Phlebotomy

R A J E S H M O H E S S , C L T .

VENIPUNCTURE

ORDER OF DRAW

Refers to the order in which blood is collected when collecting multiple tubes e.g.. Evacuated tube system (ETS)

This also includes blood tubes filled by syringes

Tubes are filled in order of sterile first then additional tubes to prevent contamination

ORDER OF DRAW

Tube order:

1. Sterile tube (blood cultures)

2. Blue top (coagulation)

3. Serum tube (with or without clot activator/gel)

4. Heparin tubes (with or without plasma separator) – e.g.. Green, royal blue

5. EDTA tubes

6. Glycolytic inhibitor tube

Rationale for Order of Draw

Blood culture (sterile containers)Yellow tops, sterile media bottlesMinimizes change of microbial contamination

Coagulation tubesLight blueCollected first because all other additives affect coagulation testing


Glass nonadditive tubesRedPrevents contamination by additives in other tubes

Plastic clot activatorRedFilled after coagulation tests because silica particles activate clotting and affect coagulation tests

Serum separator tubes (SST)Red and gray rubber stopper, Gold plastic capsFilled after coagulation tests because silica particles activate clotting and affect coagulation testsCarryover of silica into subsequent tubes can be overridden by anticoagulation in them


Plasma separator tubes (PST) and Heparin TubesGreen and gray rubber stopper, Light green plastic caps, GreenHeparin affects coagulation test and interferes in collection of serum specimenIt causes the least interference in tests other than coagulation tests, as it occur naturally in body

EDTA, Plasma preparation tubes (PPT)Lavender, pink, purple, pearl topResponsible for more carryover problemsIt elevates sodium and potassium levelsChelates and decrease calcium and iron levelsElevate PT and PTT results


Oxalates, Fluoride tubesGraySodium fluoride affects sodium levelsPotassium oxalate affects potassium levelsIt is filled after hematology tubes because oxalate damages cell membranes and causes abnormal RBC morphologyOxalate also interfere with enzyme reactions

Pneumonic To Remember Tubes

Sterile - StopLight blue - LightRed - RedSST - StayPST - PutGreen - GreenLavender - LightGray - Go

ORDER OF DRAW

If tubes are filled in the wrong order in can lead to cross contamination resulting in interference in tests results

Microorganisms, additives/anticoagulants, tissue thromboplastin can be carried overOrder of draw is implemented to avoid these problems

ORDER OF DRAW

Tissue thromboplastin is a substance present in tissue fluid. It activates the extrinsic coagulation pathway and can interfere with coagulation tests. It is usually picked up during venipuncture through the needle; especially if there is excessive manipulation of the needle. Does not have significant effects on PT, PTTHowever, if other coagulation tests are required to be collected, a discard tube should be collected

A discard tube is also needed if using a butterfly and the first tube is blue top. This is to protect the 9:1 ratio – air in the tubing displace blood in the tube

ORDER OF DRAW

Microbial contaminationBlood cultures detect organisms in bloodSpecial cleaning is necessary – iodineIt is collected first to avoid contamination from the non sterile tubesMost of the time drawn separately

Carryover/cross contamination

Transfer of additive from one tube to another

It can occur from blood touching the needle or even when transfer from a syringe

This results in the additive from the previous tube being transferred to the next tube

Carryover/cross contamination

Note: To minimize carryover, make sure that you fill tubes

from bottom up and the contents does not come in contact with the needle

EDTA tends to have the most carryover problems than any other additive

Heparin causes the least carryover because it occurs in the body naturally

If drawing specimen for trace elements (royal blue), it is recommended to be drawn separately to avoid any contamination.

If using a syringe system and collecting trace elements afterwards, the transfer device should be changed

VENIPUNCTURE SITES

VENIPUNCTURE SITE SELECTION

IV LINES – If IV is running on one limb, you should choose another site to prevent contamination and hemodilution

EDEMA – abnormal fluid accumulation

SCARRING or BURNS – difficulty palpating veins; causes contamination/sepsis. Use alternate site

DIALYSIS – Never draw from arm with fistula

MASTECTOMY – never draw from the same site; especially if lymph nodes removed

These are all pre-analytical errors

DIFFERENT TYPES OF PATIENTS

PEDIATRICS

Increased anxiety – both parents and child

Be compassionate and gentle

Take your time and gain the child’s trust and confidence

Get help with restraining

ADOLESCENTS

Relax and anticipate anxiety from the patient

Maintain eye contact

May engage in conversation

DIFFERENT TYPES OF PATIENTS

ADULTS

Be honest and pleasant

Follow HIPAA rules

GERIATRICS

Be patient and pleasant and Treat with dignity and respect

Engage in conversation

May have to speak loud and slow for some patients

COMBATIVE PATIENTS

Some patient’s may be combative – if you think you are in danger and may get yourself hurt, do not attempt to draw – notify your supervisor

ARTERIAL BLOOD DRAW

Do not perform unless your facility gave you additional training and authorize you to perform arterial puncture

Mainly used for ABGs

Most common site is Radial artery of non dominant hand

Perform the modified Allen test to confirm collateral circulation (open and close fist several time; keep fist clenched; occlude both radial and ulnar artery; have the patient open hand slowly; release ulnar artery)

Brachial sites – usually difficulty obtaining hemostasis

VENIPUNCTURE PROCEDURE

1. Review the test requisition/computer order

Should have all information such as: patient's name, person ordering the test, patient’s medical record number, DOB/Age, location of patient, test to be performed and date to be performed, test status (STAT, routine), special precaution (e.g.. Allergy, latex sensitivity)


2. Approach, Identify and Prepare the patient Be prepared with all information, materials Identify yourself: name, title and why you are there Obtain consent – ask permission to collect blood Identify patient by name and date of birth – ask patient to

state Also verify info with ID band (if applicable) Information for babies that need to be verified: name (if

available) and date of birth, gender, medical record number, mother’s last name

Prepare the patient by explaining the procedure, answer any questions


3. Verify diet restrictions and Latex sensitivity

If fasting is required, make sure the patient has been fasting

If patient is latex allergy, use latex free equipment

4. Sanitize hands

Hands can be washed or used sanitizer – follow facility protocol


5. Position patient, apply tourniquet and ask patient to make a fist

Normally inpatients are lying in bed; outpatients will be sitting in chair

Note: due to possibility of fainting, patient should not be standing up or seated on high chair/bar stools

If you lower bed rails and forget to raise it back up and patient falls, you will be liable

6. Locate and select vein to be used Release tourniquet and ask patient to open fist Most common vein is in antecubital area of arm where

veins are close to the surface


Most prominent are the Median cubital, cephalic and basilic veins – in “H” pattern

Also have median, median cephalic and median basilic veins – in “M” pattern


7. Clean and air dry the site Clean in circular motion, inner to outer, about 2-3 inches in

diameter If not cleaned, microorganisms can enter the bloodstream

causing infection Allow to air dry 30-60 seconds Note: to prevent contamination – do not: dry with unsterile

gauze; fan with your hands or blow; touch the site after cleaning

8. Prepare Equipment and put on gloves Have all equipment handy Do not remove needle cover yet ETS (evacuated tube system), Syringe system

Butterfly system – same procedure – explained in Lab


9. Reapply tourniquet Uncap and inspect needle (although rare – needle may have

deformities)Never leave the tourniquet for more than 2 minutes as it can elevate certain tests, such as: alb, AST, Ca2+, Chol, iron, T. protein, T. bili

10. Ask patient to make a fist Anchor vein and support arm: thumb 1-2 inches below site of insertion

with other fingers supporting arm below Insert needle with bevel upwards – usually will sense a “pop” sound

meaning that the needle enter the vein. You may also have less resistance

Normal angle of needle is 30 degrees; for shallow veins, may need 15 degrees

Angle range from 15-30 degrees depending on depth


11. Establish blood flow by penetrating the needle in the tube (ETS). Push with thumb while

grasping the needle holder with index and middle finger If using a syringe, will see flash blood in hub If successful venipuncture, blood will flow

Release tourniquet and ask patient to open fistTourniquet released with one pull/tug

12. Fill, remove and mix tubes in order of drawmaintain needle position while changing needle

Keep arm in downward position, so blood fills from bottom up without contact with the needle

Gentle mixing, do not mix vigorously


13. Place gauze, Remove needle, Activate safety feature and Apply pressure

Hold gauze lightly in place; do not press down until the needle is completely out of the vein

Apply pressure for about 3-5 mins or until bleeding has stopped It is okay to have patient hold pressure while you are labeling

tubes Avoid asking patient to bend arm upwards to keep pressure – it

has shown to delay clotting and increase change of bruising

14. Discard collection unit, syringe needle or transfer device

Use red biohazard container (sharps container). Do not break, cut/crush needle

Never recap needles


15. Label tubes

Place patient first and last name, DOB, MR #, date and time of collection and phlebotomist initial; additional information such as fasting

Labels in hospital already have most of these information

Before leaving, double check label information with patient’s wristband and tube label

16. Observe special handling instructions

Tubes may need to be cooled, covered from light, etc


17. Check patient’s arm and apply bandage

Instruct patient to leave bandage for at least 15 minutes

Avoid lifting heavy objects for at least one hour

18. Dispose of contaminated materials

Use proper biohazard containers – per facility protocol

19.Thank patient, remove gloves and sanitize hands

20. Transport specimen to lab


VENIPUNCTURE EQUIPMENT

VENIPUNCTURE

THE END

Science

Phlebotomy