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 of Phlebotomy

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 phlebotomist

PRO for the laboratory
Patients window to the laboratory Critical link between patient, patients

physician & clinical laboratory Delivers quality laboratory services & over-all patient care through correct blood collection practices.

SCOPE OF PHLEBOTOMY

Skin puncture Venipuncture

Arterial puncture
Bleeding 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)

VENIPUNCTURE PROCEDURE
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

VENIPUNCTURE PROCEDURE

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

Holder/ Adapter

Gauge # = bore size For evacuated systems, use w/ a syringe, single draw or butterfly system

(vacutainer) Tourniquet Wipe off with alcohol & replace frequently Alcohol Wipes 70% isopropyl alcohol

EQUIPMENT
Povidone-iodine

wipes/ swabs (blood culture) Gauze spongesApply 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

1st- blood culture

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

order of draw is:

ORDER OF DRAW
3rd- coagulation tube (light blue

stopper) NEVER the first tube drawn If 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

VENIpuncture SITE SELECTION

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

VENIpuncture SITE SELECTION

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

PERFORMANCE OF A VENIpuncture
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

PERFORMANCE OF A VENIpuncture
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

PERFORMANCE OF A VENIpuncture

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

PERFORMANCE OF A VENIpuncture

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

ADDITIONAL CONSIDERATIONS
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

ADDITIONAL CONSIDERATIONS
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

ADDITIONAL CONSIDERATIONS
Hemoconcentration due to:
Prolonged tourniquet application (no > 2

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

ADDITIONAL CONSIDERATIONS
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

ADDITIONAL CONSIDERATIONS Patient

Preparation Factors:
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

ADDITIONAL CONSIDERATIONS Patient

Preparation Factors:
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

ADDITIONAL CONSIDERATIONS Patient

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

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

ADDITIONAL CONSIDERATIONS Patient

Preparation Factors:
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

SAFETY AND INFECTION CONTROL - PROTECT

YOURSELF
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

SAFETY AND INFECTION CONTROL - PROTECT

YOURSELF
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

TROUBLESHOOTING GUIDELINES:
Or move it

backward May have penetrated too far

TROUBLESHOOTING GUIDELINES:
Adjust the angle
Bevel may be

against the vein wall

TROUBLESHOOTING GUIDELINES:
Loosen tourniquet
Try another tube

It may be obstructing

Re-anchor the vein

blood flow There may be no vacuum in the one being used Veins sometimes roll away from the point of the needle & puncture site

TROUBLESHOOTING GUIDELINES:
IF BLOOD STOPS

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

TROUBLESHOOTING GUIDELINES:
Needle may have Hold equipment

pulled out of the vein when switching tubes

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 collection

RXN Fainting

SYMPTOMS Dizziness, pallor, sweating, unconsciousness

FIRST AID Rx tourniquet & needle, apply pressure on site & elevate arm, spirit of ammonia, orange drink when conscious

Common adverse reactions to blood collection

RXN
Nausea/

SYMPTOMS

FIRST AID

vomiting

Same

Ask patient to take deep breath; cold compress on nape & forehead Remove tourniquet, needle.
Apply pressure & elevate arm. Cold compress after 5 min. if needed

Hematoma

Swelling;
purple color at site

Common adverse reactions to blood collection

RXN
Tetany

SYMPTOMS
Muscular twitches & spasms

FIRST AID

Inhale & exhale into paper bag

placed around
mouth & nose

COLLECTION TUBES FOR PHLEBOTOMY

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

separated by centrifugation USES: Chemistries, Immunology & Serology, BB (Xmatch)

COLLECTION TUBES FOR PHLEBOTOMY

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

COLLECTION TUBES FOR PHLEBOTOMY

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

COLLECTION TUBES FOR PHLEBOTOMY

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

COLLECTION TUBES FOR PHLEBOTOMY

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

COLLECTION TUBES FOR PHLEBOTOMY

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

remove Ca USES: Coagulation tests (PT & APTT), full draw required

COLLECTION TUBES FOR PHLEBOTOMY

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)

COLLECTION TUBES FOR PHLEBOTOMY

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

COLLECTION TUBES FOR PHLEBOTOMY

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)

COLLECTION TUBES FOR PHLEBOTOMY

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

inactivation USES: HLA tissue typing, paternity testing, DNA studies

COLLECTION TUBES FOR PHLEBOTOMY

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

of microorganisms USES: Microbiology - aerobes, anaerobes, fungi

COLLECTION TUBES FOR PHLEBOTOMY

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

remove Ca USES: Westergren Sedimentation Rate; requires full draw

COLLECTION TUBES FOR PHLEBOTOMY

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

COLLECTION TUBES FOR PHLEBOTOMY

Brown Top
ADDITIVE; Na heparin MODE OF ACTION: Inactivates

thrombin & thromboplastin USES: Serum Pb determination

Capillary (skin) Puncture: Main Indications

Infants & children Adults (required to

(required to fulfill physician orders)

satisfy order & where venous access is limited) For certain Point-ofCare (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
Due to Arterial

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

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

Others: Adults &

for neonates/ infants (small/ premature) Fingers (large infants, children & adults) Plantar surface of great toe (larger infant)

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 DO NOT use Betadine

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

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)

PERFORMANCE OF A FINGERSTICK
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

PERFORMANCE OF A 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

BLOOD COLLECTION ON BABIES:

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

BLOOD COLLECTION ON BABIES:

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

BLOOD COLLECTION ON BABIES:

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.

BLOOD COLLECTION ON BABIES:

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

Heelstick Technique:
Preheat area w/

commercial heel warmer or moist warm washcloth

Heelstick Technique:
Grasp foot so heel

is exposed between thumb & index finger Disinfect w/ alcohol Wipe dry w/ sterile 2x2 gauze pads

Heelstick Technique:
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

Heelstick Technique:
Wipe 1st drop

of blood to reduce tissue fluid contamination

Heelstick Technique:
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)

Heelstick Technique:
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