Blood Collection

BLOOD COLLECTION:ROUTINE VENIPUNCTURE AND SPECIMEN HANDLING

A lecture by:

Maximo B. Axibal, Jr.

MD FPSP

Objectives

Describe the venipuncture process: Proper patient ID procedures Proper equipment selection/ use Proper labeling procedures & completion of

laboratory requisitions Order of draw for multiple tube phlebotomy Preferred venous access sites, & factors to

consider in site selection, & ability to differentiate between the feel of a vein, tendon & artery

Objectives

Patient care following completion of venipuncture

Safety & infection control procedures Quality assurance issues Identify the additive, its function, volume, &

specimen considerations to be followed for each of the various color coded tubes

List 6 areas to be avoided when performing venipuncture & the reasons for the restrictions

Objectives

Summarize the problems that may be encountered in accessing a vein, including the procedure to follow when a specimen is not obtained

List several effects of exercise, posture, & tourniquet application upon laboratory values

The Art ofPhlebotomyThe Art ofPhlebotomy

“The quality of laboratory results is critically dependent on the specimen presented for analysis.”

“The quality of laboratory results is critically dependent on the specimen presented for analysis.”

PHLEBOTOMY

Procedure wherein blood is collected from a vein using a needle for diagnostic, therapeutic, or blood donation purposes.

Role of the phlebotomistRole of the phlebotomist

PRO for the laboratoryPatient’s “window” to the laboratoryCritical link between patient, patient’s

physician & clinical laboratoryDelivers quality laboratory services & over-all

patient care through correct blood collection practices.

PRO for the laboratoryPatient’s “window” to the laboratoryCritical link between patient, patient’s

physician & clinical laboratoryDelivers quality laboratory services & over-all

patient care through correct blood collection practices.

SCOPE OF PHLEBOTOMY

Skin punctureVenipunctureArterial punctureBleeding time

VENIPUNCTURE PROCEDURE

Complex procedure (knowledge & skill) Phlebotomist establishes a routine of her/

his own Essential steps for successful collection

procedure: ID patient Assess patient's physical disposition (i.e.

diet, exercise, stress, basal state)


Check requisition form for requested tests, patient information, & any special requirements

Select suitable site for venipuncture Prepare equipment, patient & puncture site Perform venipuncture Collect sample in appropriate container


Recognize complications associated w/ procedure

Assess need for sample recollection &/or rejection

Label collection tubes at bedside or drawing area

Promptly send specimens w/ requisition to the laboratory

ORDER FORM/ REQUISITION

Requisition form must accompany each sample submitted. Essential elements:

Patient's surname, first name, & middle initial

Patient's ID number Patient's date of birth & gender Requesting physician's complete name

ORDER FORM/ REQUISITION

Source of specimen (microbiology, cytology, fluid analysis, or other testing where analysis & reporting is site specific)

Date & time of collection Initials of phlebotomist Indicating test(s) requested

Sample of requisition form

LABELING THE SAMPLE

Properly labeled sample- Key Elements: Patient's surname, first & middle Patient's ID number

NOTE: Both of the above MUST match same on the requisition form

Date, time & initials of phlebotomist must be on the label of EACH tube

Sample of a requisition form

EQUIPMENT

Evacuated Collection Tubes: Designed to fill w/ a predetermined vol of

blood by vacuum Rubber stoppers (color coded according to

additive content) Various sizes are available Blood should NEVER be poured from 1 tube

to another (tubes can have different additives or coatings)

EQUIPMENT

Needles Gauge # = bore

size For evacuated

systems, use w/ a syringe, single draw or butterfly system

Holder/ Adapter (vacutainer)

Tourniquet Wipe off with

alcohol & replace frequently

Alcohol Wipes 70% isopropyl

alcohol

EQUIPMENT

Povidone-iodine wipes/ swabs (blood culture)

Gauze sponges- Apply on site from site of puncture

Adhesive bandages/ tape protects puncture site post collection

Needle disposal unit Should NEVER be

broken, bent, or recapped

Should be placed in proper disposal unit IMMEDIATELY after use

EQUIPMENT

Gloves (latex, rubber, vinyl) to protect patient & phlebotomist

Syringes used in place of evacuated collection tube for special circumstances

ORDER OF DRAW

To avoid cross-contamination of additives between tubes

Recommended order of draw is:

1st- blood culture tube (yellow-black stopper)

2nd- non-additive tube (red stopper or SST)

ORDER OF DRAW

3rd- coagulation tube (light blue stopper)

NEVER the first tube drawnIf a coagulation assay is the only test

ordered, draw a non-additive tube (red stopper or SST) first, then draw the light blue stopper tube

ORDER OF DRAW

Last draw- additive tubes in this order: Heparin (dark green stopper) EDTA (lavender stopper) Oxalate/ fluoride (light gray stopper)

NOTE: Tubes w/ additives must be thoroughly mixed. Erroneous test results may be obtained if not thoroughly mixed

PROCEDURAL ISSUES

PATIENT RELATIONS & IDENTIFICATION: Phlebotomist's role (A Professional),

courteous & understanding manner in all contacts w/ patient

Greet patient & identify yourself & indicate procedure that will take place

Effective communication- both verbal & nonverbal- is essential

PROCEDURAL ISSUES

PATIENT RELATIONS & IDENTIFICATION: Proper patient ID MANDATORY In-patient able to respond, ask full name &

always check armband for confirmation DO NOT DRAW BLOOD IF ARMBAND IS

MISSING OPD must provide ID other than verbal

statement of name. Using requisition for reference, ask patient to provide additional information (surname or birthdate)

PROCEDURAL ISSUES

PATIENT RELATIONS & IDENTIFICATION: Speak w/ the patient during the process.

Patient who is at ease will be less focused on the procedure

Always thank patient & excuse yourself courteously when done

VENIpuncture SITE SELECTION

Median cubital & cephalic veins of arm (most frequent)

Wrist & hand veins also acceptable Areas to be avoided:

Extensive scars (burns & surgery) Upper extremity on side of previous

mastectomy Hematoma- If another site not available,

collect specimen distal to hematoma


Areas are to be avoided: IVT/ BT- collect from opposite arm if possible.

Or, draw below IV by follow procedures: Turn off IV at least 2 mins pre venipuncture Apply tourniquet below IV site. Select vein

other than one w/ IV Perform venipuncture. Draw 5 ml of blood &

discard before drawing specimen tubes for testing


Areas are to be avoided: Cannula/ fistula/ heparin lock- consult 1st

attending physician Edematous extremities

PROCEDURE FOR VEIN SELECTION

Palpate & trace path of veins w/ index finger Arteries pulsate, elastic & have thick wall Thrombosed veins lack resilience, feel cord-

like & roll easily

PROCEDURE FOR VEIN SELECTION

If superficial veins not apparent, force blood into vein by:

Massage arm from wrist to elbow Tap site w/ index & 2nd finger Apply warm, damp washcloth to the site for 5

mins Lower extremity over bedside to allow veins

to fill

PERFORMANCE OF A VENIpuncture

Approach patient in a friendly, calm manner. Provide comfort as much as possible, gain patient's cooperation

Identify patient correctly Properly fill out appropriate requisition

forms, indicating test(s) ordered Verify patient's condition. Fasting, dietary

restrictions, medications, timing, & medical treatment noted on requisition


Position the patient (sit on a chair, lie down or sit up in bed). Hyperextend patient's arm

Apply tourniquet 3 - 4 inches above selected puncture site. Do not place too tightly or leave on > 2 mins

The patient should make a fist w/o pumping the hand

Select venipuncture site


Prepare patient's arm using an alcohol prep. Cleanse in a circular fashion, beginning at the site & working outward. Allow to air dry

Grasp patient's arm firmly using your thumb to draw skin taut & anchor the vein. Needle should form a 15 to 30 degree angle w/ the surface of the arm. Swiftly insert needle through skin & into lumen of the vein. Avoid trauma & excessive probing

CLEANSE BY MOVING ALCOHOL PREP PAD IN CONCENTRIC CIRCLES AWAY FROM SITE


When last tube to be drawn is filling, remove tourniquet

Remove needle from patient's arm using a swift backward motion

Press down on the gauze once needle is out of the arm, applying adequate pressure to avoid formation of a hematoma


Dispose of contaminated materials/ supplies in designated containers

Mix & label all appropriate tubes at patient bedside

Deliver specimens promptly to the laboratory

ADDITIONAL CONSIDERATIONS

To prevent a hematoma: Puncture only uppermost wall of vein Remove tourniquet before removing needle Use major superficial veins Make sure needle fully penetrates upper most

wall of vein. (Partial penetration allow blood to leak into soft tissue surrounding vein via the needle bevel)

Apply pressure to venipuncture site


To prevent hemolysis: Mix tubes w/ AC additives gently 5-10 times Avoid drawing blood from a hematoma Avoid drawing plunger back too forcefully, if

using a needle & syringe, & avoid frothing of sample

Make sure venipuncture site is dry Avoid a probing, traumatic venipuncture


Indwelling Lines or Catheters: Potential source of test error Most lines are flushed w/ a solution of

heparin to reduce risk of thrombosis Discard sample at least 3x the volume of the

line before a specimen is obtained for analysis


Hemoconcentration due to: Prolonged tourniquet application (no > 2

minutes) Massaging, squeezing, or probing a site Long- term IVT Sclerosed or occluded veins


Prolonged Tourniquet Application: Primary effect is hemoconcentration of non-

filterable elements (proteins). HP causes some H2O & filterable elements to leave extracellular space

Significant increases in TP, AST, total lipids, cholesterol, Fe

Affects packed cell volume & other cellular elements

ADDITIONAL CONSIDERATIONS Patient Preparation Factors:

Therapeutic Drug Monitoring: Pharmacologic agents have patterns of

administration, body distribution, metabolism, & elimination that affect drug concentration as measured in the blood.

Drugs will have "peak" & "trough" levels that vary according to dosage levels & intervals

Check for timing instructions for drawing appropriate samples


Effects of Exercise: Muscular activity w/ transient & longer term

effects. Inc in CK, AST, LDH, & platelet ct Stress: Transient elevation in WBC's & elevated adrenal

hormone values (cortisol/ catecholamines) Anxiety resulting to hyperventilation may cause

acid-base imbalances, & increased lactate


Diurnal Rhythms: Body fluid & analyte fluctuations during day Serum cortisol levels highest in early AM

but decreased in PM Serum Fe levels drop in AM Check timing of variations for desired

collection point


Posture: (supine to sitting etc.) Certain larger molecules not filterable into

tissue, therefore more concentrated in blood Enzymes, CHONs, lipids, Fe, & Ca

significantly increased


Other Factors: Age Gender Pregnancy Normal reference ranges are often noted

according to age

SAFETY AND INFECTION CONTROL - PROTECT YOURSELF

Universal Precautions: Wear gloves & lab coat/ gown when handling

blood/ body fluids Change gloves after each patient or when

contaminated Wash hands frequently Dispose of items in appropriate containers Dispose of needles ASAP upon removal from

patient's vein. Do not bend, break, recap, or resheath needles to avoid accidental needle puncture or splashing of contents


Clean up any blood spills w/ disinfectant (freshly 10% bleach)

If you stick yourself w/ contaminated needle: Remove your gloves & dispose properly Squeeze puncture site to promote bleeding Wash area well w/ soap & water Record patient's name & ID number Follow institution's guidelines regarding

treatment & follow-up


Use of prophylactic zidovudine following blood exposure to HIV has shown effectiveness (about 79%) in preventing seroconversion

SAFETY AND INFECTION CONTROL

PROTECT THE PATIENT Place blood collection equipment away from

patients (children & psychiatric patients) Practice hygiene for patient's protection.

When wearing gloves, change them between each patient & wash your hands frequently

Always wear a clean lab coat or gown

TROUBLESHOOTING GUIDELINES:

IF AN INCOMPLETE COLLECTION OR NO BLOOD IS OBTAINED:

Change position of needle (Move it forward)

May not be in the lumen


Or move it backward

May have penetrated too far


Adjust the angle Bevel may be

against the vein wall


Loosen tourniquet

Try another tube

Re-anchor the vein

It may be obstructing blood flow

There may be no vacuum in the one being used

Veins sometimes roll away from the point of the needle & puncture site


IF BLOOD STOPS FLOWING INTO THE TUBE:

Vein collapsed; resecure tourniquet to ^ venous filling. If unsuccessful, remove needle, take care of puncture site, & redraw


Needle may have pulled out of the vein when switching tubes

Hold equipment firmly & place fingers against patient's arm, using the flange for leverage when withdrawing & inserting tubes

PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION:

A hematoma forms under the skin adjacent to puncture site - release tourniquet ASAP & withdraw needle. Apply firm pressure.

PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION:

The blood is bright red (arterial) rather than venous

Apply firm pressure for more than 5 mins

Common adverse reactions to blood collectionCommon adverse reactions to blood collection

RXN SYMPTOMS FIRST AID

Fainting Dizziness, pallor, Rx tourniquet

sweating, & needle, apply

unconsciousness pressure on site &

elevate arm, spirit

of ammonia, orange

drink when conscious


Nausea/

vomiting Same Ask patient to take deep breath; cold

compress on nape & forehead

Hematoma Swelling; Remove tourniquet, needle.

purple color Apply pressure & elevate

at site arm. Cold compress after

5 min. if needed

Common adverse reactions to blood collection


Tetany Muscular

twitches Inhale &

& spasms exhale into

paper bag

placed around

mouth & nose

Common adverse reactions to blood collection

COLLECTION TUBES FOR PHLEBOTOMY

Red Top ADDITIVE: None MODE OF ACTION: Blood clots, serum

separated by centrifugation USES: Chemistries, Immunology &

Serology, BB (Xmatch)


Gold Top ADDITIVE: None MODE OF ACTION: Serum separator

tube (SST) contains gel at bottom to separate blood from serum on centrifugation

USES: Chemistries, Immunology & Serology


Light Green Top ADDITIVE: Plasma Separating Tube

(PST) w/ Li heparin MODE OF ACTION: Anticoagulates w/

Li heparin; Plasma separated w/ PST gel at bottom of tube

USES: Chemistries


Red-Gray Top ADDITIVE: Serum Separating Tube

(SST) w/ clot activator MODE OF ACTION: Forms clot quickly

& separates serum w/ SST gel at bottom of tube

USES: Chemistries


Purple Top ADDITIVE; EDTA liquid MODE OF ACTION: Forms Ca salts to

remove Ca USES: Hematology (CBC) & BB

(Xmatch); requires full draw- invert 8 X to prevent clotting & platelet clumping


Light Blue Top ADDITIVE: Na citrate MODE OF ACTION: Forms Ca salts to

remove CaUSES: Coagulation tests (PT & APTT),

full draw required


Dark Green Top ADDITIVE: Na or Li heparin MODE OF ACTION: Inactivates

thrombin & thromboplastin USES: For Li level (use Na heparin)

For NH3 level (use Na or Li heparin)


Dark Blue Top ADDITIVE: Na EDTA MODE OF ACTION: Forms Ca salts

Tube is designed to contain no contaminating metals

USES: For Li level (use Na heparin) Trace element testing (zinc, copper, lead, mercury) & toxicology


Light Gray Top ADDITIVE: Na fluoride & K oxalate MODE OF ACTION: Antiglycolytic agent

preserves glucose up to 5 days USES: For Li level (Na heparin)

Glucoses, requires full draw (may cause hemolysis if short draw)


Yellow Top ADDITIVE: ACD (acid-citrate-dextrose) MODE OF ACTION: Complement

inactivation USES: HLA tissue typing, paternity

testing, DNA studies


Yellow - Black Top ADDITIVE: Broth mixture MODE OF ACTION: Preserves viability

of microorganisms USES: Microbiology - aerobes,

anaerobes, fungi


Black Top ADDITIVE: Na citrate (buffered) MODE OF ACTION: Forms Ca salts to

remove Ca USES: Westergren Sedimentation Rate;

requires full draw


Orange Top ADDITIVE: Thrombin MODE OF ACTION: Quickly clots blood USES: STAT serum chemistries


Brown Top ADDITIVE; Na heparin MODE OF ACTION: Inactivates

thrombin & thromboplastin USES: Serum Pb determination

Capillary (skin) Puncture: Main Indications

Infants & children (required to fulfill physician orders)

Adults (required to satisfy order & where venous access is limited)

For certain Point-of-Care (POC) testing (glucose & protime (INR) monitoring)

Capillary (skin) Puncture: Indications

Others: (Adults) Oncology patients undergoing

chemotherapy Some geriatric patients Obese patients Drug addicts Severe burn patients Patients w/ clotting tendencies

Skin puncture cannot be used where larger volumes are required:

BB procedures ESR Blood cultures Coagulation studies

Capillary Blood Composition:

Skin puncture lacerates venules, arterioles & capillaries (mixture of venous & arterial blood + intracellular/ interstitial fluids)

Due to Arterial Pressure, higher portion of blood collected by skin puncture is arterial

More pronounced when skin is prewarmed before puncture (arterialization of capillary blood)

Capillary Blood Composition:

As a consequence, normal venous reference values may differ when blood is collected by skin puncture

Glucose is higher in capillary puncture Calcium, TP & K are lower in capillary puncture

Puncture Sites:

Most frequent: Lateral surface of Heel

for neonates/ infants (small/ premature)

Fingers (large infants, children & adults)

Plantar surface of great toe (larger infant)

Others: Adults & children

Fleshy area of distal portion of index, middle & ring finger

Most adults will prefer non-dominant hand

Precautions:

Never perform capillary puncture of: Earlobe Central area of the infant's heel Finger of a small infant Swollen, cyanotic, scarred, w/ rashes or

previously punctured site From an extremity affected by visible edema

Precautions:

Isopropyl alcohol must be used for cleansing site

Site must be air dried or wiped w/ sterile gauze (w/ alcohol hemolysis unreliable results)

DO NOT use Betadine falsely elevate K, phosphorus & UA levels

PERFORMANCE OF A FINGERSTICK

Follow steps 1- 5 as for venipuncture Best sites: 3rd & 4th fingers of non-dominant

hand Do not use tip or center of finger (less soft

tissue, vessels & nerves are located, & bone closer to surface)

2nd (index) finger (thicker, callused skin) 5th finger (less soft tissue overlying bone)


Use sterile lancet, skin puncture just off center of finger pad. Perpendicular to ridges of fingerprint so drop of blood does not run down ridges

Wipe away 1st drop of blood (excess tissue fluid) Collect drops of blood into collection device by

gently massaging finger. Avoid excessive pressure, may squeeze tissue fluid into drop of blood

Puncture Sites:

Incision made should run across grain of the fingerprint

If in the same direction as the fingerprint, blood will tend to flow down the finger instead of collecting in a nice large, round drop

APPROPRIATE TECHNIQUE FOR

GRASPING FINGER FOR FINGERSTICK


Cap, rotate & invert collection device to mix blood collected

Have patient hold a small gauze pad over puncture site for a couple of minutes to stop bleeding

Follow steps 14- 16 as venipuncture

BLOOD COLLECTION ON BABIES:

Recommended location for blood collection on a NB or infant is the heel

Green- proper area to use for heel punctures

APPROPRIATE TECHNIQUE FOR

GRASPING FOOT FOR HEELSTICK


Prewarm infant's heel (42oC, 3 to 5 mins) to obtain capillary blood for blood gas samples & increases blood flow for collection of other specimens. Do not use too high a temperature warmer, because baby's skin is thin & susceptible to thermal injury

Clean site to be punctured w/ alcohol sponge. Dry cleaned area w/ dry cotton sponge. Hold baby's foot firmly to avoid sudden movement


Use sterile blood lancet, puncture side of the heel in appropriate regions

Do not use central portion of heel (injure underlying bone close to skin surface

Do not use a previous puncture site Make cut across heelprint lines so that a drop

of blood can well up & not run down along the lines


Wipe away 1st drop of blood w/ clean, dry cotton

Newborns do not often bleed immediately, use gentle pressure to produce a rounded drop of blood (excessive pressure or heavy massaging cause blood to become diluted with tissue fluid

Fill capillary tube(s) or micro collection device(s) as needed.


When finished, elevate heel, place a piece of clean, dry cotton on puncture site, hold in place until bleeding has stopped

Dispose lancet in appropriate sharps container & contaminated materials in appropriate waste receptacles

Remove your gloves & wash your hands

Heelstick Technique:

Inspect heel & avoid areas w/ previous scarring or damage


Preheat area w/ commercial heel warmer or moist warm washcloth


Grasp foot so heel is exposed between thumb & index finger

Disinfect w/ alcohol

Wipe dry w/ sterile 2x2 gauze pads


Gently squeeze heel to help pool blood

Orient blade to cut across grain of heel

Apply firm pressure & activate lancet trigger

Correct amount of pressure comes w/ experience

Newer devices automatically pierce a defined depth of approximately 1.0 mm


Wipe 1st drop of blood to reduce tissue fluid contamination


Allow drops to collect on heel & gently touch drop w/ lip of specimen tube

Try not to scrap lip against incision site

Anticoagulated specimens, agitate frequently during collection (snap finger against bottom of tube)


Apply gentle pressure to site till bleeding ceases

Properly dispose of lancet on sharps container & contaminated supplies in appropriate biohazard container

Order of Draw:

Blood gases EDTA - Lavender Blood film Other additives Clot tubes - Red top

Blood Collection

Documents

patient information

specimens w requisition

requisition formdate

specimen considerations

site selection

sample recollection

routine venipuncture

specimen handlinga lecture