Arterial blood has been widely recommended

Procedure

1. Flush the 1 ml syringe with heparin. Excess heparin may dilute the specimen and cause haemolysis.

2. After drawing the blood, expel any air bubble in the syringe immediately to avoid gas exchange with the atmosphere.

3. Mix well by rolling the between palms for 5 seconds.

4. Remove the needle and cap the syringe immediately with a stopper (e.g. Combi-red). Do not recap the needle or sent the syringe with needle to the laboratory to avoid needle prick injury for the ward staff as well as the laboratory staff.

5. Place the syringe into ice-water (not ice cube) and send the specimen to the laboratory immediately. 

6. Please indicate sample type Arterial or Venous in request form.

Note: Complete 24-hour urine collection is of utmost important as incomplete collection will cause erroneous result.

Procedure    

1. Request the suitable 24-hour urine container from the laboratory.

2. Follow your physician’s advice regarding food, drink, or drugs before and during collection. 

3. On the day of collection, the first urine voided (e.g. at 6.00 am) must be discarded. Time of first urine voided is the onset for the 24-hour collection. Record the date and time of collection on the container.

4. Thereafter, all urine should be collected and refrigerated during the 24-hour period.

5. The patient has to empty the bladder at the same time (e.g. at 6.00 am) the next morning and must be put into the container.

6. Send the urine container to the laboratory.

Precautions

1. 1. Urine should be passed into a separate container at each voiding and then emptied into a larger container to complete the specimen. This two-step procedure prevents the danger of patient splashing him or herself with the preservative (e.g. acid) in the container.

   2. If preservative is used, mix the content thoroughly after each addition of urine.

   3. If the patient has a bowel movement during the collection period, precautions should be taken to prevent faecal contamination. 

Procedure

1. Fast the patient overnight (at least 10 hours). Drinking plain water is permitted.

2. Prepare 75 gm glucose in 250-300 ml of water. (For children, use 1.75 g/kg body weight to a maximum of 75 g.)

3. Collect a Fasting Blood Sugar sample and label as ‘FBS’.

4. Instruct the patient to drink the glucose and the solution must be finished within 5 minutes.

5. Repeat blood sampling at 120 minutes (2 hours) after the glucose load and label as 2 hr.

6. Indicate the barcode label on the form as ‘FBS’ and ‘2hr’ accordingly matching the barcode label of the specimen containers.

• Samples from Hospital Melaka

Procedure

1. Call laboratory prior to sample collection.

2. Upon approval from laboratory, collect the sample using K2 EDTA tube and state the time of sampling in PER-PAT 301 Form.

3. Tubes should be filled completely and tightly capped at all times.

4. Place immediately on ice pack.

5. Send immediately to the Chemical Pathology laboratory within 15 minutes. (delays >15 minutes has been shown to increased ammonia level.

• Samples from other hospitals

Procedure

1. Call laboratory prior sending the sample.

2. Upon approval from laboratory, collect the sample using K2 EDTA tube and state the time of sampling in PER-PAT 301 Form.

3. Centrifuge within 15 minutes of collecting the sample and separate the plasma.

4. Transport in ice pack as soon as possible to the Chemical Pathology laboratory.

• Samples from Hospital Melaka

Procedure

1. Call laboratory prior sending the sample.

2. Upon approval from laboratory, collect the sample using Sodium Fluoride / Disodium EDTA or Potassium Oxalate + Sodium Fluoride tube and state the time of sampling in PER-PAT 301 Form.

3. Tubes should be filled completely and tightly capped at all times.

4. Place immediately on ice pack.

5. Send immediately to the Chemical Pathology laboratory.

• Samples from other hospitals

Procedure

1. Call laboratory prior sending the sample.

2. Upon approval from laboratory, collect the sample using Sodium Fluoride / Disodium EDTA or Potassium Oxalate + Sodium Fluoride tube and state the time of sampling in PER-PAT 301 Form.

3. Centrifuge within 15 minutes of collecting the sample and separate the plasma.

4. Transport in ice pack as soon as possible to the Chemical Pathology laboratory. 

Sample collection must follow the Garis Panduan bagi Ujian Pengesanan Penyalahgunaan Dadah dalam Air Kencing Versi 2 – Surat Pekeliling Ketua Pengarah Kesihatan Malaysia bil 1/2021.

Procedure

1. Specimen collection must be properly supervised. Collection site must have suitable toilet facilities and free from soap, dispenser or cleaning agent.

2. The urine volume should be at least 30 ml.

3. The person supervising the collection should stand close enough and able to see it genuinely passing out from the donor to avoid any attempt in falsifying the specimen.

4. The urine bottle must be securely capped and sealed with sealing wax or sealing sticker.

5. Bottle is labelled in front of the donor with the following information:

• Donor’s name

• Identity card number

• Date and time of collection

• Signature of supervising officer

• Drug suspected.

6. The donor shall be asked to read and sign a statement ‘Akuan Pemberi’ in the Borang Permintaan Ujian Pengesanan Dadah Dalam Air Kencing, certifying that the urine specimen identified as having been collected from him or her.

Procedure

1. Consult Pharmacist regarding the time of sampling.

2. Specimen collected according to instruction given by Pharmacist.

3. Complete Therapeutic Drug Monitoring (TDM) Request Form.

Procedure

1. Give 1 mg dexamethasone orally between 11.00 pm to 12.00 pm.

2. Complete the request form with clinical summary.

3. Collect blood at 8.00 am the next morning for determination of serum cortisol. 

General Requirements

1. Request for 24 hour urinary metanephrines test must be reviewed and endorsed by specialist (Endocrine Specialist, Internal Medicine Specialist or Family Medicine Specialist).

2. Suggested candidates for screening:

i. Adrenal incidentaloma

ii. Signs and symptoms of pheochromocytoma/ paraganglioma (PPGLs) eg. headache, profuse sweating, palpitation

ii. Resistant hypertension

iv. History of cardiovascular emergency eg. myocardial infarction, stroke, heart failure

v. Previous PPGLs

vi. Family history of PPGLs

Patients Preparation

1. Food to avoid (Please avoid for 24 hours prior to, and during, the collection period)

- Coffee - Tea - Chocolate

- Cocoa - Vanilla - Banana

- Pineapple - Nuts - Watermelon

- Eggplant       - Avocado - Tomato

- Kiwi - Fruit juices

2. Drugs to avoid (Please avoid at least one (1) week before specimen collection) :

• Trycyclic antidepressants eg. Amitriptyline, imipramine

• Antipsychotics eg. clozapine, olanzapine, risperidone, chlorpromazine

• Alpha-2 blockers eg. phenoxybenzamine, phentolamine

• Beta blockers eg. labetolol, atenolol, metoprolol, propanolol

• Monoamine oxidase inhibitors (MAOI) eg. moclobamide, phenelzine

• Sympathomimetic drugs eg. pseudoephedrine, phenylephrine, dobutamine

• Recreational drug eg. amphetamines, cocaine

• Others, paracetamol, levodopa

 3. Avoid stress and vigorous exercise.

Specimen Collection

• Discard the first voided urine and note the start date and time (eg: 22/05/2020, 8.00am).

• Collect all urine voided for 24 hours duration and mixed well every time added the urine into the container.

• Do not void urine directly into the container. Please use the sterile urine container provided to avoid spillage.

• Keep the closed urine container in wet and dry area.

• At the end of the period, add the last voided sample to the container by emptying the bladder and note the finishing date and time (23/05/2020, 8.00am).

Indication 

Screening for primary hyperaldosteronism in hypertensive patients with spontaneous or diuretic induced hypokalemia. 

Suggested candidates for screening: 

1. Patients with hypertension and hypokalemia. 

2. Patients with resistant hypertension. 

3. Young hypertensive (age < 40). 

4. Patients with adrenal incidentaloma. 

Principle 

The renin-aldosterone axis is primarily regulated by renal blood flow. Subjects under investigation should, therefore, not be taking any drugs that interfere with fluid balance or potassium. 

Patient Preparation 

1. Attempt to correct hypokalemia 

• Blood should be collected slowly with syringe and needle (preferably not Vacutainer to minimize risk of spuriously raising potassium).  

• Avoid fist clenching – wait at least 5 seconds after tourniquet release to insert needle. 

• Separate plasma from cells as soon as possible or within 2 hours of collection. 

• Avoid hypokalaemia as it suppresses aldosterone secretion. Give potassium replacement (Slow K tabs) sufficient to raise plasma potassium >4.0 mmol/L. 

2. Subject should be normally hydrated and has an adequate oral intake of sodium. 

3. Drugs to avoid: 

• Spironolactone*, amiloride, triamterene.  

• *Spironolactone must be stopped for 6 weeks. 

• Potassium-wasting diuretics. 

• Product derived from licorice root. 

4. If ARR testing is not diagnostic after withdrawing above agents and hypertension can be controlled with noninterfering medications, test again 2 weeks after withdrawing other medications 

• ACE inhibitors, ARB, beta-blockers, methyldopa, clonidine. 

• Oral contraceptives and hormone replacement therapy may lower direct-renin concentration and cause false positive ARR.  

• Do not withdraw oral contraceptives unless confident of alternative-effect contraception. 

5. Drugs that do not interfere with the renin-aldosterone axis include: Prazosin, verapamil, hydralazine and terazosin. 

Requirements  

• Potassium EDTA (K2EDTA) tube for renin (DRA).  

• Potassium EDTA (K2EDTA) tube for aldosterone.  

• Blood samples should be sent rapidly to the laboratory but not in ice (within 30 minutes) as cooling would cause cryoactivation of prorenin to renin, leading to falsely raised renin. 

Conditions for blood collection  

• Collect midmorning after patient has been sitting, standing, or walking for at least 2 hours, and seated for 5-15 minutes.  

• Collect blood carefully to avoid stasis and hemolysis during collection.  

• Collect samples into 2 tubes of EDTA. 

• (Please use different tubes for Renin and Aldosterone. Suggest collecting minimum 3mL blood per sample, as at least 500µl plasma need for each analysis).  

• Maintain sample at room temperature (not in ice) during transportation to laboratory for centrifugation.  

• Fill-up the PER. PAT 301 form. Only single form is required for requesting Aldosterone Renin Ratio (ARR).  

• Patient’s clinical history, drug history and latest potassium (K+ ) level are MANDATORY.  

• Test should be requested by Specialist / Endocrine Specialist only.  

• Please record patient’s posture whether supine or upright. 

Supine sample: 

Sample taken in the early morning before the subject arises (If feasible). 

Upright sample: 

Subject should be upright for ≥ 2 hours prior to sampling.  

• Samples should be taken between 8 am to 10 am. 

Interpretation  

• High aldosterone and suppressed plasma renin indicates primary hyperaldosteronism.  

• Some patients with renal disease may give similar results.

Indication 

1. To establish a diagnosis of Cushing’s syndrome when other commonly available screening tests (overnight dexamethasone suppression test (ODST) or 24-hour urinary free cortisol) are equivocal and clinical suspicion is high.

2. Useful in the following special population (e.g pregnancy, patients on anti-epileptic drugs etc) whereby salivary cortisol recommended by Endocrine society guideline.

3. Suspected Cyclical Cushing’s syndrome.

Instruction for collection of saliva sample for “Salivary Cortisol” test by using “Salivettes”

A) Preparation:

• Do not use any steroid inhalers for 24 hours before collecting your saliva sample.

• Do not use any creams or lotions that contain steroids such as hydrocortisone.

• Do not collect a sample if your gums or the inside of your mouth is bleeding.

• Do not brush teeth or floss your teeth before collecting specimen.

• Do not eat or drink for 15 minutes prior to specimen collection.

• Collect specimen between 11.00 pm and 12.00 midnight.

• Make sure your name, identification card number, date and time of sample collection written on the tubes’ label.

B) To use the Salivette:

1. Wash your hands with soap and warm water, dry well with a clean towel.

2. Remove blue cap of the tube.

3. Place white swab directly into the mouth by tipping the tube so the swab falls into the mouth. (Do not let fingers touch the swab to prevent contamination).

4. Keep the swab in the mouth for approximately 2 minutes. Roll the swab in the mouth (swab must completely wet). Do not chew the swab. 

5. Spit the swab back into the tube. Do not let fingers touch the swab.

6. Replace the blue cap. Make sure cap is pushed/closed on tightly.

7. Write your name, IC, the date and time the sample was collected on the label.

8. Please store the collected sample in your home refrigerator (2-8 ° C).

9. Repeat step 1 to 8 for the second sample collection. (Minimum 2 sample collected on different day. More sample may be needed for diagnosis of cyclical Cushing's syndrome)

10. Return both samples to Pathology Department counter of your hospital the next day after the 2nd sample collection.

(Swab: white sponge in the tube)