CLINICAL
THE EFFECT OF PNEUMATIC TUBE SYSTEMS
ON THE HEMOLYSIS OF BIOCHEMISTRY
BLOOD SAMPLES
Authors: Gokhan Cakirca, MD, and Huseyin Erdal, MSc, Hatay, Turkey
Introduction: Pneumatic tube systems (PTSs) are widely used
in many hospitals because they lead to reduced turnaround
times and cost efficiency. However, PTSs may affect the quality
of the blood samples transported to the laboratory. The aim of
this study was to investigate the effect of the PTS used in our
hospital on the hemolysis of the biochemical blood samples
transported to the laboratory.
Methods: A total of 148 samples were manually transported
to the laboratory by hospital staff, 148 samples were
transported with the PTS, and 113 were transported with the
PTS without use of sponge-rubber inserts (PTSws). Hemolysis
rates and the levels of biochemical analytes for the different
transportation methods were compared.
Results: No significant difference was found between the
samples transported manually and with the PTS with regard to
neumatic tube systems (PTSs) are widely used in
P many hospitals for the transport of blood samples
from wards or clinics to laboratory areas by hospital
staff. A PTS provides a number of advantages, including
rapid and safe transport of the blood specimens to the
laboratory, reduced turnaround times, cost efficiency, and
reduced labor requirements. 1,2 However, a PTS may
affect the quality of blood samples because of factors such
as high transportation speeds, length of the system,
sudden acceleration/deceleration, changes in air pressure,
sudden changes in the direction of the transport containers,
Gokhan Cakirca is Assistant Professor, Department of Biochemistry, Mustafa
Kemal University Faculty of Medicine, Hatay, Turkey.
Huseyin Erdal is Research Assistant, Department of Molecular Biochemistry
and Genetics, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey.
For correspondence, write: Gokhan Cakirca, MD; E-mail: cakirca.gokhan@gmail.com.
J Emerg Nurs ■.
0099-1767
Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jen.2016.09.007
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hemolysis rate and the levels of biochemical analytes. However,
the samples transported with the PTSws showed a significant
difference compared with the samples transported manually and
with the PTS with regard to hemolysis rate and potassium and
lactate dehydrogenase levels. The percentages of the samples
that exceeded the permissible threshold for the hemolysis among
the samples transported manually, with the PTS, and with the
PTSws were 8%, 10%, and 47%, respectively.
Discussion: A PTS can be used safely for transporting
biochemistry blood samples to the laboratory. However, a
sponge-rubber insert that holds sample tubes must be used
with the PTS to prevent the hemolysis of blood samples.
Key words: Pneumatic tube system; Sponge-rubber; Hemolysis;
Blood samples
movement and vibrations of blood samples in the tubes,
and lack of cushioning. 3-5 Several studies have shown
that a PTS has an effect on blood gas samples, 6 hematology
and coagulation parameters, 7 and clinical biochemical
analytes. 8
The PTSs used in hospitals may vary in terms of
transportation speed, length of the system, and the number of
transfer stations. Therefore, these systems may have different
effects on the blood samples transported to the laboratory. In
this study, we investigated the effect of the PTS used in our
hospital on the hemolysis of the biochemical blood samples
transported to the laboratory.
Methods
SAMPLE COLLECTION AND ANALYSIS
This study was performed at Mustafa Kemal University
Medical School Hospital Blood Taking Unit (BTU)
between May 10-27, 2016. Blood samples were collected
from donors between 9 and 12 AM after an 8- to 12-hour
fasting period. All blood samples were collected by the same
expert phlebotomist from a single vein using Vacutainer
tubes. The blood samples were collected into 8.5-mL BD
Vacutainer SST II Advance tubes (Becton, Dickinson &
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TABLE
Relation between method of transport of blood specimens and results of laboratory analytes
Parameters PTSws (n = 113), mean ± SD Manual (n = 148), mean ± SD PTS (n = 148), mean ± SD P value
Hemolysis, No. (%) 53 (47) b 15 (10) a 12 (8) a .000
Alanine aminotranferase (U/L) 19.36 ± 10.23 18.34 ± 8.02 18.02 ± 7.8 .448
Aspartate aminotranferase (U/L) 20.25 ± 6.06 b 18.3 ± 5.5 a 18.9 ± 5.6 ab .019
Bilirubin, total (mg/dL) 0.51 ± 0.23 0.54 ± 0.23 0.55 ± 0.22 .405
Creatinine (mg/dL) 0.72 ± 0.12 0.70 ± 0.11 0.71 ± 0.13 .442
Potassium (mmol/L) 4.6 ± 0.38 b 4.42 ± 035 a 4.47 ± 0.38 a .001
Lactate dehydrogenase (U/L) 234 ± 54 b 211 ± 49 a 208 ± 65 a .001
Urea nitrogen (mg/dL) 12.66 ± 5.33 11.92 ± 3.52 11.81 ± 3.89 .510
Sodium (mmol/L) 138,4 ± 2 137 ± 1.6 137.5 ± 1.9 .39
Glucose (mg/dL) 94.37 ± 10.73 91.49 ± 11.63 92.93 ± 11.86 .285

PTS, Pneumatic tube system; PTSws, pneumatic tube system without sponge-rubber inserts; SD, standard deviat.
Bold values represent significant difference and P b .05. a,b: Different letters are used in the same line indicate the significant difference between two groups whereas the same letters in the same line indicate
no significant difference. Groups with "ab" designators indicate that there is no significant difference between a or b with ab in the same line; P b .05.

Co, Franklin Lakes, NJ) and transported to the laboratory constant speed of 5 m/sec. The distance of the PTS between
by the hospital staff manually, by PTS, and by PTS without the BTU and the central laboratory is approximately 170 m.
sponge-rubber inserts (PTSws). The carrier is made of high-resistant polycarbonate with a
A total of 409 blood samples were analyzed in the study. diameter of 86 mm and a length of 220 mm. The tube
Of these, 148 samples were transported to the laboratory by carrier contains removable sponge rubber. Sponge rubber
the hospital staff manually, 148 samples were transported includes 7 rings at both ends of tube carriers, which allows
with the PTS, and 113 were transported with the PTSws. us to transport 14 tubes per carrier.
Blood samples transported to the laboratory were analyzed
immediately after being centrifuged at 3500 rpm for 10 STATISTICAL ANALYSIS
minutes. An Abbott ARCHITECT c8000 autoanalyzer
(Abbott Laboratories, Lake Bluff, IL) was used for the Statistical analysis was performed using SPSS 21 for
assessment of potassium (K), sodium, glucose, creatinine, Windows (IBM Corp, Armonk, NY). The Kolmogorov-S-
alanine aminotransferase, urea nitrogen, total bilirubin, mirnov test was used to test normality. Statistical analysis of
aspartate aminotransferase (AST), and lactate dehydrogenase the transformed data was performed by one-way analysis of
(LDH) levels and hemolysis index. Hemolysis was established variance, and the Duncan test was used to evaluate the
if the index was greater than 0.3 g/L, the threshold level significance of differences between groups as post-hoc.
optimized for our laboratory, above which hemolysis is Biochemistry parameters were expressed as mean ± SD.
visible, leading to inaccurate test results. 9 Numeric values for hemolysis were tested with the χ 2 test
Throughout the study, the internal quality control (P b .05).
values of the analytes ranged between ± 2 standard
deviations (SDs). The hospital information system was
used to exclude patients from the study whose preliminary Results
diagnosis was obesity, diabetes, kidney failure, liver
diseases, hematologic diseases, or pregnancy. The study Our results indicated no significant difference between
was approved by the Mustafa Kemal University Local the samples transported manually and with the PTS in
Ethics Committee. terms of hemolysis rate and the levels of biochemical
analytes. However, in terms of hemolysis rate and the K
PNEUMATIC TUBE SYSTEM and LDH levels, the samples transported with the PTSws
showed a significant difference compared with the
The PTS used in our hospital (Swisslog Compact Station, samples transported manually and with the PTS. Moreover,
Swisslog Healthcare, Westerstede, Germany) runs at a the AST level was significantly higher in the samples

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transported with the PTSws compared with the
samples transported manually. The percentages of the
samples that exceeded the permissible threshold for the
hemolysis among the samples transported manually, with
the PTS, and with the PTSws were 8%, 10%, and 47%,
respectively (Table).
Discussion
PTS is widely used in many hospitals for the transport of
blood samples from wards or clinics to laboratory areas.
However, the clinically important failures of the PTS should
be investigated by each of the hospitals 5,10 because PTS
may lead to hemolysis as a result of its high transportation
speeds, the length of the system, sudden acceleration/
deceleration, changes in air pressure, and sudden changes in
the direction of the transport containers. 8,11,12 In turn,
hemolysis may lead to false high values of LDH, K, and
AST. 13 The blood samples with hemolysis are rejected by
the laboratory, and thus these blood samples should be
redrawn, which in turn leads to delayed laboratory results
that are necessary for diagnosis and treatment.
In the present study, a significant difference was not
observed between the samples transported with the PTS and
manually in terms of hemolysis rates. The hemolysis rate
was 8% in the samples transported manually as opposed to
10% in the samples transported with the PTS. Similarly,
Fernandes et al 14 found no significant difference between
these 2 transportation methods and reported the hemolysis
rate as 10% in the samples transported manually and 5.8%
in the samples transported with the PTS. Phelan et al 15 also
found no significant difference between these 2 transpor-
tation methods in terms of hemolysis rate.
In contrast, Kara et al 8 found that the hemolysis of the
samples transported with the PTS was 532-fold greater than
that of the samples transported manually. As a result of
hemolysis, serum creatinine, K, LDH, and AST levels were
also significantly higher in the samples transported with the
PTS. 8 The speed of the PTS examined in the study by Kara
et al 8 was 3 m/sec, and the travel length was 80 m. In our
study, although the distance of the PTS was longer and the
speed was higher, no significant difference was found
among the methods of transportation with regard to
hemolysis rate and the levels of analytes. The differences
between these studies may be associated with the variety of
the characteristics of the PTS used (eg, delivery route,
number of corners, carriers, and inserts). In a previous
study, Koroglu et al 2 found that the K, LDH, and AST
levels of the patients with acute leukemia were significantly
higher in the samples transported with the PTS than in the
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Cakirca and Erdal/CLINICAL
samples transported manually. The reported study indicated
that this difference may arise from in vitro cellular lysis of
fragile leukocyte membranes in the samples transported
with the PTS. 2 Evliyaoglu et al 3 investigated the longest
pneumatic tube system in Turkey and reported that the
effect of PTS on hemolysis rate is dependent on the length
and speed of the PTS. Similarly, another study also reported
that the long length and high speed of the PTS are
associated with increased levels of hemolysis indicators of K,
LDH, and hemoglobin. 11 Therefore speed and length
considerations must be taken into account when establish-
ing a new PTS.
The results of this study demonstrate that the
hemolysis rate and the K and LDH levels were significantly
higher in the samples transported with the PTSws than in
the samples transported with the PTS and manually. In the
PTSws, a number of factors—including high transportation
speeds, sudden acceleration/deceleration, number of cor-
ners, and sudden changes in the route of the transport
containers—increase the movements and the vibrations of
the samples in the tubes compared with the PTS, which
leads to more hemolysis. To reduce the rate of hemolysis,
sponge-rubber inserts must be used to decrease the
movements and the vibrations of the samples in the
tubes. We observed that to enable the transport of a higher
number of samples to the laboratory with the PTS, the
sponge-rubber inserts in the transport containers are
removed in some clinics of our hospital. For this reason,
each laboratory should check to determine if carrier inserts
are used in transporting blood samples with the PTS.
Limitations of this study are as follows: First, we did
not evaluate the rate of hemolysis using different sample
types. Second, turnaround times were not measured. Third,
this study was carried out only between BTU and the
laboratory, but the effect of PTS on blood samples was not
investigated in the other locations of hospital (eg, the
emergency department).
Conclusion
The present study showed that a PTS can be used safely for
transporting biochemistry blood samples to the laboratory.
In addition, a PTS should definitely be used with
sponge-rubber inserts to prevent the hemolysis of blood
samples. The literature indicates that the PTSs used in
hospitals show differences regarding the effects on hemolysis
of the blood samples transported to the laboratory.
Therefore individual studies should be performed to
investigate the effect of the PTS on the hemolysis of
blood samples in each hospital.
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