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Importance of Blood-Collectiontubes in Plasma Lidocaine Determinations

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Importance of Blood-Collectiontubes in Plasma Lidocaine Determinations CLIN. CHEM. 25/4, 617-619 (1979) Importance of Blood-CollectionTubes in Plasma Lidocaine Determinations W. W. Stargel, Charles R. Roe,2 P. A. Routledge,3 and 0. G. Shand3 Downloaded from https://academic.oup.com/clinchem/article/25/4/617/5671205 by guest on 24 September 2021 In 25 clinical samples serum lidocaine concentrations patients and transferred to Vacutainer Tubes from which the fell from a mean of 6.5 ± 2.1 mg/L (mean ± SD) to 4.9 ± red stopper had been removed. One aliquot was allowed to 1.8 mgIL(p < 0.001)whenthe blood sample was allowed clot,while another aliquot was placed in a red-stoppered tube, to make contact with the stopper of the Vacutainer#{174}col- allowed to contact the stopper, and clot. The two serum lection tube. In vitro experiments showed that this effect samples were assayed for lidocaine with one lot of EMIT5-cad of the stopper occurred only with whole blood and was (Syva Corp., Palo Alto, CA) reagents. dependenton sample concentration. The plasma binding In Vitro Experiments of lidocaine decreasedfrom a normalvalueof 56% ± 2.2 (mean ± SD)to 28% ± 2.2 (p < 0.001)whenexposedto One hundred milliliters of whole blood from a normal vol- the Vacutainer stopper. We conclude that a chemical unteer receiving no medication was collected by direct veni- leached from such stoppers displaces lidocaine from its puncture in a plastic syringe and immediately transferred to plasma- binding sites and that the drugis then redistributed a glass tube containing 500 USP units of heparin. Lidocaine into the erythrocytes, producing spuriously low lidocaine hydrochloride was added to give a final concentration of 3 g concentrations in plasma or serum. Such artifacts are of lidocaine per milliliter of blood. Two-milliliter aliquots were important in therapeutic drug monitoring and can lead to then transferred to five glass-stoppered tubes, five green- erroneous clinical decisions. stoppered Vacutainer Tubes, fivered-stoppered Vacutainer Tubes, and five red-stoppered Monojecte tubes (Sherwood Medical Industries, St. Louis, MO). The remaining blood was Additional Keyphrases drug assay . blood-collection tubes then centrifuged, and 1-mL aliquots of the plasma layer were - variation, source of added to various tubes, as described for whole blood. All tubes Therapeutic monitoring of drug concentrations in plasma were then inverted 10 times and plasma obtained from the has now become an accepted part of clinical practice, and blood samples. All plasma samples were assayed for lidocaine many new assay procedures are being developed. Although with one lot of EMIT reagent. itisknown that spurious values can resultfrom the use of The effect of increased concentrations of lidocaine(up to certaintubes forblood collection(1), thisinformationhas not 12 izg/mL) added to blood collected in Vacutainer Tubes or been very widely disseminated. Itwas firstshown that lower in an all-glass system was also investigated in quadrupli- plasma propranololconcentrationsresultedwhen Vacutainer cate. Tubes (Becton-Dickinson,Rutherford,NJ 07070) ratherthan Plasma Binding an all-glasssystem were used forblood collection.Since then, the same artifacthas been noted with the other basicdrugs: Plasma was obtained afterblood collectionintoVacutainer alprenolol,imipramine, chlorimipramine, and nortriptyline Tubes or glass-stopperedtubes,and lidocainewas added to (2), as wellas meperidine (3). Diminished plasma binding of a finalconcentrationof 2 zg/mL. Five 1-mL samples of plasma quinidine from blood collectedinVacutainer Tubes has also from each collectionsystem were dialyzed against I mL of been noted, but the resultingeffecton plasma concentration Sorensen’s phosphate buffer (pH 7.38)at 37 #{176}Cfor 6 h by was small (4,5). means of Teflon dialysiscellsand Spectrapor membranes We recently noted erraticconcentrations of the antiar- (Spectrum Medical Industries,Los Angeles,CA). Lidocaine rhythmic drug lidocainein plasma, and have investigated concentrationsinboth plasma and bufferwere measured and whether this involvesbinding displacement and redistribution calculated from appropriatestandard curves,and the per cent because of the use of the blood-collectiontubes. plasma binding was calculated. Materials and Methods Results Patients’ Samples In the 25 clinical samples, exposure to the rubber stopper lowered lidocaine concentration in serum from 6.5 ± 2.1 Blood sampleswerecollectedinto plastic syringes from tg/mL (mean ± SD) to 4.9 ± 1.8zg/mL (p <0.001 by a paired t-test). Departments ofPharmacy’ and Pediatrics,2and the Divisionof Clinical Pharmacology,3 Duke University Medical Center, Durham, In the in vitro experiment, there was a significant reduction NC 27710.Correspondence to W. W. S., Box 3028, Divn. Pediat. in the lidocaine concentration of plasma obtained from blood Metabolism,at the Center. collectedin the commercial tubes (Table 1).This was not seen Received Dec. 22, 1978; accepted Jan. 29, 1979. when plasma was added to the tubes,which shows that er- CLINICAL CHEMISTRY, Vol. 25, No.4, 1979 617 Table 1. Effect of Various Blood-Collection Tubes on Measured Lidocaine Concentration (g/mL) in Plasma Control (all glass) Green Vacutalner Tube Rod Vacutalner Tube Red Monoject Mean a SD b Mean a SD b Mean a SD b Mean a so b Whole blood 3.12 0.13 2.42’ 0.08 2.22c 0.15 2.28c 0.08 Plasma 3.16 0.06 3.02 0.19 3.08 0.13 3.18 0.28 Mean of five separatealiquots of the sameblood sample or plasma derivedfrom the blood sample; lidocaine was added to freshly withdrawn blood tomake a concentrationofabout3 sg of lidocalne per milliliter of whole blood. b SD = standard deviation. C p < 0.001 by analysis of variance. ythrocytes were involved in producing the spuriously low glycoprotein,a probable major binding sitefor these basic Downloaded from https://academic.oup.com/clinchem/article/25/4/617/5671205 by guest on 24 September 2021 concentrations. ligands (2). In our studies we have found a similar phenome- The effect of increasing concentrations of lidocaine from non with lidocaine, with reduced binding in plasma confirmed. 2 to 12 zg/mL in whole blood from Vacutainer Tubes or from It is therefore likelythat TBEP isthe compound that dis- an all-glass system on the subsequent lidocaine concentrations placeslidocainefrom its binding sitesinplasma, although the in plasma isshown inFigure 1.With eithercollectionsystem, relevant binding protein for lidocaine has not yet been iden- increasingthe initialblood concentration produced a lesser tified (8). It is interesting that the magnitude of the effect of increaseinsubsequent plasma concentration,which implies this phenomenon on lidocaine concentrations in plasma is very a decrease in the blood/plasma concentration ratio.Fur- similar to the mean percentage effect on plasma propranolol thermore, the effect of using Vacutainer Tubes diminished concentration (28%) in plasma, calculated from the data of progressively as whole blood concentration was increased, Cotham and Shand (1), despite the fact that propranolol is until there was no effect at 12 zg/mL. 90-95% bound at therapeutic concentrations whereas lido- Finally, when Vacutainer Tubes were used in blood col- caine is only about 60% bound at a plasma concentration of lection, lidocaine binding in plasma fell significantly from a 3 tg/mL (8). Presumably, the relative affinity of TBEP for normal value of 56% ± 2.2 (mean ± SD) to 28% ± 2.2 (p < the binding sites in plasma is much greater than the affinity 0.001 by an unpaired t-test). of lidocaine. Tucker and coworkers also showed that the binding of ii- Discussion docaine varied from approximately 70% at 1 ig/mL of plasma Cotham and Shand (1) postulated that there was in some to around 40% at 12 ig/mL (8). Theoretically, therefore, the rubber stoppers a chemical that could leach intoblood and effect of Vacutainer Tubes on the lidocaine concentration in reduce the plasma binding of propranolol.The increasedfree plasma measured from a whole blood sample should fall with drug could then partitionwith the drug bound to erythrocytes, increasing lidocaine concentration, and we found this to be which would lead to spuriously low plasma concentrations. the case (Figure 1). However, the percentage change of lido- The plasticizertris(2-butoxyethyl)phosphate (TBEP) has caine concentration in plasma was still marked throughout been reported to be a contaminant in plasma collectedin the “therapeutic” range (1.5 to 5.0 ig/mL of plasma). The Vacutainer Tubes (6)and identifiedas an inhibitorof drug figure also shows that the concentration ratioof blood-to- binding to protein (7).Borga and coworkers subsequently plasma increases with increasing lidocaine concentration in have showed that TBEP-inhibited protein binding of aipre- whole blood. nololand imipramine isdue to a selectiveeffecton a,-acid The enzyme immunoassay (EMIT) of lidocaine inserum or plasma has been shown to be rapid, specific, and sensitive and therefore particularly suitable for therapeutic monitoring (9). IC We feel it is important to emphasize that these advantages may be nullified and patients exposed to risk if clinical deci- 0 sions are made on the basis of spuriously low concentrations of lidocaine in plasma or serum because of the use of certain types of commercially available collection tubes. 8 Plasma We are grateful to Jan Admiraal and Peggy Rogers for their ex- Lidocoine cellent technical assistance and to Syva Corporation for the re- 6 Concentration agents. (ug/ml) References 4 - - - . au 9Ia ystea 1. Cotham, R. H.,and Shand, D. C.,Spuriouslylowplasma propra- - acutaIne, laDe, nolol concentrations resulting from blood collection methods. GUn. 2 Phormacol. Ther. 18,535 (1975). 2. Borga, 0., Piafsky, K. M., and Nilsen, 0. C., Plasma protein binding of basic drugs. 1. Selective displacement from a,-acid gly- coprotein by tris(2-butoxyethyl) phosphate. Clin. Pharmacol. Ther. 2 4 6 8 10 12 22,539(1977). Whole Blood Lidocaine Concentration 3. Wilkinson, G. R., and Schenker, S., Pharmacokinetics of meperi- Fig. 1. Effects of Increasing lidocaine concentrations in whole dine in man. Gun.
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