Phlebotomy in a Nutshell

Phlebotomy in a NutshellPhlebotomy in a Nutshell

ROUTINE VENIPUNCTURE AND ROUTINE VENIPUNCTURE AND SPECIMEN HANDLINGSPECIMEN HANDLING

ObjectivesObjectives Describe and perform the venipuncture process Describe and perform the venipuncture process

including:including:1.1. Proper patient identification procedures.Proper patient identification procedures.2.2. Proper equipment selection and use.Proper equipment selection and use.3.3. Proper labeling procedures and completion of laboratory Proper labeling procedures and completion of laboratory

requisitions.requisitions.4.4. Order of draw for multiple tube phlebotomy.Order of draw for multiple tube phlebotomy.5.5. Preferred venous access sites, and factors to consider in site Preferred venous access sites, and factors to consider in site

selection, and ability to differentiate between the feel of a selection, and ability to differentiate between the feel of a vein, tendon and artery.vein, tendon and artery.

6.6. Patient care following completion of venipuncture.Patient care following completion of venipuncture.7.7. Safety and infection control procedures.Safety and infection control procedures.

8.8. Quality assurance issuesQuality assurance issues..

ObjectivesObjectives

Identify the additive, additive function, volume, and Identify the additive, additive function, volume, and specimen considerations to be followed for each of specimen considerations to be followed for each of the various color coded tubes.the various color coded tubes.

List six areas to be avoided when performing List six areas to be avoided when performing venipuncture and the reasons for the restrictions.venipuncture and the reasons for the restrictions.

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

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

VENIPUNCTURE PROCEDUREVENIPUNCTURE PROCEDURE

The venipuncture procedure is complex, The venipuncture procedure is complex, requiring both knowledge and skill to perform. requiring both knowledge and skill to perform. Each phlebotomist generally establishes a Each phlebotomist generally establishes a routine that is comfortable for her or him. routine that is comfortable for her or him. Several essential steps are required for every Several essential steps are required for every successful collection procedure: successful collection procedure:

Identify the patient.Identify the patient. Assess the patient's physical disposition (i.e. diet, exercise, Assess the patient's physical disposition (i.e. diet, exercise,

stress, basal state).stress, basal state). Check the requisition form for requested tests, patient Check the requisition form for requested tests, patient

information, and any special requirements.information, and any special requirements. Select a suitable site for venipuncture.Select a suitable site for venipuncture. Prepare the equipment, the patient and the puncture site.Prepare the equipment, the patient and the puncture site. Perform the venipuncture.Perform the venipuncture. Collect the sample in the appropriate container.Collect the sample in the appropriate container. Recognize complications associated with the phlebotomy Recognize complications associated with the phlebotomy

procedure.procedure. Assess the need for sample recollection and/or rejection.Assess the need for sample recollection and/or rejection. Label the collection tubes at the bedside or drawing area.Label the collection tubes at the bedside or drawing area. Promptly send the specimens with the requisition to the Promptly send the specimens with the requisition to the

laboratory.laboratory.

ORDER FORM / REQUISITIONORDER FORM / REQUISITION A requisition form must accompany each sample submitted to the A requisition form must accompany each sample submitted to the

laboratory. This requisition form must contain the proper information laboratory. This requisition form must contain the proper information in order to process the specimen. The essential elements of the in order to process the specimen. The essential elements of the requisition form are:requisition form are:

1.1. Patient's surname, first name, and middle initial.Patient's surname, first name, and middle initial.2.2. Patient's ID number.Patient's ID number.3.3. Patient's date of birth and sex.Patient's date of birth and sex.4.4. Requesting physician's complete name.Requesting physician's complete name.5.5. Source of specimen. This information must be given when Source of specimen. This information must be given when

requesting microbiology, cytology, fluid analysis, or other requesting microbiology, cytology, fluid analysis, or other testing where analysis and reporting is site specific.testing where analysis and reporting is site specific.

6.6. Date and time of collection.Date and time of collection.7.7. Initials of phlebotomist.Initials of phlebotomist.8.8. Indicating the test(s) requested.Indicating the test(s) requested.

An example of a simple requisition form An example of a simple requisition form

with the essential elements is shown below:with the essential elements is shown below:

LABELING THE SAMPLELABELING THE SAMPLE

A properly labeled sample is essential so that the A properly labeled sample is essential so that the results of the test match the patient. The key results of the test match the patient. The key elements in labeling are:elements in labeling are:

Patient's surname, first and middle.Patient's surname, first and middle. Patient's ID number.Patient's ID number. NOTE: Both of the above MUST match the same on the NOTE: Both of the above MUST match the same on the

requisition form.requisition form. Date, time and initials of the phlebotomist must be on Date, time and initials of the phlebotomist must be on

the label of EACH tube.the label of EACH tube. Automated systems may include labels with bar Automated systems may include labels with bar

codescodes

Examples of labeled collection tubes are

shown below:

EQUIPMENT:EQUIPMENT: Evacuated Collection Tubes - The tubes are designed to Evacuated Collection Tubes - The tubes are designed to

fill with a predetermined volume of blood by vacuum. The fill with a predetermined volume of blood by vacuum. The rubber stoppers are color coded according to the additive rubber stoppers are color coded according to the additive that the tube contains. Various sizes are available. Blood that the tube contains. Various sizes are available. Blood should should NEVERNEVER be poured from one tube to another since be poured from one tube to another since the tubes can have different additives or coatings.the tubes can have different additives or coatings.

Needles - The gauge number indicates the bore size: the Needles - The gauge number indicates the bore size: the larger the gauge number, the smaller the needle bore. larger the gauge number, the smaller the needle bore. Needles are available for evacuated systems and for use Needles are available for evacuated systems and for use with a syringe, single draw or butterfly system.with a syringe, single draw or butterfly system.

Holder/Adapter - use with the evacuated collection system.Holder/Adapter - use with the evacuated collection system. Tourniquet - Wipe off with alcohol and replace frequentlyTourniquet - Wipe off with alcohol and replace frequently

EQUIPMENT:EQUIPMENT: Alcohol Wipes - 70% isopropyl alcohol.Alcohol Wipes - 70% isopropyl alcohol. Povidone-iodine wipes/swabs - Used if blood culture Povidone-iodine wipes/swabs - Used if blood culture

is to be drawn.is to be drawn. Gauze sponges - for application on the site from Gauze sponges - for application on the site from

which the needle is withdrawn.which the needle is withdrawn. Adhesive bandages / tape - protects the venipuncture Adhesive bandages / tape - protects the venipuncture

site after collection.site after collection. Needle disposal unit - needles should NEVER be Needle disposal unit - needles should NEVER be

broken, bent, or recapped. Needles should be placed broken, bent, or recapped. Needles should be placed in a proper disposal unit IMMEDIATELY after their in a proper disposal unit IMMEDIATELY after their use.use.

EQUIPMENT:EQUIPMENT:

Gloves - can be made of latex, rubber, vinyl, Gloves - can be made of latex, rubber, vinyl, etc.; worn to protect the patient and the etc.; worn to protect the patient and the phlebotomist.phlebotomist.

Syringes - may be used in place of the Syringes - may be used in place of the evacuated collection tube for special evacuated collection tube for special circumstances.circumstances.

ORDER OF DRAW: ORDER OF DRAW: Blood collection tubes must be drawn in a specific order Blood collection tubes must be drawn in a specific order

to avoid cross-contamination of additives between tubes. to avoid cross-contamination of additives between tubes. The recommended order of draw for plastic vacutainer The recommended order of draw for plastic vacutainer tubes is:tubes is:

1.1. First - blood culture bottle or tube (yellow or First - blood culture bottle or tube (yellow or yellow-black top)yellow-black top)

2.2. Second - coagulation tube (light blue top). If just a Second - coagulation tube (light blue top). If just a routine coagulation assay is the only test ordered, routine coagulation assay is the only test ordered, then a single light blue top tube may be drawn. If then a single light blue top tube may be drawn. If there is a concern regarding contamination by tissue there is a concern regarding contamination by tissue fluids or thromboplastins, then one may draw a non-fluids or thromboplastins, then one may draw a non-additive tube first, and then the light blue top tube. additive tube first, and then the light blue top tube.

ORDER OF DRAW:ORDER OF DRAW:

3.3. Third - non-additive tube (red top)Third - non-additive tube (red top)4.4. Last draw - additive tubes in this order:Last draw - additive tubes in this order:• SST (red-gray or gold top). Contains a gel separator SST (red-gray or gold top). Contains a gel separator

and clot activator.and clot activator.• Sodium heparin (dark green top)Sodium heparin (dark green top)• PST (light green top). Contains lithium heparin PST (light green top). Contains lithium heparin

anticoagulant and a gel separator.anticoagulant and a gel separator.• EDTA (lavender top)EDTA (lavender top)• ACDA or ACDB (pale yellow top). Contains acid ACDA or ACDB (pale yellow top). Contains acid

citrate dextrose.citrate dextrose.• Oxalate/fluoride (light gray top)Oxalate/fluoride (light gray top)

NOTE: NOTE: Tubes with additives must be Tubes with additives must be thoroughly mixed. Erroneous test results may thoroughly mixed. Erroneous test results may be obtained when the blood is not thoroughly be obtained when the blood is not thoroughly

mixed with the additive. mixed with the additive.

Plastic Tube  (Stopper Color)

Additive Laboratory Use

1. Blood Culture Broth mixture  

2a. Red NoneWaste tube, needed if drawing from line or for Clotting factors only

2b. RedNone  

2c. Red

None Drugs, Hep C

3. Light Blue Sodium Citrate PT/PTT

Plastic Tube  (Stopper Color)

Additive Laboratory Use

3. SST (Red-Gray, or Gold stopper)

Gel separator + clot activator

Iron, TIBC, PSA, B12

4a. Dark Green

Sodium Heparin BMP, CMP Lipid

4b. PST –

Light Green Lithium Heparin + gel separator

LAP, Drug Screen, Alcohol

Plastic Tube  (Stopper Color)

Additive Laboratory Use

Lavender

EDTA CBC, A1C, Retic, H&H

Pale Yellow (ACDA or ACDB)

Acid citrate dextrose

Basic Immune Profile, HLA tissue typing, paternity testing, DNA studies

Light Gray

Oxalate/fluoride Lactic Acid

VENIPUNCTURE SITE VENIPUNCTURE SITE SELECTION: SELECTION:

Although the larger and fuller median cubital Although the larger and fuller median cubital and cephalic veins of the arm are used most and cephalic veins of the arm are used most frequently, the basilic vein on the dorsum of frequently, the basilic vein on the dorsum of the arm or dorsal hand veins are also the arm or dorsal hand veins are also acceptable for venipuncture. Foot veins are a acceptable for venipuncture. Foot veins are a last resort because of the higher probability of last resort because of the higher probability of complications complications

Certain areas are to be avoided Certain areas are to be avoided when choosing a site: when choosing a site:

Extensive scars from burns and surgery - it is Extensive scars from burns and surgery - it is difficult to puncture the scar tissue and difficult to puncture the scar tissue and obtain a specimen.obtain a specimen.

The upper extremity on the side of a The upper extremity on the side of a previous mastectomy - test results may be previous mastectomy - test results may be affected because of lymphedema.affected because of lymphedema.

Certain areas are to be avoided Certain areas are to be avoided when choosing a site:when choosing a site:

Hematoma - may cause erroneous test results. Hematoma - may cause erroneous test results. If another site is not available, collect the If another site is not available, collect the specimen distal to the hematoma.specimen distal to the hematoma.

Intravenous therapy (IV) / blood transfusions - Intravenous therapy (IV) / blood transfusions - fluid may dilute the specimen, so collect from fluid may dilute the specimen, so collect from the opposite arm if possible. Otherwise, the opposite arm if possible. Otherwise, satisfactory samples may be drawn below the satisfactory samples may be drawn below the IV by following these procedures:…IV by following these procedures:…

IV SITESIV SITES

Turn off the IV for at least 2 minutes before Turn off the IV for at least 2 minutes before venipuncture.venipuncture.

Apply the tourniquet below the IV site. Select Apply the tourniquet below the IV site. Select a vein other than the one with the IV.a vein other than the one with the IV.

Perform the venipuncture. Draw 5 ml of blood Perform the venipuncture. Draw 5 ml of blood and discard before drawing the specimen tubes and discard before drawing the specimen tubes for testing.for testing.

HEP LocksHEP Locks

Cannula/fistula/heparin lock - hospitals have Cannula/fistula/heparin lock - hospitals have special policies regarding these devices. In special policies regarding these devices. In general, blood should not be drawn from an general, blood should not be drawn from an arm with a fistula or cannula without arm with a fistula or cannula without consulting the attending physician.consulting the attending physician.

Edematous extremities - tissue fluid Edematous extremities - tissue fluid accumulation alters test results.accumulation alters test results.

PROCEDURE FOR VEIN PROCEDURE FOR VEIN SELECTION: SELECTION:

Palpate and trace the path of veins with the index Palpate and trace the path of veins with the index finger. Arteries pulsate, are most elastic, and have a finger. Arteries pulsate, are most elastic, and have a thick wall. Thrombosed veins lack resilience, feel thick wall. Thrombosed veins lack resilience, feel cord-like, and roll easily.cord-like, and roll easily.

If superficial veins are not readily apparent, you can If superficial veins are not readily apparent, you can force blood into the vein by massaging the arm from force blood into the vein by massaging the arm from wrist to elbow, tap the site with index and second wrist to elbow, tap the site with index and second finger, apply a warm, damp washcloth to the site for 5 finger, apply a warm, damp washcloth to the site for 5 minutes, or lower the extremity over the bedside to minutes, or lower the extremity over the bedside to allow the veins to fill. allow the veins to fill.

PERFORMANCE OF A PERFORMANCE OF A VENIPUNCTURE: VENIPUNCTURE:

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

Identify the patient correctly.Identify the patient correctly. Properly fill out appropriate requisition forms, Properly fill out appropriate requisition forms,

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

restrictions, medications, timing, and medical restrictions, medications, timing, and medical treatment are all of concern and should be noted on treatment are all of concern and should be noted on the lab requisition.the lab requisition.

PERFORMANCE OF A PERFORMANCE OF A VENIPUNCTURE:VENIPUNCTURE:

Check for any allergies to antiseptics, adhesives, or latex Check for any allergies to antiseptics, adhesives, or latex by observing for armbands and/or by asking the patient.by observing for armbands and/or by asking the patient.

Position the patient. The patient should either sit in a Position the patient. The patient should either sit in a chair, lie down or sit up in bed. Hyperextend the patient's chair, lie down or sit up in bed. Hyperextend the patient's arm.arm.

Apply the tourniquet 3-4 inches above the selected Apply the tourniquet 3-4 inches above the selected puncture site. Do not place too tightly or leave on more puncture site. Do not place too tightly or leave on more than 2 minutes.than 2 minutes.

The patient should make a fist without pumping the hand.The patient should make a fist without pumping the hand. Select the venipuncture site.Select the venipuncture site. Prepare the patient's arm using an alcohol prep. Cleanse Prepare the patient's arm using an alcohol prep. Cleanse

in a circular fashion, beginning at the site and working in a circular fashion, beginning at the site and working outward. Allow to air dry.outward. Allow to air dry.

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

PERFORMANCE OF A PERFORMANCE OF A VENIPUNCTURE:VENIPUNCTURE:

When the last tube to be drawn is filling, remove the When the last tube to be drawn is filling, remove the tourniquet.tourniquet.

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

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

Dispose of contaminated materials/supplies in designated Dispose of contaminated materials/supplies in designated containers.containers.

Mix and label all appropriate tubes at the patient bedside.Mix and label all appropriate tubes at the patient bedside. Deliver specimens promptly to the laboratoryDeliver specimens promptly to the laboratory

The first step is always to identify the patient. The first step is always to identify the patient. Outpatient phlebotomy, as shown here, should Outpatient phlebotomy, as shown here, should take place with the patient seated. take place with the patient seated.

The requistion form should be completely The requistion form should be completely filled out, and the requisition must indicate filled out, and the requisition must indicate the tests ordered. the tests ordered.

Here is the equipment for performing Here is the equipment for performing phlebotomy. Barrier protection for the phlebotomy. Barrier protection for the phlebotomist consists of the latex gloves phlebotomist consists of the latex gloves

The tourniquet is applied and the The tourniquet is applied and the phlebotomist palpates for a suitable vein phlebotomist palpates for a suitable vein for drawing blood. for drawing blood.

The area of skin is cleaned with a The area of skin is cleaned with a disinfectant, here an alcohol swab. disinfectant, here an alcohol swab.

The vein is anchored and the needle is The vein is anchored and the needle is inserted. inserted.

The vacutainer tube is depressed into the needle to begin The vacutainer tube is depressed into the needle to begin drawing blood. Additional vacutainer tubes can be utilized. drawing blood. Additional vacutainer tubes can be utilized. Determine what tests are ordered and what tubes will be Determine what tests are ordered and what tubes will be necessary BEFORE you begin to draw blood, and necessary BEFORE you begin to draw blood, and determine the order of draw for the tubes. determine the order of draw for the tubes.

When the final tube is being drawn, When the final tube is being drawn, release the tourniquet. Then remove the release the tourniquet. Then remove the tube, and remove the needle tube, and remove the needle

After the needle is removed from the vein, After the needle is removed from the vein, apply firm pressure over the site to apply firm pressure over the site to achieve hemostasis. achieve hemostasis.

Apply a bandage to the area. Apply a bandage to the area.

Dispose of the needle into a sharps Dispose of the needle into a sharps container that is close by. container that is close by.

Label the tubes, checking the requisition Label the tubes, checking the requisition for the proper identification. for the proper identification.

PERFORMANCE OF A PERFORMANCE OF A FINGERSTICK: FINGERSTICK:

Follow the procedure as outlined above for Follow the procedure as outlined above for greeting and identifying the patient. As greeting and identifying the patient. As always, properly fill out appropriate always, properly fill out appropriate requisition forms, indicating the test(s) requisition forms, indicating the test(s) ordered.ordered.

Verify the patient's condition. Fasting, dietary Verify the patient's condition. Fasting, dietary restrictions, medications, timing, and medical restrictions, medications, timing, and medical treatment are all of concern and should be treatment are all of concern and should be noted on the lab requisition.noted on the lab requisition.

PERFORMANCE OF A PERFORMANCE OF A FINGERSTICK:FINGERSTICK:

Position the patient. The patient should either sit in a chair, Position the patient. The patient should either sit in a chair, lie down or sit up in bed. Hyperextend the patient's arm.lie down or sit up in bed. Hyperextend the patient's arm.

The best locations for fingersticks are the 3rd (middle) and The best locations for fingersticks are the 3rd (middle) and 4th (ring) fingers of the non-dominant hand. Do not use 4th (ring) fingers of the non-dominant hand. Do not use the tip of the finger or the center of the finger. Avoid the the tip of the finger or the center of the finger. Avoid the side of the finger where there is less soft tissue, where side of the finger where there is less soft tissue, where vessels and nerves are located, and where the bone is vessels and nerves are located, and where the bone is closer to the surface. The 2nd (index) finger tends to have closer to the surface. The 2nd (index) finger tends to have thicker, callused skin. The fifth finger tends to have less thicker, callused skin. The fifth finger tends to have less soft tissue overlying the bone. Avoid puncturing a finger soft tissue overlying the bone. Avoid puncturing a finger that is cold or cyanotic, swollen, scarred, or covered with a that is cold or cyanotic, swollen, scarred, or covered with a rash.rash.

PERFORMANCE OF A PERFORMANCE OF A FINGERSTICK:FINGERSTICK:

Using a sterile lancet, make a skin puncture just off Using a sterile lancet, make a skin puncture just off the center of the finger pad. The puncture should be the center of the finger pad. The puncture should be made perpendicular to the ridges of the fingerprint so made perpendicular to the ridges of the fingerprint so that the drop of blood does not run down the ridges.that the drop of blood does not run down the ridges.

Wipe away the first drop of blood, which tends to Wipe away the first drop of blood, which tends to contain excess tissue fluid.contain excess tissue fluid.

Collect drops of blood into the collection device by Collect drops of blood into the collection device by gently massaging the finger. Avoid excessive gently massaging the finger. Avoid excessive pressure that may squeeze tissue fluid into the drop of pressure that may squeeze tissue fluid into the drop of blood.blood.

PERFORMANCE OF A PERFORMANCE OF A FINGERSTICK:FINGERSTICK:

Cap, rotate and invert the collection device to mix the Cap, rotate and invert the collection device to mix the blood collected.blood collected.

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

Dispose of contaminated materials/supplies in Dispose of contaminated materials/supplies in designated containers.designated containers.

Label all appropriate tubes at the patient bedside.Label all appropriate tubes at the patient bedside. Deliver specimens promptly to the laboratory.Deliver specimens promptly to the laboratory.

Here is the equipment for fingersticks (heelsticks). The Here is the equipment for fingersticks (heelsticks). The lancets come in different lengths. There are several lancets come in different lengths. There are several standard microtainers utilized to collect fingerstick (or baby standard microtainers utilized to collect fingerstick (or baby heelstick) blood. The purple cap is for hematology heelstick) blood. The purple cap is for hematology specimens and the green cap is for chemistry specimens. specimens and the green cap is for chemistry specimens. The dark brown-red microtainer protects a neonatal The dark brown-red microtainer protects a neonatal bilirubin sample from the light.bilirubin sample from the light.

The proper location on the 3rd or 4th finger of the non-The proper location on the 3rd or 4th finger of the non-dominant hand for performing a fingerstick is outlined here dominant hand for performing a fingerstick is outlined here between the green lines. The puncture should be made just between the green lines. The puncture should be made just off center and perpendicular to the fingerprint ridges. (A off center and perpendicular to the fingerprint ridges. (A puncture parallel to the ridges tends to make the blood run puncture parallel to the ridges tends to make the blood run

down the ridges and hamper collection.)down the ridges and hamper collection.)

The lancet is placed over the proper The lancet is placed over the proper location on the finger and the puncture is location on the finger and the puncture is made quickly. made quickly.

A drop of blood appears at the puncture site. A drop of blood appears at the puncture site.

The first drop of blood that may contain The first drop of blood that may contain tissue fluid is wiped away. tissue fluid is wiped away.

The finger is gently massaged from base The finger is gently massaged from base to tip and the blood drops are collected to tip and the blood drops are collected into the proper collection device. into the proper collection device.

The blood is mixed in microtainers with an The blood is mixed in microtainers with an additive. additive.

To prevent a hematoma: To prevent a hematoma:

Puncture only the uppermost wall of the veinPuncture only the uppermost wall of the vein Remove the tourniquet before removing the needleRemove the tourniquet before removing the needle Use the major superficial veinsUse the major superficial veins Make sure the needle fully penetrates the upper most Make sure the needle fully penetrates the upper most

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

Apply pressure to the venipuncture siteApply pressure to the venipuncture site

To prevent hemolysis To prevent hemolysis

Mix tubes with anticoagulant additives gently Mix tubes with anticoagulant additives gently 5-10 times5-10 times

Avoid drawing blood from a hematomaAvoid drawing blood from a hematoma Avoid drawing the plunger back too Avoid drawing the plunger back too

forcefully, if using a needle and syringe, and forcefully, if using a needle and syringe, and avoid frothing of the sampleavoid frothing of the sample

Make sure the venipuncture site is dryMake sure the venipuncture site is dry Avoid a probing, traumatic venipunctureAvoid a probing, traumatic venipuncture

Indwelling Lines or Catheters Indwelling Lines or Catheters

Potential source of test errorPotential source of test error Most lines are flushed with a solution of Most lines are flushed with a solution of

heparin to reduce the risk of thrombosisheparin to reduce the risk of thrombosis Discard a sample at least three times the Discard a sample at least three times the

volume of the line before a specimen is volume of the line before a specimen is obtained for analysisobtained for analysis

Hemoconcentration: Hemoconcentration: An increased An increased concentration of larger molecules and formed concentration of larger molecules and formed

elements in the blood may be due to several factors:elements in the blood may be due to several factors:

Prolonged tourniquet application (no more Prolonged tourniquet application (no more than 2 minutes)than 2 minutes)

Massaging, squeezing, or probing a siteMassaging, squeezing, or probing a site Long-term IV therapyLong-term IV therapy Sclerosed or occluded veinsSclerosed or occluded veins

Prolonged Tourniquet Application: Prolonged Tourniquet Application:

Primary effect is hemoconcentration of non-filterable Primary effect is hemoconcentration of non-filterable elements (i.e. proteins). The hydrostatic pressure elements (i.e. proteins). The hydrostatic pressure causes some water and filterable elements to leave the causes some water and filterable elements to leave the extracellular space.extracellular space.

Significant increases can be found in total protein, Significant increases can be found in total protein, aspartate aminotransferase (AST), total lipids, aspartate aminotransferase (AST), total lipids, cholesterol, ironcholesterol, iron

Affects packed cell volume and other cellular Affects packed cell volume and other cellular elementselements

Patient Preparation Factors Patient Preparation Factors

Therapeutic Drug Monitoring: different Therapeutic Drug Monitoring: different pharmacologic agents have patterns of pharmacologic agents have patterns of administration, body distribution, metabolism, administration, body distribution, metabolism, and elimination that affect the drug and elimination that affect the drug concentration as measured in the blood. Many concentration as measured in the blood. Many drugs will have "peak" and "trough" levels that drugs will have "peak" and "trough" levels that vary according to dosage levels and intervals. vary according to dosage levels and intervals. Check for timing instructions for drawing the Check for timing instructions for drawing the appropriate samples. appropriate samples.

Patient Preparation FactorsPatient Preparation Factors

Effects of Exercise: Muscular activity has both Effects of Exercise: Muscular activity has both transient and longer lasting effects. The transient and longer lasting effects. The creatine kinase (CK), aspartate creatine kinase (CK), aspartate aminotransferase (AST), lactate aminotransferase (AST), lactate dehydrogenase (LDH), and platelet count may dehydrogenase (LDH), and platelet count may increase. increase.

Patient Preparation FactorsPatient Preparation Factors

Stress: May cause transient elevation in white Stress: May cause transient elevation in white blood cells (WBC's) and elevated adrenal blood cells (WBC's) and elevated adrenal hormone values (cortisol and catecholamines). hormone values (cortisol and catecholamines). Anxiety that results in hyperventilation may Anxiety that results in hyperventilation may cause acid-base imbalances, and increased cause acid-base imbalances, and increased lactate. lactate.

Patient Preparation FactorsPatient Preparation Factors

Diurnal Rhythms: Diurnal rhythms are body Diurnal Rhythms: Diurnal rhythms are body fluid and analyte fluctuations during the day. fluid and analyte fluctuations during the day. For example, serum cortisol levels are highest For example, serum cortisol levels are highest in early morning but are decreased in the in early morning but are decreased in the afternoon. Serum iron levels tend to drop afternoon. Serum iron levels tend to drop during the day. You must check the timing of during the day. You must check the timing of these variations for the desired collection these variations for the desired collection point. point.

Posture: Postural changes (supine to sitting etc.) are Posture: Postural changes (supine to sitting etc.) are known to vary lab results of some analytes. Certain known to vary lab results of some analytes. Certain larger molecules are not filterable into the tissue, larger molecules are not filterable into the tissue, therefore they are more concentrated in the blood. therefore they are more concentrated in the blood. Enzymes, proteins, lipids, iron, and calcium are Enzymes, proteins, lipids, iron, and calcium are significantly increased with changes in position.significantly increased with changes in position.

Other Factors: Age, gender, and pregnancy have an Other Factors: Age, gender, and pregnancy have an influence on laboratory testing. Normal reference influence on laboratory testing. Normal reference ranges are often noted according to age.ranges are often noted according to age.

SAFETY AND INFECTION SAFETY AND INFECTION CONTROLCONTROL

Because of contacts with sick patients and their Because of contacts with sick patients and their specimens, it is important to follow safety and specimens, it is important to follow safety and infection control procedures.infection control procedures.

PROTECT YOURSELFPROTECT YOURSELF Practice universal precautions:Practice universal precautions:

Wear gloves and a lab coat or gown when handling Wear gloves and a lab coat or gown when handling blood/body fluids.blood/body fluids.

Change gloves after each patient or when contaminated.Change gloves after each patient or when contaminated. Wash hands frequently.Wash hands frequently. Dispose of items in appropriate containers.Dispose of items in appropriate containers.

SAFETY AND INFECTION SAFETY AND INFECTION CONTROLCONTROL

Dispose of needles immediately upon removal Dispose of needles immediately upon removal from the patient's vein. Do not bend, break, from the patient's vein. Do not bend, break, recap, or resheath needles to avoid accidental recap, or resheath needles to avoid accidental needle puncture or splashing of contents.needle puncture or splashing of contents.

Clean up any blood spills with a disinfectant Clean up any blood spills with a disinfectant such as freshly made 10% bleach.such as freshly made 10% bleach.

SAFETY AND INFECTION SAFETY AND INFECTION CONTROLCONTROL

If you stick yourself with a contaminated needle:If you stick yourself with a contaminated needle:1.1. Remove your gloves and dispose of them properly.Remove your gloves and dispose of them properly.

2.2. Squeeze puncture site to promote bleeding.Squeeze puncture site to promote bleeding.

3.3. Wash the area well with soap and water.Wash the area well with soap and water.

4.4. Record the patient's name and ID number.Record the patient's name and ID number.

5.5. Follow institution's guidelines regarding treatment and Follow institution's guidelines regarding treatment and follow-up.follow-up.

6.6. NOTE: The use of prophylactic zidovudine following NOTE: The use of prophylactic zidovudine following blood exposure to HIV has shown effectiveness (about blood exposure to HIV has shown effectiveness (about 79%) in preventing seroconversion79%) in preventing seroconversion

PROTECT THE PATIENT PROTECT THE PATIENT

Place blood collection equipment away from Place blood collection equipment away from patients, especially children and psychiatric patients, especially children and psychiatric patients.patients.

Practice hygiene for the patient's protection. Practice hygiene for the patient's protection. When wearing gloves, change them between When wearing gloves, change them between each patient and wash your hands frequently. each patient and wash your hands frequently. Always wear a clean lab coat or gown.Always wear a clean lab coat or gown.

TROUBLESHOOTING GUIDELINES:

• Change the position of the needle. Move it forward (it may not be in the lumen)

• or move it backward (it may have penetrated too far).

• Adjust the angle (the bevel may be against the vein wall)

• Loosen the tourniquet. It may be obstructing blood flow.

• Try another tube. There may be no vacuum in the one being used.

• Re-anchor the vein. Veins sometimes roll away from the point of the needle and puncture site.

TROUBLESHOOTING GUIDELINES

IF BLOOD STOPS FLOWING INTO THE

TUBE: • The vein may have collapsed;

resecure the tourniquet to increase venous filling. If this is not successful, remove the needle, take care of the puncture site, and redraw

TROUBLESHOOTING GUIDELINES

• The needle may have pulled out of the vein when switching tubes. Hold equipment firmly and place fingers against patient's arm, using the flange for leverage when withdrawing and inserting tubes.

PROBLEMS OTHER THAN AN INCOMPLETE

COLLECTION: • A hematoma forms under the skin

adjacent to the puncture site - release the tourniquet immediately and withdraw the needle. Apply firm pressure.

TROUBLESHOOTING GUIDELINES

• The blood is bright red (arterial) rather than venous. Apply firm pressure for more than 5 minutes.

In the view above, there has been more extensive In the view above, there has been more extensive subcutaneous hemorrhage, and even tearing of the subcutaneous hemorrhage, and even tearing of the skin from adhesive tape applied with a bandage, in a skin from adhesive tape applied with a bandage, in a patient on corticosteroid therapy patient on corticosteroid therapy

In older patients with thin, loose skin and less In older patients with thin, loose skin and less subcutaneous tissue, the minor trauma of subcutaneous tissue, the minor trauma of venipuncture is more likely to produce local venipuncture is more likely to produce local hemorrhage. Note the small hematomas in the view hemorrhage. Note the small hematomas in the view above.above.

BLOOD COLLECTION ON BABIES:

• The recommended location for blood collection on a newborn baby or infant is the heel. The diagram below indicates in green the proper area to use for heel punctures for blood collection:

Heel Stick ProcedureHeel Stick Procedure

Prewarming the infant's heel (42 C for 3 to 5 minutes) Prewarming the infant's heel (42 C for 3 to 5 minutes) is important to obtain capillary blood gas samples and is important to obtain capillary blood gas samples and warming also greatly increases the flow of blood for warming also greatly increases the flow of blood for collection of other specimens. However, do not use collection of other specimens. However, do not use too high a temperature warmer, because baby's skin is too high a temperature warmer, because baby's skin is thin and susceptible to thermal injury.thin and susceptible to thermal injury.

Clean the site to be punctured with an alcohol sponge. Clean the site to be punctured with an alcohol sponge. Dry the cleaned area with a dry cotton sponge. Hold Dry the cleaned area with a dry cotton sponge. Hold the baby's foot firmly to avoid sudden movement.the baby's foot firmly to avoid sudden movement.

Heel Stick ProcedureHeel Stick Procedure

Using a sterile blood lancet, puncture the side Using a sterile blood lancet, puncture the side of the heel in the appropriate regions shown of the heel in the appropriate regions shown above in green. Do not use the central portion above in green. Do not use the central portion of the heel because you might injure the of the heel because you might injure the underlying bone, which is close to the skin underlying bone, which is close to the skin surface. Do not use a previous puncture site. surface. Do not use a previous puncture site. Make the cut across the heelprint lines so that Make the cut across the heelprint lines so that a drop of blood can well up and not run down a drop of blood can well up and not run down along the lines. along the lines.

Heel Stick ProcedureHeel Stick Procedure

Wipe away the first drop of blood with a piece Wipe away the first drop of blood with a piece of clean, dry cotton. Since newborns do not of clean, dry cotton. Since newborns do not often bleed immediately, use gentle pressure to often bleed immediately, use gentle pressure to produce a rounded drop of blood. Do not use produce a rounded drop of blood. Do not use excessive pressure or heavy massaging excessive pressure or heavy massaging because the blood may become diluted with because the blood may become diluted with tissue fluid. tissue fluid.

Heel Stick ProcedureHeel Stick Procedure

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

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

Be sure to dispose of the lancet in the appropriate Be sure to dispose of the lancet in the appropriate sharps container. Dispose of contaminated materials sharps container. Dispose of contaminated materials in appropriate waste receptacles. Remove your gloves in appropriate waste receptacles. Remove your gloves and wash your hands.and wash your hands.

Two heelsticks have been performed on this baby. Two heelsticks have been performed on this baby. One of them has been performed correctly. One One of them has been performed correctly. One was performed improperly. was performed improperly.

Blood SmearingBlood Smearing

1. A single smear can be made per slide (smear running the length of the slide) or two (or even three) smears can share a slide, with the smears running the width of the slide. Putting two smears per slide saves on weight (glass is heavy) for field trips, and storage space.

2. It is easiest to use microscope slides with a frosted end, so that identifying information can be written there with pencil. Compare different pencils to find one that does not yield labels that rub off or wash off in the methanol dip.

Warning:

3. Place a drop of blood approximately 4 mm in diameter on the slide (near the end if one smear is to be made, or at the proper location if two smears are to share a slide).

4. Spread the drop by using another slide (called here the “spreader”), placing the spreader at a 45° angle and BACKING into the drop of blood. The spreader catches the drop and it spreads by capillary action along its edge. To make a short smear, hold the spreader at a steeper angle, and to make a longer smear, hold it closer to the drop. Now, push the spreader across the slide; this PULLS the blood across to make the smear. Do not push the blood by having it ahead of the smearing slide! It should take about one second to smear the drop. A smooth action is required, with the edge of the spreader held against the slide. This will yield a nice, even smear.

Why do ABGs

►Precise measurement of acid – base balance of the blood

►Check lungs’ ability to oxygenate blood and to remove CO2

►Assess respiratory function • O2 and CO2 levels determined primarily by

the lungs

Puncture Procedure

► Check for Ordersa. Check for indications and contraindications

• Indications can be wide and varied• No absolute contraindications, mostly

just extra precautions and hazards

i. Dialysis shunt – choose another site

ii. Mastectomy – use opposite sideiii. Pt on anticoagulant therapy –

MAY have to hold pressure on puncture site longer than normal – includes aspirin therapy

Puncture Procedure

► Introduce yourself and explain what is ordered

a. Patient cooperation needed to help simplify and minimize painb. if patient refuses, notify physician

► Make positive patient I.D.a. Ask patient their nameb. Check patient I.D. wristband

► Put on gloves

Puncture Procedure

► Assemble needle to syringea. keep needle sterileb. eject excess heparin and air

bubbles, if using syringe with liquid heparin

c. pull back syringe plunger to at least 1cc to give room for blood to fill

syringe when puncture is maded. NEVER recap needle

Puncture Procedure► Select Site

A. Palpate the right and left radials arterial pulse and visualize the course of the artery.

B. Pick strongest pulse1. Radial artery is always the first choice

and should be used because of it provides collateral circulation

i. if radial pulse weak on right, move to left

ii. if pulse on left weak, then try brachial

2. Brachial used as alternative site3. Femoral is the last choice in normal

situations• almost every related complication

has been with femoral site• usually first choice puncture site

in code

Other Puncture Sites:

Puncture Procedure: Allen’s Test

► When using radials, perform Allen's Test for collateral circulation

A. In a conscious and cooperative patient:

1. compress ulnar and radial arteries at wrist to obliterate pulse

2. have patient clench and release pulse until hand blanches

3. with radial still compressed, release pressure on ulnar artery

4. watch for pinkness to return should “pink up” within 10 – 15 second

Puncture Procedure: Allen’s Test

B. In an unconscious: 1. compress ulnar and radials 2. elevate hand above head, squeeze hard 3. release ulnar and lower hand below heart

► Palpate left and right radial arteries noting maximal pulse. The one with the stronger pulse will be your site of entry.

Performing Allen’s Test

The idea here is to figure out if there is adequate collateral circulation from the ulnar artery to perfuse the hand.

Puncture Procedure

► Drape the bed and stabilize the wrist in the position that gives maximal pulse

• (hyper-extended, using a rolled up towel if necessary)

► Prepare the site► Cleanse the chosen area with a alcohol and/or

iodine► Secure needle to syringe and remove cap

from needle

Puncture Procedure

Puncture Procedure

► Pierce the skin at puncture site keep needle angle constant Bevel of needle up, or into the arterial flow

(Bevel faces the heart)

Angle of Entry

Angles of Entry

Puncture Procedure

► Slowly advance in one plane► When the artery is punctured, blood will

enter the syringe –“flash”

Puncture Procedure

► Slowly allow blood to fill syringe if no blood appears, remove, change needles,

and start again

Puncture Procedure

► Upon removal of the needle, hold pressure on the puncture site for at least 5 minutes. • Pressure may need to be held longer (> 5

mins) if the patient is on anticoagulant therapy

Puncture Procedure

► Check for: Bleeding movement of fingers and tingling

sensation pulse distal to puncture

► if pulse not palpable, notify physician STAT

Post Puncture Procedure

► Remove any air bubbles from sample and cap syringe • Dispose of needle in sharps container

► Roll syringe to mix heparin with sample► Immerse in ice► On lab slip indicate:

a. FIO2 b. patient temperature c. ventilator parameters

► Deliver to lab

Post Puncture Procedure

Complications of Arterial Punctures:

Complications of Arterial Punctures:

Technical Causes of Abnormal Results:

► Delay in running sample O2 consumption will continue as will CO2

production – pH does what CO2 tells it to do Iced, sample will last an hour without a change in

the results– un-iced, ABG's can be significantly changed after 10

min► Venous sample drawn

Usually this in shocky patient that you expect low pressures and dark blood

Should doubt when PO2 is significantly lower than expected

►draw venous blood to check comparison or►redraw sample

Technical Causes of Abnormal Results:

► Capillary samples From infants warmed heel CAUTION – pay attention to puncture site and

sample type ONLY diagnostic values are pH and PaCO2 PaO2 value is NOT diagnostic

► Heparin Sodium Heparin 1% solution should be use

ammonium heparin will alter pH dry lithium heparin is OK

►• All unnecessary heparin should be ejected from syringe, excess can effect results

Technical Causes of Abnormal Results:

► Patient pain a. Can cause hyperventilation or breath holding b. An anesthetic may be injected prior to stick for

pain, although this hurts probably as much►• Usually 2% lidocaine

• CAUTION – some people allergic to “caines”► Machine errors

a. Improper calibration b. Air bubbles in electrodes c. Torn membranes

Quality Control/Performance Improvement

► Quality control levels (high, normal, low) are run every 8 hours to check performance of machine

► Levey-Jennings chart – assesses whether control value falls within acceptable limits. i. trend – 6 or more results in an increasing or

decreasing pattern ii. shift – 6 or more results falling on the same

side of the mean