PHLEBOTOMY

Created By: Michelle Huffman

Introduction to Blood Collection

Objectives• Recognize the Importance of Correct Blood Collection• Factors That Influence Integrity of Blood Specimen• Safety Precautions Related to Blood Collection• Differentiate Between Whole Blood, Plasma and Serum• Actions of Anticoagulants, to Prevent Blood Coagulation• Describe the Appearance of Hemolyzed, Icteric, and Lipemic Specimen• Differentiate Between Arterial, Venous and Capillary Blood• Special Specimen Handling Procedures• Purpose of Quality Assurance in Blood Collection

SAFETY PRECAUTIONSIn addition to safety precautions specifically associated with blood

collection. Personnel must observe all STANDARD precautions required in Patient Care .

• Wearing appropriate personnel protective equipment• Observation of Isolation Practices• Hand Washing (15-20 secs.) and BETWEEN Patients• Using ONLY Needles with Safety Devices in the Intended Manner• Using only the recommended transfer devices to transfer blood

from syringes to evacuated tubes• Disposal of Entire Assembled Tube Holder and Needle After Use• Recording All Accidental Needlesticks and Exposures as Required • Disposal of Contaminated Materials in Designated Biohazard

Containers• Decontamination of Surfaces Using an Approved Disinfectant.

NOTE:

Blood Collection poses a serious risk for exposure to blood borne pathogens (ex. HIV, hepatitis B, hepatitis C,

Most blood-borne pathogen exposures associated with blood collection occur as a result of accidental puncture with a contaminated needle.

Types of Patient Isolation

• Strict Isolation – required for a patient with highly contagious diseases that can be spread by direct contact and through the air. (ex. Chicken pox, diphtheria) GLOVES, GOWN and MASK

• Contact Isolation - indicated for highly transmissible disease that is spread primarily by direct contact, such as influenza and infections with antibiotic-resistant bacteria. GLOVES, GOWN and MASK

• Respiratory Isolation – Patient with infection that can be spread via droplets or through the air, such as whooping cough (pertussis), meningicoccal meningitis and Haemophilus influenza. GLOVES and MASK

• AFB-TB Isolation – (acid-fast bacillus) Patient with active tuberculosis. N95 Respirator Mask, GOWN and GLOVES

What Does Being A Phlebotomist Mean??

Factors that are the responsibility of the collector and include:• Monitoring of Specimen Ordering• Correct Patient Identification• Patient Communication and Patient Safety• Patient Preparation• Timing of Collections• Phlebotomy Equipment• Collection Techniques• Specimen Labeling• Specimen Transportation to the Laboratory• Specimen Processing

Importance of correct specimen collection

• Laboratory testing of blood specimens is VITAL to the correct DIAGNOSIS, TREATMENT and MONITORING of a patient’s condition.

• Although the primary concern of personnel collecting blood specimens is understandably to obtain the specimen, failure to adhere to the collection procedure can compromise the integrity of a successfully collected specimen.

Note: approximately 56% of laboratory errors occurs during the preanalytical phase (process that occurs before testing)

Types of SpecimensThe laboratory refers to blood specimens in terms of WHOLE BLOOD, PLASMA

and SERUM.

WHOLE BLOOD - A whole blood specimen contains erythrocytes (red blood cells), leukocytes (white blood cells), and thrombocytes (platelets) suspended in plasma and essentially represents blood as it circulates through the body. (CBC, blood typing)

Note: Majority of laboratory tests are performed on the liquid portion of blood (plasma or serum) which contain substances, such as proteins, enzymes, organic and inorganic chemicals and antibodies.

PLASMA – Plasma is the liquid portion of blood that has not clotted. Plasma is often defined as the liquid portion of blood that contains fibrinogen and other clotting factors. Plasma is obtained by centrifugation of unclotted specimens.

SERUM - Serum is the liquid portion remaining after clotting has occurred. Serum does not contain fibrinogen and other clotting factors. Serum is obtained by centrifugation of clotted specimens.

NOTE:

• The presence or absence of anticoagulants in the tubes into which blood specimens are placed determines the type of specimen available for testing.

• WHOLE BLOOD and PLASMA – require an anticoagulant to prevent clot formation

• SERUM – is obtained from tubes that DO NOT contain and anticoagulant.

EVACUATED TUBES AND ORDER OF DRAW

• Evacuated tubes come in a variety of sizes, volumes and colors. The tubes are labeled with the type of anticoagulant or additive, the draw volume, and the expiration date.

• Evacuated tubes have color coded rubber stoppers or plastic shields covering the stoppers.

• Evacuated tubes fill automatically because of the premeasured vacuum present in the tube.

Why Does It Matter!?!?!?

• The order in which the tubes are drawn is one of the MOST IMPORTANT considerations when collecting blood specimens.

• Tubes MUST be collected in a specific order to prevent invalid test results caused by contamination of the specimen by microorganisms, tissue thromboplastin, or carryover of additives or anticoagulants between tubes.

• The order of draw changes when collecting a capillary specimen due to how quickly the blood can clot. In order to achieve maximum quality for a specimen the microtainer tubes need to be collected purple then green.

Most Common Tubes DrawnColor of Tube Main Tests Run Serum/Plasma Anticoagulant

Blood Cultures Microbiology NA medium

Red Send out serum No Clot activator

No gel

Blue Coagulation plasma Sodium Citrate

Gold chemistry serum Clot activator

Green chemistry plasma Lithium heparin

Pink Blood bank plasma K2 EDTA

Purple hematology plasma K2 EDTA

Gray chemistry plasma PotassiumOxalate/

Sodium Fluoride

ADDITIVESGels are found in green and gold top evacuated and microtainer tubes. Most commonly used for separating

Plasma and serum from the red blood cells.

SODIUM CITRATE BINDS CALCIUM

MOST COMMONLY USED FOR COAGULATION STUDIES

GOLD CLOT ACTIVATORS – INITIATES OR ENHANCES COAGULATION

LITHIUM HEPARIN INHIBITS THROMBIN

MOST COMMONLY USED FOR CHEMISTRY DETERMINATIONS

K2 EDTA

(ETHYLENEDIAMINETETRAACETIC ACID)

BINDS CALCIUM

MOST COMMONLY USED FOR HEMATOLOGY STUDIES

POTASSIUM OXALATE/ SODIUM FLUORIDE BINDS GLUCOSE

OFTEN USED FOR GLUCOSE TESTING

Special Requirements• Drug Levels – Usually ordered as a timed study (should be treated as a STAT) and

required to be drawn as close to the time requested as possible due to the peak and trough levels of medication that has been given to the patient.

• Cold Agglutinins – Because cold agglutinins in serum attach to the RBC’s when the blood cools below body temperature, the specimen must be kept warm until the serum can be separated from the cells.

• Specimens Sensitive to Light – Exposure to light will decrease the concentration of bilirubin, beta-carotene, folate, vitamins A, B12, and B6 and Porphyrins.

• Chilled Specimens – Specimens for tests such as lactic acid and ammonia as well as many others need to be placed on ice (chilled) immediately after collection to prevent deterioration.

• Cortisol Stimulation – These tests are ordered by Chemistry after the nurse has dosed the patient. These tests MUST be done on time with NO EXCEPTIONS. If a patient receiving cortisol is not drawn on time the patient must wait 3 days before being able to repeat the test.

Appearances of Blood

• Normal serum and plasma appear clear and pale yellow.

• Variations in the normal appearance can indicate that certain tests results may be adversely affected. (ex. results can be severely decreased or increased.)

• Hemolyzed – Pink to red color, indicating red blood cell destruction

• Icteric – Dark yellow color indicating the presence of increased bilirubin

• Lipemic – Cloudy, milky appearance indicating the presence of increased lipids.

HemolysisHemolysis – is the breakage of red blood cell’s membrane, causing the release of the

hemoglobin and other internal components into the surrounding fluid.

Which can be caused by a variety of factors including but not limited to:• Rapidly pulling back on the plunger of a syringe• Forcing blood from syringe into tubes• Capillary draws that are not free flowing• Improper choice in venipuncture site• Prolonged tourniquet time • Cleansing the venipuncture site with alcohol and not allowing the site to dry• Improper venipuncture indicated by slow blood flow• The use of a small bore needle resulting in a large vacuum force applied to the blood, causing

stress on the red blood cells which may cause them to rupture• Vigorous mixing or shaking of a specimen • Prolonged contact of serum or plasma with cells

Test results from all laboratory disciplines can be affected by hemolysis. The only corrective action is to…………………

Must invert tubes 8-10 times:

• to prevent hemolysis

• to ensure adequate mixing of blood with anticoagulant

Tests Affected By Hemolysis• Acetone

• Alcohol

• Ammonia

• AST

• C-Peptide

• CK

• CEA

• Cortisol

• Direct Bilirubin

• Free T4

• Folate

• FSH

• Glucose

• Iron

• Lactic Acid

• LDH

• LH

• Lipase• Magnesium• Phosphorus• POTASSIUM• Protein Electrophoresis• PSA• Testosterone• Total Protein• Total T4• TSH • Vitamin B12• D-Dimer• ESR

Fibrinogen• Hemoglobin• Hematocrit• PT• PTT

Redraw

The

Specimen

Which Way do I Collect the Blood??

• Venipuncture can be performed using an evacuated tube system, a syringe system, or a winged blood collection (butterfly) set. Each of these systems requires its own unique equipment.

• The system that is chosen for venipuncture is ALWAYS based on the assessment of the patient’s veins.

NOTE: Each and every person has different veins (ex. Shape, size, and stability)

VENIPUNCTURE EQUIPMENT

• Differentiate between evacuated tube, syringe, winged blood collection set for collection of blood by venipuncture.

• Differentiate various needle sizes, length, guage and purpose.• Safely disposing of contaminated needles.• Identify types of evacuated tubes by color, types of

anticoagulants, additives present, mechanism of action, special characteristics, and purpose of each.

• List correct order of draw for various types of blood collection tubes.

• Purpose of tourniquet• Substances used to clean skin prior to venipuncture.• Quality Control of Venipunture.

Evacuated Tube System(Vacutainer)

• The evacuated tube system is the most frequently used method for performing venipuncture.

• Blood is collected directly into the evacuated tube.• This system allows for the collection of numerous tubes from a

single venipunture.• This system is usually chosen when a patient has a large median

cubital vein, or other large veins in the antecubital area that are easily palpated. (15 to 30 degree angle)

SYRINGES

• Syringes – may be preferred over an evacuated tube system at times when drawing blood from patients with poorly anchored, rolling veins that will NOT support a vacuum. (10 to 15 degree angle)

• The advantage of this system is that the amount of suction pressure on the vein can be controlled by slowly pulling back on the syringe plunger.

NOTE: blood drawn in a syringe must be immediately transferred to appropriate evacuated tubes to prevent the formation of clots.

WINGED BLOOD COLLECTION SETS

(BUTTERFLY)• WINGED BLOOD COLLECTION SETS – or butterflies

as they are routinely called are used for:• Performing venipuncture from very small veins (10-15

degree angle)• Obtaining specimens from children and elderly.

WHAT SIZE NEEDLE WOULD YOU USE?

• Needle sizes are determined by the number on the package. The BIGGER the number the SMALLER the (gauge) needle.

• Therefore the SMALLER the number the BIGGER the (gauge) needle.

Ex: 23’ gauge

22’ gauge

21’ gauge

Where Are the Veins?• Proper positioning is important for succesful

Venipuncture. Patients should not stand or sit on

High stools because of possiblity of fainting

• Slight rotation of the patient’s arm is necessary

or vein exposure.

• As a rule of thumb, the tourniquet should not be left

On the patient for more than 1 minute at a time

Because of discomfort, However the tourniquet is left on

During the blood draw.

• Tourniquets – are used to allow the veins to fill to

Capacity

Hand Veins & Nerve Damage

• The Posterior surface of the wrist

Should be used for hand venipunctures.• The hand is full of nerves and the

venous Network. EXTREME caution

needs to be used when selecting

a vein in the hand or wrist for

venipuncture. • Nerve Damage can also occur with

Excessive needle punctures.

• Never draw blood from a FOOT!!!!!!

PERIOD!!!!

Capillary Specimens

• Capillary specimens are to be drawn only when necessary.

• When a patient has no discernable veins in hands or arm and you need a CBC.

• Always be sure that the test required can be done from a capillary specimen before drawing the patient if there is no other way to obtain the specimen.

Phlebotomy Tips• Bevel on Upper Wall – rotate bevel slightly• Needle slipped beside vein – withdraw needle untilThe bevel is just under the skin and redirect needle intoVein.• Needle Position cannot be determined – withdraw Needle until bevel is just under the skin, relocate vein, and redirect into vein.• Needle too deep and penetrated through vein – Withdraw needle slightly• Needle Not Deep Enough – push needle gently into vein• Collapsed Vein – Vein disappears when entered due to vacuum, or pressure caused by pulling on syringe plunger. (try again using smaller tubeOr pull more slowly on syringe plunger.)NOTE: If unable to obtain specimen discontinue Phlebotomy and try again using appropriate actions.

Is it Venous, capillary or arterial?

• VENOUS blood is the specimen of choice for clinical laboratory testing.

• ARTERIAL blood is the required specimen for arterial blood gas determinations.

• CAPILLARY blood is a mixture of arterial and venous blood and is collected by dermal puncture. (ex. fingerstick, heelstick) When properly collected capillary blood is suitable for some lab tests Therefore it should always be indicated on the label whether a specimen is venous or capillary.

• This information must accompany the results for interpretation by the physician.

QUALITY ASSURANCE

• As you can see many factors related to blood collection can affect laboratory Quality Assurance. Remember that Laboratory Personnel are available to answer questions and should be consulted whenever NEEDED.

Pre-analytical Errors

https://www.youtube.com/watch?v=Ph4H1AuvOH0

Blood Culture Collection

• Watch blood collection video

QUESTIONS?????