153
List of Test (Outsourced)
Test Perform Site / Referral Lab
Sample/ Container
Specimen TAT (working
days)
Special Requirement/
Forms
Histopathology specimens: • Big specimen • Bone
(decalcification)
Histopathology Unit, Hospital Selayang
Leak proof container with 10% Formalin (10 x specimen)
Tissue 30 days (Routine) 7 to 14 days (urgent)
PER–PAT 301
Histopathology specimens: • Small biopsies • Big specimen
• (Breast & Colon only)
Hospital UITM, Sungai Buloh
Leak proof container with 10% Formalin
Tissue 30 days (Routine) 7 to 14 days (urgent)
PER–PAT 301
Frozen section Histopathology Unit, Hospital Selayang & Hospital UITM, Sungai Buloh
Universal Container (fresh)
Tissue - PER–PAT 301
Histopathology specimens (Brain)
Histopathology Unit, HKL / Histopathology Unit, Hospital Selayang
Plain container with 10% neutral buffered formalin (NBF)
Brain tissue
30 days (Routine) 7 to 14 days (urgent)
PER–PAT 301
Histopathology specimens (Oral)
Stomatology Unit, IMR
Leak proof container with 10% Formalin
Oral tissue
30 days (Routine) 7 to 14 days (urgent)
IMR Pathological Specimens
Cytology specimens (Non-gynaecology and FNAC)
Cytology Unit, Hospital Selayang
Leak proof container
Tissue 14 days (Routine) 7 days (urgent)
PER–PAT 301
Pap smear (Gynaecology)
Cytology Unit, Hospital Selayang
Not applicable
Slide 14 days (Routine)
Pap smear Request Form
154
List of Request Forms – Histopathology & Cytology
FORMS CODE DESCRIPTION
PER-PAT 301 Form Per-pat 301 For Histopathology and Cytology H.Selayang, Hospital UiTM Sg Buloh dan Histopathology HKL
Borang Permohonan Ujian Pap Smear
PS 1/98 For Pap smear
IMR Pathological Specimens (STOMATOLOGY)
Medl. 135 For Stomatologi IMR
Permohonan untuk Pinjaman Slide Histopatologi/Sitologi
HS/JP/WI (HC:09)-001: Appendix [4]
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*All request forms can be downloaded from the P:\borang-borang\borang pathology