Pathology Services Handbook 2021 Hospital Sungai Buloh

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

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

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

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

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

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

7 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 & Outsourced to Hospital Selayang, Hospital Kuala Lumpur, Cytology 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

8 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 Sunday & Public Holidays of Request

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.

9 Type of Request

The scope of tests were grouped into 4 categories as follows:

Tests offered Tests offered Tests by batches / Tests by appointment as urgent after office hour schedule MICROBIOLOGY

• AFB stain • AFB stain • Molecular • BFMP • BFMP • Serology • Cryptococcal • Cryptococcal antigen antigen Refer to Section • CSF Bacterial • CSF Bacterial Microbiology antigen antigen • Microfilaria • Microfilaria (Blood film) (Blood film) • Stool for ova & • Stool for ova & cyst cyst • Stool for • Stool for microscopy microscopy examination examination • Infective • All culture & screening sensitivity (Needle Stick Injury case) • Merscov–PCR CHEMICAL PATHOLOGY

• BUSE • BUSE • FSH, LH, • Creatinine • Creatinine Progesterone, • Bilirubin • Serum Bilirubin Oestradiol, • ALT • ALT Testosterone • ALP • ALP (Tuesday) • AST • AST • Tumour markers (Thursday) • LDH • LDH • Iron, Transferrin, • Amylase • Amylase Folate, B12 • Calcium • Calcium (Wednesday & • Ammonia • Ammonia Friday) • Lactate • Lactate • CSF • CSF Biochemistry Biochemistry • hs–Troponin I • hs–Troponin I • Urine Paraquat • Urine Paraquat • Acetaminophen • Acetaminophen • Salicylate • Salicylate

10 Tests offered Tests offered Tests by batches / Tests by appointment as urgent after office hour schedule HEMATOLOGY

• FBC • FBC • D–Dimer • Bone Marrow • FBP • FBP • Hb Analysis Aspiration • PT • PT • Bone Marrow Trephine • APTT • APTT Biopsy • Fibrinogen • Fibrinogen • Kleihauer test • D–Dimer • ESR • Mixing Test • G6PD Screening TRANSFUSION SERVICES

• First stage • GSH • Phenotype Blood for Crossmatch • GXM Thalassemia Patient • Antibody • Antibody • Rhesus Negative for Identification Identification Elective OT Cases (send to PDN) (send to PDN) • Rare phenotype blood (Anti–JK3, etc.) HISTOPATHOLOGY AND CYTOLOGY (OUTSOURCED)

• Unstained slides (for special staining, etc.)

11 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

12 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

13 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.

14 How to Manage Samples

1. Click Place Order

2. Select Record Collection

3. Select Record Dispatch

15 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

16 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

17 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

18 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

19 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

20 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

21 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

22 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

23 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

24 3. Click ‘Search’  ‘All Files and Folder’

4. Paste the copied number in the column as shown below.

25 5. List of result/s (PDF form) will be shown

26 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.

Critical Limit Test 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

27 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

28 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

29 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 All tests • Cultures Microbiology • Serology & Virology • NS1 Antigen • Dengue rapid • Organ transplant • Needle Stick Injury (NSI) • BFMP • AFB Chemical All tests • BUSE Pathology • Creatinine Note: Batch tests will still be run ABG according to its schedule • • Amylase • Lactate • Ammonia • Calcium • Bilirubin Haematology • FBC • FBC • PT/APTT • PT/APTT • Fibrinogen • Fibrinogen • G6PD Note: For other tests, kindly call MO/Specialist to request Blood • GSH • GSH Transfusion • GXM • GXM Service • Antibody Identification • Antibody Identification Histopathology All tests None & Cytology

30 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

Collect the hard copy results at the counter Note: • 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

31 Sending Covid-19 Specimen General workflow for Covid-19 samples

DO’S DON’TS 1. Collect Specimen DO NOT open the tube cap (loose cap will cause spillage during Note: For Paediatrics (< 8 yrs.) centrifugation) FBC & G6PD, use elevated DO NOT use normal paediatric EDTA Paediatric microtainer microtainer 2. Label DO NOT wrap the Specimen tube with gauze/ plaster

3. Put into For Hematology & double Biochemistry DO biohazard NOT put into cylinder plastics 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

32 Test Offered During Covid-19 Outbreak

Unit Tests Specific Requirements Medical All tests None Microbiology Chemical All test EXCEPT: Pathology • 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

33 • Use derived method

CD4/CD8 • Not indicated Blood As usual Transfusion Service Histopathology As usual & Cytology

34 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

35 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.

36 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 Delays in transit can cause significant changes in (more than 4 hr) 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.

37 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

38 Collection Chart – Chemical Pathology

Tube / Container Sample/Tube Common Use Special Instruction Description Adult Serum / Clinical Chemistry: Mix sample gently SST Gel Routine Biochemistry 8 – 10 times analysis. Then stand for 15 Special Protein & mins before Immunology: centrifuging C3, C4, hs–CRP, RF, ASOT

Anaemia Profiles: Iron, Transferrin,

Ferritin & Folate, B12 Paeds Hs–Trop I Tumour Markers Hormones

Adult Whole blood / HbA1c (Glycosylated Mix sample gently K2EDTA Haemoglobin) 8 – 10 times

Paeds

39 Tube / Container Sample/Tube Common Use Special Instruction Description Adult Plasma / Sodium Clinical Chemistry: Mix well gently. fluoride Glucose testing, GTT Please specify if fasting or non–fasting and any glucose load given to patient

Paeds

Lithium Heparin Specialised test Mix sample gently (Outsourced): 8 - 10 times Plasma Amino acid

Heparinised Blood Gases Mix Well. syringe Please send samples in slurry ice water

40 Tube/Container Tube Common Use Special Instruction Description Bijou sterile CSF biochemistry and Please ensure cap is bottle body fluids tight and secure biochemistry

Sterile urine Urine and other body Please ensure cap is container fluids biochemistry tight and secure

Dried blood spot NA NA

24 hr urine 24 hr urine chemistries Additives will be sterile container added by lab staff depending on the test requested

41 List of Test (in–house) & Reference Interval

Test Sample TAT Reference Interval Remarks Container Acetaminophen Plain tube 2 hrs Therapeutic level 9.98 – 19.95 ug/mL Toxic level >15 ug/mL Alanine Transaminases Plain tube / 4 hrs 10 – 49 U/L (ALT/ SGPT) Heparinised Albumin Plain tube / 4 hrs 32 – 48 g/L Heparinised Albumin to Creatinine Spot urine in 4 hrs < 3.4 mg/mmol ratio, strip Sterile urine container Alkaline phosphatase Plain tube / 4 hrs 46 – 116 U/L (ALP) Heparinised Alpha Fetoprotein (AFP) Plain tube 5 working < 8.1 ng/mL Run every days Thursday Ammonia EDTA 60 mins 11 – 32 μmol/L (adults) Send in ice Amylase, serum Plain tube / 4 hrs 30 – 118 U/L Heparinised Amylase, urine Sterile urine 4 hrs ≤ 650 U/L (Diastase) container Anti–streptolysin ‘O’ Titre Plain tube / 4 hrs Children preschool (ASOT) Heparinised ≤100.0 IU/mL Children school age ≤ 250.0 IU/mL Adult ≤ 200.0 IU/mL Aspartate Transaminase Plain tube/ 4 hrs 34 U/L (AST) Heparinised Beta HCG (Quantitative) Plain tube 60 mins Non-pregnant females 1.5 – 4.2 mIU/mL Bilirubin, direct Plain tube / 4 hrs ≤ 5 μmol/L Heparinised Bilirubin, total Plain tube / 4 hrs 0 – 1 day Heparinised <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

42 Test Sample TAT Reference Interval Remarks Container 3 –19 μmol/L > 90 years 3 – 15 μmol/L Blood Gases Heparinised 60 mins pH Send in (Arterial / Venous) syringe 7.35 – 7.45 slurry ice 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 % Body fluids biochemistry Sterile urine 4 hrs Reference interval for (pleural / peritoneal / container body fluids are not synovial) available Calcium, serum Plain tube 4 hrs 2.08 – 2.65 mmol/L Calcium, urine 24 hr 24 hr urine 4 hrs 2.50 – 7.50 mmol/day container Cancer Antigen (CA125) Plain tube 5 working <35 U/mL Run every days Thursday Carbamazepine Plain tube 60 mins Therapeutic level without gel 16.9 – 50.8 μmol/L Carbohydrate Antigen Plain tube 5 working <37 U/mL Run every (CA19–9) days Thursday Carcinoembryonic Plain tube 5 working <5 ng/mL Run every Antigen (CEA) days Thursday Chloride, 24 hr urine 24 hr urine 4 hrs 110 – 250 mmol/day container 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

43 Test Sample TAT Reference Interval Remarks Container 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 4 hrs 57.7 – 806.8 nmol/day container C–Reactive protein, high Plain tube 4 hrs <1.0 mg/dL sensitive Creatine kinase (CK) Plain tube 4 hrs Males 46 – 171 U/L Females 34 – 145 U/L Creatinine Plain tube / 4 hrs Males Heparinised 62 – 115 μmol/L Females 49 – 90 μmol/L Creatinine clearance 24 hr urine 4 hrs container & Plain tube Creatinine, urine 24 hr 24 hr urine 4 hrs Males container 8.4 – 22 mmol/day Females 5.3 – 15.9 mmol/day CSF Protein Sterile urine 60 mins 0.08 – 0.32 g/L container / Bijou container CSF Chloride Sterile urine 60 mins 116 – 130 mmol/L container / Bijou container CSF Glucose Sterile urine 60 mins Adult Concurren container / 2.2 – 3.9 mmol/L t Random Bijou Infant / child Blood container 3.3 – 4.4 mmol/L Sugar (RBS) test CSF Lactate Fluoride 60 mins 1.2 – 2.1 mmol/L Oxalate Estradiol Plain tube 5 working Adult Reference Interval Run every days Tuesday

44 Test Sample TAT Reference Interval Remarks Container 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 Deficient Run every days 0.79 – 7.63 nmol/L Wednesda Indeterminate y 7.64 – 12.19 nmol/L Normal 12.19 – 46.4 nmol/L

45 Test Sample TAT Reference Interval Remarks Container Follicle–stimulating Plain tube 5 working Adult Reference Interval Run every hormone (FSH) days Tuesday 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 Gentamicin Plain tube 4 hrs Peak level 8.64 – 21.6 μmol/L Globulins, qualitative Plain tube 4 hrs Glucose tolerance test Fluoride Fasting Please Oxalate <6.1 mmol/L mix well 2 hours post prandial <7.8 mmol/L

46 Test Sample TAT Reference Interval Remarks Container Glucose, 2 hr post Fluoride 4 hrs <7.8 mmol/L Please prandial Oxalate mix well Glucose, fasting Fluoride 4 hrs <6.1 mmol/L Please Oxalate mix well Glucose, random Fluoride 4 hrs <11.1 mmol/L Please Oxalate mix well 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 Glucose, urine 4 hrs < 2.8 mmol/day Hemoglobin A1c EDTA 5 working Normal days < 5.6 % Prediabetes 5.6 – 6.2 % Diabetes > 6.3 % High density lipoprotein Plain tube 4 hrs <1.03 mmol/L cholesterol (HDL-C) Interleukin-6 (IL6) Plain tube 24 2.7 - <4.4 pg/mL hours Iron Plain tube 3 working Male Run every days 11.6 – 31.3 μmol/L Wednesda Female y & Friday 9.0 – 30.4 μmol/L Lactate Dehydrogenase Plain tube / 4 hrs 120 – 246 U/L Heparinised Lactate, plasma Fluoride 60 mins 0.50 – 2.20 mmol/L Send in Oxalate ice

Low density lipoprotein Plain tube 4 hrs <3.0 mmol/L cholesterol (LDL–C) Luteinising Hormone (LH) Plain tube 5 working Adult Reference Interval Run every days Tuesday 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

47 Test Sample TAT Reference Interval Remarks Container 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 / 4 hrs 0.66 – 1.07 mmol/L Heparinised Magnesium, 24 hr Urine 24 hr urine 4 hrs 0.99 – 10.45 mmol/day container Osmolality, serum Plain tube 4 hrs 270 – 295 mOsm/kg Osmolality, urine Sterile urine 4 hrs 300 – 900 mOsm/kg container Paraquat, urine Sterile urine 4 hrs Negative container pH, urine Sterile urine 60 mins 4.5 – 7.5 container Phenytoin Plain tube 4 hrs Peak level 39.6 – 79.2 μmol/L

48 Test Sample TAT Reference Interval Remarks Container Phosphate Inorganic Plain tube / 4 hrs 0.78 – 1.65 mmol/L Heparinised Phosphate Inorganic, 24 24 hr urine 4 hrs 12.9 – 42.0 mmol/day hr urine container (on restricted diet) Potassium Plain tube/ 2 hrs 3.5 – 5.1 mmol/L Heparinised Potassium, spot urine Sterile urine 2 hrs container Potassium, urine 24 hr 24 hr urine 2 hrs 25 – 125 mmol/day container Procalcitonin Plain tube 60 mins < 0.05 ng/mL Progesterone Plain tube 5 working Males Run every days 0.89 – 3.88 nmol/L Tuesday

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 Prolactin Plain tube 5 working Adult Reference Interval Run every days Tuesday Females Non pregnant 59 – 619 mIU/L Pregnant 206 – 4420 mIU/L Post–menopausal 36 – 430 mIU/L Males

49 Test Sample TAT Reference Interval Remarks Container 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, Plain tube 5 working <4 ng/mL Run every total days Thursday Protein total, serum Plain tube / 4 hrs 57 – 82 g/L Heparinised Protein, 24 hr urine 24 hr urine 4 hrs 0.01 – 0.14 g/L container At rest 0.05 – 0.08 g/day After intense exercise 0.25 g/day Rheumatoid factor (RF) Plain tube / 4 hrs < 14 IU/mL Heparinised Salicylate Plain tube 4 hrs Toxic level >300 mg/L Sodium Plain tube / 4 hrs 136 – 145 mmol/L Heparinised Sodium, spot urine Sterile urine 20 mmol/L container Sodium, 24 hr urine 24 hr urine 4 hrs 40 – 220 mmol/L/24 hr container

50 Test Sample TAT Reference Interval Remarks Container Testosterone Plain tube 5 working Adult Reference Interval Run every days Tuesday 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 Thyroid Stimulating Plain tube 24 hrs 1 – 23 months Hormone (TSH) 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

51 Test Sample TAT Reference Interval Remarks Container 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 Males Run every days 2.15 – 3.65 g/L Wednesda Females y & Friday 2.50 – 3.80 g/L 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 Plain tube 24 hrs Adult (FT3) 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, Plain tube 60 mins Female high–sensitive < 38.64 pg/mL Male < 53.53 pg/mL Urea Plain tube / 4 hrs 3.2 – 8.2 mmol/L Heparinised Urea, 24 hr urine 24 hr urine 4 hrs 0.43 – 0.71 mol/24 hr container Uric Acid Plain tube / 4 hrs Male Heparinised 220 – 547 μmol/L Female 184 – 464 μmol/L Uric Acid, urine 24 hr 24 hr urine 4 hrs 1.48 – 4.43 mmol/24 hr container 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 Normal Run every days 156 – 672 pmol/L Wednesda Deficient y & Friday

52 Test Sample TAT Reference Interval Remarks Container 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.

53 Therapeutic Drug Monitoring (TDM) Range

Test Dosing umol/l mg/l Amikacin Multiple Peak Adult 34-51 20-30 Dosing Paeds Trough Adult <17 <10 Paeds 3.4-8.5 2-5 Single Daily Peak Adult 102 60 Dosing Paeds 34-51 20-30 Trough Adult <1.71 <1 Paeds 3.4-8.5 2-5 Gentamicin Multiple Peak Adult 10.5-21 5-10 Dosing Paeds 10.5-25 5-12 Trough Adult <4.2 <2 Paeds <2.1 <1 Single Daily Peak Adult 21-42 10-20 Dosing Paeds 11-25 5-12 Trough Adult < 2.1 <1 Paeds Vancomycin Peak 17.3-27.6 25-40 Trough Non-complicated 6.9-10.4 10-15 infection 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 27.75-55.5 5-10 neonates 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

54 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 / Sample/ Volume TAT Forms / Referral Lab Container (Working Special days) Requirement Adrenocorticotrophic Chemical Plain tube 3 ml 5 days PER–PAT 301 Hormone Pathology, HKL Aldosterone Endocrine Unit, EDTA 4 ml 30 days PER–PAT 301 Hospital Putrajaya Alpha–1–Acid Unit Patologi Plain tube 3 ml 7 days PER–PAT 301 Glycoprotein Kimia, Hospital Ampang Alpha-1-antitrypsin Special Protein Plain tube 3 ml 7 days Request Form Quantitation Unit, IMR for Multiple (03-26162669 Myeloma and /2731) Specific Proteins Alpha 1-Antitrypsin Molecular EDTA 1-2x2.5ml 3 Request Form Deficiency Diagnostic, IMR blood months for Molecular (SERPINA1) (03-26162540) EDTA or Diagnostic dried Services blood Must have spots specialist Signature

By consultation only

55 Test Perform Site / Sample/ Volume TAT Forms / Referral Lab Container (Working Special days) Requirement Amino Acid (plasma) Biochemistry Unit, Lithium 2 ml 15 days Special Form (for Amino acid IMR heparin (IEM Request disorders) (03-2616 2640 / (Send in Form) 2649) ice) Amino Acid (CSF) Biochemistry Unit, Sterile 1 ml 15 days Special Form (for Amino acid IMR (03– container (IEM Request disorders) 26162627 / Form) 2498) Must send together with plasma Amino Acid (Urine) Biochemistry Unit, Sterile 2 ml 15 days Special Form (for Amino acid IMR (03– container (IEM Request disorders) 26162792 / (Send in Form) 2498) ice) After consultation only Amikacin Chemical Plain tube 3 ml 3 days TDM Form Pathology, Hospital Selayang Anti-Mullerian Endocrine Unit, Plain tube 2-3 ml 14 days PER–PAT 301 Hormone Assay IMR (03-26162636 / to be 2644 / 2645) REQUESTED ONLY by O&G Specialist from Infertility Clinics/OBG clinics. Anti–Thyroglobulin Chemical Plain tube 3 ml 7 days PER–PAT 301 (anti-TG) Pathology, Hospital Selayang Please provide relevant history & latest TFT result Anti–thyroid Chemical Plain tube 3 ml 7 days PER–PAT 301 Peroxidase Pathology, (anti-TPO) Hospital Selayang Please provide relevant history & latest TFT result

56 Test Perform Site / Sample/ Volume TAT Forms / Referral Lab Container (Working Special days) Requirement Beta–2 Microglobulin Chemical Plain tube 3 ml/ 20 7 days PER–PAT 301 Pathology, ml Hospital Ampang Caeruloplasmin Chemical Plain tube 3 ml 5 days PER–PAT 301 Pathology, HKL Cancer Antigen Clinical EDTA 3 ml 2 days PER–PAT 301 15–3 Toxicology, HKL (CA 15–3) Carnitine Free & Total Biochemistry Unit, EDTA 2 ml 5 days PER–PAT 301 IMR (03– 26162792 / 2498) Cholinesterase Chemical Plain tube 3 ml 2 days PER–PAT 301 Pathology, Hospital Selayang Copper, 24H urine Toxicology & 24H urine 5 ml PER–PAT 301 Pharmacology container Unit, IMR Samples must (03-26162626) 14 days be collected using an Copper, Serum Toxicology & Plain tube 1-3 ml appropriate Pharmacology container, free Unit, IMR of heavy metal (03-26162626) or trace elements C–Peptide Chemical Plain tube 3 ml 5 days PER–PAT 301 Pathology, HKL By Appointment Metanephrines, Endocrine Unit, 24H urine - 30 days PER–PAT 301 24 hr Urine Hospital Putrajaya container * Acidify Must have with 10 ml specialist of 25% HCl signature Cyclosporine Clinical EDTA 3 ml 5 days TDM Form Toxicology, HKL Dehydroepiandrostero Chemical Plain tube 3 ml 10 days PER–PAT 301 ne Sulphate (DHEA– Pathology, HKL S) Once a week Panel Diabetes Endocrine Unit, Plain tube 3 ml 14 days PER–PAT 301 antibodies: Anti- IMR To be requested Glutamic Acid 03-26162636 ONLY by endocrinologist / Decarboxylase (GAD), general physician

57 Test Perform Site / Sample/ Volume TAT Forms / Referral Lab Container (Working Special days) Requirement Anti-Insulinoma- / Family medicine associated Antigen 2 specialist (for hospital without (IA2) & Anti Islet Cells in house (ICA) endocrinologist) Digoxin Chemical Plain tube 3 ml 5 days TDM Form Pathology, Hospital Selayang Fructosamine Chemical Plain tube 3 ml 7 days PER–PAT 301 Pathology, Hospital Ampang Gamma Glutamyl Chemical Plain tube 3 ml 5 days PER–PAT 301 Transpeptidase (GGT) Pathology, Hospital Selayang Galactosemia Biochemistry Unit, Dried blood 3 circles 5 days Special Form Screening IMR (03– spot (DBS) of DBS (IEM Request (Total Galactose & 26162791 / on Form) Galactose–1–Uridyl 2498) Whatman Transferase), 903 Filter blood spot paper Growth Hormone Chemical Plain tube 3 ml 10 days PER–PAT 301 (Somatotropin) Pathology, HKL Once a week Haptoglobin Chemical Plain tube 3 ml 5 days PER–PAT 301 Pathology, HKL Once a week Immunoglobulin A Makmal Protein, Plain tube 3 ml 7 days PER–PAT 301 (IgA) Hospital Ampang Immunoglobulin G Makmal Protein, Plain tube 3 ml 7 days PER–PAT 301 (IgG) Hospital Ampang Immunoglobulin M Makmal Protein, Plain tube 3 ml 7 days PER–PAT 301 (IgM) Hospital Ampang Immunoglobulin E Allergy Unit, IMR Plain tube 0.5 ml / 5 days PER–PAT 301 (IgE) – Total (03–26162587 / 3 ml 2804 / 2789) Immunoglobulin E Allergy Unit, IMR Plain tube 0.5 ml / 5 days PER–PAT 301 (IgE) – Specific (per– (03–26162587 / 3 ml allergen) 2804 / 2789) Send immediately to the lab Insulin Chemical Plain tube 3 ml 10 days PER–PAT 301 Pathology, HKL Once a week

58 Test Perform Site / Sample/ Volume TAT Forms / Referral Lab Container (Working Special days) Requirement Insulin–like Growth Endocrine Unit, Plain tube 3 ml 21 days PER–PAT 301 Factor I (IGF–1) Hospital Putrajaya Inborn Error Unit Biokimia, IMR Dried blood 3 circles 3 days Special Form Metabolism (IEM) (03–26162792 / spot (DBS) of DBS (IEM Request screening, blood spot 2498) on Form) Whatmann 903 Filter paper Inborn Error Biochemistry Unit, Sterile 2 ml 10 days Special Form Metabolism (IEM) IMR (03– container (IEM Request Screening, Urine 26162796 / Form) 2498) 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 15 ml 4 – 6 Daily container weeks Mucopolysaccharide Biochemistry Unit, Sterile 5 ml 10 days Special Form (GAGs / HRE) Urine IMR (03– container (IEM Request 26162627 / (1st Form) 2498) Morning Urine) Methotrexate (MXT) Clinical Plain tube 3 ml 5 days PER–PAT 301 Toxicology, HKL Daily (office hrs) Mycophenolic acid Clinical EDTA 3 ml 1 day TDM Form Toxicology, HKL Every Thursday Organic Acid, Urine Biochemistry Unit, Sterile 5 ml 5 days Special Form IMR (03– container (IEM Request 26162594 / (Send in Form) 2792) ice) Transport FROZEN, easily destroyed by heat

59 Test Perform Site / Sample/ Volume TAT Forms / Referral Lab Container (Working Special days) Requirement Orotic Acid, Urine Biochemistry Unit, Sterile 5 ml 5 days Special Form IMR container (IEM Request (Send in Form) ice) Parathyroid Hormone Chemical EDTA 3 ml 5 days PER–PAT 301 (PTH 1–84) Pathology, HKL (Send in ice) 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 / Biochemistry Unit, Sterile 5 ml 15 days Special Form porphobilinogen / IMR (03– container (IEM Request Uroporphobilinogen 26162627 / Form) Urine 2498) Protect from light, easily destroyed by light

60 Test Perform Site / Sample/ Volume TAT Forms / Referral Lab Container (Working Special days) Requirement Progesterone, Endocrine Unit, Plain tube 3 ml 20 days PER–PAT 301 17–OH IMR (03– 26162645) Keep FROZEN or within 2– 8’C during transportation Protein Electrophoresis Makmal Protein, Plain tube/ 3 ml / – PER–PAT 301 (Serum / Urine) Hospital Ampang 24 hour 20 ml urine Must send container serum & urine together Protein Electrophoresis Makmal Protein, Bijou bottle 1–2 ml 21 days PER–PAT 301 CSF Hospital Ampang (CSF Oligoclonal Must send Band) 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 Plain tube 3 ml 5 days TDM Form Pathology, Hospital Selayang Prostate Specific Chemical Plain tube 3 ml – PER–PAT 301 Antigen (PSA), Free Pathology, HKL Renin Endocrine Unit, EDTA 3 ml 30 days PER–PAT 301 Hospital Putrajaya Must have specialist signature Sirolimus Clinical EDTA 3 ml 1 day TDM Form Toxicology, HKL Succinyl acetone, urine Biochemistry Unit, Sterile 2 ml 15 days IEM Request IMR container Form

61 Test Perform Site / Sample/ Volume TAT Forms / Referral Lab Container (Working Special days) Requirement 03-26162640/ 2511 Tacrolimus Clinical EDTA 3 ml 5 days TDM Form Toxicology, HKL Theophylline Clinical Plain tube 3 ml 5 days TDM Form Toxicology, HKL Total Homocysteine, Biochemistry Unit, EDTA 2 ml 10 days IEM Request Plasma IMR Form

Separate plasma immediately Thyroglobulin Chemical Plain tube 3 ml 20 days PER–PAT 301 Pathology, HKL Please provide relevant history and latest TFT result Thyroid Stimulating Chemical Plain tube 3 ml 14 days PER–PAT 301 Hormone Receptor Pathology, HKL Antibody Please (anti-TSHR) provide relevant history and latest TFT result Urine Myoglobin & Biochemistry Unit, Sterile 5 ml 5 days Special Form Haemoglobin IMR (03– container (IEM Request 26162627 / Form) 2498) Urine Tetra glucoside Biochemistry Unit, Sterile 15 ml 4 weeks PER–PAT 301 IMR container Urine Oligosaccharide Biochemistry Unit, Sterile 5 ml 15 days Special Form IMR (03– container / (IEM Request 26162791 / 1st Morning Form) 2498) Urine Vitamin D Level Chemical Plain tube 3 ml 2 – 4 PER–PAT 301 Pathology, weeks Hospital Putrajaya Must have specialist signature

62 List of Request Forms – Chemical Pathology

FORMS CODE DESCRIPTION

General PER-PAT Form PER-PAT 301 For other tests Molecular Diagnostics Services IMR/SDC/UMDP/MOLDX/ IMR Request Form REQUEST FORM Multiple Myeloma and Specific IMR/SDC/UMDP/PROTEIN/R IMR Proteins Request Form EQUEST FORM Inborn Error Metabolism (IEM) IMR/SDC/BC/FORM-RQ IMR Request Form Primary Immunodeficiency (PID) IMR/AIRC/PID/RF For PID Quantitation Request Form of Immunoglobulin & Complement IMR Borang Permintaan Ujian - HKL Pengesanan Dadah Dalam Air Kencing Therapeutic Drug Monitoring TDM FORM (dari Jabatan Biochemistry Unit, Request Form Farmasi) 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

63 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.

64 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)

65 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.

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 Common Use Special Instruction Description Adult Serum / Serology tests Mix sample gently SST Gel 8 – 10 times

Then stand for 15 mins before centrifuging

Paeds

Tube / Container Sample/Tube Common Use Special Instruction Description Adult Whole blood / Molecular test: Mix sample gently K2EDTA For blood PCR such as 8 – 10 times HIV viral load, Hep B viral load, Hep C viral, etc.

Paeds

Amies Transport Swab sample for Media culture High vaginal swab, eye, ear, nasal swab, etc.

Viral Transport Swab sample for For Rapid Test Kit Media (VTM) and viral/bacterial PCR (RTK) Antigen for Dacron swab (throat swab, Covid, no need VTM nasopharyngeal swab)

Bijou sterile For fluid sample (CSF, Please ensure cap is bottle pleural fluid, peritoneal tight and secure fluid, etc.) DO NOT STORE IN THE REFRIGERATOR

Tube / Container Sample/Tube Common Use Special Instruction Description

Sterile urine Urine and other body Please ensure cap is container fluids biochemistry tight and secure

DO NOT ADD FORMALIN FOR TISSUE CULTURE

Stool Container NA DO NOT CONTAMINATE STOOL WITH URINE

Sputum cup

Blood culture Mix with swirling bottle (Aerobic/ method Anaerobic)

DO NOT STORE IN THE REFRIGERATOR Adult

Paeds

Myco F/ Lytic Mix with swirling bottle method

DO NOT STORE IN THE REFRIGERATOR

70 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 1 – 2 ml of aspirate is required and to be inoculated directly into aspirate the bottles.

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 i. Collect 3 – 4 ml of CSF into sterile Bijoux bottles for the Fluid (CSF) 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 i. Collect fresh stool in a sterile container. Specimens collected difficile culture in formalin or swabs are not acceptable and toxin ii. Transport to the laboratory immediately detection

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

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: Acceptable specimens: Acid-fast bacilli Respiratory secretions, urine, CSF, body fluids, whole blood and stains and culture 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/ i. Send pus if available, in a sterile universal container Tissue 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 Nasal swab specimens 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

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)

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: i. Withdraw the prepuce When culture for tubercle bacilli is and cleanse the glans required, collect at least 50 ml of penis with soapy water early morning midstream urine on and thoroughly rinse with 3 consecutive mornings into water sterile containers 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

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 General Note: hair • 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

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 • CSF specimens (3 – 5 ml) should be collected in a sterile fluid container for microscopy and culture

Pus  Pus from undrained subcutaneous abscesses or sinus tracts should be collected with a sterile needle and syringe

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 Method of collection: fluid 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

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 i. Collect 3 – 5 ml blood in Plain tube (without the anticoagulant) tests 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

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 i. Nasopharyngeal / Oropharyngeal swab to be sent in Viral specimen 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

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 i. Remove portions, about 1.5 cm cube, of various parts of the viral diagnosis 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 i. Collect the scraping in a screw-capped test tube containing scraping 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

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 i. Insert a flexible, fine shafted polyester swab into the nostril swab 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 i. Patient must sit comfortably, and the head tilted slightly aspirate (NPA) 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

82 List of Test (in-house):

1. Bacteriology & Mycology Section

TEST CONTAINER SPECIMEN VOLUME TAT

Antibiotic sensitivity Not Not Not 3 – 4 days testing Applicable Applicable Applicable (positive culture) Aspirate culture & Sterile Container Aspirate Not 1 – 5 days sensitivity Applicable (negative culture) 3 – 4 days (positive culture) Blood culture & Aerobic sterile Blood 3-10 ml 1 – 5 days sensitivity (aerobic) container (negative culture) 3 – 4 days (positive culture) Blood culture & Anaerobic sterile Blood 3-10 ml 1 – 5 days sensitivity (anaerobic) container (negative culture) 3 – 4 days (positive culture) Body Fluids culture & Sterile container Body Fluid Not 1 – 5 days sensitivity Applicable (negative culture) 3 – 4 days (positive culture) Bronchial aspirate Sterile Container Bronchial Not 1 – 5 days culture & sensitivity Alveolar Applicable (negative Lavage culture) 3 – 4 days (positive culture) Cerebrospinal fluid Sterile Tube CSF 3 ml 1 – 5 days culture & sensitivity (negative culture) 3 – 4 days (positive culture) Clostridium difficile Sterile container Stool 3 ml/ peanut 1 – 2 days toxin size Cryptococcal antigen Sterile Container CSF 2 ml 2 hours CSF Bacterial Antigen Sterile Tube CSF 3 ml 1 hour Ear swab culture & Amies TM Pus Not 1 – 5 days sensitivity Applicable (negative culture) 3 – 4 days (positive culture)

TEST CONTAINER SPECIMEN VOLUME TAT

Fungal Blood culture & Fungal Blood Blood 5 ml 3 – 21 days sensitivity Container Fungal culture & Sterile Container Tissue Not 3 – 21 days sensitivity Applicable Genital culture & Amies Pus Not 1 – 5 days sensitivity Applicable (negative culture) 3 – 4 days (positive culture) Modified Ziehl-Neelsen Sterile Container Stool 5 ml 1 day for Cryptosporidium MTB Gene Xpert / RIF Sterile bottle Sputum, Not 24 hours CSF, applicable bronchoalveolar lavage and tracheal aspirate Nasal swabs culture & Amies TM Swab Not 1 – 5 days sensitivity Applicable (negative culture) 3 – 4 days (positive culture) Peritoneal Fluid culture Sterile Container Peritoneal > 1 ml 1 – 5 days & sensitivity fluid (negative culture) 3 – 4 days (positive culture) Pus culture & sensitivity Amies TM Pus 3 ml 1 – 5 days (aerobic) Anaerobic (negative culture) 3 – 4 days (positive culture) Pus culture & sensitivity Sterile Container Pus 3 ml 1 – 5 days (anaerobic) (negative culture) 3 – 4 days (positive culture) Rectal Swab culture & Sterile Container Rectal swab Not 1 – 5 days sensitivity Applicable (negative culture) 3 – 4 days (positive culture) Respiratory culture & Amies TM Sputum Not 1 – 5 days sensitivity Applicable (negative culture) 3 – 4 days (positive culture)

TEST CONTAINER SPECIMEN VOLUME TAT

Rotavirus Antigen Sterile container Stool 3 ml / 1 – 2 days peanut size Stool culture & Sterile Container Stool 3 ml 1 – 5 days sensitivity (negative culture) 3 – 4 days (positive culture) Stool for Clostridium Sterile Container Stool 3 ml 1 – 5 days difficile culture & (negative sensitivity culture) 3 – 4 days (positive culture)

2. Parasitology Section

TEST CONTAINER SPECIMEN VOLUME TAT

Blood Film Malaria Thick/thin film Blood Smear 2 hours parasites (BFMP) Cryptosporidium (Modified Sterile Stool 3 ml 1 day Acid Fast Stain) Container Isospora belli (Modified Sterile Stool 3 ml 1 day Acid Fast Stain) Container Microfilaria (Blood film) Thick / thin film Blood Smear 2 hours (Preferred mid- night sample) Microsporidium (Modified Sterile Stool Peanut size 1 day Trichrome Stain) Container Stool for ova & cyst Sterile Stool ¾ of 4 hours Container container volume Stool microscopy Plain Container Stool ¾ of 4 hours examination container volume

85 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

86 Thick / Thin Blood Film Malaria Parasite

87 3. Molecular Section

TEST CONTAINER SPECIMEN VOLUME TAT

BK Virus Genome EDTA tube / Blood / Urine 5 ml 1 – 2 Detection (Quantitative) Sterile container days CMV-DNA Genome EDTA tube / Blood / CSF/ BAL 5 ml / min 1 – 2 Detection (Qualitative & Sterile Bijoux 0.3 ml days Quantitative) bottle COVID-19 Genome VTM/Sterile Nasopharyngeal Not 24 Detection bottle swab / oropharyngeal applicable hours swab / tracheal aspirate / Nasopharyngeal aspirate EBV DNA Genome EDTA tube Blood / CSF / 5 ml 1 – 2 Detection (qualitative & TISSUE days quantitative) HBV DNA Genome EDTA tube Blood 5 ml 1 – 2 Detection (quantitative) days HCV RNA Genome EDTA tube Blood 5 ml 1 – 2 Detection (quantitative) days HIV RNA Genome EDTA tube Blood 10 ml 1 – 2 Detection (quantitative) days HSV I & II DNA Genome EDTA tube / Blood / CSF Vesicle 5 ml 1 – 2 Detection Sterile Bijoux fluids days bottle Influenzae A, Influenzae VTM Nasopharyngeal Not 1 – 2 B, RSV Swab / applicable days Oropharyngeal Swab Meningoencephalitis Sterile Bijoux CSF 0.5 - 2 ml 1 – 2 Panel bottle days (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

TEST CONTAINER SPECIMEN VOLUME TAT

E. coli K, Cryptococcus neuformans, Cryptococcus gattii MERS Coronavirus Dacron swab Sputum, throat swab, Not 24 Genome Detection (for swab only) / bronchoalveolar applicable hours Sterile bottle lavage, tracheal aspirate, nasopharyngeal aspirate, and tissue from lung biopsy MTB/RIF Gene Xpert Sterile bottle Sputum, CSF, Not 24 Ultra bronchoalveolar applicable hours lavage and tracheal aspirate Respiratory Pathogen Sterile Nasopharyngeal 2 ml 1 – 2 Panel Container aspirate, days (i.e. Influenza A, bronchoalveolar Influenza A H1, Influenza lavage (BAL) and A H3, Influenza B, tracheal aspirates 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 VZV DNA Genome EDTA tube Blood / CSF Vesicle 5 ml 1 – 2 Detection (qualitative) fluids days ZIKA Genome Detection Plain Serum/plasma 0.5 - 3 ml 1 – 2 tube/EDTA / CSF/Urine days Sterile Bijoux bottle / Sterile container

89 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 Plain tube Blood 5 ml 1 – 2 days IgM Anti-nuclear antibodies Plain tube Blood 5 ml 1 – 2 days Aspergillus antigen Plain tube Blood / BAL 3 ml / BAL 1 – 2 days 1-3 ml 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- Plain tube Blood 5 ml 1 – 2 days Anti Jo1 Extractable Nuclear Antigen- Plain tube Blood 5 ml 1 – 2 days Scl 70 Extractable Nuclear Antigen- Plain tube Blood 5 ml 1 – 2 days Sm Extractable Nuclear Antigen- Plain tube Blood 5 ml 1 – 2 days RNP Extractable Nuclear Antigen- Plain tube Blood 5 ml 1 – 2 days SSA/ Ro Extractable Nuclear Antigen- Plain tube Blood 5 ml 1 – 2 days SSB/ La 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 Plain tube Blood 3 – 5 ml 1 – 2 days Immunoblot

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 Plain tube Blood 5 ml 1 – 2 days Rickettsia (IIP) Legionella Antigen Detection Sterile Urine 5 ml 1 – 2 days Container 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 Plain tube Blood 5 ml 1 – 2 days (Syphilis) 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 Plain tube Blood 3-5 ml 1 – 2 days Agglutination Varicella Zoster Virus-IgM Plain tube Blood 3 – 5 ml 1 – 2 days

91 List of Test (outsourced) Test Perform Container Sample Volume TAT Schedule Site (Working days) Allergy Testing Microbiology, Plain Tube Blood 5 ml 5 days Daily (Screening) HKL (Office Hour) Allergy Testing Microbiology, Plain Tube Blood 5 ml 5 days Daily (Specific) HKL (Office Hour) Anti- Immunology, Plain Tube Blood 5 ml 14 days Daily Acetylcholine IMR (Office Hour) Receptor Anti- Microbiology, Plain Tube Blood 5 ml 1 week Daily Phospholipid H. Selayang (Office Hour) Antibody Anti-Neutrophil Microbiology, Plain Tube Blood 5 ml 1 week Daily Cytoplasmic H. Selayang (Office Hour) ANCA Anti- Microbiology, Plain Tube Blood 5 ml 1 week Daily Mitochondrial H. Selayang (Office Hour) Antibody (AMA) Anti- Microbiology, Plain Tube Blood 5 ml 1 week Daily Thyroglobulin H. Selayang (Office Hour) Antibody Anti-Glomerular Immunology, Plain Tube Blood 5 ml 14 days Daily Baseline IMR (Office Hour) Antibody Panel Tissue Immunology, Plain Tube Blood 5 ml 14 days Daily Antibodies: IMR (Office Hour) Anti-Gastric Parietal Cell Antibody (APC), Anti Mitochondrial Antibodies, Anti Smooth Muscle Anti-Liver Microbiology, Plain Tube Blood 5 ml 14 days Daily Kidney H. Selayang (Office Hour) Microsome Ab (LKM) Anti-Intrinsic Microbiology, Plain Tube Blood 5 ml 1 week Daily H. Selayang (Office Hour) Anti-Aquaporin 4 Immunology, Plain Tube/ Blood/ 5 ml 10 days Daily IMR Bijou bottle CSF (Office Hour)

Test Perform Container Sample Volume TAT Schedule Site (Working days) Burkholderia Bacteriology, Plain Tube Blood 2 – 3 ml 5 days Daily pseudomallei IMR (Office Hour) Antibody IgM Bordetella Bacteriology, For NPA/ 1 – 2 ml 5 days Daily pertussis PCR IMR nasophary- Swab (Office Hour) ngeal Transport aspirates, in ice use sterile container

For swab, use Dacron swab in Stuart's transport media

Do not use calcium alginate or cotton swab HLA Antibody Immunology, Plain Tube Blood 10 ml 4 weeks Appointment Test Panel IMR is not Reactive required. For Antibody transplant recipient (PRA)/Donor only Specific (screening Antibody (DSA) test) Human Immunology, Sodium Blood Donor: 10 days For solid Leukocyte IMR Heparin 18 ml organ Antigens (HLA) (donor), transplantati Crossmatch Patient: on (Complement Plain Tube 5 ml Active by Dependent (patient) appointment only. Please Cytotoxicity) call 03- 26162581 Human Immunology, Sodium Blood Donor: 10 days For solid Leukocyte IMR Heparin 18 ml organ Antigens (HLA) (donor), transplantati Crossmatch Patient: on (Flow Plain tube 5 ml Active by Cytometry) (patient) appointment only. Please call 03- 26162581

Test Perform Container Sample Volume TAT Schedule Site (Working days) Human Immunology, 2 K2EDTA Blood 6 ml 10 days Active by Leukocyte IMR tubes appointment Antigens (HLA) only Typing Class I Please call (Loci A, B and 03-2616258 C) - low/medium resolution (SSO/SSP-PCR) Human Immunology, 2 K2EDTA Blood 6 ml 10 days Active by Leukocyte IMR tubes appointment Antigens (HLA) only Typing Class Please call II(Loci DR,DQ) - 03-2616258 Low/medium resolution (SSO/SSP-PCR) Human Immunology, 2 K2EDTA Blood 6 ml 10 days Active by Leukocyte IMR tubes appointment Antigens (HLA) only Typing Class I Please call and II (Loci A, B 03-2616258 and DR) - Medium/High Resolution (SSO-PCR) Human Immunology, 2 K2EDTA Blood 6 ml 10 days Active by Leukocyte IMR tubes appointment Antigens (HLA) only Typing Class I Please call and II (Loci A, B, 03-2616258 C, DR and DQ) - high resolution (SSO-PCR) per loci Human Immunology, 2 K2EDTA Blood 6 ml 10 days Active by Leukocyte IMR tubes appointment Antigens (HLA) only Typing for Transport condition: Disease Room Association Temperature (HLA (WITHOUT B27/B57:01/ ICE). B15:02) Please call 03-2616258

Test Perform Container Sample Volume TAT Schedule Site (Working days) Human Immunology, 2 K2EDTA Blood 6 ml 10 days Active by Leukocyte IMR tubes appointment Antigens (HLA) only. Typing Class I Please call and II (Loci A, B, 03-2616258 C, DR & DQ) - low resolution (PCR) Chikungunya Makmal Plain Tube Blood 1-3 ml 2 weeks Daily Virus IgM / IgG Kesihatan (Office Hour) Awam Kebangsaan, Sg Buloh Chikungunya Virologi, IMR Plain Tube Blood 5 ml 2 weeks Daily Genome (Office Hour) Detection Dengue Makmal Plain sterile Blood Blood: 3 weeks Daily Genotyping Kesihatan tube 5 ml (Office Hour) (Qualitative) Awam Kebangsaan, Sterile Bijoux CSF CSF: Sg Buloh bottle minimum Sterile Tissue 0.3ml container Diabetes Immunology, Plain Tube Blood 5 ml 2 weeks Daily Mellitus IMR (Office Hour) Autoantibodies: Anti-Glutamic Acid Decarboxylase (GAD), Anti-Insulinoma- Associated Antigen 2 (IA2) & Anti-Islet Cells (ICA) Enterovirus Virology, Sterile plain Stool/ Stool: 2 weeks By Genome IMR container BAL/ >5 g or appointment Detection sputum pea size Reach lab within 12 Pleural Pleural hours after fluid fluid: collection 1 – 3 ml

CSF CSF: 1 – 3 ml

Test Perform Container Sample Volume TAT Schedule Site (Working days) Serum Serum: 3 – 5 ml

VTM (Swab) Rectal swab Throat swab Vesical swab Ulcer swab Organ biopsies

Enterovirus Virology, Sterile plain Stool/ Stool: 4 – 6 Daily Virus Culture IMR container BAL/ 5 g or weeks (Office Hour) sputum pea size

Pleural Pleural fluid fluid: 1 – 3 ml

CSF CSF: 1 – 3 ml

Serum Serum: 3 – 5 ml

VTM (Swab) Rectal swab Throat swab Vesical swab Ulcer swab Organ biopsies

HIV Genome Virology, EDTA Blood 5 ml 2 weeks For newborn Detection for IMR cases babies (0-18 months)

Test Perform Container Sample Volume TAT Schedule Site (Working days) Interferon Makmal Special Blood 5 ml 4 weeks Please Gamma Kesihatan bottle from (1 ml per contact Releasing Assay Awam MKAK tube) MKAK for (IGRA) Kebangsaan collection tubes and special instruction. By appointment ONLY through MKAK's Clinical Microbiologist Japanese Makmal Plain tube Blood 1 – 3 ml 7 days Samples encephalitis Kesihatan should be serology Awam Bijou Bottle CSF collected Kebangsaan within 5 days of illness

Japanese Virology, Plain Tube Blood 1 – 3 ml 2 weeks Daily encephalitis IMR (Office Hour) PCR Sterile CSF container

Sterile Organ containers biopsies containing VTM Leptospira PCR Microbiology, EDTA Blood 5 ml 2 weeks Send before IMR start Sterile Sterile antibiotic container body fluid Daily Tissue (Office Hour) Leptospiral Microbiology, Plain Tube Blood 5 ml 1 week Daily Micro- IMR (Office Hour) agglutination Titer (LeptoMAT) Mycobacterium Makmal Sterile plain Sputum CSF/ 7 weeks Daily C&S Kesihatan container Tissue fluid/ (Office Hour) Awam CSF Pus: Kebangsaan 1 – 2 ml Pus Body fluids

Test Perform Container Sample Volume TAT Schedule Site (Working days) Mycobacterium Microbiology, Sterile plain Sputum CSF/ 2 weeks Daily TB Genome IMR container Tissue fluid/ (Office Hour) Detection CSF Pus: 1 – 2 ml Pus Body fluids

Measles IgM Makmal Plain Tube Blood 1-3 ml 1 week Daily Kesihatan (Office Hour) Awam Kebangsaan Measles Viral Makmal Sterile plain Urine Urine: 3 weeks Daily Culture Kesihatan container 10 ml (Office Hour) Awam Kebangsaan NPA NPA/TA: 1 ml VTM Tracheal aspirate Throat swab Measles RT- Makmal Sterile plain Urine Urine: 1 Daily PCR Kesihatan container 10 ml week (Office Hour) Awam Kebangsaan NPA NPA/TA: 1 ml VTM Tracheal aspirate Throat swab Nipah IgG Virologi, IMR Plain Tube Blood 1-3 ml 2 – 4 Daily weeks (Office Hour) Sterile CSF container Nipah IgM Virology, Plain Tube Blood 1-3 ml 2 – 4 Daily IMR weeks (Office Hour) Sterile CSF container Nipah Virus Virology, Leak-proof Serum Serum/ 2 weeks Daily PCR IMR sterile CSF: (Office Hour) container CSF 2 – 3ml

Test Perform Container Sample Volume TAT Schedule Site (Working days) Blood Blood: 5 ml

Organ Organ: biopsies 1.5 cm cube Parvo VirusB19 Makmal Plain Tube Blood Serum: 1 Daily DNA Detection Kesihatan 5 ml week (Office Hour) Awam Kebangsaan Sterile plain CSF CSF: container 1 ml

Polio virus / Virology, Sterile plain Stool Stool: 4 – 6 Daily Acute Flaccid IMR container 5 g or weeks (Office Hour) Paralysis (AFP) pea size

CSF CSF: 1 – 2 ml

VTM Throat swab Rectal swab Rubella Viral Makmal Sterile plain Urine Urine: 4 weeks Daily culture Kesihatan container 10 ml (Office Hour) Awam Kebangsaan NPA NPA/TA: 1 -3 ml VTM Throat swab Tracheal aspirate Viral Culture Makmal Sterile bottle CSF CSF: 4 – 6 Daily Kesihatan 1 – 3 ml weeks (Office Hour) Awam Kebangsaan BAL Others: NPA Not Vesicle applicable fluid Stool Tissue

Test Perform Container Sample Volume TAT Schedule Site (Working days) Viral Culture Virology, VTM bottle Throat Not 4 – 6 Daily IMR swab applicable weeks (Office Hour) Nasal swab Rectal swab Lesion swab

100 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 AFP Case Investigation Form IMR AFP Case Investigation Form HIV PCR Request Form IMR/Viro/HIV/2 IMR (Baby) IMR/VIRUS/NARL2 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 MKAK-BPU-K03 MKAK Mycobacterium leprae Request Form Dengue dan Flavivirus Request Form MKAK-BPU-02 MKAK (rev_Nov_2015) Measles Request Form MSLF:01/2004 MKAK MKAK Lab Request Form MKAK-BPU-U01 For MKAK viral identification HLA Crossmatch Test Request Form IMR/AIRC/TI/RF-1 IMR (Living Donor) HLA Typing Test Request Form IMR/AIRC/TI/RF-2 IMR HLA Typing Test Request Form IMR/AIRC/TI/RF-3 IMR (Disease Association) HLA Antibody Test Request Form IMR/AIRC/TI/RF-4 IMR

HLA Crossmatch Test Request Form IMR/AIRC/TI/RF-5 IMR (Deceased Donor)

*All request forms can be downloaded from the P:\borang-borang\borang pathology

101

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.

102 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 Delays in transit affects coagulation testing and cause Platelet, specimens (> 4 hours) RBC and WBC cell degradation

Inadequate filling of Improper ratio of blood to anticoagulant causes prolonged PT blood collection tubes 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 Specimens not stored or transported according to storage/ transport recommended temperature may cause aberrant results. e.g. CD4/CD8 Enumeration should be sent at room temperature not cold temperature (2- 8 °C)

103 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

104 Specimen Collection Chart – Haematology

Tube / Container Sample/Tube Common Use Special Description Instructions Adult Whole blood / Routine Haematology: Mix sample K2EDTA Full Blood Count gently Full Blood Picture 8 - 10 times Retic Count G6PD Screening

Specialised test: CD4/ CD8 Hb Analysis

Specialised test

(Outsourced): Paeds G6PD Assay DNA Analysis

3.2% Sodium Citrate Coagulation test Mix sample gently 3 - 4 times

Must be filled until the marked indicator

105

Tube / Container Sample/Tube Common Use Special Description Instructions 3.8% Sodium Citrate ESR Fill within the (ESR tube) 2 markers

Mix sample gently 8 - 10 times

Lithium Heparin Specialised test Mix sample (Outsourced): gently Chromosome Analysis / 8 - 10 times Cytogenetic for Genetic Disease

Sodium Specialised test Mix sample Heparin (Outsourced): gently Cytogenetic for Leukemia 8 - 10 times (Blood & Bone Marrow Aspiration)

SST Gel Specialised test Mix sample (Plain tube) (Outsourced): gently Serum Erythropoietin 5 - 6 times

106

Tube / Container Sample/Tube Common Use Special Description Instructions Plain tube (without Specialised test Mix sample Gel) (Outsourced): gently Platelet Antibody 5 - 6 times Screening

Sterile urine Specialised test Please ensure container with added (Outsourced): cap is tight formalin Bone marrow trephine and secure biopsy

107 List of Test (in–house) & Reference Interval

Test Sample TAT Reference Remarks Container/ Interval Volume 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 Slide smear Urgent: 1 day - By appointment Aspiration Routine: 7 days Bone Marrow Sterile urine 20 working By appointment Trephine container with days Biopsy 10% formalin

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 Urgent: 90 mins <500 ng/ ml Run twice a week Citrate Routine: 3 (Tues & Fri) Paeds: 1.8 ml working days Adult: 2.7 ml 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

108

Test Sample TAT Reference Remarks Container/ Interval Volume 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 90 mins 276-471 mg/ dL Citrate Paeds: 1.8 ml Adult: 2.7 ml 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 EDTA Urgent: 1 day Please call MO for Picture Paeds: 0.5 ml Routine: 5 days urgent FBP Adult: 2 ml MO code required after office hours G6PD EDTA 2 ml 1 day Batch test performed screening twice daily (8 am & 3 pm) (Peripheral/ cord blood) 3 months post transfusion

Do not send during hemolytic crisis Haemoglobin EDTA 6 weeks Hb A (%): Run once a week (Hb) Analysis Paeds: 0.5 ml 96.8-97.85 (Thursday) Adult: 2 ml Hb F (%): Send immediately at <2 years: <5 Room Temperature <12 years: 2-3 Adult: < 1 3 months post transfusion Hb A2(%): 2.2-3.2 Please exclude IDA before sending Reference: - Standardization

109

Test Sample TAT Reference Remarks Container/ Interval Volume National For family screening, Hematology details of index case Workshop must be clearly Langkawi, 2015 stated - Thalassemia Carrier Diagnosis in Malaysia, Dr Elizabeth George, 1998 Kleihauer test EDTA 3 days By appointment Paeds: 0.5 ml Adult: 2 ml Please provide cord blood sample as control Mixing test 3.2 % Sodium 1 day By appointment Citrate 2.7 ml (2 tubes) Prothrombin 3.2 % Sodium Urgent: 60 mins 9.4-12.5 secs Send immediately Time (PT)/ Citrate Routine: 90 after collection International Paeds: 1.8 ml mins normalized Adult: 2.7 ml ratio (INR) Reticulocyte EDTA 2 hrs 0.5-2.5% count Paeds: 0.5 ml Adult: 2 ml 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.

110 List of Test (Outsourced)

Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab

ADAMTS-13 Clinical 3.2% Blood 1 tube 4 - 6 • By appointment Hematology Sodium *Collect weeks • Fresh specimen Lab, citrate until Hospital indicate Request form: Ampang d mark Hospital Ampang Special Hematology Lab Requisition form

Anti-Xa Clinical 3.2% Blood 1 tube 7 • Send Hematology Sodium *Collect working immediately to Lab, citrate until days lab Hospital indicate • By Ampang d mark Appointment

Request form: Hospital Ampang Special Hematology Lab Requisition Form Chromosome Cytogenetics Lithium Blood 4 ml 60 • By appointment analysis Unit, heparin working • Fresh specimen (for genetic WCH KL days • Send to HSgB disease) (ext. 2711) 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 Clinical Sterile Bone Minimu 30 • Appointment with Analysis for Hematology transpo Marrow m 1-2 working haematologist, Leukaemia / Lab, rt ml days Hospital Ampang Cytogenetic Hospital medium • Fresh specimen Ampang with • Send to HSgB heparin lab Mon-Wed only • Samples must reach before 9 am

111

Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab

• Do not send on PH and eve of PH.

Request form: Hospital Ampang Special Hematology Lab Requisition Form

Cytogenetic Clinical Sterile BMA Minimum 18 • Appointment with FISH Hematology transport 1-2 ml working haematologist, Lab, Hospital medium days Hospital Ampang Ampang with heparin • Fresh specimen 2 tubes of Blood Minimum *Case to • Send to HSgB case sodium 5 ml lab Mon-Wed Heparin basis only (2.5ml in • Samples must reach before each tube) 9 am • Do not send on PH and eve of PH.

Request form: Hospital Ampang Special Hematology Lab Requisition Form

Coagulation: Haemostasis 3.2% Specimen: Blood 20 • Send • Factor Unit, PDN Sodium working immediately to Assay citrate > 1 year: days lab • VWF test 2.7 mL x 5 tubes Request form: PDN Haematology/ ≤ 1 year: Serology Request 2.7 mL x 2 tubes Form

112 Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab Dihydrorhoda- AIRC Unit, Lithium Blood 2 ml 15 • By appointment mine test IMR heparin working • Fresh specimen (DHR) (ext. 2587) (without days • Send to HSgB gel) 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- Hematology EDTA Blood Adult: 90 Must attach: Alpha Unit, HKL 2 mL working • Hb Analysis Thalassemia (ext. 5746/ days Report 5748) Paeds: • latest FBC result 0.5 mL (< 3 months) • Detailed history on index case for family screening

Request form:

113

Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab DNA analysis of Thalassemia Syndromes & Haemoglobinopathy’ s Request Form (Latest version) DNA Analysis- Hematology EDTA Blood Adult: 90 Must attach: Beta Unit, HKL 2 mL working • Hb Analysis Thalassemia HKL days Report (ext. 5746/ Paeds: • latest FBC result 0.5 mL (< 3 months) 5748) 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 Clinical Plain tube Blood 3.5 ml 6-12 • By appointment (sEPO) Hematology weeks • Fresh sample Lab, Hospital Request form: Ampang Hospital Ampang Special Hematology Lab Requisition Form

G6PD Hematolog y EDTA Blood Adult: 25 • By appointment Quantitative Unit, WCH 2 mL working • Send to HSgB Assay KL (Ext days lab Mon-Wed 2169) Paeds: only 0.5 mL • Samples must reach before 9 am • Do not send on PH and eve of PH.

114

Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab

• 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 Hematology EDTA Blood / 2 ml x 2 21 • Fresh sample -typing (IPT) Unit, WCH, Bone tubes working • Send to HSgB Leukemia / KL marrow days lab Mon-Wed Lymphoma only before 9 am. • Do not send on PH and eve of PH.

Request form: PER–PAT 301

Lymphocyte AIRC Unit, Sodium Blood 2 ml 15 • By appointment Proliferation IMR Heparin working • Fresh specimen Test (ext. 2587) days • 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

115

Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab

Molecular Clinical EDTA Blood Minimum 4 • Fresh sample 5 ml weeks Analysis for Hematology • Send to HSgB Leukaemia Lab, lab Mon-Wed Hospital only Ampang • Samples must reach before 9 am Minimum • Do not send on Bone PH and eve of

marrow 1-2 ml PH

Request form: Hospital Ampang Special Hematology Lab Requisition form

Molecular Clinical EDTA Blood Minimum 4 • Fresh sample 5 ml BCR/ABL 1 Hematology weeks • Send to HSgB Lab, (2.5 ml x lab Mon-Wed Hospital 2 tubes) only Ampang • Samples must reach before 9 am Minimum • Do not send on Bone PH and eve of 1-2 ml marrow PH.

Request form: Hospital Ampang Special Hematology Lab Requisition form

Molecular Unit of Specimen requirements are 3 • All cases must Genetic Test Molecular according to cases. Please refer months be referred to Diagnostics to Request Form for Molecular and endorsed by and Protein Diagnostic Services or call IMR a Clinical (UMDP), (03-26162540/2590) for details Geneticist before sending IMR KL specimens

Request form: Request Form for Molecular Diagnostics Services

Molecular Clinical EDTA Blood / 2 ml x 2 8 • Send to HSgB JAK 2 Hematology Bone tubes weeks lab Mon-Wed Lab, marrow only Hospital Ampang

116

Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab

• 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 Hematology Lithium Blood 2 ml x 2 15 • By appointment Fragility Test Unit, HKL heparin tubes working • Inform HSgB Lab (ext. 6549) (without days before requesting gel) • Fresh sample required • Send additional 2 mL healthy person’s blood as control

NOTE: 3 months post transfusion

Request form: PER–PAT 301

Platelet Hemostasis - - - - • By appointment Aggregation Unit, PDN • Patient to go Test directly to PDN

PID AIRC Unit, EDTA Blood 2 ml 10 • By appointment Lymphocytes NIH working basis (T & B Cell) (ext. 8386) days • Send to HSgB Subset lab on every Enumeration working Mondays and Measurement of : Thursdays 1. Total T only cells • Samples must (CD3) reach HSgB 2. T lab before 9 helper am cells • Do not send on (CD4) PH and eve of 3. Cytoto PH xic T • Please call cells (2122 / 2152) if (CD8) there is any 4. B cells

117 (CD19) delay/ 5. Natural cancellation. Killer cells Request form: IMR PID Request Form

PID Plain Blood 5 ml Immunoglobuli n and complement

Measurement of IgA, IgM, IgG, IgE*, C3 and C4.

118

Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab

Platelet Makmal EDTA & Specimen: Blood 20 • By appointment Antibody Platelet Plain tube working with PDN Screening Antibodi, (without Baby: days Specialist on-call PDN gel) - Patient: • Register test for 2mL EDTA x 5 tubes patient only. Write down parent’s details - Father’s blood: (Name and IC 2mL EDTA x 5 tubes no.) on the sample tube - Mother’s blood: 2mL EDTA x 5 tubes Request form: & 10mL plain tube PDN Haematology/ Serology Request Adult: Form 2mL EDTA x 5 tubes & 10mL plain tube

PNH Hematology EDTA Blood 2 ml x 2 25 • Fresh sample (Paroxysmal Unit, WCH, tubes working • Send to HSgB Nocturnal KL days Lab Mon-Wed Hemoglobinuria) only • Samples must reach before 9 am • Do not send on PH and eve of PH.

Request form: PER–PAT 301

Thrombophilia Hemostasis 3.2% Specimen: Blood 2 • Send Screening: Unit, PDN Sodium weeks immediately to citrate Adult: lab (within 4 hours collection • Lupus 6-7 tubes (15 ml) anticoagulant • Please follow the (LA) Paeds 1- 12 years: PDN guidelines (Available in 4-5 tubes (10 ml) Public Folder) • Activated

Protein C Paeds ≤ 1 year: Resistance Not indicated for: 2-3 tubes (5 ml) • during acute • Anti- episodes of cardiolipin thrombosis and pregnancy

• Anti-B2 • patients who had Glycoprotein 1 provoked VTE

119

Test Perform Sample/ Specimen Volume TAT Special Site / Container Requirement/ Referral Forms Lab

• Antithrombin Patients on activity anticoagulants should be • Protein C & S discontinued as Activity below: • Warfarin: • Antiphospho- suggest sending lipid Antibody 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.

120 List of Request Forms - Hematology

FORMS CODE DESCRIPTION

Borang Permohonan Ujian PER-PAT 301 General form Perkhidmatan Patologi Cytogenetic Request Form for HKL/GE/TPM/N-1-(1) Chromosome Analysis for Peripheral Blood Samples genetic disorder (WCH,KL) DNA Analysis for Thalassemia IMR/CaRC/HAEM/22/220 DNA Analysis test Syndromes & 3/03(1)/REQForm (Alpha : HKL, Beta : IMR) Haemoglobinopathies Form Hospital Ampang Special Hem-RQ19 Version 2 Clinical Haematology Haematology Requisition Lab, Hospital Ampang Form Hematology/Serology Request PDN/H/QP-01/01 PDN Form Molecular Diagnostics IMR/SDC/UMDP/MOLDX/ IMR Services Request Form REQUEST FORM Primary Immunodeficiency IMR/AIRC/PID/RF For PID Quantitation of (PID) Request Form Immunoglobulin & Complement IMR

*All request forms can be downloaded from the P:\Borang-borang\Borang pathology

121 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

122

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

123

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 0.1 - 1.0 Dacie & Lewis 12th Edition Years Basophils (x 10^9/ L) Adult 0.0 - 0.9 Ambayya et al. (2014)

124 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 20 – 30 mins and Cryosupernatant

125 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

126 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.

127 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.

128 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 • Performed for cases where probability of transfusion is low Hold (GSH) • 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 • Performed for cases where probability of transfusion is high. matching (GXM) • 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 • Performed if cross match not compatible (for recipient and (DCT) donor) • Investigation for transfusion reaction

129 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

130 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)

131 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.

132 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.

133 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.

134 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.

135 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).

136 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

137 16. Storage, Transportation and Duration for Transfusion of Blood Components

BLOOD Red cells Platelets Thawed Thawed COMPONENTS (all types of red Plasma Cryoprecipitate/ cells) Cryosupernatant STORAGE 2 - 6ºC 20 - 24ºC Shall be Shall be issued issued once once the product the product is is thawed thawed TRANSPORTATION 2 - 10ºC Should be 2 - 10ºC 20 - 24ºC (thawed kept at product) 20 - 24ºC.

NEVER put platelets in refrigerator TRANSPORT Insulated box Insulated Insulated box Insulated box BOXES with coolant box with coolant WITHOUT ICE pack. Direct WITHOUT pack. Direct contact with ICE contact with coolant shall be coolant shall AVOIDED be AVOIDED DURATION BEFORE 30 minutes after Start as As soon as As soon as the TRANSFUSION removing the soon as the the thawed thawed pack is packs from pack is pack is received from the blood received received from blood bank refrigerator from the the blood bank blood bank DURATION DURING SHOULD NOT SHOULD - - TRANSFUSION more than 4 NOT be hours to more than completion to 30 minutes avoid risk of bacterial contamination

138 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.

139 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).

140 Collection Chart – Transfusion Medicine

Tube / Container Sample/Tube Common Use Special Instruction Description

Plain tube Antibody identification Mix sample gently without gel 5 times

Adult EDTA GSH, GXM, Antibody Mix sample gently identification 8 – 10 times

Paeds

Sterile urine For Urine Hb – Please ensure cap is container Transfusion reaction tight and secure case

141 List of Request Forms – Transfusion Medicine

FORMS CODE DESCRIPTION

General PER-PAT Form PER-PAT 301 For other tests Borang Pemohonan Transfusi WJD011379-PNMB., For GSH, GXM, Antibody Darah K.L. Identification Borang Laporan Reaksi kepada BTS/TR/2/2016 For Transfusion Reaction Darah atau Komponen Darah Report Permohonan Rujukan Ujian PDN/IH/QP-01/04 For Antibody Identification Immunohematologi PDN Permohonan Rujukan Ujian PDN/IH/QP-03/03 PDN Platelet Immunologi Borang Persetujuan Pemindahan BTS/TC/2/2016 Consent form for patient Darah atau Komponen Darah (Consent Form) Worksheet for Investigation of BTS/TRW/2/2016 For pathology staff Transfusion Reaction (transfusion unit) Reporting Form for BTS/HV/3/2016 For pathology staff Transfusion-Related Adverse (transfusion unit) Event

*All request forms can be downloaded from the P:\borang-borang\borang pathology

142 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.

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.

143 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

144 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.

145 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.

146 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 4C 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.

147 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)

148 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.

149 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

150 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

151 Collection Chart – Histology & Cytology

Tube / Container Sample/Tube Common Use Special Instruction Description

Sterile container with 10% formalin (for Histopathology specimen) -

without formalin (for Cytology specimen)

Disposable For surgical specimen container -

152 List of Test (Outsourced)

Test Perform Site / Sample/ Specimen TAT Special Referral Lab Container (working Requirement/ days) Forms

Histopathology Histopathology Leak proof Tissue 30 days PER–PAT 301 specimens: Unit, Hospital container (Routine) • Big specimen Selayang with 10% 7 to 14 days • Bone Formalin (urgent) (decalcification) (10 x specimen) Histopathology Hospital UITM, Leak proof Tissue 30 days PER–PAT 301 specimens: Sungai Buloh container (Routine) • Small biopsies with 10% 7 to 14 days • Big specimen Formalin (urgent) • (Breast & Colon only) Frozen section Histopathology Universal Tissue - PER–PAT 301 Unit, Hospital Container Selayang & (fresh) Hospital UITM, Sungai Buloh Histopathology Histopathology Plain Brain 30 days PER–PAT 301 specimens (Brain) Unit, HKL / container tissue (Routine) Histopathology with 10% 7 to 14 days Unit, Hospital neutral (urgent) Selayang buffered formalin (NBF) Histopathology Stomatology Leak proof Oral 30 days IMR specimens (Oral) Unit, IMR container tissue (Routine) Pathological with 10% 7 to 14 days Specimens Formalin (urgent) Cytology Cytology Unit, Leak proof Tissue 14 days PER–PAT 301 specimens Hospital container (Routine) (Non-gynaecology Selayang 7 days and FNAC) (urgent) Pap smear Cytology Unit, Not Slide 14 days Pap smear (Gynaecology) Hospital applicable (Routine) Request Form Selayang

153 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 PS 1/98 For Pap smear Pap Smear IMR Pathological Specimens Medl. 135 For Stomatologi IMR (STOMATOLOGY) Permohonan untuk Pinjaman HS/JP/WI (HC:09)-001: - Slide Histopatologi/Sitologi Appendix [4]

*All request forms can be downloaded from the P:\borang-borang\borang pathology

154