PAGE 144

2023 March; 29(2): 144-149

p-ISSN 0854-4263 e-ISSN 2477-4685
Available at www.indonesianjournalofclinicalpathology.org

A Comparative Study of PTS and Manual Transportation for Platelet

Count and Aggregation Test

Sri Suryo Adiyanti, Bernadette Elvina Setiadi

Department of Clinical Pathology, Faculty of Medicine, the University of Indonesia/ Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
E-mail: theayukari@yahoo.com

ABSTRACT

The transportation effect of the Pneumatic Tube System (PTS) on platelet activity remains controversial. This study
aimed to analyze the effect of PTS in the platelet aggregation test in Dr. Cipto Mangunkusumo Hospital, Jakarta. This
cross-sectional study was carried out in the Clinical Pathology Laboratory of Dr. Cipto Mangunkusumo Hospital (RSUPNCM)
from March to April 2021. There were 50 subjects involved in this study, each of whom 6 sodium citrate blood tubes were
extracted. Three tubes were sent through PTS while the rest were transported manually. All tubes were then tested for
platelet count and platelet aggregation using ADP agonists of 1 μM, 5 μM, and 10 μM. There was a lower platelet count
(p=0.046) and platelet aggregation in ADP 1 μM (p=0.037), ADP 5 μM (p <0.001), and ADP 10 μM (p <0.001) at
PTS-transported samples. Eleven samples were interpreted distinctively as low platelet aggregation in PTS transportation
became normal in manual delivery. Cohen's Kappa value was 0.51 (p <0.001). A decreasing platelet count and platelet
aggregation in PTS samples indicated that acceleration and deceleration during transportation could lead to platelet
activation, thus resulting in a lower result after being added to an agonist. Cohen's Kappa test showed that manual
transportation could not be replaced with PTS for the platelet aggregation test. Platelet count and platelet aggregation were
found to be lower in PTS-transported samples. It was suggested to centralize specimen taking for platelet aggregation tests,
thus manual transportation can be conducted more efficiently.

Keywords: Pneumatic tube system, platelet aggregation, manual transportation

INTRODUCTION transported via PTS and recommended manual

transport for this assay, while other studies found no
A pneumatic Tube System (PTS) is a effect of PTS transport on platelet aggregation
transportation system using pneumatic tubes in assays.1
hospitals, which provides fast interconnection This study was performed to determine the
among units and has been widely used to transport influence of PTS compared to manual transportation
samples to laboratories, thereby reducing sample on the platelet count and platelet aggregation at the
delivery time and turnaround time in the laboratory. Clinical Pathology Laboratory of RSUPNCM.
During transportation, various physical factors such
as rapid acceleration, deceleration, and the radial METHODS
gravitational force received by the sample can cause
preanalytical stage problems, such as hemolysis, cell This study used a cross-sectional design
damage, and activation, which can affect the analysis conducted at the Clinical Pathology Laboratory of
results.1 RSUPNCM from March 2021 to April 2021. The target
Problems in the preanalytic stage still occur in the population was the general population at
hemostasis test, including during sampling, sample RSUPNCM. The research subjects were students of
transportation, and sample storage. Transport Specialist Medical Education and laboratory staff at
through PTS in hemostasis studies has been the Department of Clinical Pathology, Faculty of
investigated and yielded contradictory results. Medicine, University of Indonesia (FKUI)/RSUPNCM
According to Lorenzen et al., sample acceleration who met the inclusion criteria. The inclusion criteria
and deceleration in PTS affect platelet function. A in this study were all research subjects aged 20-60
platelet function test can be carried out by analyzing years, adult age according to the World Health
its aggregation.1 Several studies demonstrated Organization (WHO), and were willing to fill out
decreased platelet aggregation in samples informed consent. The exclusion criteria in this study

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Indonesian Journal of Clinical Pathology and Medical Laboratory, 2023 March, 29 (2) : 144 -149 PAGE 145

were patients without fasting for at least 8 hours the remaining three tubes were sent via manual
before sampling, clotted, lysed, insufficient blood delivery and were then analyzed within 30-120
sample, patients who smoked within 30 minutes minutes.
before sampling, and patients whose platelet count First, Platelet Rich Plasma (PRP) was prepared by
was less than 100,000/μL in samples transported by centrifuging the blood at a speed of 1000 rpm or 100
manual delivery.2 Calculation of the sample size was g for 15 minutes and then the plasma obtained was
determined based on the regulation by Clinical and transferred to a cuvette of at least 1500 L, the platelet
Laboratory Standards Institute (CLSI) EP09-A3, which count was analyzed using a Sysmex XN-1000
required a minimum sample size of 40 to analyze the hematology analyzer. The PRP platelet count should
comparison between the two methods.3 The sample be 200,000-300,000/L; a platelet count of less than
size in this study was set at 50 samples. The accuracy 100,000/L will lead to difficult to determine an optical
test carried out was a within-run test 5 times in a row baseline. Furthermore, the remaining blood in the
from one normal subject on the same day. The basic citrate tube was centrifuged again at 2400 g for 20
data on the characteristics of the research subjects minutes and was then transferred to a 500 L cuvette
such as age and gender were taken from the as Platelet Poor Plasma (PPP).4
National Identity Card (KTP). Blinding was not Platelet aggregation test was carried out using a
implemented in this study because the type of data Chrono-Log 490 aggregator with the Turbidimetric
was objective data obtained from measurements method according to Born based on changes in light
following the research flow in Figure 1. transmission as shown in Figure 2. Before the
A platelet aggregation test was carried out to addition of agonists, PRP light transmission was low
analyze the function of platelets by using ADP because platelets were still homogeneously
agonists with concentrations of 1 M, 5 M, and 10 M. suspended. After the addition of an agonist, platelets
The test used a whole blood sample from a vein undergo primary aggregation, then the aggregate
which was collected in a 3 mL tube containing 0.109 releases endogenous ADP, which causes secondary
M Na citrate anticoagulant in 6 tubes with Na citrate: aggregation and precipitates, leading to the
blood equal to 1:9. Three tubes were sent via PTS and production of clear plasma and increased light
transmission as described in Figure 3. The biological

PPDS participants or employees of the RSCM Central Laboratory of the Department of Clinical
Pathology, FKUI-RSCM

Inclusion criteria :
o 20-60 years old
Willing to fill out informed consent

Yes No

Exclusion criteria :
Yes
o The patient did not fast Not included in the research
o Frozen, lysed, an insufficient blood sample
o The patient smoked 30 minutes before sampling
No

μ 6 tubes of Whole blood with anticoagulant Na Citrate

Delivery of samples via PTS Sample delivery via manual delivery

and platelet count test and platelet count test

Platelet aggregation test and interpretation of results

statistic test

Figure 1. Research flowchart

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Indonesian Journal of Clinical Pathology and Medical Laboratory, 2023 March, 29 (2) : 144 -149 PAGE 146

reference value for ADP 1 M was 3-15%, ADP 5 M was

25-68%, and ADP 10 M was 49-84%.4

Figure 4. Pneumatic tube system6

The Clinical Pathology Laboratory of RSUPNCM

uses the PTS Aerocom AC3000 fully automatic
system in which users do not need to search for the
address of the destination station but simply place a
Figure 2. The working principle of the light tube carrier on the sending panel, each of which
transmission device according to Born5 connects each station. The PTS speed used is 3-4 m/s
from all stations and the return speed to all stations is
6-8 m/s, the speed can be changed as needed. Speed
The PTS is a transportation system for distributing is affected by the load of the sample being sent, a
goods between units using tubes, consisting of a maximum of 2.5 kg. The size of the system used is
sending station and a receiving station connected by Outside Diameter 110 (OD 110), i.e., the pipe
a pressurized pipeline, as shown in Figure 4. At the diameter at the PTS is 110 mm. The sample receiving
sending and receiving stations there are blowers or line uses rails to reduce impact when the tube carrier
air pumps as well as sounds or lights, which flash to containing the sample arrives. The length of the PTS
signal when a tube has just been received. The blower line at the 24-hour laboratory counter to the Clinical
can suck air from the tube or blow air into it according Pathology Laboratory RSUPNCM is 75 m.7 Manual
to the needs of the tube delivery direction, the tube delivery is a method of sending samples by courier
movement speed is determined by the blower force, on foot from each counter to the Clinical Pathology
the stronger the suction force or the blower thrust laboratory using a sample storage box without ice
force, the faster the tube movement. Its speed can cubes, the sample is in a position vertically at room
reach 10 m/s, equivalent to 5-6 times faster than temperature.
walking.6

Figure 3. (A) Illustration of PRP sample before the addition of agonist, low light transmittance. (B) Illustration of
PRP sample after addition of agonist, light transmittance increases. (C) PRP samples before and after
the addition of agonist

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Indonesian Journal of Clinical Pathology and Medical Laboratory, 2023 March, 29 (2) : 144 -149 PAGE 147

Data processing was carried out using the SPSS A total of 50 subjects who met the inclusion
version 25 program. The accuracy test was used to criteria were included in this study consisting of 12
determine the average value, standard deviation, (24%) males and 38 (76%) females with a median age
and Coefficient of Variation (CV). Numerical variables of 34 years. The description of the characteristics of
were tested for normality to determine the the subject can be seen in Table 2.
distribution of data using the Saphiro-Wilk test
Table 2. Characteristics of research subjects
because the number of samples was < 50. Numerical
data were presented in mean and standard deviation Characteristics n=50
if the data distribution was normal or median and the
Age 34 (26-57)
minimum maximum value if the data distribution
Gender
was not normal. If the data distribution is normal,
Male 12 (24%)
then the mean difference between the examination
Female 38 (76%)
results of the samples sent by PTS and manual
submissions can be assessed by paired T-test. If the
The mean platelet count and platelet aggregation
data distribution is not normal, then the difference
with ADP agonists 1, 5, and 10 M in samples
between the two means can be analyzed by the
transported via PTS and manual delivery can be seen
Wilcoxon test. The Kappa test was conducted to
in Table 3.
assess the suitability of the interpretation of platelet
The results of the Saphiro-Wilk test results
aggregation results between samples sent via PTS
showed that data of platelet count and platelet
and manual delivery.
This research has been approved by the Research aggregation with ADP 1, 5, and 10 M in samples
Ethics Committee of the Faculty of Medicine, transported by PTS and manual delivery were not
University of Indonesia/Cipto Mangunkusumo normal (p>0.05). The mean platelet count and
Hospital with the number KET-113/UN2.F1/ETIK/ platelet aggregation with ADP 1, 5, and 10 M were
PPM.00.02/2021. presented in the median form (min–max) and
followed by the Wilcoxon test. Wilcoxon test results
RESULTS AND DISCUSSIONS showed p < 0.05, which indicated that there was a
significant difference between the mean platelet
The results of the within-run platelet aggregation count and platelet aggregation results with ADP 1, 5,
accuracy test using ADP 1, 5, and 10 M agonists can and 10 M in samples transported by PTS and manual
be seen in Table 1. delivery.

Table 1. In-run accuracy test of platelet aggregation against ADP 1, 5, and 10 M in the clinical pathology
laboratory of RSUPNCM
Test ADP 1 µM (%) ADP 5 µM (%) ADP 10 µM (%)
1 0 32 70
2 0 22 61
3 0 28 78
4 0 45 71
5 0 29 71
Mean 0 31.2 70.2
SD 0 8.5 6.1
CV (%) 0 27.3 8.6

Table 3. Mean platelet count, and platelet aggregation results with ADP 1, 5, and 10 M in samples transported
by PTS and manual delivery
Transportation
Parameter Difference in Results p-value
PTS Manual
3
Platelet count (x 10 /μL) 230.5 (54–329) 242.5 (105–323) 7.5 (-87–159) 0.046
ADP 1 μM (%) 0 (0–11) 1 (0–12) 0 (-5–9) 0.037
ADP 5 μM (%) 15.5 (0–88) 25 (0–72) 6 (-24–43) <0.001
ADP 10 μM (%) 35 (0–84) 60 (1–88) 9.5 (-24–50) <0.001

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Indonesian Journal of Clinical Pathology and Medical Laboratory, 2023 March, 29 (2) : 144 -149 PAGE 148

Table 4. Interpretation of platelet aggregation results with ADP 1, 5, and 10 M in samples transported by PTS
and manual delivery
Interpretation of Platelet Transportation
Aggregation Results with ADP 1, 5,
and 10 µM PTS Manual
Low platelet aggregation 31 (62%) 20 (40%)
Normal platelet aggregation 19 (38%) 30 (60%)
High platelet aggregation 0 0

Table 5. The results of the Kappa suitability analysis of platelet aggregation in samples transported by PTS and
manual delivery
Platelet aggregation test results
Total Kappa p-value
with PTS
Low Normal High
Platelet Low 20 0 0 20 0.51 <0.001
aggregation test Normal 11 19 0 30
results with manual High 0 0 0 0
delivery transport Total 31 19 0 50

The interpretation of platelet aggregation results variable CV in some studies.5

was divided into 3, such as low, normal, and high This study did not analyze the characteristics of
platelet aggregation. In samples transported by PTS, the research subjects. There was a significant
31 subjects had low platelet aggregation and 19 decrease in the platelet count in the samples sent via
subjects had normal platelet aggregation. These PTS with a p-value of 0.046. This was similar to a
results were different from the samples transported study by Subbarayan et al. in India with a total of 75
by manual delivery, which showed 20 subjects with research subjects, which reported a significant
low platelet aggregation and 30 subjects with decrease in the platelet count in samples sent via PTS
normal platelet aggregation as shown in Table 4. with a p-value of <0.001.8
There were 11 samples with different interpretations: Thalen et al. found a decrease of up to 20% in
from low platelet aggregation in PTS transport to platelet aggregation results in all samples
normal platelet aggregation on manual transport. transported by PTS compared to manual transport
Kappa analysis was carried out on the interpretation with p < 0.001.1 This was similar to several results,
of platelet aggregation results and showed a which found that there was a significant decrease in
sufficient level of Kappa suitability (Kappa=0.510; p < platelet aggregation in all concentrations of ADP and
0.01), as shown in Table 5. the most significant decrease in ADP 5 M and 10 M
The within-run accuracy test on the Chrono-Log with p-values of both <0.01. The lower platelet
490 aggregator obtained a CV of 0% at 1 M ADP, aggregation results in PTS indicate that the
27.3% at 5 M ADP, and 8.6% at 10 M ADP. Overall, the acceleration and deceleration that occurs during
CV obtained was better when compared to the sample delivery can trigger platelet activation, which
research conducted by Wirawan.4 The results of 0% results in lower platelet aggregation in samples sent
CV at 1 M ADP showed that the instrument via manual delivery when an agonist is added.
consistently gave 0% results on the same sample for The results of the Kappa suitability analysis for
5 measurements. At 5 M ADP obtained a CV of 27.3%, platelet aggregation showed sufficient suitability of
this CV variation was greater when compared to 0.51. The Kappa value, which is considered good and
research conducted by Wirawan, which reported a can replace each other is > 0.8. These results prove
CV variation of 13.2%. At 10 M ADP obtained a CV of that the manual transportation method is not good
8.6%, this result was relatively better compared to when it is replaced with PTS in the platelet
research conducted by Wirawan, which was 12.1%.4 aggregation test. There were 11 samples (22%) that
Platelet aggregation test with the principle of had contradictory results of the platelet aggregation
changes in light transmission is the gold standard; test, namely from low platelet aggregation in
however, there is no commercial control available to samples through PTS to normal platelet aggregation
check the validity of the test results, which results in a in samples sent via manual delivery.

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Indonesian Journal of Clinical Pathology and Medical Laboratory, 2023 March, 29 (2) : 144 -149 PAGE 149

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