Platelets

ISSN: 0953-7104 (Print) 1369-1635 (Online) Journal homepage: http://tandfonline.com/loi/iplt20

The impact of pneumatic tube transport on whole

blood coagulation and platelet function assays

Peter H. Nissen, Dorte E. Wulff, Niels Tørring & Anne-Mette Hvas

To cite this article: Peter H. Nissen, Dorte E. Wulff, Niels Tørring & Anne-Mette Hvas (2018):
The impact of pneumatic tube transport on whole blood coagulation and platelet function assays,
Platelets, DOI: 10.1080/09537104.2018.1430361

To link to this article: https://doi.org/10.1080/09537104.2018.1430361

Published online: 14 Feb 2018.

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ISSN: 0953-7104 (print), 1369-1635 (electronic)

Platelets, Early Online: 1–4

© 2018 Taylor & Francis. DOI: https://doi.org/10.1080/09537104.2018.1430361

The impact of pneumatic tube transport on whole blood coagulation and

platelet function assays
Peter H. Nissen, Dorte E. Wulff, Niels Tørring , & Anne-Mette Hvas

Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark

Abstract Keywords
Pneumatic tube is an attractive way to transport blood samples from the emergency depart- Aggregometry, pneumatic tube, thromboe-
ment to the central laboratory facility. We aimed to investigate the impact of pneumatic tube lastometry, whole blood coagulation
transportation on blood samples for analysis of whole blood coagulation and platelet function.
We included 21 healthy adult individuals and measured global coagulation assays by rotational History
thromboelastometry (ROTEM) and platelet aggregation induced by arachidonic acid (AA) and
Received 13 January 2018
adenosine diphosphate (ADP) using impedance aggregometry (ROTEM Platelet), on samples
Accepted 15 January 2018
transported manually or by pneumatic tube transport. Statistical testing was performed with
Published online 14 February 2018
paired tests with post-hoc Bonferroni correction for multiple testing.
Our data revealed no difference in the far majority of ROTEM parameters (P > 0.003), while
significantly decreased values were observed for INTEM clotting time (CT) (P = 0.002) and
maximum clot firmness (MCF) including the amplitude after 10 min (A10) (P < 0.0001).
No statistically significant difference was observed on impedance aggregometry results when
manual transport was compared to pneumatic tube transport (P > 0.003).
This study indicates that only minor and unsystematic differences between manual transport
and pneumatic tube transport may be observed in ROTEM analyses, and that there is no
influence from pneumatic tube transport on impedance aggregometry analyses using AA and
ADP.

Introduction Materials and methods

Pneumatic tube (PT) systems offer a convenient way to transport
blood samples minimizing time from sample collection at the
patient bedside to sample arrival at the central laboratory.
Thromboelastometry (ROTEM®/TEG®) provides analysis of
dynamic whole blood coagulation and is increasingly used in
bleeding patients (1). However, the ROTEM analysis has been
limited by the fact that platelet function during antiplatelet ther-
apy was not systematically revealed (2). Thus, very recently the
ROTEM Platelet has been marketed to make it possible to test for
reduced platelet function for example due to antiplatelet therapy
(3). Fast action is required when handling trauma patients or
patients with major bleeding during surgery, and in this setting
PT transport is warranted.
While PT transport reduces sample transport time, the external
forces influencing the samples during transport may affect the
whole blood coagulation and platelet assay by platelet activation
and subsequent platelet exhaustion (4,5). The impact of PT trans-
port on a range of routine chemistry, hematology, and coagulation
assays is well described (4), but conflicting results for particularly
impedance aggregometry analyses have been published (6–11).
In this study, we aimed to evaluate the impact of a newly
established PT system on whole blood coagulation and platelet
function tests.
Correspondence: Peter H. Nissen, Department of Clinical Biochemistry,
Aarhus University Hospital, Aarhus DK 8200, Denmark. Tel: +45 4046
5966; E-mail: peteniss@rm.dk
In total, 21 healthy individuals > 18 years of age were included.
Exclusion criteria were a history of chronic disease and any
medication affecting coagulation.
Sampling and transport
From each individual, duplicate samples were collected in sodium
citrate tubes (3.5 ml Vacuette) with 3.2% sodium citrate (Greiner
Bio One International GMBH., Bad Haller, Austria). Sampling
was performed by the same trained biomedical technician, using a
21 gauge needle. The samples were transported either by bicycle
(distance: 600 m) or by the PT system (Sumetzberger GMBH.,
Vienna, Austria) (distance: 855 m) at a predefined speed of 3.7 m
pr. second (m/s). Samples were destined to the Department of
Clinical Biochemistry, where the analysis equipment was located.
All samples were collected and analyzed over a one-week period.
Thromboelastometry
Whole blood coagulation was assessed by the ROTEM delta unit
(TEM innovations GMBH., Munich, Germany) using EXTEM,
INTEM, and FIBTEM assays according to the manufacturer’s
instructions.
The within-laboratory precision was calculated for clotting
time (CT) from 27 measurements of the Rotrol-N control
(lot#42023001, TEM innovations GMBH). The coefficient of
variation was 7.3% for EXTEM CT and 7.7% for INTEM CT.
2 P. H. Nissen et al. Platelets, Early Online: 1–4

Impedance aggregometry Figure 1 shows Bland–Altmann plots, indicating minor relative

Platelet function was assessed by impedance aggregometry using
the newly developed ROTEM Platelet unit for the ROTEM
equipment. Platelets were activated by arachidonic acid
(ARATEM) and by adenosine diphosphate (ADPTEM).
Statistics
Statistical analyses were performed using Analyse-IT for Excel
(Analyset-it Software, Ltd., Leeds, UK) and GraphPad Prism
version 6 (GraphPad Software, Inc., La Jolla, CA, USA).
Evaluating data for Gaussian distribution was done by histograms
and Q-Q plots. The difference between manual- and PT transport
of samples was tested using two-sided paired t-test or Wilcoxon
matched-pairs signed rank test, when the data were following a
Gaussian distribution or a non-Gaussian distribution, respectively.
A null hypothesis stating no difference between the two types of
transport was assumed, and the null hypothesis was rejected if
P < 0.003, after Bonferroni correction for multiple testing
(0.05/18).
Quantitative data are expressed as either mean ± standard
deviation (SD) for data following a Gaussian distribution or
median with interquartile range (25 and 75% percentiles, IQR)
for data not following a Gaussian distribution.
Results and discussion
We included 21 healthy individuals of which 10 (48%) were
women and 11 (52%) were men, ranging from 26 to 62 years of
age. Results of ROTEM and ROTEM Platelet parameters are
presented in Table I.
For ROTEM parameters we found no statistically significant
difference between samples transported manually compared to
samples transported by PT system in 11 of 16 tested parameters
(Table I, P > 0.003). However, three INTEM parameters showed
a statistically significant reduction after PT transport: clotting
time (CT) (P = 0.002), the amplitude at 10 min after CT (A10)
(P < 0.0001) and maximum clot firmness (MCF) (P < 0.0001).
differences between the two modes of transportation, with a
median relative bias for INTEM CT of 5.9%, while the mean
relative bias for INTEM MCF and A10 was 2.4 and 1.8%, respec-
tively. A reduced CT indicates an increase in coagulation activity
and a reduced MCF and A10 indicates impaired coagulation
strength. Thus, these findings do not reflect a systematic effect
on the coagulation system due to the mode of transport, but
presumably an unsystematic response with little or no clinical
significance.
Thus, our ROTEM data expands results reported in previous
studies, finding no or only subtle effects of PT transport
(6,10,12–14).
In a study by Amann and colleagues (15) that investigated a
PT system of 270 m with a speed of 3 m/s, no impact of PT
transport was observed for EXTEM and INTEM CT, while MCF
was significantly reduced for both tests. Increasing the speed to
7 m/s on the 270 m stretch maintained the reduction in MCF. The
impact of PT transport changed dramatically when the distance
was increased to 1080 m at a speed of 7 m/s, revealing a further
decrease in INTEM CT and a decrease in EXTEM CT (15). The
length of the PT system stretch in the present study was 855 m
and the samples were transported at 3.7 m/s. These findings
support that the impact of PT transport on ROTEM results may
be dependent on both speed and distance.
For the impedance aggregometry parameters ARATEM and
ADPTEM no significant difference was found between samples
transported manually compared to samples transported by PT
system (P > 0.003). These results are in conflict with some
other studies demonstrating significantly reduced platelet aggre-
gation in samples transported by PT system compared to manual
transport (6,16,17). On the other hand, our data are in accordance
with another study reporting no difference in platelet response,
between manual transport and PT transport using light transmis-
sion aggregometry to evaluate the platelet response to arachidonic
acid and adenosine diphosphate (10).
The present study is strengthened by the uniform protocol for
sampling and analysis over a short period of time, minimizing

Table I. ROTEM and ROTEM platelet results. Comparison of results obtained from samples transported manually or by pneumatic tube system. Data
are expressed as median (IQR) or mean ± SD.

Manual transport Pneumatic tube transport P-value Reference interval*

ROTEM EXTEM
CT, s 59 (56; 63.0) 55 (53; 63) 0.04 38–74
CFT, s 82 ± 12 81 ± 12 0.42 34–159
Max Vel, mm/min 16 ± 2 15 ± 2 0.04 8–22
T Max Vel, s 102 ± 19 97 ± 25 0.43 48–154
MCF, mm 63 ± 3 62 ± 3 0.12 48–66
LI30, % 100 (100; 100) 100 (100; 100) >0.99 94–100
A10, mm 56 ± 4 55 ± 4 0.05 43–65
ROTEM INTEM
CT, s 191 (184; 199) 178 (175; 183) 0.002 129–181
CFT, s 78 ± 13 78 ± 12 0.64 30–110
Max Vel, mm/min 16 (14; 18) 16 (14; 18) 0.74 11–25
T Max Vel, s 220 (210; 226) 202 (196; 213) 0.01 147–223
MCF, mm 62 ± 3 60 ± 3 <0.0001 51–67
LI30, % 100 (99; 100) 100 (99; 100) 0.22 94–100
A10, mm 55 ± 3 54 ± 4 <0.0001 44–68
ROTEM FIBTEM
MCF, mm 14 (12; 17) 13 (11; 15) 0.07 8–20
A10, mm 13 (12; 15) 13 (11; 14) 0.11 9–24
ROTEM platelet
ARATEM, ohm/min 92 ± 18 93 ± 20 0.69 42–112
ADPTEM, ohm/min 66 ± 22 69 ± 24 0.32 38–113

*Reference intervals for ROTEM parameters are locally established based on 73 healthy individuals (18), except for A10 where the reference intervals
from Lang et al. (2015) were used (19). For ROTEM platelet reference intervals supplied by the manufacturer were used.
DOI: https://doi.org/10.1080/09537104.2018.1430361
Figure 1. Bland–Altman plots illustrating the relative difference between
manual transport and pneumatic tube transport of samples for ROTEM
parameters. Bland–Altman plots show A) INTEM clotting time (CT), B)
INTEM maximum clot firmness (MCF) and C) INTEM amplitude 10 min
after CT (A10). The Y-axis shows the relative difference in the results
when samples are transported manually relative to samples transported by
the pneumatic tube system. The X- axis is the mean value of the samples
transported manually and transported by the pneumatic tube system. The
grey dotted line indicates the median (CT) or mean (MCF and A10)
difference (%).
variation in the data. The study is limited by the relatively low
number of individuals included, and the fact that only healthy
individuals were investigated.
In conclusion, this study indicates that the minor differences
observed between manual transport and PT transport on some
ROTEM analyses probably did not reflect systematic changes in
the coagulation activity. Further, platelet function measured by
ROTEM Platelet was unaffected by PT transport.
Pneumatic tube transport and whole blood coagulation 3
Acknowledgments
We thank the Department of Clinical Biochemistry, Aarhus University
Hospital, Denmark for supporting this study with reagents and utensils.
Declaration of Interest
The authors declare no conflict of interest regarding the present
manuscript.
ORCID
Niels Tørring http://orcid.org/0000-0001-8450-8052
References
1. Afshari A, Wikkelso A, Brok J, Moller AM, Wetterslev J.
Thrombelastography (TEG) or thromboelastometry (ROTEM) to
monitor haemotherapy versus usual care in patients with massive
transfusion. Cochrane Database Syst Rev. 2011 Mar 16;(3):
CD007871.
2. Holck MH, Christensen TD, Hvas AM. Influence of selected antith-
rombotic treatment on thromboelastometric results. Scand J Clin
Lab Invest. 2017 Nov 20;1–7. [Epub ahead of print]
3. [Internet]; c2017 [cited 2017 12/11]. Available from: https://www.
rotem.de/en/products/rotem-platelet/.
4. Kapoula GV, Kontou PI, Bagos PG. The impact of pneumatic tube
system on routine laboratory parameters: A systematic review and
meta-analysis. Clin Chem Lab Med. 2017 Oct 26;55(12):1834–
1844.
5. Pupek A, Matthewson B, Whitman E, Fullarton R, Chen Y.
Comparison of pneumatic tube system with manual transport for
routine chemistry, hematology, coagulation and blood gas tests. Clin
Chem Lab Med. 2017 Aug 28;55(10):1537–1544.
6. Glas M, Mauer D, Kassas H, Volk T, Kreuer S. Sample transport by
pneumatic tube system alters results of multiple electrode aggrego-
metry but not rotational thromboelastometry. Platelets. 2013;24
(6):454–461.
7. Braun S, Von Beckerath N, Ellert J, Kastrati A, Schomig A, Vogt W,
Sibbing D. Assessment of platelet function in whole blood by
multiple electrode aggregometry: Transport of samples using a
pneumatic tube system. Am J Clin Pathol. 2009 Nov;132(5):802–
804. author reply.
8. Espinosa A, Ruckert A, Navarro J, Videm V, Sletta BV. Are TEG
((R)) results in healthy blood donors affected by the transport of
blood samples in a pneumatic tube system?. Int J Lab Hematol.
2016 Aug;38(4):e73–6.
9. Lance MD, Kuiper GJ, Sloep M, Spronk HM, Van Oerle R, Ten
Cate H, Marcus MA, Henskens YM. The effects of pneumatic tube
system transport on ROTEM analysis and contact activation
assessed by thrombin generation test. Thromb Res. 2012 Sep;130
(3):e147–50.
10. Le Quellec S, Paris M, Nougier C, Sobas F, Rugeri L, Girard S,
Bordet JC, Negrier C, Dargaud Y. Pre-analytical effects of pneu-
matic tube system transport on routine haematology and coagulation
tests, global coagulation assays and platelet function assays. Thromb
Res. 2017 May 153;7–13.
11. Nybo M, Lund ME, Titlestad K, Maegaard CU. Blood sample
transportation by pneumatic transportation systems: A systematic
literature review. Clin Chem. 2017 Dec 8. [Epub ahead of print]
12. Wallin O, Soderberg J, Grankvist K, Jonsson PA, Hultdin J.
Preanalytical effects of pneumatic tube transport on routine haema-
tology, coagulation parameters, platelet function and global coagu-
lation. Clin Chem Lab Med. 2008;46(10):1443–1449.
13. Martin J, Schuster T, Moessmer G, Kochs EF, Wagner KJ.
Alterations in rotation thromboelastometry (ROTEM(R)) para-
meters: Point-of-care testing vs analysis after pneumatic tube system
transport. Br J Anaesth. 2012 Oct;109(4):540–545.
14. Colucci G, Giabbani E, Barizzi G, Urwyler N, Alberio L.
Laboratory-based ROTEM((R)) analysis: implementing pneumatic
tube transport and real-time graphic transmission. Int J Lab
Hematol. 2011 Aug;33(4):441–446.
15. Amann G, Zehntner C, Marti F, Colucci G. Effect of acceleration
forces during transport through a pneumatic tube system on
ROTEM(R) analysis. Clin Chem Lab Med. 2012 Mar 9;50
(8):1335–1342.
4 P. H. Nissen et al.
16. Bolliger D, Seeberger MD, Tanaka KA, Dell-Kuster S, Gregor M,
Zenklusen U, Grapow M, Tsakiris DA, Filipovic M. Pre-analytical
effects of pneumatic tube transport on impedance platelet aggrego-
metry. Platelets. 2009 Nov;20(7):458–465.
17. Thalen S, Forsling I, Eintrei J, Soderblom L, Antovic JP.
Pneumatic tube transport affects platelet function measured by
multiplate electrode aggregometry. Thromb Res. 2013 Jul;132
(1):77–80.
Platelets, Early Online: 1–4
18. Andersen MG, Hvas CL, Tonnesen E, Hvas AM.
Thromboelastometry as a supplementary tool for evaluation of
hemostasis in severe sepsis and septic shock. Acta Anaesthesiol
Scand. 2014 May;58(5):525–533.
19. Lang T, Bauters A, Braun SL, Potzsch B, Von Pape KW, Kolde HJ,
Lakner M. Multi-centre investigation on reference ranges for
ROTEM thromboelastometry. Blood Coagul Fibrinolysis. 2005
Jun;16(4):301–310.