Special Diagnostic Procedures

Our Lady of Fatima University – Pampanga

College of Medical Laboratory Science
PRELIM

LABORATORY SAFETY UNIVERSAL PRECAUTION

● Instituted by CDC (1987).
OCCUPATIONAL SAFETY AND HEALTH ACT (OSHA) ● All patients are considered to be possible carriers of
blood-borne pathogens.
● Public Law 91-596
● Recommends wearing gloves when collecting or
● Was enacted by the U.S. Congress in 1970.
handling blood and body fluids contaminated with blood.
● Authorized to conduct on-site inspections to determine
whether an employer is complying with the mandatory ● Wearing face shields when there is danger of blood
standards. splashing on mucous membranes.
MAIN GOAL OF OSHA ● Disposing all needles and sharp objects in
puncture-resistant containers.
● Provide all employees with a safe work environment.
● CDC excluded urine and body fluids not visibly
OSHA STANDARD contaminated by blood from UP, although many
specimens can contain a considerable amount of blood
● OSHA standards that regulate safety in the laboratory
before it becomes visible.
include the following:
● The modification of UP for body substance isolation
1. Bloodborne Pathogen Standard
(BSI) helped to alleviate this concern.
2. Formaldehyde Standard (0.75 ppm)
● BSI guidelines are not limited to blood-borne pathogens;
3. Laboratory Standard
they consider all body fluids and moist body
4. Hazard Communication Standard
substances to be potentially infectious.
5. Respiratory Standard
6. Air Contaminants Standard
7. Personal Protective Equipment Standard BSI GUIDELINES
● Personnel should wear gloves at all times when
BLOODBORNE PATHOGEN STANDARD encountering moist body substances.
● Applies to all exposure to blood or other potentially ● A major disadvantage of BSI guidelines is that they do
infectious materials in any occupational setting. not recommend handwashing following removal of
● Universal Precaution and PPE. gloves unless visual contamination is present.
● Mandates the development of an exposure control plan.
● Decontamination and safe handling of specimens. STANDARD PRECAUTION
● Requirement for HBV vaccination. 1. Handwashing
2. Gloves
HAZARD COMMUNICATION STANDARD 3. Mask, eye protection, and face shield
● Toxic and Hazardous Substances regulations. 4. Gown
● To ensure that the hazards of all chemicals used in the 5. Patient care equipment
workplace have been evaluated and that this hazard 6. Environmental control
information is successfully transmitted to employers and 7. Linen
their employees. 8. Occupational health and blood-borne pathogens
9. Patient placement
BIOLOGICAL HAZARD
CHEMICAL SAFETY HAZARD COMMUNICATION
● OSHA published the new Hazard Communication
Standard (Right to Know Law).
● To comply with the regulation, clinical laboratories must:
○ Plan and implement a written hazard
communication program.
○ Obtain Material Safety Data Sheets (MSDS).
○ Educate all employees.
○ Maintain hazard warning labels on containers
received or filled on site.
 MATERIAL SAFETY DATA SHEET
● Major source of safety information for employees who Flash Points
may use hazardous materials
○ Product name and identification ● 4 – Below 73˚F
FIRE HAZARD ● 3 – Below 100˚F
○ Hazardous ingredients Red Diamond ● 2 – Above 100˚F not exceeding
○ Permissible exposure limit (PEL) 200˚F
○ Physical and chemical data ● 1 – Above 200˚F
○ Health hazard data and carcinogenic potential ● 0 – Will not burn
○ Primary routes of entry
○ Fire and explosion hazards
○ Reactivity data ● 4 – May Detonate
○ Spill and disposal procedures REACTIVITY ● 3 – Shock & Heat may detonate
○ PPE recommendations Yellow Diamond ● 2 – Violent Chemical Change
○ Handling ● 1 – Unstable if heated
● 0 - Stable
○ Emergency and first aid procedures
○ Storage and transportation precautions
● ACID – Acid
○ Chemical manufacturer’s name, address, and ● ALK – Alkali
telephone number SPECIFIC HAZARD ● COR – Corrosive
White Diamond ● OXY – Oxidizer
○ Special information section ● ☢– Radioactive
● W – Use No Water

OSHA LABORATORY STANDARD

● To address the shortcomings of the Hazard
Communication Standard ECOLOGICAL SOLID WASTE MANAGEMENT ACT OF 2000
● Requires the appointment of a chemical hygiene officer (REPUBLIC ACT 9003) BY DENR
and the development of a chemical hygiene plan. ● Biodegradable Waste
○ Food wastes, yard wastes, etc.
CHEMICAL HYGIENE PLAN ● Non-biodegradable/Recyclable Wastes
○ Paper, plastic, styrofoam, tin cans, bottles, etc.
● Procedures describing how to protect employees against
● Non-recyclable /Residual Wastes
teratogens, carcinogens, and other toxic chemicals must
○ Used/worn out rugs, ceramics, soiled plastics,
be described in the plan.
candy wrappers, etc.
● Must detail engineering controls, PPE, safe work
● Special/Hazardous Wastes
practices, and administrative controls, including
○ Used fluorescent lamps/bulbs, batteries, spray
provisions for medical surveillance and consultation, when
canisters, etc
necessary.

OTHERS ORGANIZATIONS/LAW CONCERNED WITH SAFETY AWARENESS FOR

LABORATORY SAFETY CLINICAL LABORATORY PERSONNEL
1. Clean Water Act Employer’s Responsibilities
2. Resource Conservation and Recovery Act ● Establish laboratory work methods and safety policies.
3. Toxic Substances Control Act ● Provide supervision and guidance to employees.
4. The Clinical and Laboratory Standards Institute (CLSI) ● Provide safety information, training, personal protective
● Provides excellent general and infection control equipment, and medical surveillance to employees.
guidelines in their documents. ● Provide and maintain equipment and laboratory facilities
5. The Joint Commission (TJC) that are adequate for the tasks required.
6. College of American Pathologists (CAP) ● Know and comply with the established laboratory work
7. National Fire Protection Association (NFPA) safety methods.
● Have a positive attitude toward supervisors, coworkers,
NFPA HAZARD COMMUNICATION (HAZCOM) SYMBOLS facilities, and safety training.
● Give prompt notification of unsafe conditions or practices
to the immediate supervisor and ensure that unsafe
conditions and practices are corrected.
● Engage in the conduct of safe work practices and use of
personal protective equipment.

GENERAL LABORATORY SAFETY PRACTICES

● No smoking, eating, and application of cosmetics.
HEALTH HAZARD ● 4 – Deadly
● 3 – Extreme Danger ● Proper use of PPE (should never be worn outside the
Blue Diamond
● 2 – Hazardous laboratory).
● 1 – Slightly Hazardous ● Shoes should be made of nonporous materials with closed
● 0 – Normal Material
toes and heels.
Special Diagnostic Procedures 2
 ● Hand washing should be done between each patient even
if gloves are worn.
● Needles and other sharps should be discarded into Explosive
puncture-resistant and leak-proof containers (½ to ¾
full before disposal).

SAFETY EQUIPMENT
● All laboratories are required to have Corrosive
○ Safety showers, (recommended that safety
showers deliver 30 to 50 gallons of water per
minute at 20 to 50 psi)
○ Eyewash stations Toxic/Poison
○ Fire extinguishers
○ Fire blankets, spill kits, and first aid supplies.

Chemical Fumes and Biological Safety Cabinet

Environmental

CHEMICAL HAZARDS
FLAMMABLE/COMBUSTIBLE CHEMICALS
● Flash point, which is the temperature at which sufficient
vapor is given off to form an ignitable mixture with air.
● Acetone, Benzene, Ethanol, Heptane, Isopropanol,
Methanol, Toluene, xylene.
● Certain gases, such as hydrogen, and solids, such as
BIOLOGIC SAFETY GENERAL CONSIDERATIONS paraffin.
Spills
● Wear appropriate protective equipment. CATEGORIES OF CHEMICALS
● Use mechanical devices to pick up broken glass or other 1. Corrosive
sharp objects. ● Chemicals with a pH of <2 or >12.5.
● Absorb the spill with paper towels, gauze pads, or tissue. 2. Toxic Substances
● Clean the spill site using a common aqueous detergent. ● Poisons, irritants, and asphyxiants.
● Disinfect the spill site using approved disinfectant or 3. Carcinogens
10% bleach, using appropriate contact time. ● Capable of causing cancers.
● Rinse the spill site with water. 4. Mutagens and Teratogens
● Dispose of all materials in appropriate biohazard ● Capable of causing chromosomal aberrations
containers. and congenital malformations.
5. Ignitable
LABORATORY SAFETY GENERAL CONSIDERATIONS ● Flammable and combustible.
Concentrated Acid/Base Spills 6. Reactive
● Should be diluted with water before cleanup is attempted. ● Explosives and oxidizers.
● Cover the spill with neutralizer.
○ Sodium bicarbonate- acids CORROSIVE CHEMICALS
○ Boric acid- bases ● Injurious to the skin or eyes by direct contact.
● Absorb spill using an absorbent. ● Injurious to the tissue of the respiratory and
● Surface should be covered with soap and water. gastrointestinal tracts if inhaled or ingested.
● Acids (acetic, sulfuric, nitric, and hydrochloric).
OTHER CHEMICAL HAZARDS AND SYMBOLS ● Bases (ammonium hydroxide, potassium hydroxide, and
sodium hydroxide).

REACTIVE CHEMICALS
Flammable
● With molecular structures of high reactivity.
● Oxidizers with high oxygen content or compounds with
redox groups.
● Substances that, under certain conditions, can
Irritant
spontaneously explode or ignite or that evolve heat or
flammable or explosive gases.
● Some strong acids or bases react with water to generate
Special Diagnostic Procedures 3
 heat (exothermic reactions). GAMMA RAYS
● Mixture of oxidizing agents, such as peroxides, and ● No mass or charge but with great penetrating ability.
reducing agents, such as hydrogen, generate heat and ● Produce significant internal and external hazards if in high
may be explosive. concentration.
● Produced by 125I and 131I.
OSHA REGULATED CARCINOGENS CHEMICALS
● Chloromethyl methyl ether- vinyl chloride X-RAYS
● N-Nitrosodimethylamine ● Differ from gamma rays only in the origin of radiation.
● Benz[a] pyrene
● 4-Aminobiphenyl THRESHOLD LIMIT VALUES
● Benzidine ● Exposure limits to toxic chemicals in the workplace.
● 1-Naphthylamine
● 2-Naphthylamine
THREE TYPES THRESHOLD LIMIT VALUES
● 4-Nitrobiphenyl
1. Time-Weighted Average (TLV-TWA)
● Benzene
● Represents the maximum allowable exposure
● Ethylenimine
over an 8-hour work day.
● P-Dimethylaminobenzene
2. Short-Term Exposure Limit (TLV-STEL)
● Β-Propiolactone
● Represents the maximum amount of allowable
● Bis Chloromethyl ether
exposure for a short period such as 15 minutes.
3. Ceiling Value Form (TLV-C)
RADIATION SAFETY AND ENVIRONMENTAL PROTECTION
● Represents the concentration of an agent that
● Nuclear Regulatory Commission (NRC) license is required must never be exceeded.
if the total amount of radioactive material exceeds a
certain level.
STORAGE OF CHEMICALS
● Film badge or dosimeter must be worn when handling
● Stored in an uncluttered area (properly ventilated).
radioactive chemicals.
● Away from heat source.
● Should not be stored above eye levels.
● Inorganics should be stored separately from organics
(EXCEPT NITRIC ACID).
● Flammables should be stored in an approved flammable
safety cabinet.
● Water reactive chemicals should be stored in a dry
environment (no automatic sprinkler system).
FOUR TYPES OF IONIZING RADIATION
1. Alpha Particles (e.g. Plutonium) FIRE SAFETY
2. Beta Particles The Chemistry of Fire
3. Electromagnetic Radiation (gamma rays and x-rays) ● All the elements essential for fire to begin are
4. Neutron present—fuel, heat or ignition source, and oxygen
(air).
EFFECTS:
➔ Damage to DNA leading to mutation, cancer or cell death. CLASSIFICATION OF FIRES
1. Alpha Particles
● Large and can travel only a very short range in
air.
● May be stopped by skin or paper.
● Cause tissue damage if inhaled or ingested.
2. Beta Particles
● Smaller and they are negatively charged
electrons.
● With limited penetrating power.
● Cause tissue damage if inhaled or ingested.
● Emitted by 3H, 14C, 32P.
3. Neutrons
● Arise from spontaneous fission of some isotopes
and produced by atomic reactors and
accelerators.
4. Gamma Rays and X-rays
● Composed of electromagnetic energy and not
Class A Ordinary combustible solid
composed of atomic particles.

Special Diagnostic Procedures 4

 STRESS TEST
materials, such as paper,
wood, plastic, and fabric STRESS TESTING
● It is a tool used to evaluate and manage patients with
Class B Flammable liquids/gases and known or suspected heart disease.
combustible petroleum ● Cardiac assessment (blood rate + heart rate + blood
products pressure)
● Used to detect severe blockage in the artery
Class C Energized electrical
● Assess the coronary flow system
equipment.
● Induced through exercise
Class D Combustible/reactive metals ○ Treadmill test
such as magnesium, sodium, ○ Exercise test
and potassium. IMPORTANCE OF STRESS TEST SEGMENT
● ST segment change may predict coronary artery disease
● Falt, isoelectric section of the ECG; end of the S wave
(beginning of the T wave)
● Interval between ventricular depolarization and
repolarization
● Important cause (Abnormal ST segment)
○ Ischemia/infarction
○ Elevated of depressed
How does it work?
● Increase the heart rate
● Check the blood pressure
● Check the increase of blood flow through each coronary
artery
● Atherosclerosis – plaque/fat deposits
● Assesses the breathing and how tired the patient is
PATIENT SUBJECTED FOR STRESS TESTING
● Irregular heart beat
○ Arrhythmia – bradycardia; tachycardia
● Symptoms related to your heart
○ Chest pain; difficulty breathing
ELECTRICAL HAZARDS
● If the medicines/treatments are working
● Use only explosion-proof equipment in hazardous ● To check what Exercise/ Rehabilitation program is
atmospheres. recommended for you
● Be particularly careful when operating high-voltage ● Other tests: coronary angiogram narrowing arteries
equipment, such as electrophoresis apparatus.
PATIENT PREPARATION BEFORE THE STRESS TEST
● Use only properly grounded equipment (three-pronged
● Inform your doctor about any medicines you take.
plug).
○ OTC, herbs, supplements, vitamins
● Check for frayed electrical cords.
● NPO may be suggested for 2-4hrs.
● Promptly report any malfunctions or equipment.
○ Fasting
● Do not work on “live” electrical equipment
○ Avoid caffeine
● Equipment should be checked annually for current
● Stop smoking a day or 2-4 hrs before the procedure.
leakage and ground integrity.
● Unusual physical exertion must be avoided
● Wear comfortable clothes and shoes.
LABORATORY SAFETY RULES ● For nuclear stress test: don't apply oil, lotion or cream to
1. Always follow the teacher’s directions and only do your skin that day
laboratory work when a teacher is present. ● Preparation time: 1 hour
2. Conduct yourself in a responsible manner at all times. ● Actual test: 15 minutes
3. Do not touch any equipment, chemicals, or other materials PATIENT DURING THE STRESS TEST
until told to do so. ● No eating or drinking until both parts of the test are
4. Do not eat food, drink beverages, or chew gum in the lab. completed.
Do not use lab glassware as food or beverage containers ● Follow the instructions of the medical professionals.
5. Report ALL accidents to your teacher immediately, even if ● Stop the test anytime if you're too uncomfortable to
you think it is minor. continue exercising.
● Discontinue when symptoms show
○ Moderate to severe chest pain
○ Severe shortness of breath
○ Abnormal high or low BP
○ Abnormal heart rhythm
Special Diagnostic Procedures 5
 ○ Dizziness MAIN TYPES OF STRESS
○ Fatigue 1. Exercise Stress Test
○ Certain changes in ECG 2. Nuclear Stress Test
PATIENT AFTER THE STRESS TEST 3. Pharmacological Stress Test
● Stand still for several seconds and then lie down for a EXERCISE STRESS TEST
period of time with the monitors in place. ● Uses exercise with ECG and BP monitoring
● Most people are instructed to resume their normal meals, ● Most commonly used and widely available stress test
medications, and activities immediately after the study is ○ Low cost/Less expensive
ended. ○ ECG, BP monitor, Treadmill or Upright bicycle
CONTRAINDICATIONS ● Bruce and Modifies Bruce - stress protocol
● Acute myocardial infarction within 2 to 3 days ○ Every three minutes monitoring
● Unstable angina not previously stabilized by medical ○ Different speed range
therapy ● Preferred with patients who reaches 85% MPR (maximum
○ Angina – chest pain predicted heart rate)
○ Unstable Stable ○ 220 – age = MPR (bpm)
■ kahit nakaupo, at rest and nagtake na ○ 75% level = .75 x given MPR = bpm
ng medication, hindi parin nagstastable ● Treadmill
or di parin nawawala chest pain ○ Treadmill – widely available
○ Variant angina ○ Used to patients with normal findings and do not
● Uncontrolled cardiac arrhythmias take drugs like digoxin (inotropic agent)
○ Related to hemodynamic ● Upright bicycle
■ Problem in the blood flow ○ Dynamic first-pass imaging
○ Hemodynamic NUCLEAR STRESS TEST
■ Blood flow
● Imaging of blood flow
● Acute myocarditis or pericarditis or endocarditis
● Reserved for patients who are unable to exercise
● Severe hypertension
adequately.
○ >200mmHg – systolic
● Done both during exercise* and while at rest.
○ >110 mmHg – diastolic
● Typically uses the radioactive tracer Tc-99 will expose you
● Severe pulmonary hypertension
to 11 millisieverts of radiation
○ Problem with the pressure in the lungs
○ Thallium-201 (TI-201)
● Inability to exercise
■ Technetium -99m (Tc-99m)
● Individuals with acute aortic dissection
● Short lived form of Tc99
○ Tear in the inner layer of the aorta
● Shorter half-life (6 hours)
○ Fatal or deadly for the individual to do stress test
● Doesn’t remain in the body or
RISKS AND PRECAUTIONS environment for a long time
● There’s very little risk for treadmill stress test. ● Radioactive Tracer
● Medical professionals are on-site in cause of any unusual ○ Introduced through IV
situations that may happen during the test ○ Check the imaging of the heart using the gamma
○ Severe shortness of breath camera
○ Moderate to Severe chest pain ○ Images of the blood flow
○ Blood pressure is too high or low ○ Eliminated through excretion of feces
○ Abnormal heart rhythm ● Myocardial perfusion imaging
○ Certain changes in the ECG
■ Elevation or depression of the ST
segment
● Allergic reaction
○ Can be caused by the radioactive tracer
● Except for a bit of fatigue from performing the exercise,
you should expect no side effects at all.
● If you have any unusual symptoms after this test, you
should bring them to the doctor’s attention
DETECTING CORONARY ARTERY DISEASE (CAD)
● A positive stress test is an indicator of advanced CAD
○ Usually late CAD
■ 70% blockage of arteries
● Coronary artery
● IHD – Ischemic Heart Disease
● Atherosclerosis heart disease
● Nuclear Stress Test and ECG
○ More accurate

Special Diagnostic Procedures 6

 PHARMACOLOGIC STRESS TEST ○ Require specific cycling brake to keep up with the
● Reserved for patients who are unable to exercise work rate
adequately. ■ Work rate in watts or kpm/min
● Induced by pharmacologic agents is demonstrated in ● Electronically brake
patients with decreased functional capacity or in patients ○ Could control the work rate
who cannot exercise. ● Physiological response
● Combined with imaging modalities such as radionuclide ○ Maximum oxygen uptake if compared to treadmill
imaging and echocardiography ■ Lower that 5-20%
○ Drug used BLOOD PRESSURE EQUIPMENT
■ Vasodilators ● Manual auscultation
● Adenosine ○ Most commonly used
● Dipyridamole ○ Feasible method
● Preferred by the physicians ○ Easily used
■ Inotropic agents ○ Sphygmomanometer
● Dobutamine ○ Manometer
● Dopamine ■ Recommended: mercury
● Digoxin ■ More accurate and easier to maintain
● Adenosine, Dipyridamole, Dobutamine and calibrate
○ Most commonly used ○ Aneroid manometer
MACHINE AND EQUIPMENT ● Automated blood pressure units are available, but these
1. Treadmill devices are expensive and may perform erratically at high
2. Electrocardiogram (ECG) Machine exercise intensities because of motion
● Measures the heartbeat and heart waves o S
waves and P waves
● Use metal disk (electrodes), wires
3. Bicycle ergometer
4. Blood pressure equipment
TREADMILL
● Electrically driven and should accommodate a variety of
body weights
● For patient safety and stability, padded front and side rails
are recommended.
● Must have an emergency stop button
● 156.5kg (350lb)
● 1.6km (1mph) – 12.8km (8pm) speed
● No elevation (20%)
● Platform length (minimum)
○ Length: 127cm (50 inch)
○ Width: 40.65cm (16 inches)
ECG
● Essential for continuous monitoring of heart rhythm and
evaluation of ischemic ECG changes during exercise
and recovery.
● Some have built-in arrythmia censoring
● 12-lead ECG
○ Mason-Ilkar adaptation
○ Electrodes
■ Silver-silver chloride
● Flexible knit tube shirt
○ Stabilize electrodes and cable systems
BICYCLE ERGOMETER
● Alternative to treadmill testing
● Less expensive
● Portable substitute for testing
● Has the capability to control the work rate
● Resistance
○ Cycling rate
■ Working intensity
● Mechanically brake

Special Diagnostic Procedures 7

 ELECTROCARDIOGRAPHY (ECG / EKG) node to the beginning of the next heart beat also initiated
by an impulse from the SA node.

BRIEF HISTORY ELECTRICAL EVENTS

➔ Depolarization, repolarization of the atria and
1788 Dr. Luigi Galvani first noted that
electrical current could be recorded from depolarization and repolarization of the ventricle.
skeletal muscles.
MECHANICAL EVENTS
1887 The first ‘electrogram’ (ECG) from ➔ Contraction or relaxation of the atria and ventricles.
the intact human heart was recorded NORMAL ELECTRICAL CONDUCTION PATHWAY
with a mercury capillary electrometer
by Augustus D Waller at St. Mary’s
Hospital, London.

1895 Einthoven, using an improved

electrometer and a correction formula
developed independently. He labeled
the corrected derived deflections
PQRS and T.

1900 First article source using the term

“Elektrokardiogramm” (EKG) by
Willem Einthoven. ECG SETUP

1902 Einthoven published the first

electrocardiogram recorded on a
string galvanometer.

2018 Apple smart watch: Over 400,000

people enroll in a study being
conducted by researchers at Stanford
and Apple to determine whether a
wearable technology can identify
irregular heart rhythms suggestive of
atrial fibrillation.

ELECTROCARDIOGRAPHY TYPES OF ECG

● Measures the heart’s electrical activity RESTING ECG TRAINING
● ECG/EKG
➔ Carried out while the
patient is lying down in
IMPORTANT DIAGNOSTIC TOOL IN THE EVALUATION OF
a comfortable position
CVD
● Abnormal heart rhythm (arrhythmias)
● Myocardial ischemia/infarction
● Chamber enlargement EXERCISE OR STRESS ECG
● Electrolyte abnormalities (especially K and Ca)
➔ Carried out while the
PURPOSE OF ECG patient is using an
● Detects your heart's electrical rhythm and produces what's exercise like bike or
known as a tracing. treadmill
○ This tracing consists of representations of several
waves that recur with each heartbeat.
● The wave pattern should have a consistent shape. If your
HOLTER MONITOR/ AMBULATORY ECG
waves are not consistent, or if they do not appear as
➔ The electrodes are connected
standard waves, this is indicative of heart disease.
to a small portable machine
worn at the wrist so the
CARDIAC CYCLE
patient’s heart can be
➔ is the sequence of events; electrical and mechanical monitored at home for 1 or
events taking place in the heart from the beginning of one more days.
heart beat initiated by an impulse from the sinoatrial (SA)

Special Diagnostic Procedures 8

 ECG LEADS ➔ Corresponds to phase O.
BIPOLAR LIMB LEADS Q WAVE
● Lead 1 - right arm and left arm (+) ➔ Interventricular septum depolarization.
● Lead 2 - right arm and left leg (+) R WAVE
● Lead 3 - left arm and left leg (+) ➔ Apical depolarization
S WAVE
➔ Depolarization of the base of the ventricle
T WAVE
➔ Ventricular repolarization.
➔ Corresponds to phase 3 of repolarization.
UNIPOLAR LIMB LEADS U WAVE
➔ The ECG machine ➔ Uncommon wave that is believed to be due to the slow
usually augments the repolarization of papillary muscles.
potential by 1.5 than the ST SEGMENT
original potential. ➔ Starts at the end of S to the beginning of T.
➔ Comes from a central ➔ Represents phase 2 of ventricular repolarization.
terminal. ST INTERVAL
● Lead aVR - towards right
➔ Starts at the end of S to the end of T.
arm
➔ Measures the whole period of latent repolarization.
● Lead aVL - towards left
ISOELECTRIC LINE
arm
● Lead aVF - towards left foot ➔ Basis for the positive and negative waves.

CHEST LEADS TWO FORMS OF WAVES IN THE ECG

➔ Landmark: Angle of Louis 1. POSITIVE WAVE
➔ Chest leads represent the horizontal plane of the heart. ● P, R, and T waves are the common positive
POSITION OF CHEST LEADS waves.
● V1 – attached at the 4th 2. NEGATIVE WAVE
intercostal space, left parasternal ● Normal negative waves are the Q and S wave
border ECG RULES
● V2 – 4th intercostal space, right ● Depolarization ➜ electrode = upward
parasternal border ● Depolarization away from (+) electrode = downward
● V3 – located between V2 and V4 ● Repolarization ➜ (+) electrode = downward
● V4 – 5th intercostal space, left ● Repolarization away from (+) electrode = upward
midclavicular line (usually located NOTE:
below the nipple) Atrial muscle
● V5 – left anterior axillary line, at ● First to depolarize and first to repolarize.
the same level as V4 Ventricular muscle
● V6 – same level as V4 and V5 but located at the mid axillary ● First to depolarize and last to depolarize.
line EXAMINATION PROTOCOLS
● Lead V4R - same level as V4 but located on the right PRE- EXAMINATION
● Lead V3R - between V1 and V4R ● Remove any jewelry or other objects that may interfere
with the test.
ECG WAVES ● Depending on the reason for your ECG, your doctor may
ask you to stop taking some of your medications.

EXAMINATION
● Remove clothing from the waist up.
● Lie flat on a table or bed for the test.
● If your chest, arms, or legs are very hairy, the technician
may shave or clip small patches of hair, as needed, so
that the electrodes will stick closely to the skin.
● Electrodes will be attached to your chest, arms, and
legs.
P WAVE ● The lead wires will be attached to the electrodes.
➔ Represents atrial depolarization. ● Once the leads are attached, the technician may enter
QRS WAVE identifying information about you into the machine's
computer.
➔ Ventricular depolarization
Special Diagnostic Procedures 9
 ● The ECG will be started. It will take only a short time for STANDARD PAPER SPEED
the tracing to be completed. ➔ 25 mm/speed
● Once the tracing is completed, the technician will EACH SMALL SQUARE
disconnect the leads and remove the skin electrodes. ➔ 1 mm × 1 mm = 40 msec. = 0.04 sec
EACH LARGE SQUARE
➔ 5 mm × 5 mm = 200 msec. = 0.2 sec
EACH MINUTE (60 sec)
➔ 300 large square = 1500 small square
TERMINOLOGIES
WAVEFORM
➔ Movement away from the baseline in either a positive or
negative
SEGMENT
➔ A line between waveforms
INTERVALS
➔ A waveform and a segment
COMPLEX
➔ Consists of several waveforms
POST EXAMINATION
● You should be able to go back to your normal diet and FRONTAL PLANE LEADS (LIMB OR EXTREMITY)
activities, UNLESS your doctor tells you differently. ● To determine the axis – Look at leads 1 and aVF!
● Generally, there is no special care after an ○ Use your hands as a guide. Lead 1 is your left
electrocardiogram (ECG). thumb while Lead aVF is your right thumb. If
● Tell your doctor if you develop any signs or symptoms you the deflection is positive, your thumb goes up.
had before the ECG (for example, chest pain, shortness of If it is negative, your thumb goes down.
breath, dizziness, or fainting).

When reading the ECG, look at the:

1. Name
2. Age
3. Date
4. Standardization

INTERPRETING THE RESULT

THE TRACING
● A tracing consists of repeated waves that have a
standard shape.
● The waves have sections called the P wave, QRS
complex, ST segment, and T wave.
● There is also a PR interval between the P wave and the Right Thumb Up Right Axis Deviation
QRS complex, and a QT interval between the QRS
complex and the T wave. Left Thumb Up Left Axis Deviation

Two Thumbs Up Normal

Two Thumbs Down Extreme Right Axis Deviation or

Intermediate Axis

RULE OF THUMBS
Positive
➔ Travels towards the lead (upward)
Negative
➔ Travels away from the lead (downward)

INTERPRETING THE RESULT

STANDARD VOLTAGE SENSITIVITY CALIBRATION
➔ Each 1 mV gives a 10 mm (1 cm) deflection

Special Diagnostic Procedures 10

 ABNORMALITIES DETECTED IN ECG
● Not all abnormalities can be detected. The only
abnormalities that can be detected are the following:
○ Arrhythmia
■ Bradycardia, tachycardia
■ Abnormal pacemakers
■ Heart block
○ Myocardial ischemia/injury/ infarction
○ Cardiac enlargement
○ Hyperkalemia/hypokalemia
○ Hypocalcemia

CLINICAL CONDITIONS
ISCHEMIA
● We are looking for ST depression
IONIC IMBALANCE
○ Downsloping depression
○ Upsloping depression Hyperkalemia
○ Horizontal depression ➔ Very tall T (peaked T waves that is the same as QRS).

Hypokalemia
VENTRICULAR HYPERTROPHY/CARDIAC ENLARGEMENT ➔ Prominent U wave (3-5 mm of U wave)
● Very tall R waves
● Very deep S waves
● QRS interval is >0.10 sec
● Right ventricular hypertrophy
○ Tall R waves in V1, deep S waves in V6
● Left ventricular hypertrophy
○ Tall R waves in V6, deep S waves in V1

Hypocalcemia
R wave S wave
➔ Prolonged ST and QT intervals.
RVH Very tall in V1, V2 Very deep in V5, V6

LVH Very tall in V5, V6 Very deep in V1, V2

Special Diagnostic Procedures 11

 ECHOCARDIOGRAPHY COLOR DOPPLER
ECHOCARDIOGRAPHY ● Enhanced form of Doppler
● Echocardiogram or diagnostic cardiac ultrasound ● Different colors are used
● It utilizes sound waves to create live images of the ● Simplifies the interpretation of the Doppler technique
patient’s heart.
● It uses ultrasound to show how the patient’s heart
muscle and valves are working.

CLINICAL APPLICATIONS
TRANSTHORACIC (TTE)
● Most common type
● Transducer will be placed on your chest over your heart.

Why do I need an echo test?

● Heart murmur (unpleasant sound)
● Heart attack
● Chest pain
● Atherosclerosis
TRANSESOPHAGEAL ECHO (TEE)
● Congenital heart disease
● It is used if the doctor’s need a detailed view of the
● Pericarditis
patient’s heart
● Use a much smaller transducer down your throat
ECHO TECHNIQUES
through your mouth.
2-D ‘CROSS SECTIONAL’
● Two dimensional
● “See” the actual motion of the heart structures
● Real-time motion of the heart’s structure can be
observed

FETAL ECHOCARDIOGRAPHY
M-MODE ● Used on expectant mothers sometime during weeks 18 to
● Time motion display 22 of pregnancy.
● Image similar to a tracing than an actual picture of heart ● The transducer is placed over the woman’s abdomen to
structure check for heart problems in the fetus.
● Useful for measuring or viewing heart structures 3D ECHO
● Either transesophageal or transthoracic
echocardiography to create a 3-D image of your heart.
● Multiple images from different angles.
● Used prior to heart valve surgery. It’s also used to
diagnose heart problems in children.

DOPPLER
● Doppler effect
● Can estimate how fast blood flows
● Used to measure and assess the flow of blood through
the heart’s chambers and valves
● Can detect abnormal blood flow within the heart.

Special Diagnostic Procedures 12

 BASIC COMPONENTS OF AN ULTRASOUND SCANNER

INTERPRETING RESULTS
The report should include:
● Rate of the heartbeat
● Evaluation of the size of the heart
Gray scale: indicated intensity of the reflected ultrasound ● Description of the pericardium
● Fluid or blood appears black ● Assessment of the thickness of the heart
● Highly reflective structures (i.e. calcifications on cardiac ● A conclusion about the function of your ventricles with
valves, pericardium) appear white details about any abnormalities.
● Tissues ● Evaluation about the shape and movement of your heart
○ Myocardium - more gray valves
○ Muscle - unique speckle pattern ● Comment on any blood clots
● Unexpected findings.
DISADVANTAGE OF ECHOCARDIOGRAPHY
➔ Do not visualize the coronary arteries or blockages in
your coronary arteries.

SAMPLE IMAGE OF ECHOCARDIOGRAM

Echocardiography

Doppler

Special Diagnostic Procedures 13

Special Diagnostic Procedures
Our Lady of Fatima University – Pampanga
College of Medical Laboratory Science
MIDTERM

PERFUSION TECHNOLOGY TYPICAL CPB CIRCUIT

PERFUSION TECHNOLOGY
● It involves the study of physiology, pathology and the
associated equipment used to support the function of
heart’s and/or lungs during surgical procedures.
● It can be a cardiopulmonary bypass, heart surgery, or
anything related to the heart.
PERFUSION
● can be defined as the process in which blood is forced to
flow through a network of microscopic vessels within
biologic tissue, allowing exchange of oxygen and other
molecules across semipermeable microvascular walls.
PERFUSATE
● any fluid flowing through a tissue or organ
PERFUSIONIST
● individual (or RMT) responsible for operating
extracorporeal circulation equipment during an open-heart
surgery or any other medical procedure in which it is CARDIOPULMONARY MACHINE
necessary to artificially support or temporarily replace a ●also called as HEART/LUNG MACHINE
patient's circulatory or respiratory function. ○ plastic tubing
CARDIOPULMONARY BYPASS (CPB) ○ reservoir
● technique that temporarily replaces the function of the ○ oxygenator
heart and lungs while the heart is arrested to provide a still ○ pump
and bloodless surgical field MECHANISM OF CPM:
● Instead of lung and heart will pump, the cardiopulmonary 1. The venous blood is drained by gravity into the reservoir
equipment will be use to pump and give the oxygen in the via cannula that placed in the right atrium or in the large
body vein
● provides a pump to substitute for the function of the heart 2. Then, pump to the oxygenator and return to the patient’s
and a gas exchange device, the “OXYGENATOR” to act arterial system via cannula in the aorta or other large
as an artificial lung artery
● allows the patient’s heart and lungs to be temporarily JOHN GIBBONS - credited by developing the first cardiopulmonary
devoid of circulation, and respiratory and cardiac activity bypass machine.
suspended, so that intricate cardiac, vascular or thoracic COMPONENTS OF CPB MACHINE AND
surgery can be performed in a safe and controlled EXTRACORPOREAL CIRCUIT
environment.
● Provides the patient with cardiac and pulmonary support EQUIPMENT FUNCTION
while bypassing the heart and the lung
Oxygenator system, Oxygenate, remove carbon dioxide
● Artificially, it provides the patients three (3) venous reservoir, and cool/re-warm blood
physiologic processes/ functions: Oxygenator heat
○ It adds oxygen to the blood. exchanger
○ It pumps and circulates the blood through both
the cardiopulmonary bypass circuit and the Gas line and FiO2 blender Deliver fresh gas to the oxygenator
patient. in a controlled mixture
○ It removes excess carbon dioxide from the blood.
Arterial pump Pumps blood at a set flow rate to
the patient

Cardiotomy suckers and Scavenges blood from the

vents operative field and vents the heart.

Arterial line filter Removes microaggregates and

particulate matter >40um
 Cardioplegia systems Deliver high-dose potassium cardioplegia delivery system
solutions to arrest the heart and
preserve the myocardium 1/4’ (6.0 mm) Suction tubing, blood section of the
blood cardioplegia delivery system
Cannulae Connect the patient to the
extracorporeal circuit 3/8’ (9.0 mm) Arterial pump line for the flow rates
<6.7l/minute, majority of the
arterial tubing in the extracorporeal
MONITORING COMPONENTS OF CPB MACHINE AND circuit
EXTRACORPOREAL CIRCUIT
1/2’ (12.0 mm) Venous line, larger tubing is
MONITORING DEVICE FUNCTION required to gravity drain blood from
the patient
Low-level alarm Alarms when level in the reservoir
reaches minimum running volume NOTES: The size of tubes used at different points in the circuit is
determined by the pressure and rate of the blood flow.
Pressure monitoring (line Alarms when line pressure
pressure, blood exceeds set limits CANNULAE
cardioplegia pressure and
vent pressure) ● Connect the patient to the circuit and hence to the CPB
machine. They are made of PVC and are wire reinforced
Bubble detector (arterial Alarms when bubbles are sensed to prevent obstruction due to kinking.
line and blood Arterial cannulae
cardioplegia) ● is used to connect the “arterial limb” of the CPB circuit to
the patient and so deliver oxygenated blood from the
Oxygen sensor Alarms when oxygen supply to the heart-lung machine directly into the patient’s arterial
oxygenator fails
system. (PABALIK. From machine back to the circulatory)
Sa O2 Sv O2 and Continuously measures these ● Ascending aorta – most common site of arterial
hemoglobin levels from the extracorporeal cannulation for routine cardiovascular surgery.
monitor circuit Venous cannulae
● allows deoxygenated blood to be drained from the patient
In-line blood gas Continuously measures arterial into the extracorporeal circuit of venous (Remove the
monitoring and venous gases from the oxygenated blood from the patient to machine)
extracorporeal circuit ● Use: patients does not involve opening the chambers of
the heart
Perfusionist Constantly monitors the Bicaval Cannulation
cardiopulmonary bypass machine
and the extracorporeal circuit ● An alternative method of venous cannulation for CPB
● It is usually use for procedures that require cardiac
chambers to be open
NOTES: Ideally, all alarm systems are linked in a computer system
COMMONLY USED ARTERIAL CANNULAE
of a cardiopulmonary bypass machine and directly regulates or
stops the pump when inappropriate. That alarm system is used
within the circuit aide the perfusionist running in the safe pump and
all are vital components. It is important that the perfusionists are
trained.

TUBING
● Interconnects all of the main components of the circuit
Materials used:
1. POLYVINYL CHLORIDE (PVC) - most commonly used
because of its versatility rigid plastic and flexibility
2. Silicone - reserved for arterial pump boot (because it COMMONLY USED VENOUS CANNULAE
causes or produce, but tend to release micro plastics than
PVC
3. Latex rubber- least used because it can generate more
hemolysis.

MONITORING COMPONENTS OF CPB MACHINE AND

EXTRACORPOREAL CIRCUIT

TUBING SIZE FUNCTION

3/16’ (4.5 mm) Cardioplegia section of the blood

Special Diagnostic Procedures 2

 PUMP HEADS MONITORING
ROLLER PUMP ● In-line blood gas analysis and venous
● produced the flow. saturation/hematocrit monitors.
● They tend to resemble or mimic the pattern of blood flow PRE-BYPASS CHECKLIST
generated by the heart cycle or cardiac cycle. ● Minimum requirements for cardiopulmonary bypass
● MOST COMMONLY USED because of its price and procedures.
reusability. ● Covering all aspects from sterility to backup components.
CENTRIFUGAL PUMP
● produced a pressure. SAFETY CONCERNS PRIOR TO, DURING, AND AFTER CPB
● There is a cone. It produced less hemolysis compared to PRE-CPB SAFETY CONCERNS
roller pumps. ● Heparin given, activated clotting time (ACT) >400 seconds
● Expensive because of the actual pump that is disposable ● Arterial cannula correctly placed, pulsatile swing on an
or single use. aneroid pressure gauge connected to a side arm of the
● It is used when the surgery is complex/ long. Less damage arterial line.
in the blood. ● Venous reservoir has a safe level of prime, additional fluid
available to add, level alarm activated.
ROLLER PUMP CENTRIFUGAL PUMP
● Oxygen analyzer monitoring gas supply to oxygenator on,
Afterload independent Afterload dependent alarm activated.
● Sweep rate appropriate for patient (usually 2-3l, FIO2=0.6)
No flowmeter required Needs flowmeter ● Venous cannula relatively free of air
● Shunt lines are clamped, apart from arterial filter purge
Increase blood trauma and Decrease blood trauma and tubing line and drug administration manifold line.
tubing debris debris ● No clamps on the arterial or venous lines placed by
surgical team
No backflow occurs Retrograde flow possible if pumps
● Alarm overrides deactivated
stop
● Vasopressors prescribed and available
Cheap Expensive SAFETY CONCERNS DURING CPB

CONCERN COMMON CAUSE

Low level alarm on venous - Impaired

Short-term use Long-term use
reservoir - Tubing kinked
- Air lock
Bulky Portable
- Hemorrhage
- Misplaced venous cannula
Circuit disruption from No disruption - Clotting within circuit
excessive pressure
High pressure alarm on - Clamping or kinking of line
Greater risk of air Lesser risk of air embolism arterial line - Manipulation of the aorta
embolism - Clotting within circuit
- Aortic dissection
Priming volume less Priming volume more
Bubble alarm - Air in line
- Sensor malfunction
RESERVOIR
● Acts as a chamber for the venous blood to drain into Low mixed venous oxygen - Erratic flow
before it is pumped into the oxygenator and permits ready saturation - Considerable time spent with
access for the addition of fluids and drugs. suboptimal flows
OXYGENATOR - Hemorrhage
● Provides an interface of high surface area between blood - Depth of anesthesia lightening
- Shunt clamp inadvertently
on one side and gas on the other.
removed
● The distance gas has to travel across the interface is - Excessive transfusion with non
minimized by constructing the membrane from very thin blood product
material.
CARDIOPLEGIA DELIVERY SYSTEM Clotting - Inadequate heparinization
● The common constituent of all cardioplegia solutions in a
high concentration of potassium, as this produces diastolic Poor blood gasses despite - Oxygenator failure
cardiac arrest. adequate sweep gas
HEMOFILTERS delivery and pump flow
● Contain semipermeable membranes that permit passage
Electrical activity of the - Intervals between cardioplegia
of water and electrolytes out of blood. heart too long

Special Diagnostic Procedures 3

 ANTICOAGULATION
- Too little cardioplegia delivered
- Aortic regurgitation UNFRACTIONATED HEPARIN (UFH)
● remains the standard anticoagulant for CBP for several
Hyperthermia - Overaggresive re-warming reasons. It is relatively safe, easy to use, has a fast onset
strategy of action and is measurable, titratable and reversible. It is
- Failure to maintain temperature
also cost-effective.
gradient between heat exchanger
and venous blood <10C

SAFETY CONCERNS ON SEPARATING FROM CPB

● Ventilation not established
● Intracardiac vent still in place
● Shunt lines open on CPB with the potential to
exsanguinate the patient into circuit
● Suction still in used during protamine administration
● Inattention to level in venous reservoir whilst transfusing
● Draining the venous line while cannula still positioned in
the right atrium
● Dismantling the CPB circuit before hemodynamic stability
as been achieved TEMPERATURE MANAGEMENT
● Hypothermia is frequently used during CPB for its
CONDUCT OF CPB presumed organ protective effects.
PRIMING ● Blood viscosity increases with hypothermia and allows
maintenance of a higher perfusion pressure despite
● The deairing of CPB circuit is done by priming solutions,
hemodilution.
consisting of a mixture of crystalloids and colloids. Priming
causes hemodilution which improves flow during HYPOTHERMIA TEMPERATURE USE
hypothermia.
Tepid 33-35 Good for short
operations, healthy
patients with higher
HCTs

Mild 31-32 Protection of beating

heart and
neurological systems

Moderate 25-30 Protection of

non-beating heart
and neurological
systems

Deep 15-20 DHCA for typically

40-60 minutes

ACID-BASE MANAGEMENT
● With cooling, CO2 becomes more soluble in the blood
Heparin 1000-2500 U/L of prime to ensure (partial pressure decreases) causing alkalosis.
adequate anticoagulation

Bicarbonate 25 mmol/L of prime as buffer when

unbalanced priming solutions are
used

Mannitol Osmotic diuretic and free radical

scavenger

Calcium Needed if citrated blood is added WEANING

to the prime to prevent chelation of ● Process of transition from cardiopulmonary bypass (CPB)
calcium
to normal, physiological circulation, requires excellent
communication and teamwork between perfusionist,
Steroids To attenuate systemic
inflammatory response to CPB surgeon and anesthetist.
(evidence weak)

Special Diagnostic Procedures 4

 COMPLICATION Kidneys Veins
● Selective cerebral perfusion
● Plaque dislodgement and dissection Intestines Skin
● Massive air embolism
● Qualitative and quantitative platelet dysfunction Pancreas Bones
● Inflammatory response
● Hypotension TRANSPLANT SCREENING TEST
● Acute kidney injury (AKI)
BLOOD TYPE TEST
● Acute respiratory distress syndrome
● The first test establishes your ABO blood type
HLA
ORGAN DONATION AND SCREENING
ORGAN DONATION ● The tissue type of all potential donors is considered
● is the process of removing tissues or organs from a live in donor selection.
or recently dead person to be used in another. CROSSMATCH
DONOR ● Obtained several times during preparation for a LRD
● refers to an individual who voluntarily donates an transplant, particularly if donor-specific blood
organ, tissue, or part thereof gratuitously to another who transfusions are employed.
accepts it SEROLOGY
RECIPIENT ● Blood testing is conducted for potentially transmissible
● an individual who received the organ through diseases.
transplantation
DONATION SCREENING OF DONOR AND RECIPIENT
● act of which the owner of something voluntarily transfers
the title or the possession to another person as a gift.
TYPES OF DONORS
LIVING DONOR
● an individual who is willing to donate an organ tissue or
part of the body while still alive
LIVING RELATED DONOR
● related to the recipient by blood within the fourth civil
degree of consanguinity
LIVING NON-RELATED DONOR
● not related to the recipient by blood or related by blood
beyond the fourth civil degree of consanguinity but who is
willing to donate organs, tissues, or parts thereof
DECEASED/CADAVERIC DONOR
● individual who has just died and was previously known
to be healthy patient who have suffered irreversible
catastrophic brain injury of known etiology.
HOW TO DETERMINE IF A DONOR IS ELIGIBLE?
➔ He/She must be 18 years old and above
➔ Free from risk factors for, and clinical evidence of,
infection due to relevant communicable disease agents
and diseases
➔ No existing clinical conditions
➔ Free from communicable disease risks associated with
xenotransplantation
➔ The results of donor testing for relevant communicable
disease agents are negative or nonreactive

ORGANS AND TISSUES THAT CAN BE DONATED

ORGANS TISSUES

Heart Cornea

Lungs Tendons

Liver Valves

Special Diagnostic Procedures 5

 VIRAL (Both Donor & Recipient)
● CMV
● EBV
● Other herpesviruses
● Hepatitis B Virus
● Hepatitis C Virus
● HIV
● West Nile Virus
● SARS
● Rabies Virus
FUNGAL
● Active systemic fungal infection in the donor is a
contraindication to transplantation. The endemic
mycoses in particular may be present in dormant form.
● Transmission of histoplasmosis by transplantation has
been described, but most cases appear to be the result of
reactivation of past infection in the recipient.
PARASITIC
● Toxoplasmosis is a major concern particularly in heart
transplantation, where the Toxoplasma-seropositive heart
is at highest risk for developing active toxoplasmosis
post-transplant.
● Transmission of Chagas disease by transplantation is a
significant problem in endemic areas.
PRE-TRANSPLANT COUNSELING
● Prevention strategies for infection should not be limited to
medications and vaccinations. A thorough education of
the transplant recipient and his or her family is a very
important preventive tool. Pretransplant classes and
printed materials are helpful and should include
information on handwashing/hand hygiene, environmental
exposures, activities to avoid, food safety and handling,
foodborne pathogens, pets and travel. It is also helpful for
patients to have a general idea of the infections to which
transplant patients are susceptible and the prevention
strategies in use at their particular center.

DONOR SCREENING
BACTERIAL
● Mycobacterium tuberculosis has been transmitted by
transplantation;
● Antibiotics should be administered for at least 14 days
for Gram-negative bacilli, S. aureus or Candida species
● Syphilis has rarely been transmitted by transplantation,
but it is not a contraindication to organ donation if the
recipient is treated post transplant with an appropriate
course of benzathine penicillin.

Special Diagnostic Procedures 6

 SCHEMATIC DIAGRAM OF THE DECEASED DONOR RA 8504
REFERRAL PROCESS FLOW “Philippine AIDS Prevention and Control Act of 1998”
● Consists of 9 articles
● With 52 sections
● Approved on February 13, 1998 by President Fidel V.
Ramos
RA 11166
“Philippine HIV and AIDS Policy Act”
● The newest law passed by the legislative department
modified certain provisions of the original version to be
more effective in dealing with HIV conditions in the
Philippine setting.
● An act strengthening the Philippine Comprehensive Policy
on HIV/AIDS prevention, treatment, care, and support,
and, reconstituting the Philippine National Aids Council
(PNAC), repealing for the purpose Republic Act No. 8504
● Consists of 8 articles
● With 57 sections
● Approved on December 20, 2018 by President Rodrigo
R. Duterte

PREVENTIVE MEASURES, SAFE PRACTICES AND

PROCEDURES
● The DOH shall establish a program to prevent mother-to-
child HIV transmission that shall be integrated in its
RA 7170 maternal and child health services.
“Organ Donation Act of 1991” ● Standard Precaution on the Donation of Blood, Tissue, or
● With 19 articles Organ. The DOH shall enforce the following guidelines on
● With 52 sections the donation of blood, tissue, or organ:
● Approved on January 7, 1992 by President Corazon C. (a) Donation of tissue or organ shall be accepted by
Aquino a laboratory or institution only after a sample
● An act authorizing the legacy or donation of all or part of a from the donor has been tested negative for HIV;
human body after death for specified purposes. (b) All donated blood shall also be subjected to HIV
SEC. 4. Person Who May Execute a Donation. testing;
(c) All donors whose blood, organ or tissue has been
● Any of the following persons, in the order of priority stated tested positive shall be deferred from donation,
hereunder, in the absence of actual notice of contrary notified of their HIV status, counselled, and
intentions by the decedent or actual notice of opposition referred for care and clinical management as
by a member of the immediate family of the decedent, soon as possible;
may donate all or any part of the decedent’s body for any (d) Donations of blood, tissue, or organ testing
purpose specified in Section 6 hereof: positive for HIV may be accepted for research
● The persons authorized by subsection (a) of this section purposes only, and shall be subject to strict
may make the donation after or immediately before sanitary disposal requirements; and
death. (e) A second testing may be demanded as a matter
SEC.6. Persons Who May Become Legatees or Donees. of right by the blood, tissue, or organ recipient or
● The following persons may become legatees or donees of his/her immediate relatives before transfusion or
human bodies or parts thereof for any of the purposes transplant, except during emergency cases
stated hereunder:
1) Any hospital, physician or surgeon; SCREENING, TESTING AND COUNSELING
2) Any accredited medical or dental school, college ● As a policy, the State shall encourage voluntary HIV
or university; testing. Written consent from the person taking the test
3) Any organ bank storage facility must be obtained before HIV testing.
4) Any specified individual ○ Fifteen (15) to below eighteen (18) years of age,
SEC. 14. International Sharing of Human Organs or Tissues. consent to voluntary HIV testing shall be
● Sharing of human organs or tissues shall be made only obtained from the child without the need of
through exchange programs duly approved by the consent from a parent or guardian;
Department of Health: Provided, That foreign organ or ○ Young persons aged below fifteen (15) who are
tissue bank storage facilities and similar establishments pregnant or engaged in high- risk behavior shall
grant reciprocal rights to their Philippine counterparts to be eligible for HIV testing and counseling, with
draw human organs or tissues at any time.

Special Diagnostic Procedures 7

 the assistance of a licensed social worker or 3. Schedules recipient and donor laboratory tests to
health worker. determine histocompatibility of blood or tissue of recipient
○ Consent to voluntary HIV testing shall be and donor.
obtained from the child's parent or legal guardian 4. Compares collected data to normal values and correlates
if the person is below fifteen (15) years of age or and summarizes laboratory reports, x rays, and other
is mentally incapacitated. tests.
● Compulsory HIV testing shall be allowed only in the 5. Solicits medical and community groups for organ donors
following instances: and assists medical teams in retrieval of organs for
○ To test a person who is charges with any of the transplantation, using medical instruments.
offenses punishable by law (serious and slight 6. Coordinates in-hospital services and counsels recipient
physical injuries, rape and simple seduction) and donor to alleviate anxieties and assist recipient and
○ When it is necessary to resolve relevant issues donor throughout procedure.
under Executive Order No. 209, otherwise 7. Advises post-operative patients on therapies for
known as "The Family Code of the Philippines" managing health after transplant.
○ As a prerequisite in the donation of blood
PROGRAM DEVELOPMENT
DISCRIMINATORY ACTS AND PRACTICES 1. Collaborate in the development of protocols and
Exclusion from Credit and Insurance Services guidelines for patient management.
➔ exclusion from health, accident or life insurance, or 2. Develop, implement and evaluate comprehensive patient
credit and loan services, including the extension of such education programs.
loan or insurance facilities of an individual; 3. Participate in the development and execution of quality
Discrimination in Hospitals and Health Institutions assurance programs and projects.
➔ denial of health services, or being charges with a higher 4. Assure that the Organ Transplant Program (NODTP)
fee, on the basis of actual, perceived or suspected HIV remains in compliance with the POTDTB.
status is discriminatory act and is prohibited; RESEARCH
Denial of Burial Services 1. Support planning of and participating in clinical research
➔ denial of embalming and burial services for a projects.
deceased person who had HIV and AIDS or who was 2. Participate in the development and implementation of
known, suspected, or perceived to be HIV-positive; research protocols and interpret the protocols for
Bullying participation of patient and family members.
➔ in all forms, including name-calling, upon a person 3. Collect and analyze data for ongoing clinical research
based on actual, perceived, or suspected HIV status, projects.
including bullying in social media and other online portals. 4. Incorporate research findings into the Organ Transplant
Program Practice.
TRANSPLANT COORDINATOR
● refers to the designated trained health care EDUCATION
professional who takes the central role and acts as 1. Participate in teaching activities at DOH for physicians,
liaison between the referring hospital and the retrieval nurses, allied health professionals and for students in
and transplant team members. those disciplines.
Clinical Transplant Coordinator 2. Develop and present information to professional groups
➔ refers to the TC who shall have the responsibility of regarding organ transplantation and organ donation.
coordinating the transplant candidate's evaluation, 3. Develop and present information to community
management, and follow-up care groups regarding organ transplantation and organ
Procurement Transplant Coordinator donation.
➔ refers to a healthcare professional of organ 4. Participate in the development of marketing information
procurement organization, designated to coordinate regarding organ transplantation and organ donation.
with the donor family and facility in order to facilitate a
donation and proper transport of donated organ or tissue. CONSULTATION
1. Provide patient status reports to community and referring
DIRECT PATIENT CARE physicians.
1. Plans and coordinates in-hospital transplant services, 2. Provide consultation to the other physicians, nurses and
solicits organ donors, and assists medical staff in organ other health care professionals who provide health care
retrieval for patients undergoing organ or tissue to organ transplant patients.
transplantation. 3. Compile information and data for PHILNOS, NODTP, and
2. Analyzes medical data of potential organ donors and the institution.
transplant recipients from medical and social records,
physical examination, and consultation with health team
members.

Special Diagnostic Procedures 8

Special Diagnostic Procedures 9
 NUCLEAR MEDICINE TECHNOLOGY
NUCLEAR MEDICINE
● Specialized area of radiology
● It uses radioactive materials or radiopharmaceuticals
to examine a body organ’s function and structure.
● Treat abnormalities very early in the progression of a
disease.
RADIOLOGY VS. NUCLEAR MEDICINE
RADIOLOGY
● Gives information about the anatomy
● Radiation source is from OUTSIDE the patient
IONIZING RADIATION
➔ High frequency
➔ Radiation of sufficient energy to disrupt DNA strands
➔ Consists of subatomic particles
➔ Naturally occurring
➔ Medical purposes
➔ Artificial
NUCLEAR MEDICINE PARTICLES
● Gives information about the physiology Alpha
● Radiation source goes INSIDE the patient’s body ➔ 241Am, 226Ra, 228Th
➔ CANNOT penetrate the skin
➔ Stopped by a sheet of paper or outer layer of the skin
➔ Therapeutic
Beta
➔ H,14C, 90Sr
3

➔ CAN penetrate the skin, tissues

NUCLEAR MEDICINE TECHNOLOGIST ➔ Stopped by a layer of clothing or by a few millimeters of
● aka Nuclear Medical Technologist substance
● Prepare and administer the radionuclide to the patient. ➔ Responsible for therapeutics uses of nuclear
● Perform the imaging procedure and could also involved in medicine
radiation therapy Neutrons
➔ Cf, 239Pu
252

ELECTROMAGNETIC WAVES
Gamma Rays
➔ 137Cs, 60Co, 192Ir
➔ Highly penetrating
➔ Used with shield
➔ Diagnostic procedure
APPLICATION OF RADIATION
RADIOTRACER
➢ Tc-99m PO4 (Technetium Pertechnetate)
➢ Tc-99m HDP (Hydroxy Diphosphonate)
➢ Iodine 131
RADIATION ➢ Tc-99m Sestamibi
● Describes any process in which energy travels through a GAMMA CAMERA
vacuum or through a medium, ultimately to be absorbed ● Does not contain radiation
by another body ● Main Nuclear Medicine equipment
● Also used to refer to the ENERGY itself that is radiated ● Collimator
● Has two types: Ionizing and Non-ionizing radiation ○ the “lens” of the gamma camera
● The radiation is inside the patient’s body
● Ex. Cardiac scan

Special Diagnostic Procedures 10

 HOW NUCLEAR MEDICINE WORKS COMMON PRIMARY CANCERS THAT METASTASIZE TO THE
BONE (PBKTL)
● Breast CA
○ As of October 2012, is the most prevalent cancer
in the country - 50-85%
● Lung carcinoma - 30-50%
● Kidney - 80%
● Prostate - 50-75
● Hodgkin’s lymphoma - 50-75
● Thyroid cancer - 40%

COMMON NUCLEAR MEDICINE DIAGNOSTIC PROCEDURE

1. Thyroid Scan
2. Whole Body Iodine Scan
3. Bone Scan
4. Myocardial Perfusion Imaging
5. PET (Positron Emission Tomography)
6. Scintimammography MYOCARDIAL PERFUSION IMAGING
7. Renal Scintigraphy ● Detect and diagnose coronary artery disease
8. HIDA (Hepatobiliary Scan) ● Assess functional significance of known coronary artery
9. Lung Perfusion Scan disease
THYROID SCAN ● “The risk of cardiac death and myocardial infarction in a
● One of the most common requested procedures patient with a normal stress perfusion study is < 1%
● Imaged with 131I or 99mTcpertechnetate annually”
● Assess the size of the thyroid gland MYOCARDIAL VIABILITY STUDY
● Normal size of thyroid gland: 4x2cm Myocardial Ischemia
● With 2 lobes connected by an isthmus ➔ Narrowing of blood vessels
● The only scan were you can assess if the nodule of ➔ Nuclear medicine role in providing information of the
interest is hot or cold benefit from cardiac bypass or stenting
Myocardial Infarction
➔ Particular area in the myocardium that had been already
compromised with the circulation for some time
➔ Area is usually not viable
➔ Can no longer benefit from cardiac bypass or stenting
PET (POSITRON EMISSION TOMOGRAPHY)
● Establish if patient is responsive to chemotherapy
● Established possibility of tumor especially in areas
difficult to access
WHOLE BODY IODINE SCAN
● Can be used as a screening tool and monitoring tool
● Staging of thyroid cancer
● Detect presence of metastasis specific for thyroid
cancer

BONE SCINTIGRAPHY/SCAN
● Assess different tissue metabolism and function
● Uses 99mTc MDP/HDP QUESTION PET CAN ANSWER:
● Useful in Oncology planning and management
1. Where is the tumor?
● A 5% bone turnover can be detected by bone scan while a
2. Is it benign or malignant?
50% minimum mineral loss is required before lesion is
3. What is the extent of the disease?
visualized on radiographs
4. Is the treatment working?
5. Has the cancer recurred?

Special Diagnostic Procedures 11

PET/CT from mm to cm → thyroid gland shrinks and
● Combination of CT scanning and PET normalize
● Better localization of lesions ● For Hyperthyroidism/For Differentiated Thyroid
SCINTIMAMMOGRAPHY Cancer
● Uses 99mTc-sestamibi to detect cancer cells in the ○ If the primary cancer from the thyroid gland
breasts and axillae metastasizes, iodine will spread to the part where
● Used in patients with abnormal mammograms, dense there are thyroid gland metastatic lesions to stop
breasts, and postoperatively the spread

RENAL SCINTIGRAPHY
● Evaluate perfusion, cortical, and excretory functions
● Used also to evaluate functional transplanted kidney

HIDA (HEPATOBILIARY SCAN)

● Hepatobiliary iminodiacetic acid (HIDA) scan
● Help diagnose acute and chronic cholecystitis, biliary
atresia
● Provide information on post-surgical bile drainage and
biliary leakage

LUNG PERFUSION SCAN

● Detection of pulmonary embolism
● V/Q Scan and Pulmonary Embolism
● Identify ventilation-perfusion mismatch
● Management: give heparin

COMMON NUCLEAR MEDICINE THERAPEUTIC PROCEDURE

Radionuclide Therapies
● Uses beta particle
● Radioactive Iodine Treatment for Thyroid Diseases
○ Usually taken via oral route → absorbed from
GIT → iodine goes directly to thyroid tissue →
radioactive iodine starts to emit beta particles

Special Diagnostic Procedures 12

 VETERINARY LABORATORY PROCEDURES PART 1 Microscope
COMMON LABORATORY EQUIPMENT
MICROHEMATOCRIT CENTRIFUGE
● For centrifugation of capillary tube to determine the
packed cell volume (Hct).
● Provides plasma samples for protein analysis.
● Specimen: Plasma with Packed RBC

Automated Stainer
● For blood film and cytology apparatus.
● Stains 20-25 slides per cycle.

Refractometer
● Measures urine and plasma total protein specific gravity.
○ Reagent strip
■ In the lab, It is used to measure specific
gravity.
Chemistry Analyzer
■ Sample: Uncentrifuged urine.
■ Not used in veterinary medicine. ● Sample: Serum
■ Limitation: Animal urine has high SG. ● For veterinary use only.
■ Specific gravity: 1.000 -1.030 ● Principle: Photometry

Coagulation analyzer
Centrifuge ● Sample: Citrated whole blood
● Separates blood component, urine and fecal. ● For coagulation testing.
● Force: Revolution per minute (RPM) ● Test:
● 2 Types: ○ PT
○ Variable angle ○ APTT
■ AKA “Horizontal centrifuge” ○ TT
■ Swingging buckets. ○ INR
○ Fixed angle ○ Fibrinogen
■ 50O angle

I. HEMATOLOGY
BASIC HEMATOLOGIC TECHNIQUES
Mechanical blood mixing table
1. Blood mixing
● Tilts tube back and forth at a rate of 20-30 oscillations per ➔ For all hematologic measurements.
minute.
2. Packed cell volume (PCV)
● Force: Oscillation per minute (OPM)
➔ Using microhematocrit to obtain HCT.
3. Plasma protein estimation
➔ By refractometry.
➔ For veterinary only.
4. Cell counting instrumentation
● Principle of CBC automated analyzer:
➔ Electrical Impedance
➔ Flow Cytometry
◆ Based on granularity and size of the cell.
● CBC (RBC count and WBC count)

Special Diagnostic Procedures 13

 ➔ Hemocytometer or Neubauer counting
chamber
◆ Manual cell counting.
◆ Primary square: 9
◆ Secondary square: 16
◆ Tertiary square: 25
5. Preparation of blood films

6. Differential leukocyte count and blood film examination

PROPER BLOOD COLLECTION AND HANDLING TECHNIQUES
a) Jugular vein (neck)
- Most common site for mammals.
b) Cephalic vein
c) Lateral saphenous vein (Legs)
C = Canine (Dogs)
d) Medial saphenous vein (Legs)
● Similar characteristics and lifespan to humans.
COLLECTION DEVICES FOR BLOOD SAMPLES
● Slightly larger than cats.
1. Purple top (EDTA)
● Mild polychromasia
➔ For hematological studies. ● Life span: 110-120 days
2. Redtop (w/o anticoagulant) ● Occasionally seen: NRBC, HJB
➔ For Chemistry studies E = Equine (Horses)
3. Serum separation tube
➔ For Chemistry studies F = Feline (Cats)
4. Green top (Lithium heparin) ● Variable size of RBC.
● Little to no central pallor.
➔ For blood gas analysis, electrochemical determination
● Life span: 65-76 days
such as electrolytes and blood gasses.
B = Bovine (Cattle and cows)
5. Blue top (Citrate)
● Shape and size varies.
➔ For Coagulation studies.
6. Balance heparin syringes with cups
➔ For electrochemical diagnostic test collection.
➔ Example:
◆ Blood gasses
◆ Electrolytes
➔ Most common handling error: Over heparinization
HEMATOLOGICAL PROCEDURES
1. RBC count
2. WBC count
3. WBC estimate
4. Platelet count
5. Platelet estimate ERYTHROCYTE MORPHOLOGY
6. Peripheral blood smear (PBS) Stain: Wright stain
7. Packed cell volume (PCV) 1. Anisocytosis
8. Red cell indices ➔ RBC variation in size.
9. Reticulocyte count
10. Reticulocyte Production index (RPI)
NORMAL ERYTHROCYTE MORPHOLOGY
➔ Diameter of human RBC: 6-8 um
➔ Normal MCV (human): 80-100 fL
➔ Wright stain is used.
➔ Anucleated erythrocyte
◆ RBC of mammals.
➔ Cammelidae
◆ Doesn’t have a biconcave disc shape RBC.
◆ Oval erythrocyte

2. Poikilocytes
➔ RBC variation in shape.
3. Chromasia
➔ Color variation.

Special Diagnostic Procedures 14

 ● Stain use:
○ Diff quick stain

○ New methylene blue(Supra vital stain)

■ Used in retics.

ANISOCYTES
Hypochromic (pale)
➔ Increase central pallor.
➔ Low hemoglobin content.
➔ Causes: IDA, Chronic blood loss, Anemia
Polychromic (bluish)
➔ Immature RBC in blood.
➔ Mild variance is accepted in cats and dogs. ● Causes: Diabetes, Lymphoma, Hyperthyroidism,
➔ Causes: Anemia, Bone marrow disease Hemolytic anemia, Acetaminophen toxicity
Macrocytic (large) POIKILOCYTES
Acanthocytes
Microcytic (small) ● aka “Spurr cells”
● Blunt or club shape projections.
● Different lengths of the blunt with irregular intervals.
INCLUSION BODIES
● Causes: Hemangiosarcoma (cancer in vascular
Basophilic stippling endothelium), Increase blood cholesterol, IDA, Renal
● Spontaneous aggregation of rRNA. disease, Liver disease
● Causes: Lead poisoning, Regenerative anemia, Bone
marrow disorder

Echinocytes
● aka “Crenated cells” or “Spiculated cells”
Howell-Jolly bodies ● Evenly distributed short and blunt projections.
● Small round basophilic inclusion. ● Causes: Excessive EDTA (non-pathological),
● Nuclear remnant seen in RBC. Chemotherapeutic agents, Salicylates, Lymphoma, Renal
● Uncommon dogs. disease, After exercise
● Causes: Splenic disease, Thalassemia, Regenerative ● Seen in horses
anemia

Heinz bodies Keratocytes

● Precipitates or oxidized hemoglobin. ● aka “Helmet cells” or “Bite cells”
● Uncommon to dog, Possible if the dog suffers from onion ● Blister-like defects.
toxicity. ● Causes: DIC, Vasculitis, Hemangiosarcoma, IDA, Hepatic
● Small pink or short blunt projection. lipidosis
● Seen in cats

Special Diagnostic Procedures 15

 Schistocytes
● “Horn-like cell” fragments appearance. Dacrocytes
● Causes: DIC, IDA, Hemangiosarcoma, Splenic disease, ● “Tear drop” shape cell.
Vasculitis, Glomerular disease

REFERENCE INTERVALS FOR ABSOLUTE LEUKOCYTE

Stomatocyte CONCENTRATION OF COMMON DOMESTIC ANIMAL SPECIES
● “Mouth-like” appearance.
● Uniconcave RBC
● Causes: Absence of HGB, Lead poisoning, Degenerative
anemia, Liver disease, Thick smear, Non-pathological

CANINE WBC MORPHOLOGY

Neutrophil
Codocytes ● Cytoplasm: White
● aka “Mexican hat cell” or “Target cell” ● Granules: Small pink
● Cluster of hemoglobinized cytoplasm. ● Lobes: Multi-lobe
● Only observed in dogs. ● Chromatin: Condense
● Causes: Excessive EDTA (non-clinical), Liver disease, ● Stain: Deep purple
Regenerative anemia, Phospholipid abnormalities ○ Romanowsky stain
○ Giemsa stain

Ovalocytes Eosinophil
● Oval or elliptical shape cells. ● Cytoplasm: Pink blue or Pink
● Causes: Slide preparation (non-clinical), Hepatic lipidosis ● Granules: Round pink orange
● Seen in cats ● Lobes: Less lobes than neutrophil
● Chromatin: Condense

Special Diagnostic Procedures 16

 Basophils Eosinophil
● Confused with monocytes. ● Cytoplasm: Pink blue or Pink
● Nucleus: Kidney bean shape ● Granules: Rod shape Pink lavender
● Cytoplasm: Pale blue, gray or lavender ● Lobes: Less lobes than neutrophil
● May contain small vacuoles. ● Chromatin: Condense
● Granules: Dark blue or purple
● Lobes: Less lobes than neutrophil
● Chromatin: Condense

Basophils
● Confused with monocytes.
Lymphocytes ● Nucleus: Kidney bean shape
● Cytoplasm: light blue ● Cytoplasm: Pale blue, gray or lavender
● May contain small vacuoles.
● Granules: Dark blue or purple
● Lobes: Less lobes than neutrophil
● Chromatin: Condense

Monocyte
● Cytoplasm: Gray or Blue (angular shape)
● Few small vacuoles
● Granules: Small pink Lymphocytes
● Lobes: Multi-lobe
● Cytoplasm: light blue
● Chromatin: Less dense

Monocyte
FELINE WBC MORPHOLOGY
● Cytoplasm: Gray or Blue (Circular shape)
Neutrophil ● Few small vacuoles
● Cytoplasm: White or Pink ● Granules: Small pink
● Granules: Lacks visible granules ● Lobes: Multi-lobe
● Lobes: Multi-lobe ● Chromatin: Condense
● Chromatin: Condense
● Stain: Deep purple
○ Romanowsky stain
○ Giemsa stain

Special Diagnostic Procedures 17

 ○ Water bath the sample for 60 sec.
○ Check if a clot is formed.
○ If none, repeat every 5 seconds until a noticeable
clot is formed.
○ DO NOT SHAKE
● ACT (Dogs): 120 seconds
● ACT (Cats): 90 seconds
Buccal mucosal bleeding time
ABNORMAL WBC MORPHOLOGY ● It is typically used in patients with normal platelet numbers
Toxic Neutrophil but questionable platelet function.
● Dohle body present in the cytoplasm. ● Procedure:
● Associated with increased neutrophil production and ○ Lancet is used.
shortened maturation time. ○ Small incision underside of the lips.
● Associated with left shift in immature WBC. ○ Blood is blot on a paper.
● Causes: Inflammation ● BT (Dogs): < 4 minutes
● BT (Cats): <3 minutes and 30 seconds
Automated clotting tests
● Many reference laboratories and in-house analyzers can
perform tests to establish if clotting issues are present.
● Analyzed for pTT/ apTT, PT, and thrombin time (TT).
● These three factors provide information on which portion
of the clotting cascade may or may not be working
properly.
● Anticoagulant: Blue top
Atypical Lymphocyte
● Azurophilic cytoplasmic granules can be seen.
● Associated with chronic antigenic stimulation.

Reactive Lymphocyte
● Associated with chronic antigenic stimulation.
● Secondary to vaccine infection.

COAGULATION TESTING
Activated clotting time
● In-house test that is used to determine how clotting factors
of the clotting cascade are working.
● The ACT will be prolonged in patients with faulty clotting
factors and a low platelet count.
● Anticoagulant: Gray top
● Procedure:
○ Clean stick
○ Search for the vessel.
○ Fill the tube.
○ Mix gray top tube to the blood.
Special Diagnostic Procedures 18
 HEMATOLOGIC REFERENCE RANGES

Special Diagnostic Procedures 19

 II. CLINICAL CHEMISTRY
Specimen: Serum

Special Diagnostic Procedures 20

Special Diagnostic Procedures 21
Special Diagnostic Procedures 22
 VETERINARY LABORATORY PROCEDURES PART 2 PHYSICAL EXAMINATION
III. URINALYSIS VOLUME
SAMPLE COLLECTION ● Polyuria
1. Free catch (voided sample) ● Oliguria
● Anuria
2. Bladder expression
Normal daily urine output: 1mL/kg/h
3. Catheterization
4. Cystocentesis COLOR
TYPE OF ADVANTAGE DISADVANTAGE ● Straw
COLLECTION ● Colorless-pale
● Deep yellow
Free catch NO risk/complication Contamination ● Orange-red
Easiest to collect Unsuitable for culture ● Red-brown
● Milky white
Bladder Can be performed Trauma ODOR
expression anytime Unsuitable for culture ● Strong odor
*Not recommended ● Ammonia
for patients w/ ● Putrid
suspected ● Fruity
obstruction or fragile TUBIDITY
bladders ● Clear (0)
● Slightly cloudy (1)
Catheterization Collected in sterile Difficult to perform in ● Cloudy (2)
manner female animals ● Turbid (3
Increased trauma/ SPECIFIC GRAVITY
iatrogenic infection ● Hypersthenuria: dogs: >1.030;
cats: >1.035
Cystocentesis Sterile Sedation may be
● Hyposthenuria: <1.008
Appropriate for required
bacterial culture Can be performed for ● Isosthenuria: 1.008-1.012
restrained animals
Expensive CHEMICAL EXAMINATION
REAGENT STRIP
SAMPLE PRESERVATIVES ● Simple, rapid means for performing medically significant
1. Refrigeration chemical analysis of urine
2. Freezing -glucose -bilirubin
3. Toluene -ketones -specific gravity
4. Formalin (40%) -blood -pH
5. Boric acid (0.8%) -protein -urobilinogen
6. Commercial preservation tablets -nitrite -leukocytes
7.
MICROSCOPIC/SEDIMENT EXAMINATION
PRESERVATIVES ADVANTAGE DISADVANTAGE
CELLULAR CONSTITUENTS
Refrigeration Doesn’t interfere with Precipitates
chemical tests amorphous
Raises sp. gr

Freezing Inhibit bacterial (+) cellular and

growth protein damage
Doesn’t interfere with
chemical tests

Toluene Doesn’t interfere with Floats on the

routine tests surface of the
specimen

Formalin Excellent sediment Interfere w/

preservative chemical analysis

Boric acid Preserves protein Pptn of crystals

and formed elements

Commercial Control pH
preservatives Inhibits microbes

Special Diagnostic Procedures 23

 URINARY CASTS IV. PARASITOLOGY
SAMPLE COLLECTION
HYALINE EPITHELIAL GRANULAR
● A minimum of 10 g of fresh feces should be collected.
● Pooled fecal samples describes a collection of fecal
samples obtained from a group of animals that are housed
together.
GROSS/PHYSICAL EXAMINATION
CONSISTENCY
URINARY CRYSTALS
● Soft
8. ● Watery
AMMONIUM URATE AMORPHOUS URATES ● Hard
COLOR
● Note unusual color
BLOOD
● Bright red
● Black
● Tar-like consistency
BILIRUBIN CALCIUM CARBONATE
MUCOUS
● Note if present
GROSS PARASITES
● Examples: roundworms, tapeworms
DFS
● Requires very little amount of feces
CALCIUM OXALATE CALCIUM OXALATE ● Useful for viewing live, motile trophozoites
(DIHYDRATE) (MONOHYDRATE) FECAL FLOATATION
● Semi-quantitative method
● Number of parasite ova per gram of feces
○ Sodium nitrate solution- most common
○ Sheather’s solution & zinc sulfate- other sol’ns
● DO NOT DELAY examination
CENTRIFUGATION TECHNIQUE
CHOLESTEROL CYSTINE ● More efficient at recovering parasite ova
● Requires a little more specialized equipment
● 1g feces in 10mL sol’n. *1500rpm
BAERMANN TECHNIQUE
● Used to recover parasite larvae
● Baermann apparatus is needed.
● 5g of sample
MISCELLANEOUS FINDINGS ● Sample must be sit for at least 8 hrs or overnight.
COMMON PARASITES OF DOMESTIC SPECIES
(Canine and Feline)
NEMATODES

Special Diagnostic Procedures 24

 CESTODES

Special Diagnostic Procedures 25

 TREMATODES

ECTOPARASITES

PROTOZOAN

Special Diagnostic Procedures 26

Special Diagnostic Procedures 27
 Special Diagnostic Procedures
Our Lady of Fatima University – Pampanga
College of Medical Laboratory Science
FINAL TERM

FERTILITY TESTING SEMEN ANALYSIS

Purpose: ● For fertility testing: 2-3 samples in every 2 weeks
To know whether the individual is capable of conceiving. ● For post vasectomy semen analysis (to check whether
● For both male and female. the male is still producing sperm).
● Assess the inability of the couple to conceive even after ● For forensic analysis (medico-legal purposes; if patient
one year of trying (unprotected sex). has alleged rape).
● Females must be below 35 years old (because female ● Post-ejaculate urine sample - used if a patient has
encounter difficulty in conceiving after 35 years old), we retrograde ejaculation (semen enter the bladder).
can identify them as infertile or baog (if even after 1 year ● Dry orgasm - very little or no orgasm at all during sexual
of trying is hindi pa rin nakakapag conceive) climax.
● Possible padin na maconsider na infertile yung male or ● Fructose test - performed kung walang sperm na nakikita
female kahit na nabuntis or nakabuntis na. in association of low sperm volume.
● A woman can be considered infertile if she keeps on METHOD OF COLLECTION
having miscarriages or stillbirth. ● Masturbation
● Infertility is fairly common and can be worked up ● Coitus interruptus (interrupted sexual intercourse)
depending on the problem in the individual. ● Condom method
● After 1 year of trying, 15% of couples are not yet still able ● Vaginal vault aspiration (can be used for medico-legal)
to conceive a baby. ● Abstinence: 2-3 days not more than 5 days
In fertile couples, chance of conception: MACROSCOPIC EXAMINATION
● In a month: 20% ● Performed after liquefaction.
● In 3 months: 50% ● Note: The semen must be transported to the lab within
● In 6 months: 75% 30-60 minutes after collection at the temperature 37°C.
● In a year: 90% ● Viscosity
Note: ● Volume - 2 to 5 mL or depends on the abstinence.
● Ang bilang ng egg cells ng female from the day she was ● Semen pH - alkaline; 7.2 to 7.8
born ay hindi nadadagdagan, instead nababawasan ito SPERM CONCENTRATION
everytime na nagkakaroon siya ng monthly menstrual ● Normal: 20-160 mil./ml
period. Hence, the quality of the egg cells decrease or ● Oligospermia - low concentration of sperm.
deteriorate kapag tumatanda. Note: We use 2 WBC squares or 5 RBC squares. We usually
GRAVIDA/GRAVIDITY (G) utilize diluting fluids (cold water, sodium bicarbonate, or formalin).
● Number of pregnancies. For WBC squares:
𝑛𝑜. 𝑜𝑓 𝑐𝑒𝑙𝑙𝑠×𝑑𝑖𝑙𝑢𝑡𝑖𝑜𝑛 (20)
PARA/PARITY (P) 𝑛𝑜. 𝑜𝑓 𝑠𝑞𝑢𝑎𝑟𝑒𝑠 (2)×0.1
× 1000
● Number of births of viable offspring.
For RBC squares:
● Out of all the pregnancies ilan doon yung napanganak. 𝑛𝑜. 𝑜𝑓 𝑐𝑒𝑙𝑙𝑠×𝑑𝑖𝑙𝑢𝑡𝑖𝑜𝑛 (20)
× 1000 vb
ABORTUS (Ab/A) 𝑛𝑜. 𝑜𝑓 𝑠𝑞𝑢𝑎𝑟𝑒𝑠 (5)×0.004

● Number of abortion.
SPERM COUNT
PRIMARY INFERTILITY
● G0P0 ● Normal: at least 40 mil./ejaculate
● Never got pregnant. ● Sperm count=sperm concentration volume
● Couples that never got pregnant at least a month of trying
without using birth control methods. SPERM MOTILITY
SECONDARY INFERTILITY ● >50% shows moderate to strong forward motion.
● G2P0 ● Performed on a well-mixed liquified semen within 1 hr of
● Has been pregnant previously but is having a hard time specimen collection.
getting pregnant. ● Athenospermia - dysmotility.
● Couples who are able to get pregnant at least once but ● Hanging drop motion - for estimation, gine-grade yung
are now unable to. motility.
MALE FERTILITY TESTING Grade 4 Rapid straight movement
● Semen analysis
● Ultrasound Grade 3 Slower speed, some lateral
● Testicular biopsy movement
● Vasography
● Panleukocyte Immunocytochemical Staining Grade 2 Slow, noticeable lateral
 movement abnormal sperm
morphology
Grade 1 No forward movement
Masses Presence of Most commonly
Grade 0 No movement at all vascularity, varied adenomatoid
echotexture tumors; others
include
SPERM MORPHOLOGY cystadenomas,
● >50% normal forms mesotheliomas,
○ Teratospermia - abnormal morphology sarcomas
○ Strict - above 30% (normal forms)
○ 200 sperms are evaluated Obstruction Epididymal Normal-volume
○ Stains used: Wrights, Giemsa, Papanicolau enlargement, ejaculate with
prominence of rete oligo-/azoospermia
testis, hypoechoic
appearance

TESTICLES

Infections Early - decreased Associated with

echogenicity, subsequent
increased infertility,
heterogeneity particularly with
enlargement postpubertal
mumps
Late - atrophy,
● Teratozoospermia index(TZI): average # of defects per
increased
sperm
echogenicity
● Most observed characteristic of abnormal sperm is the
wide variability of the size of the acrosomal cap.
Trauma May visualize May lead to
SPERM AGGLUTINATION
seminiferous secondary infertility,
● Sperms tend to stick to each other if they are motile. tubules, antisperm
● The clumping prevents the sperm from entering the hematomas antibodies
cervical membrane.
Direct or indirect mixed agglutination reaction (MAR) –
for IgG or IgA -Immunobead assay – detect all three Ig
classes when beads are coated with monospecific
TRANSRECTAL ULTRASOUND
antisera to each class.
● Sperm agglutination is distinguished from clumping due to
bacterial infection. PROSTATE
ULTRASOUND
Cysts May be located May result in
● Cost-effective & non-invasive.
peripherally, obstruction, rare
● Potentially be able to uncover underlying pathologies that
midline, malignant
are not seen during physical examination.
paramedian, processes
● Assess testicular anatomy and vascularity.
hypo-/anechoic,
● More accurately which may determine more accurate
thin wall
options and treatment.
● Note: Urologist - male for fertility testing

SCROTAL ULTRASOUND SEMINAL VESICLE

Epididymis Normal caput EDOa Dilated ejaculatory Low-volume

diameter 7-8 mm duct and SVs, may ejaculate,
have calcifications oligo-/azoospermia,
Cysts Hypo-/anechoic, Simple cysts (no decreased fructose
well circumscribed, sperm) and and semen pH,
commonly located spermatoceles requires
at head (sperm present) not confirmatory
associated with aspiration
infertility demonstrating
sperm

Infections Enlarged, MAGI associated

thickened, with decreased
decreased motility, increased
echogenicity sperm DNA
fragmentation,

Special Diagnostic Procedures 2

 TESTICULAR BIOPSY CAUSES OF MALE INFERTILITY
Purpose: Sperm abnormalities may be caused by
● Check the location and condition of a lump in the testes. ● Inflammation of the testicles
● Diagnose causes of male infertility.
● Swollen veins in the scrotum
● Obtain sperm for IVF
● Abnormally developed testicles
OPEN BIOPSY
Low sperm count or lack of sperm
● Surgical biopsy.
● A pre-existing genetic condition
● Small tissue sample is taken from both testicles.
● Use of alcohol, tobacco or other drugs
● The doctor will make a small incision and a small amount
● Severe mumps infection after puberty
of tissue is removed.
● Hernia repairs
PERCUTANEOUS BIOPSY
● Hormone disorder
● Fine needle biopsy.
● Exposure to poisonous chemicals
● Tissue sample is aspirated.
● Also performed on both testicles. ● Exposure to radiation
● This procedure will depend on the needle used. ● Blockage caused by a previous infection
● During core-needle biopsy, you will hear clicking sound. ● Wearing restrictive or tight underwear
● Fine-needle biopsy or core-needle biopsy ● Injury to the groin area
VESICULAR BIOPSY Ejaculation problems
● Fasting is observed when receiving general anesthesia. ● Premature ejaculation
● Can be done with out-patient procedure. ● Retrograde ejaculation
● Performed around 15-20 minutes.
● Erectile dysfunctions
Drugs that can cause risk:
● Anticoagulants (blood thinners) ● Complications from radiation therapy or surgery
● NSAID (aspirin, ibuprofen, advil) Other causes of Male infertility
● History of STDs.
VASOGRAPHY
● UTI
● To detect the blockage in the ducts.
● Use of certain types of medications
● Used to evaluate the condition of vas deferens and
ejaculatory ducts. MANAGEMENT OF MALE INFERTILITY
● Uses radiologic dye. Lifestyle Change
● X-ray is taken as the dye flows through the ● Avoid heat sources, radiation, chemicals, alcohol,
ejaculatoryducts. drugs,tobacco.
● Only performed when there are abnormal findings in Artificial Insemination
biopsy and when the ultrasound is uncertain. ● Sperm is collected through multiple ejaculations.
PAN LEUKOCYTE (CD45) IMMUNOCYTOCHEMICAL STAINING ● Manually placed in the female’s uterus or fallopian tubes.
Hormone Treatment
● Detects the peroxidase negative polymorphonuclear
leukocytes, which can only be detected thru ● Clomid or testosterone may increase sperm count.
immunocytochemical. IVF
● Helps in differentiating leukocytes and germ cells. ● Fertilization of mature ovum in lab & re-implantation of
● Consensus threshold value zygotes into uterus via laparoscopy.
○ 1.0 x 106 cells/mL for peroxidase positive cells FEMALE FERTILITY TESTING
● Hormone testing
● Other infertility testing
AMENORRHEA
● Absence of menstrual flow:
○ Genetic and/or anatomic abnormality.
○ Endocrine abnormality.

PRL TSH FT4 DIAGNOSIS

Leukocytes in semen. High Normal Normal Imaging of

CD45-bearing cells are stained red. pituitary for
➔ If there are fewer CD45-positive cells than prolactinoma
spermatozoa in the sample (i.e. <400), the sampling
Normal/High Abnormal Abnormal Thyroid disease
error will exceed 5%. In this case, report the sampling
error for the number of cells counted.
➔ If fewer than 25 CD45-positive cells are counted, report A STEPWISE APPROACH TO EVALUATING AMENORRHEA
the number of CD45-positive cells observed with the Step 1:
comment “too few for accurate determination of ● HCG is measured to exclude pregnancy. Although a result
concentration”. >5 mIU/mL is typically indicative of pregnancy, or other
conditions.

Special Diagnostic Procedures 3

Step 2: ● Oral contraceptives continuously to suppress ovulation &
● PRL, TSH, and FT4 are measured to exclude tx endometriosis.
prolactinoma and thyroid disease. ● Surgical removal – for moderate to severe disease
Step 3: [laparoscopy].
● If HCG, PRL, TSH, and FT4 are all normal, then Cervical problems:
endogenous estrogen status is evaluated with the ● Estrogen Therapy
progestin withdrawal test. ● Cryosurgery
Step 4: Endocrine problems
● Serum FSH and LH levels determined. ● Ex.: Hypothyroid – replacement therapy [Synthroid]
Step 5: ● Hyperthroid – surgery, radioiodine, meds.
● Serum androgens measured. Fallopian tube problems
INFERTILITY TEST FOR WOMEN ● Tx infections: Terazol, Metronidazole
● Lysis and excision of adhesions - with microsurgery.
TEST DESCRIPTION

Pelvic Ultrasound Helps to see the size and position of

the vagina, cervix, uterus, and ovaries

Hysterosalpingogram Look at the inside of the uterus and

(HSG) fallopian tubes and the area around
them.

Sonohysterogram Utilizes saline and ultrasound to look

at the female reproductive organs.

Laparoscopy Used to assess the woman’s pelvic

organs (uterus, fallopian tube, and
ovaries) using a thin, lighted scope
that is put through a small cut
(incision) in the belly.

Pap smear Routine physical exam for women.

Collects a small sample of cells from
the cervix.

Colposcopy Test to look at the vagina and cervix

through a lighted magnifying tool
(coloscope)

CAUSES OF FEMALE INFERTILITY

Ovulation disorders:
● PCOS
● Hypothalamic dysfunction
● Premature ovarian failure
● Too much PRL
Tubal infertility:
● Pelvic inflammatory disease
● Previous surgery in the abdomen or pelvis
● Pelvic tuberculosis
Endometriosis:
● Extra tissue growth outside the uterus
● Affects the lining of the uterus
Uterine or cervical causes:
● Benign polyps or tumors
● Endometriosis scarring
● Uterine abnormalities present from birth
● Cervical stenosis
MANAGEMENT OF FEMALE INFERTILITY
Infection:
● Terazol; Metronidazole
Endometriosis:
● Danazol (Danocrine)

Special Diagnostic Procedures 4

 FORENSIC SCIENCE PART 1 FORENSIC SCIENCE PART 2
THE MAJOR BODY FLUIDS FORENSIC DNA ANALYSIS
BLOOD ● Deoxyribonucleic acid (DNA) is a molecule that is found
Presumptive Test in nearly all cells.
● React with the hemoglobin present in blood ● Known as a polymer, a molecule made up of repeating
● Colorimetry , Fluorescence, or Chemiluminescence simpler units, called monomers
Colorimetric Tests ● DNA is located in two regions in a cell: the nucleus and
● the testing chemical is added to the suspected stain and mitochondria.
then an oxidant is added, usually 3% hydrogen peroxide NUCLEAR DNA
● Catalytic color tests are phenolphthalein, benzidine, ● Found in a geometric shape called a double helix.
leucomalachite green, and tetramethylbenzidine (TMB) ● Made up of alternating sugar molecules (deoxyribose)
Luminol and Fluorescein and phosphates
● predominantly used for large scale serology testing. ● Dangling off each sugar molecule is one of four bases or
Luminol nucleotides: adenine (A), guanine (G), cytosine (C), and
● very sensitive to hemoglobin and will detect blood in thymine (T).
dilutions of 1 in 5,000,000. DNA TYPING
● Does NOT affect polymerase chain reaction (PCR) of RESTRICTION FRAGMENT LENGTH POLYMORPHISM (RFLP)
DNA. 1. DNA is extracted from biologic material and then severed
Fluorescein into small fragments called using restriction enzymes
● prepared much in the same way as luminol except that the Minisatellites.
commercial preparation contains a thickener 2. The length polymorphism present in these minisatellites is
● Stays on the surface better than luminol, making it easier used to discriminate a population of people.
to use on walls and other vertical surfaces 3. In forensic analysis, four to six of these highly
● Produces fluorescence and must be illuminated at 450 polymorphic loci are analyzed.
nanometers POLYMERASE CHAIN REACTION (PCR)
CONFIRMATORY TESTS FOR BLOOD Notes:
● formation of crystals through the application of heat and ● Sensitive; prone to contamination.
testing chemicals ● DNA extractions are always done in a location physically
● Ex. Takayama test (also known as the hemochromogen isolated from the place where the subsequent
test) amplifications will be performed
1. Sample of the presumptive stain is placed under ● Done in thermal cyclers
a cover slip. STEPS IN PCR:
2. Sample is heated briefly and observed through a 1. Denaturation.
microscope.
● The DNA added to PCR containing the reaction mixture
3. If blood is present, salmon-colored crystals form.
● Heated to 95°C. → double stranded DNA denatures.
NOTE: “Practically speaking, most forensic laboratories today
● Bonds between the base pairs holding the strands
do not conduct confirmatory tests for blood—the sample, if
together break, resulting in single stranded DNA.
presumptively positive, will go straight to the DNA unit.”
● Each strand will be the template for the formation of a
SEMEN new piece of double-stranded DNA.
Presumptive Tests for Semen 2. Annealing
● detection of acid phosphatase
● Attach a short strand of synthetic DNA (called primers)to
● Most common test is Brentamine Fast Blue B applied to
each of the separated strands.
the sample on an alphanaphthyl phosphate substrate
● Primers serve as starting points for the addition of new
○ (+) Reaction – Purple Color
bases to complete the reproduction of each strand.
Confirmatory Tests for Semen
● The thermal cycler temperature drops to 60 °C
● detection of acid phosphatase 3. Extension.
● Traditional method for sperm identification is to use the
● Reaction Temperature raised to 72 °C.
Christmas tree stain
● Under the influence of Taq polymerase, single bases
● (+) Sperm head turns pink, middle portion blue, tail
(nucleotides) are added to the primer.
yellow-green
● In this way the entire complementary strand is built up,
● Skin cells will stain green to blue-green.
● Double-stranded DNA is produced.
SALIVA
● Temperature raised to 94 °C → process repeats.
● Bite marks, licked adhesives (like envelopes and
MITOCHONDRIAL DNA (mtDNA)
stamps), eating and drink surfaces, or even expectoration
Differences between mtDNA and genomic DNA:
(spitting) can yield important DNA evidence
● Enzyme amylase occurs in saliva, and tests exist for ● mtDNA is circular in shape
amylase; amylase also occurs in many other body fluids. ● More numerous than genomic DNA (each cell has only
2 copies)
● All male and female mtDNA comes from the mother

Special Diagnostic Procedures 5

● mtDNA often shows a high degree of variation between VOIDS
unrelated ● an indicator that some secondary object came between a
● People, making it a powerful tool in forensic typing blood spatter and the final target; leaves an outline or
“shadow” on the final target
FORENSIC SCIENCE PART 3
BLOODSTAIN PATTERN ANALYSIS (BPA)
● is the analysis and interpretation of the dispersion,
shape characteristics, volume, pattern, number, and
relationship of bloodstains at a crime scene to
reconstruct a process of events
TERMINOLOGY
PASSIVE BLOOD STAIN
● clots, drops, flows, and pooling.
TRANSFER BLOODSTAINS POINT-OF-ORIGIN
“Whenever the direction of a bloodstain can be determined, it
● wipes, swipes, pattern transfers, and general contact
can be expected to have originated at a point somewhere
bloodstains
along that line.”
PROJECTED OR IMPACT BLOODSTAINS
● Can demonstrate a convergence of lines (paths),
● spatters, splashes, cast-off stains, and arterial spurts or
indicating point of origin
gushes
● Presumptive serological tests can be employed to
WIPE STAIN discover if the stain in question is truly blood
● created when an object moves through a pre-existing DOCUMENTATION
bloodstain (ex: clean rag moved through a pool of blood). “Document the entire scene as discovered, including
SWIPE STAIN “establishing” photographs.
● transfer of blood onto a target by a moving object that is ● Photograph pattern transfers, pools, and other fragile
itself bloodstained (ex: bloodied rag being moved patterns first.
through unstained floor) ● Document patterns with “establishing” photographs that
SPATTER show the pattern’s relationship to landmarks or other
● technical term describing stains resulting from blood items of evidence
hitting a target. ● Take macro and close-up photographs; include a scale
FORWARD SPATTER in every photograph.
● When reconstructing point-of-origin, document individual
● blood droplets projected AWAY from item
stains used in the reconstruction
BACK SPATTER
● blood droplets being projected TOWARD the item
CAST-OFF STAIN
● blood being flung or projected from a bloody object in
motion or one that stops suddenly

ARTERIAL SPURTS/GUSHES
● occurs when an artery is breached while the heart is
pumping; produces zigzag, up and down pattern

Special Diagnostic Procedures 6