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Authors: Sharrat C, Gilbert C, Cornes M, Ford C, Gama R. EDTA sample contamination is common and often undetected, putting patients at unnecessary risk of harm. Int J Clin Practice 2009; 63: 1259-62
Potassium is one of the blood analytes most frequently measured in
the clinical laboratory and at the point of care. Compared with
most laboratory measurements, potassium is unusually prone to
preanalytical error so that pseudohyperkalemia, defined as raised
serum or plasma potassium concentration despite normal in vivo
potassium concentration, is a relatively common occurrence that
must be considered in any patient with unexplained hyperkalemia.
There are many ways in which poor sample collection and handling
can give rise to spuriously raised serum/plasma potassium. A
recently published UK study focuses on one of these - contamination
of the sample at the time of collection with K+-EDTA, the
anticoagulant additive used to preserve samples destined for
hematological investigation. Gross K+-EDTA contamination
of biochemical samples arises from the wholly unacceptable practice
of decanting blood from the hematology sample tube to the
biochemistry sample tube. The gross contamination that results from
this practice is easily recognized because it causes spuriously
raised potassium (and reduced calcium due to EDTA chelation) of
such magnitude that it is almost, if not actually, incompatible
with life. This study focused on the more subtle contamination that
can occur as a result of backflow of K+-EDTA-
contaminated blood-to-blood collection system (e.g. vacutainer)
with transfer of minute amounts of K+-EDTA to
subsequently collected samples. Those responsible for this study
measured EDTA in all 665 samples identified during a 1-month study
period that had either a raised serum potassium, reduced serum
calcium, reduced serum magnesium or reduced serum zinc. EDTA
contamination was found in 31 samples. Twenty-five of the 31
patients were available for immediate re-testing and in all but
two, biochemistry was entirely normal on re-testing. In the other
two cases results were closer to normal than they had previously
been. In discussion of their findings the authors remind that
pseudohyperkalemia due to subtle K+-EDTA
contamination is avoided by the simple expedient of collecting
blood for biochemistry testing before collecting blood
into K+-EDTA- containing tubes. They suggest that,
since education on correct order of blood draw is unlikely to be
entirely successful in eliminating the problem, laboratories should
consider measuring EDTA in all samples with raised potassium or
reduced calcium, magnesium or zinc to avoid reporting spurious
results, a policy that they have already in part adopted at their
laboratory.
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