Title: Haematology & Blood Transfusion Laboratory Handbook...1. All Rhesus negative women as soon as...

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Haematology & Blood Transfusion Laboratory Handbook

Haematology/Blood Transfusion/Clinical Chemistry 11133

Chris Brammer and Marie Hughes

4.0

Haematology & Transfusion

Sheila Kowalczyk

23-Apr-2012

23-Apr-2014

Intranet

All Haematology, Chemistry & Transfusion Locations

23-Apr-2012 09:32

23-Apr-2012 09:38

Department of Haematology, Blood Transfusion & Clinical Chemistry

Authorised

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Haematology & Blood Transfusion Laboratory Handbook - Version: 4.0. Index: Haematology/Blood Transfusion/Clinical Chemistry 11133. Printed: 23-Apr-2012 09:38

Authorised on: 23-Apr-2012. Authorised by: Sheila Kowalczyk. SOP Unique Reference: 112-20550291. Due for review on: 23-Apr-2014

Author(s): Chris Brammer, Marie Hughes

Department of Haematology and Blood Transfusion

Laboratory Handbook

Section Contents

1 Introduction, Location & Telephone Numbers 2 General Comments 3 Laboratory Opening Hours and Emergency Service 4 Request Forms 5 Specimen Tubes 6 Blood Transfusion 7 Obstetric Haematology 8 Further Points to Remember 9 Anticoagulation 9.1 Heparin 9.2 Warfarin 10 Discharge on Warfarin 11 Thrombophilia Screening 11.1 Who to Test 11.2 When to Test 12 Haematology Tests, Reference Ranges and Turnaround Times 12.1 - Haematology Tests Special Precautions 12.2 - Haematology Tests Time Limit for adding Additional Request 12.3 -Screening for Malaria and other blood borne parasites 12.4 -Requesting and interpreting Haematinics tests (B12, Folate, Iron

studies) 12.5 -Screening for Thalassaemia and Haemoglobinopathies 12.6 -Investigation of Hereditary Spherocytosis 13 Reference Lab Addresses

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1. INTRODUCTION, LOCATION AND TELEPHONE NUMBERS A routine Haematology and Transfusion service is provided from Forth Valley Royal Hospital between 8.45am and 5pm. Out with normal working hours the laboratory operates an out of hours service. The laboratory is located on the second floor as shown on the following floor plan:

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CONSULTANTS Dr. C. Brammer ext. 66771 (external 01324 566771) Dr. R.F. Neilson ext. 66772 (external 01324 566772) Dr. M. Hughes ext. 66770 (external 01324 566770) Dr R. Boulton-Jones ext. 66768 (external 01324 566768) Secretary ext. 67084 (external 01324 567084) For urgent clinical queries Consultant Haematologist can be contacted on 01324 567675 Mon-Fri 9am – 5pm. On-call Haematologist can be contacted via hospital switchboard outwith these hours. Non-urgent clinical or laboratory queries should be directed to the departmental mailbox which will be reviewed daily Monday to Friday. Email address: [email protected] SENIOR LABORATORY STAFF Mrs Sheila Kowalczyk BMS 4 ext. 66767 (external 01324 566767) Mr Tom Ford BMS 3 ext. 66775 (external 01324 566775) Mrs Mandy Dawson BMS 3 ext. 66777 (external 01324 566777) Mr Mark Gilmour Quality Manager ext. 66773 (external 01786 566773) LAB NUMBERS Laboratory Emergency Pager out of hours 1777 Specimen Reception Routine Enquiries ext. 66695 (external 01324 566695) Specimen Reception Emergency Requests ext. 66693 (external 01324 566693) Haematology Laboratory ext. 66755 (external 01324 566755) Transfusion Laboratory ext. 66779 (external 01324 566779) Transfusion Practitioner ext. 66762 (external 01324 566762) FORTH VALLEY ROYAL SWITCHBOARD 01786 566000

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2. GENERAL COMMENTS We provide a service to all hospitals and General Practitioners in the area and receive about 2000 specimens each day. Please ensure that specimens and request forms are both adequately labelled so that they can be matched up without error and the result sent to the appropriate destination. If you do not use the CHI number, we may not be able to link earlier results to the same patient. If you have access to laboratory results electronically they may not be available to you. Relevant clinical details help us to be more helpful to you. It is rarely possible, for example, to interpret blood film morphology without some knowledge of the clinical situation. A comment such as “routine” is not any help. The Consultant Haematologists are always willing to discuss problems and to give advice. 3. LABORATORY OPENING HOURS AND EMERGENCY SERVICE LABORATORY OPENING HOURS –HAEMATOLOGY AND BLOOD TRANSFUSION Monday to Friday 08.40 – 17.00 (Normal Service) Monday to Friday 17.00 -08.40 (Reduced 24 hour service) Saturday and Sunday all day – (Reduced 24 hour service) Out of hours: The department operates a shift system for Haematology and Transfusion, and the duty BMS should be contacted through the switchboard or internal page number 1777. On Sunday mornings the shift BMS will deal with the necessary but non-emergency work that inevitably occurs. It is much appreciated if you can send predictable samples early in the day and notify the laboratory of what you are sending. EMERGENCY SERVICE When sending urgent samples please notify the Laboratory in advance on the numbers below:

Haematology / Transfusion

0845-2000 Monday to Friday and 0900-1700 Saturday and Sunday phone specimen reception 66693 or the laboratory number as in section 1. At all other times contact the duty BMS by paging 1777 or phone the laboratory number. From outside the hospital phone switchboard on 01786 and ask for page 1777.

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4. REQUEST FORMS 1. Haematology: The front sheet (Red on White) of the multi-layer request form

is for Haematology but not Blood Transfusion. If your request is for other departments also you MUST write firmly with a ballpoint pen and if address labels are used, attach them to all relevant pages. If you do take labels from the patient’s notes check that they refer to the right patient.

2. Blood Transfusion: (Blue on White): all requests for blood or blood products

including “group and save” procedures and Anti-D requests. 5. SPECIMEN TUBES Specimens are taken by the Becton Dickinson system. Under or overfilling may lead to invalid results. All anti-coagulated specimens should be mixed gently by repeated inversion, not shaken. Becton Dickinson distributes charts with information on which bottles to use for which test, order of draw and mixing requirements. Charts are available through the practice development team. A list of tests performed and the type of specimen tube required is in section 25. Please ensure that separate bottles are sent for haematology and clinical chemistry tests. A list of tests performed and the type of specimen tube required is in section 25. Addressograph labels are acceptable on some sample bottles except under no circumstances will they be accepted for blood transfusion work or ante-natal grouping. This practice has been shown to increase the likelihood of misidentification. DO NOT pre-label bottles, the same applies. Sample bottles should be labelled at the bedside by the person taking blood and initialled by them. For blood transfusion work or ante-natal blood groups both bottle and request must be identically marked with the patient’s full name (First name and surname), date of birth and CHI number. The accident department numbers are acceptable alternatives if CHI does not yet exist. The first line of the address should also be given when available and the bottle initialled by the person taking blood. The practice of labelling sample bottles for patients before proceeding to take samples is VERY DANGEROUS and is never to be used. Samples where the bottle is labelled with an addressograph label will be rejected.

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6. BLOOD TRANSFUSION The NHS Forth Valley Blood Transfusion Policy document details the procedures adopted by this organisation to maximise transfusion safety and is based on national guidelines. Please use the link below. http://www.nhsforthvalley.com/__documents/qi/CE_Guideline_TransfusionPolicies/TransfusionProtocol.pdf 7. OBSTETRIC HAEMATOLOGY

ANTI-D IMMUNOGLOBULIN Indications for Administration: 1. All Rhesus negative women as soon as possible after, or at least within 72

hours of, delivery of a Rhesus D positive infant, when the post delivery maternal venous blood specimen contains no detectable anti-Rhesus D antibody.

Advice should be sought if other antibodies are present. 2. All pregnant Rhesus negative women with no Rhesus D antibody on record, to

be given as soon as possible after, or at least within 72 hours of, the following potential sensitising episodes:

• Miscarriage; complete, incomplete or threatened at > 12/40; • Persistent PV bleeding at any stage of pregnancy • Termination of pregnancy • Amniocentesis • Anti-partum Haemorrhage • External Version • Clinically substantial closed abdominal injuries at >12/40

Dosage and Administration: 250 units (50 µg) intramuscularly up to 20 weeks gestation. 500 units (100 µg) intramuscularly after 20 weeks gestation. Timing To be given preferably within 24 hours of the potential sensitising incident, and in no case later than 72 hours. However, in the case of accidental omission, Anti-D should still be given up to 7 days after the incident. The preferred site of injection is the deltoid muscle. Injections should be given every 6 weeks if there is continued ante partum bleeding.

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Prophylactic anti-D programme A programme for administration during pregnancy of prophylactic Anti-D to suitable Rh(D) Negative women is now in place. Women are offered a dose of 1500 IU Prophylactic Anti-D at 30 weeks. To request Prophylactic Anti-D on this programme send the request to the transfusion laboratory with the 28 weeks grouping sample, stating on the Transfusion Request Form when and where the Anti-D is required, the dose required and that it is to be administered as part of the programme. If a sensitising episode occurs at any stage of pregnancy to a patient who is on the Anti-D Prophylactic Programme, they must be tested in the same way as patients who are not on the programme as above. Anti-D will be issued if appropriate and a Kleihauer test will be performed if the event is after 20 weeks

Kleihauer Tests This measures the quantity of feto-maternal transplacental haemorrhage (FMH) for calculation of any additional dose of Anti-D that may be necessary in non-sensitised Rh(D) Negative patients. A specimen of maternal blood in 4 ml EDTA (FBC Tube) for a Kleihauer test in addition to the 6 ml EDTA grouping sample is required in the following circumstances:

• Instrumentation at any gestation • Within 2hrs after delivery • Any potentially sensitising event after 20 weeks gestation (as above) • Following a large transplacental bleed (as below)

For any FMH > 4 ml an appropriate supplementary dose of anti-D immunoglobulin must be given immediately. A repeat estimation of the FMH should be carried out 48 h following the initial anti D injection. The serum plasma should be screened for anti-D. Kleihauer Serum Action No fetal cells present No free anti-D Give standard dose of anti-D

Repeat Kleihauer in 48 hrs No fetal cells present Free anti-D No further action Fetal cells present No free anti-D Quantify and give further appropriate

dose of anti-D Repeat Kleihauer in 48 hrs

Fetal cells present Free anti-D Repeat Kleihauer in 48 hrs

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8. FURTHER POINTS TO REMEMBER: 1. THE COMMONEST CAUSE OF SENSITISATION TO THE RHESUS D

ANTIGEN IS FAILURE TO ADMINISTER ANTI-D IN APPROPRI ATE CASES. 2. Particular vigilance is necessary in cases of abortion, whether therapeutic or

spontaneous; threatened, complete or incomplete, where stay in hospital is brief. Results must be telephoned as a matter of urgency and staff trained to act properly on them. There must be close liaison between the laboratory, the clinical units and the primary care teams.

3. Where threatened or complete abortion occurs at home, the General

Practitioner must ascertain whether anti-D is necessary. 4. Anti-D given to the mother antenatally is not harmful to the baby. 5. Passively administered anti-D may be detected up to 6 weeks after

administration, and occasionally up to 6 months. 6. If antibody is not detectable at delivery, further administration of

immunoglobulin is necessary whether or not the mother was given a prophylactic dose antenatally.

7. If there is any doubt about whether to give anti-D, advice may be obtained

from the Blood Transfusion Laboratory or from Consultant Haematologist. 8. Seek advice when any other antibody is present. 9. Additional doses of anti-D immunoglobulin, when recommended should be

administered in multiple muscular sites to avoid local reactions.

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9. ANTICOAGULATION

9.1 Heparin Low Molecular Weight Heparins are now used for most indications, but should only be used according to your department’s protocols. Intravenous unfractionated heparin has the remaining advantage that the effect rapidly subsides on stopping treatment. If using Unfractionated Heparin: For consistent and immediate anticoagulation always use continuous intravenous infusion for treatment of DVT, PE, unstable angina and post tPA thrombolysis. For prophylaxis of DVT/PE use subcutaneous Heparin 5,000 units bd (Minihep). All patients should have a clotting screen and platelet count before commencing anticoagulation. • Maintain APTT to control ratio within therapeutic range 1.5 to 2.5 (see Heparin

Schedule). • For DVT/PE continue for three to five days, starting Warfarin between days 1 -

3. (Serious PE’s may need longer). • For unstable angina and post tPA continue for forty-eight hours to five days

(plus Aspirin). • Practical points

- For each Heparin dose change make up new syringe containing new 24 hour dose (in dextrose or saline). Do not alter dose by changing infusion rate of previous syringe.

- Try and measure APTT at the same time (approx) each day (diurnal

variation). - APTT is useless after Warfarin started so don’t measure it. - Samples should be analysed within two hours (liaise with lab and write time

on tube). - Avoid even temporary (longer than ten minutes) discontinuation of IV

Heparin pumps (patients baths, showers etc).

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HEPARIN SCHEDULE * Loading dose - 5,000 units IV over 5 minutes Initial infusion rate - 30,000 units Heparin per 24 hours Check APTT at 6 hours. Adjust infusion rate per 24 hours (new syringe) according to ratio APTT to control as follows:-

APPT RATIO ACTION

>7 Stop infusion for 1 hour, reduce by 10,000 units per 24 hours

5.1 - 7.4 Reduce by 10,000 units per 24 hours 4.1 - 5 Reduce by 7,000 units per 24 hours 3.1 - 4 Reduce by 2,000 units per 24 hours 2.6 - 3 Reduce by 1,000 units per 24 hours

1.5 - 2.5 No change 1.2 - 1.4 Increase by 5,000 units per 24 hours

<1.2 Increase by 10,000 units per 24 hours If APTT not therapeutic repeat after further ten hours (approx). Then repeat daily (preferably am) for three days (or until Warfarin started) and subsequently only as necessary if patient is stable.

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9.2 Warfarin Table 2 - Warfarin Schedule Day INR (9-11am) Warfarin dose(mg)

given at 5-7 pm 1st <1.4 10 2nd <1.8 10 1.8 1 >1.8 0.5 3rd <2.0 10 2.0 - 2.1 5 2.2 - 2.3 4.5 2.4 - 2.5 4 2.6 - 2.7 3.5 2.8 - 2.9 3 3.0 – 3.1 2.5 3.2 - 3.3 2 3.4 1.5 3.5 1 3.6 - 4.0 0.5 >4.0 0 Predicted maintenance dose 4th <1.4 >8 1.4 8 1.5 7.5 1.6 - 1.7 7 1.8 6.5 1.9 6 2.0 - 2.1 5.5 2.2 - 2.3 5 2.4 - 2.6 4.5 2.7 - 3.0 4 3.1 - 3.5 3.5 3.6 - 4.0 3 4.1 - 4.5 Miss out next day’s dose

then give 2 mg >4.5 miss out 2 days doses

then give 1 mg

An INR of 2-3 prevents recurrence of venous thrombo-embolism. A higher level (3-4.5) is required for recurrent PE and prosthetic heart valves. The INR is reliable in patients also on unfractionated heparin only if the APTT ratio is less than 2.5. Both prescribing doctor and patient must be familiar with the many drug inter- actions. Duration of treatment varies greatly and the following is only a guide: • One month is probably

adequate for post surgical DVT.

• Three months for PE or extensive venous thrombosis.

• Indefinite for prosthetic valves & recurrent (i.e. more than one episode) PE.

STARTING WARFARIN 1/ With loading dose - Start Warfarin 3 days before planned cessation of Heparin. The schedule on the left is appropriate for patients of normal metabolic size aiming for a target INR of 2 –3. A smaller starting dose (5mg) is appropriate for: - elderly patients, - heart failure, - liver disease, - potentiating drugs. 2/ Without Loading Dose - For patients with no urgency in instituting anticoagulation (e.g. for A.F.), it is safer to start without a loading dose at an estimated patient maintenance dose, (ca. 3mg daily in an otherwise fit person of average size), testing INR after a week.

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10. DISCHARGE ON WARFARIN Ensure an early referral is made to the General Practitioner who will be monitoring warfarin therapy in the community. Ensure that whoever is to carry on treatment knows about changes in the patient’s condition and medication. Ensure the patient has written information (e.g. yellow booklet) and dosing instructions.

11. THROMBOPHILIA INVESTIGATION AND TESTING 11.1 Introduction Testing for thrombophilia is available through the haematology service in NHS Forth Valley. However, indiscriminate application of thrombophilia tests is clinically inappropriate and can be clinically misleading. The following document is guidance for clinicians considering undertaking testing for thrombophilic abnormalities in their patients. The Guidance is derived from the British Committee for Standards in Haematology Clinical Guidelines for testing for heritable thrombophilia (2009). A full copy of this document and supporting references can be found at: http://www.bcshguidelines.com/documents/published_t hrombocytosis_bjh_042010.pdf 11.2 Tests Available and Sample Requirements: The following tests comprise the thrombophilia screen:

• Antithrombin Assay • Protein C assay • Protein S assay (Total & Free) • Lupus anticoagulant and anticardiolipin assays • Modified activated protein C sensitivity • Prothrombin G20210A mutation • APC:SR ratio as marker for Factor V Leiden

Genetic analysis for Factor V Leiden will only be undertaken if the APC:SR is abnormal. Screening should be requested on a routine haematology request form. The request form should be marked ‘THROMBOPHILIA SCREEN’ in the ‘other tests’ part of the form. The request form MUST include full patient and family history details and drug therapy, especially oral contraceptive use or HRT, where appropriate.

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Samples required for a thrombophilia screen are:

4 x citrate samples (blue topped tubes) ALL REQUESTS FOR THROMBOPHILIA SCREENING WILL BE SCRUTINISED BY A CONSULTANT HAEMATOLOGIST. INCOMPLETE OR CLINICALLY INAPPROPRIATE REQUESTS WILL BE REJECTED AND THE REQUESTING CLINICIAN INFORMED. In all cases, if there is a doubt about who and whe n to test please contact a consultant haematologist to discuss prior to sending the samples. 11.3 When and Who to Test 11.3.1 When to Test The laboratory interpretation of thrombophilia tests is difficult and fraught with pitfalls, which occasionally lead to under diagnosis and frequently to over diagnosis of defects. Some tests for heritable thrombophilia are affected by the acute and sub acute post-thrombotic state and by anticoagulant use. Also, the finding of a thrombophilic abnormality almost never influences the management of an acute thrombotic event. Accordingly there is NO virtue in testing when the patient presents with an acute thrombotic event, and samples sent at the time of the acute event will NOT routinely be analysed. Testing is usually best delayed until at least one month after the acute event or completion of anticoagulant therapy. If possible testing for heritable thrombophilia should be avoided during intercurrent illness, pregnancy or recent gestation, or use of oral contraceptive pill or HRT. 11.3.2 Who to Test

• Acute VTE (DVT+/- PE) See section A • Venous thrombosis of Upper Limb/Eye/Venous See section B

Sinus of Brain/Intra-abdominal Veins • Coronary, cerebral and peripheral arterial thrombosis See section C • Woman being considered for HRT/COCP See section D • Prevention of VTE in hospitalised patients See section E • Relatives of patients with a history of VTE See section F • Children See section G

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Section A Patients with Acute VTE (DVT or PE) It is now apparent that testing for heritable thrombophilia typically does not predict likelihood of recurrence in unselected patients with symptomatic venous thrombosis and testing for inherited thrombophilia did not reduce recurrence of venous thrombosis in a large cohort study. There is a low risk of thrombosis in affected asymptomatic relatives followed prospectively and the results of thrombophilia tests are frequently misinterpreted. Guidance:

• Initiation and intensity of anticoagulant therapy f ollowing a diagnosis of acute venous thrombosis should be the same in pa tients with and without heritable thrombophilia (1B).

• Indiscriminate testing for heritable thrombophilias in unselected

patients presenting with a first episode of venous thrombosis is not indicated (1B).

• Decisions regarding duration of anticoagulation (li felong or not) in

unselected patients should be made with reference t o whether or not a first episode of venous thrombosis was provoked o r not, other risk factors, and risk of anticoagulant therapy-related bleeding, regardless of whether a heritable thrombophilia is known (1B) .

• Testing for heritable thrombophilias in selected pa tients, such as

those with a strong family history of unprovoked re current thrombosis, may influence decisions regarding durat ion of anticoagulation (C). It is not possible to give a v alidated recommendation as to how such patients should be se lected.

Section B Venous Thrombosis in Upper Limb/Eye/Cavernous Venous System of Brain

• Testing is not recommended in unselected patients with upper limb venous thrombosis (1B).

• Testing is not recommended in patients with CVC-related venous

thrombosis (1C).

• Testing for heritable thrombophilias after a first episode of Cavernous venous Thrombosis has uncertain predictive value for recurrence (C). Decisions regarding duration of anticoagulant therapy in relation to the results of testing are not evidence based.

• Testing is not indicated in patients with retinal vein occlusion (1B).

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• Testing for heritable thrombophilias after a first episode of intra-abdominal

vein thrombosis has uncertain predictive value for recurrence (C). Decisions regarding duration of anticoagulant therapy in relation to the results of testing are not evidence based.

Section C Coronary, cerebral and peripheral arterial thrombosis In arterial artery thrombosis the material contribution of heritable thrombophilia, as compared with established cardiovascular risk factors, is not proven and is not sufficient to change therapy for primary and secondary prevention. Despite this, young patients are sometimes tested after an arterial occlusive event. As there is no established causal relationship and as treatment and secondary prevention should be in relation to established cardiovascular risk factors thrombophilia testing is not recommended. Guidance:

• Testing for heritable thrombophilia is not indicated in patients with arterial thrombosis (1B).

Section D Women being considered for oestrogen containing hormone preparations (COCP/HRT)

In some women heritable thrombophilia has already been established whilst in others it is perceived that testing would enable informed decision making regarding use of a combined oral contraceptive (COCP) or hormone replacement therapy (HRT). However, the absolute risk of thrombosis is low and the fact that venous thrombosis has a polygenic basis with incomplete penetrance makes counselling in relation to genetic testing uncertain. Similar principles apply to HRT, although the baseline risk is higher as the population is older. If HRT is considered essential then a non-oral formulation is associated with a significantly lower risk of venous thrombosis. Guidance:

• If a first degree relative with venous thrombosis h as not been tested then suggest woman considers an alternative contrac eptive or transdermal HRT. Testing for heritable thrombophili a will provide an uncertain estimate of risk and is not recommended

• If a first degree relative with venous thrombosis h as been tested and

the result is negative then suggest woman considers an alternative contraceptive or transdermal HRT. Testing for herit able thrombophilia will provide an uncertain estimate of risk and is not recommended (1C).

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• If a first degree relative with venous thrombosis h as been tested and

the result is positive then suggest woman considers an alternative contraceptive or transdermal HRT before offering te sting as a negative test result does not exclude an increased risk of venous thrombosis. Testing for heritable thrombophilia may assist counselling of selected women particularly if a hig h risk thrombophilia has been identified in the symptomati c relative (C).

Section E Prevention of venous thrombosis in hospitalised patients Thromboprophylaxis for hospitalised patients should be in accordance with a structured risk assessment based on procedural and personal risk factors for venous thrombosis. Screening for heritable thrombophilia is not indicated although a previously identified heritable thrombophilia may influence the assessment of risk. Guidance:

• Thrombophilia screening of hospitalised patients to identify patients at risk of hospital-acquired venous thrombosis is n ot indicated (1A).

• All hospitalised patients should be assessed for ri sk of venous

thrombosis regardless of heritable thrombophilia ba sed on a clinical risk assessment (1B). The presence of a previously known heritable thrombophilia may influence the assessment of risk.

Section F Asymptomatic relatives of patients with a history of venous thrombosis Guidance:

• Case finding of asymptomatic relatives with low ris k thrombophilia, such as FV Leiden or F2G20210A, is not indicated (1B).

• Case finding of asymptomatic relatives with high ri sk thrombophilia,

such as deficiency of antithrombin, protein C or pr otein S, should only be considered in selected thrombosis-prone familie s (1B). If testing is performed the risks, benefits and limita tions of testing should be discussed in the context of explained inh eritance and disease risk.

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• Case finding for very rare homozygosity or compound heritable thrombophilia is not indicated as these defects are so rare, they are not predicted by family history, and the risk of un provoked thrombosis is low (2C).

Section G Children Guidance:

• Neonates and children with purpura fulminans should be tested urgently for protein C and S deficiency (1B).

• It is suggested that testing for heritable thrombop hilia is not indicated in children with stroke (2C).

---------------------------------------------------------------------------------------

In all cases, if there is a doubt about who and whe n to test please contact a

Consultant Haematologist to discuss prior to sending the samples. Criteria used to quote levels and grades of evidence are according to the GRADE system (Guyatt, et al 2006). Strong recommendations (grade 1, 'recommended') are made when there is confidence that the benefits either do or do not outweigh the harm and burden and costs of treatment. Where the magnitude of benefit or not is less certain a weaker grade 2 recommendation ('suggested') is made. Grade 1 recommendations can be applied uniformly to most patients whereas grade 2 recommendations require judicious application. The quality of evidence is graded as A (high quality randomised clinical trials), moderate (B) or low (C)

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12. HAEMATOLOGY TESTS, REFERENCE RANGES AND TURNA ROUND TIMES Sample type and container sst serum separation tube yellow cap coag citrate for coagulation blue cap edta K+ EDTA purple cap

pink cap (transfusion) h heparin green cap u urine – use plain universal container genetic Marrow transport media kept at 2-8oC contact department

Notes * By arrangement with lab ** Referred elsewhere. Must be in laboratory before Thursday 12 midday. 1 Specimen tube must not be under or overfilled 2 The blood must be transported to the laboratory at 37oC 3 D-dimers may be raised in presence of thrombosis, disseminated intravascular coagulation, inflammation, infection, underlying malignancy or recent surgery. The sensitivity of the laboratory test currently only allows for assessment of coagulopathy. Testing for underlying thrombosis requires a lithium heparin sample and is not performed by the laboratory but by other hospital departments. 4 Sample should be taken pre-dose 5 Must be requested PRE-TRANSFUSION 6 Early morning sterile urine sample 7 Must be sent before starting cobalamin treatment as test disrupted by high levels of serum B12 8 Samples should arrive in laboratory no later than 2pm 9 A positive test must be followed by haemoglobin electrophoresis to distinguish between heterozygote and homozygote 10 Affected by recent dietary folate intake. It is advisable to measure red cell folate in addition to serum folate to definitively diagnose folate deficiency 11 Please specify which are of clinical interest

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Turnaround Times : • For urgent tests contact the laboratory as in secti on 3 • Urgent Full Blood Count and Coagulation: results wi thin 2 hours

from receipt of sample • If other tests are required urgently contact labora tory staff • See table below for routine turnaround times • Results are available in SCI store between 15 – 45 minutes after

completion in the laboratory. Test Notes Sample

type(s) Vol. (ml)

Reference range (adult unless otherwise stated)

Reference laboratory (page 28)

Expected turnaround time for results

Acetyl choline receptor antibodies

** sst 2 <0.1nmol/l xvi 4 weeks

Anti-neural antibodies (e.g. anti-Hu, Yo)

** sst 2 - xvi 4 weeks

Anti-nuclear factor sst 7 less than 1/64 7-14 days

Anti-neutrophil antibodies

** edta, sst

20, 10

- i 4 weeks

Auto-antibodies (DNA binding, ENA, AMA, SMA, Ro, La, TTG, Gastric parietal cell, MPO, Scl70/Jo1, TPO)

11,** sst 7 - viii 4 weeks

Anti-musk ** sst 1 - xvii 4 weeks Anti-skeletal (anti-striated muscle)

** sst 3 - xix 4 weeks

Serum B12 See Section 12.4

5 sst 7 180-900ng/l 72 hours

Bcr-abl pcr ** edta 4 - ii 2 weeks Bleeding time * - - up to 10 minutes 24 hours Bone marrow * - - - 72 hours Cell marker analysis ** edta 4 - iii 2 weeks Coagulation screen (PT, APTT, fibrinogen)

1 coag 4 PT +APPT controls reported with results fibrinogen 1.5-4.0 g/l

12 hours

Coagulation factor assay

** coag 4 - iv 1 week

Cold agglutinin titre *, 2 sst, edta

7,4 less than 1/64 1 week

Complement ** sst 7 viii 4 weeks C3 0.877-1.82 iu C4 0.185-0.452 iu Factor B 0.137-0.348 iu C1esterase inhibitor

0.178-0.351 iu

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CH50 - Cystic fibrosis gene testing

** edta 2 - xi 4 weeks

Cytogenetics ** genetic 5 - xi 4 weeks D-dimer 3 coag 4 <0.5mg/l 12 hours Direct anti-globulin test (coombs’ test)

edta 4 positive in up to 5% of normal controls

12 hours

Erythropoietin ** sst, edta

7,4 5-25 mU/ml v 4 weeks

ESR 1 edta 4 Men 0-5mm in 1 hour Women 0-7mm in 1 hour

12 hours

Ferritin See section 12.4

5 sst 7 Age 18-45 male 36-225 ug/l female 10-65 ug/l Age 45+ male 42-262 ug/l female 24-155 ug/l

72 hours

Folate (serum) See section 12.4

5,10 sst 7 2.1-14.0 ug/l 72 hours

Folate (red cell) See section 12.4

5 edta 7 160-640 ug/l 72 hours

Full blood count edta 4 see later tables for reference ranges

8 hours

GAD ** sst 5 - xiv 4 weeks Ganglioside antibodies

** sst 2 - xvi 4 weeks

G-6-PD edta 4 4.3-10.5 iu/gHb at 37oC

xxi 2 weeks

Haemoglobin electrophoresis See section 12.5

5 edta 4 1 week

A2 1.8-3.2% F 0.5-0.9% A1c Target range for good

diabetic control is 48– 59 mmol/mol (IFCC units)

Haemoglobin DNA screening

** edta 4 - xii 4 weeks

Haemosiderin 6 u 20 - 1 week Haptoglobin sst 7 0.2-2.0 g/l 4 weeks H.I.T. screen (anti-PF4)

** sst 2 - vi 4 weeks

HLA-DR ** edta 10 - ix 4 weeks Infectious Mononuleosis test

sst 7 - 48 hours

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Intrinsic factor antibody

7 sst 7 - 2 weeks

INR coag 4 see notes on warfarin page 20

12 hours

Islet cell antibodies ** sst 1 - xv 4 weeks JAK 2 pcr ** edta 4 - vii 4 weeks Kleihauer edta 4 See transfusion

section 48 hours

Lupus anticoagulant 8 coag 16 - 2 weeks Malarial screen (and other blood borne parasites (thick and thin film and plasmodium antigen test) See section 12.3

edta 4 - 12 hours antigen test 24 hours thin film

Mast cell tryptase ** edta 5 2-14 ug/l xiv 4 weeks Mitochondrial mutation


Myotonic dystrophy (genetic testing)


Osmotic fragility h 20 median fragility before incubation 4.0-4.45 after incubation 4.65-5.9 g/l

48 hours

Pneumococcal antibodies

** sst 5 - xiii 4 weeks

Radio-Isotope studies * Not available in house, but may be arranged by referral to tertiary centre. Discuss with consultant haematologist Red cell mass radio-

isotope study *

Reticulocytes 5 edta 4 10-150 x109/l 4 hours Rheumatoid factor sst 7 72 hours Salivary duct antibodies

** sst 5 xiii 4 weeks

Sickle test 5,9 edta 4 - 24 hours Thrombophilia screen ** coag,

edta 16,4 See page 21 iv 2 weeks

Tetanus antibodies ** sst 5 - xiii 4 weeks Thyroid stimulating receptor antibody

** sst 3 - xx 4 weeks

Tissue typing ** edta 20 - ix 4 weeks Plasma Viscosity edta 4 1.24-1.76 cP at 37oC 48 hours Voltage gated Ca+ channel antibodies

** sst 1 - xvii 6 weeks

Warfarin assay **,4 sst 2 - x 2 weeks

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The list above is not exhaustive so if the test required is not listed phone the laboratory for advice. If a new test is required a “New Test Request Form” must be completed and submitted to the Laboratory Service Manager. The form is available from laboratory senior staff (contact details in section 1).

NORMAL RANGES FULL BLOOD COUNT

ADULTS MEN WOMEN White Cell Count (x109/l) 3.9 - 10.6 3.5 - 11.0 Red Cell Count(x1012/l) 4.4 - 5.9 3.8 - 5.2 Haemoglobin (g/l) 133 - 177 117 - 157 Packed Cell Volume .40 - .52 .35 - .47 Mean Cell Volume (fl) 81 - 100 81 - 100 Mean Cell Haemoglobin (pg) 26.6 - 33.8 26.4 - 34.0 MCH Concentration (g/dl) 31.5 - 36.3 31.4 - 35.8 Platelet Count (x109/l) 150 - 440 150 - 440

CHILDREN BIRTH 1 YEAR 6 10 WBC (x109.l) 9.30 6.0 - 17.5 5.0 -14.5 4.5 - 13.5 Hb (g/l) 14.6 - 23.4 9.0 - 14.6 10.6 - 15.5 10.7 - 15.5

DIFFERENTIAL WHITE CELL COUNT (as absolute counts, x 109/l)

1 year 6 10 Adult Neutrophils 1.5 - 8.5 1.5 - 8.0 1.5 - 8.0 1.8 - 7.7 Lymphocytes 4.0 - 10.5 1.5 - 7.0 1.5 - 6.5 1.0 - 4.8 Monocytes 0.05- 1.1 0 - 0.65 0 - 0.8 0 - 0.8 Eosinophils 0 – 0.65 0 - 0.65 0 - 0.60 0 - 0.45 Basophils 0 - 0.20 0 - 0.20 0 - 0.20 0 - 0.20

(Data extracted from “Haematology”, W J Williams et al., 3rd edition, 1983, McGraw Hill)

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12.1 SPECIAL PRECAUTIONS:

a) All known high risk samples must be clearly labelled as such on the sample and form.

b) There are no other special precautions required other than those in the table of tests.

12.2 TIME LIMIT FOR REQUESTING ADDITIONAL REQUESTS: Coagulation: 2 hours from venesection Full Blood Count: 4 hours from venesection Clotted samples, e.g. haematinics: 24 hours Transfusion: Contact the transfusion laboratory for advice Referred tests: Contact the referral laboratory for advice 12.3 SCREENING FOR MALARIA AND OTHER BLOOD BORNE PA RASITES If a diagnosis of malaria is suspected, the gold standard diagnostic test is a thick blood film for detection of parasites, accompanied by a thin film for species identification and estimation of parasitaemia. Thick and/or thin films may also detect other blood borne parasites, such as microfilaria or trypanosomes. For specific diagnostic and clinical advice, please contact a consultant haematologist and/or infectious disease specialist. If malaria is suspected: a) Send 4ml blood in EDTA (FBC sample) urgently to the haematology laboratory –

samples should ideally arrive in the laboratory within 2 hours of venepuncture (lengthy exposure to anticoagulant may significantly diminish the likelihood of detecting parasites).

b) The request form must clearly state that malaria is suspected, and include travel history – which should be as specific as possible. This is likely to significantly aid species identification.

c) A thick film and a thin film will be prepared and examined. d) In addition, a rapid malarial antigen detection test (for Plasmodium spp.) will be

performed to complement microscopy. Outside of normal working hours, this may be reported before a blood film has been examined. Please note that a negative antigen test must be confirmed by microscopy, and, if clinical suspicion is high, a negative antigen test alone must not be relied upon to fully exclude malaria.

e) If the initial thick film proves negative, yet clinical suspicion remains high, send two further consecutive daily samples for malaria screening. Three negative thick films make a diagnosis of malaria unlikely.

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12.4 REQUESTING AND INTERPRETING HAEMATINIC TESTS ( B12, FOLATE, IRON STUDIES) Serum B12 and Folate assay a) Tests for serum vitamin B12 and folate levels and serum ferritin are frequently

requested for the initial investigation of anaemia, or microcytosis/macrocytosis in the absence of anaemia. In addition, a serum B12 assay is included in the list of screening tests in a number of neurological and psychiatric conditions, and ferritin is used as a marker of whole body iron levels in patients with (suspected and confirmed) haemochromatosis. Interpretation of results can be problematic.

b) For information on B12 and folate requesting and interpretation refer to the clinical

guideline “B12 and Folate: Practical Guide” which can be found on the intranet at the following link:

http://www.nhsforthvalley.com/__documents/qi/CE_Guideline_Haematology/B12PracticalGuide.pdf Iron studies a) Serum Ferritin is the usual test for iron deficiency. b) The normal range is different for women of childbearing age compared to men and

postmenopausal women, but it is debatable whether this is a real physiological difference or simply reflects a high incidence of iron deficiency in the population of women from whom the normal range is derived.

c) In general, a serum ferritin <12µg/L is diagnostic of iron deficiency, and if <30µg/L is highly suggestive. Interpretation should be in the context of the FBC (MCH, MCV and blood film features).

d) Ferritin is an acute phase reactant, so may be normal even in the presence of iron deficiency if there is intercurrent infection, inflammation or neoplasia. A rough guide might be to interpret a ferritin of <100µg/L with caution in the presence of intercurrent illness, as iron deficiency cannot be excluded. Again, haematological parameters are likely to help.

e) A high serum Ferritin (>300µ/l) may indicate iron overload, but such a finding is common in hospitalised patients and others with intercurrent illness.

f) A better guide to iron overload is the Transferrin Saturation (calculated from serum iron x100 divided by TIBC – see Chemistry handbook), which, if over 55% (men) or 50% (women) warrants further investigation.

g) Serum iron and TIBC are generally unreliable tests for diagnosing iron deficiency.

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12.5 SCREENING FOR THALASSAEMIA AND HAEMOGLOBINOPAT HIES Indications for screening for thalassaemia and/or h aemoglobinopathies include:

• Investigation of a hypochromic blood picture in the absence of iron deficiency • Investigation of anaemia in a patient of non-Northern European ancestry • Screening in an individual with a family history of thalassaemia or

haeemoglobinopathy • Antenatal screening Identification of Sickle haemoglobin prior to surgery in

patients from ethnic • Groups with a high incidence of Sickle Cell Disease.

When requesting thalassaemia and/or haemoglobinopathy screening please include the following clinical information: a. Ethnic origin of the patient (as precisely as possible). b. Whether or not there is a family history of thalassaemia/haemoglobinopathy, with

details of diagnosis if available. c. Please state clearly if the test is for antenatal screening purposes (pregnant woman

or partner). d. Reason for request. This information will help direct laboratory tests, which in general will include: a. FBC and blood film examination b. Serum ferritin if MCH is subnormal. c. High Pressure Liquid Chromatography (HPLC) for HbA2, HbF and variant

haemoglobins. d. Further analysis by gel electropheresis or DNA testing dependent on HPLC. Further

samples may be requested from the patient. 12.6 INVESTIGATION OF HEREDITARY SPHEROCYTOSIS Based on BCSH Guidelines 2011 http://www.bcshguidelines.com/documents/HS_BCSH_Sept_2011_final.pdf a) Although the diagnosis of HS is often made in childhood and young adult life,

it may be diagnosed at any time of life including old age. Diagnostic testing a) Newly diagnosed patients with a family history of HS, typical clinical features

and laboratory investigations (spherocytes on blood film, raised MCHC, increase in reticulocytes, negative DCT) do not require any additional tests.

b) If there is no family history AIHA should be excluded.

c) If the diagnosis is equivocal the EMA (Eosin-5-maleimide) binding test has a high predictive value for HS.

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d) This is a flow cytometry test performed at Gartnavel Hospital using an EDTA sample. Testing should be discussed with a haematology consultant and the correct request form obtained.

e) Gel electrophoresis analysis of erythrocyte membranes is the method of choice for diagnosis of atypical cases.

13 REFERENCE LABORATORY ADDRESSES

i. International Blood Group Reference Laboratory Southmead Road Bristol BS10 5ND 0117 991 2108

ii. Department of Molecular Haematology

Glasgow Royal Infirmary 82 Castle Street Glasgow G4 OSF 0141 211 4000

iii. Department of Haematology Western Infirmary Dumbarton Road Glasgow G11 6NT 0141 211 2156

iv. Department of Haematology Glasgow Royal Infirmary 82 Castle Street Glasgow G4 OSF 0141 211 4000

v. SAS Erythropoietin Laboratory Department of Clinical Biochemistry King’s College School of Medicine and Dentistry Bessemer Road London SE5 9PJ 020 7737 4000

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vi. Scottish National Blood Transfusion Service Shelley Road Gartnavel General Hospital Great Western Road Glasgow 0141 357 7700

vii. Scottish National Blood Transfusion Service Ninewells Hospital

Dundee

viii. Department of Immunology Western Infirmary Dumbarton Road Glasgow G11 6NT 0141 211 2000

ix. West of Scotland Histocompatibility and Immunogenetics Laboratory Glasgow Royal Infirmary 10 Alexandra Parade Glasgow 0141 211 4549

x. Department of Clinical Chemistry Queens Medical Centre Nottingham NG7 2UH 0115 9249924 Ex. 63411

xi. Department of Medical Genetics Royal Hospital for Sick Children Yorkhill Glasgow G3 8SJ 0141 201 0000

xii. Dr J M Old (MG) Institute of Molecular Medicine John Radcliffe Hospital Oxford OX3 9DU

xiii. Department of Immunology Newcastle General Hospital Newcastle Upon Tyne 0191 282 5295

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xiv. Protein Reference Unit Department of Immunology

PO BOX 894 Sheffield S5 7YT 0114 271 5552

xv. Immunology Laboratory

Floor 1 Royal Victoria Infirmary Queen Victoria Road Newcastle-Upon-Tyne NE1 4LP 0191 233 6161

xvi. Department of Neuro-Immunology

Institute of Neurological Sciences Southern General Hospital Glasgow G51 4TF 0141 201 2491

xvii. Angela Vincent

Department of Neuroscience Institute of Molecular Medicine John Radcliffe Hospital Oxford OX3 9DU 01865 222443

xviii. Professor Mowbray St Mary’s Hospital Medical School Norfolk Place London W2

xix. Immunopathology Department

Ninewells Hospital Dundee

xx Department of Biochemistry Glasgow Royal Infirmary Alexandra Parade Glasgow 0141 211 4000

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xxi Department of Haematology Edinburgh Royal infirmary

51 Little France Crescent Edinburgh, EH16 4SA 0131 536 1000

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Title: Haematology & Blood Transfusion Laboratory Handbook...1. All Rhesus negative women as soon as...

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Transcript of Title: Haematology & Blood Transfusion Laboratory Handbook...1. All Rhesus negative women as soon as...