The process of collecting blood to cut a vein Two main phlebotomy procedures:

Venipuncture II. Capillary puncture

I.

1.

Professionalism
Appearance, Attitude, Communication skills,

Bedside Manner

2.
3. 4.

Patient Consent (implied consent) Legal Issues Infection Control (PPE, hand hygiene, isolation)

Arteries and veins are comprised of three layers of tissue: Tunica intima
Innermost, smooth layer

Tunica media
Middle, thickest layer

Tunica adventitia
Outer covering

Capillaries comprise only one layer of tissue.

Arterial Blood

Venous Blood

Has a larger Has a larger concentration concentration of of carbon oxygen than dioxide carbon dioxide Pumped by Pumped by the the heart to heart to the body the lungs cells

i.

Arteries
Elastic, muscular and thick walled Arterial blood is bright red (oxygenated blood)

ii.

Veins
Thinner walls Venous blood is dark red (deoxygenated blood)

iii.

Capillaries
Smallest blood vessels. One cell thick to allow for gas and nutrient exchange.

The most commonly used veins for venipuncture are located in the antecubital fossa.

Which vein is BEST for venipuncture?

1st Choice Median cubital vein

2nd Choice
3rd Choice

Cephalic vein
Basilic vein

Hand Veins

Dorsal venous arch

Metacarpal plexus

When the antecubital veins are not accessible, the hand veins may be used for venipuncture.
Hand veins are smaller and less anchored. NOTE: This can be very painful for the patient.

1.
2. 3.

Whole blood Plasma Serum

1.

Whole blood
Contains the liquid portion of the blood (plasma) and the cellular components
i. Arterial ii. Venous

1.

Whole blood
i.

Arterial
Oxygenated blood with bright red color Deoxygenated blood with a dark red color

ii. Venous

2.

Plasma
The liquid portion of an unclotted or anticoagulated blood Contains fibrinogen

3.

Serum
The liquid portion of clotted blood Plasma minus the fibrinogen

Three (3) Basic Methods

1. Evacuated Tube System 2. Needle and Syringe

3. Winged Infusion Set (Butterfly)

i.

Tourniquet
made of pliable rubber or a strip with Velcro Used to locate the patients veins

Nonlatex strap

Velcro

i.

Tourniquet
applied to a patients arm during venipuncture. must not be left on longer than 1 minute

i.

Tourniquet

ii.

Needle
Size gauge and bore are inversely related 21 gauge standard for routine venipuncture.

Three (3) Basic Methods

1. Evacuated Tube System a. Multisample needle b. Tube holder (barrel/adapter) c. Evacuated tubes

Three (3) Basic Methods

1. Evacuated Tube System a. Multisample needle b. Tube holder (barrel/adapter) c. Evacuated tubes

Three (3) Basic Methods

1. Evacuated Tube System
Screw the needle into the tube adapter
Insert the first tube to be collected into the tube adapter Push the tube up to the adapter guideline

Three (3) Basic Methods

2. Needle and Syringe a. Syringe needles b. Syringe c. Transfer device

Three (3) Basic Methods

3. Winged Infusion Set (Butterfly) a. Luer fitting for syringe b. Luer adapter for ETS

Three (3) Basic Methods

3. Winged Infusion Set (Butterfly) Used to collect blood from people with small, fragile veins, such as the elderly and children Provides greater control with non-stable patients.

Common Stopper Colors and Additives

Common Stopper Colors and Additives

Tube additives
A. Anticoagulant

1. Light Blue (citrate) 2. Green (heparin) 3. Lavender (EDTA)

B. Antiglycolytic Agents

C. Clot Activators 5. Red (silica) 6. Orange (thrombin) D. Thixotropic gel 6. Gold (serum) 7. Light Green (plasma)

4. Gray (sodium fluoride)

Reduce the risk of specimen contamination by microorganisms and additive carry-over.

Order of Draw

Tube Stopper Color

1. Blood culture tubes 2. Coagulation tubes 3. Glass non additive tube 4. Plastic clot activator tube Serum Separator tubes (SST) 5. Plasma separator tubes (PST) Heparin tubes 6. EDTA tubes Plasma preparation tubes Oxalate/fluoride tubes

Yellow SPS Light blue Red Red Gold Plastic / Red-gray rubber Light green / Green-gray rubber Green Lavander / Pink Pearl Top Gray

1.

Yellow SPS
Additive: Sodium Polyanethol Sulfonate (SPS) Department: Microbiology (Blood Culture)

2.

Light Blue
Additive: Sodium Citrate Department: Hematology (Coagulation - PT, PTT, APTT)

3.

Red / Red Rubber

Glass Nonadditive tube Department: Chemistry, Blood Bank and Serology

4.

Red
Additive: Clot activator tubes Department: Chemistry

4.

Red and Gray Rubber

Additive: Serum Separator Tubes Department: Chemistry

4.

Gold Plastic
Additive: Serum Separator Tubes Department: Chemistry

5.

Light Green (Plasma barrier tubes)

Additive: Lithium heparin or Sodium heparin with

Gel Separator Department: Chemistry

5.

Green
Additive: Lithium heparin or Sodium heparin Department: Chemistry

6.

Lavender
Additive: EDTA (Ethylene Diamine Tetraacitic Acid) Department: Hematology (CBC)

6.

Gray
Additive: Sodium fluoride (with potassium oxalate) Department: Chemistry (Blood glucose and alcohol)

Order of Draw

Tube Stopper Color

1. Blood culture tubes 2. Coagulation tubes 3. Glass non additive tube 4. Plastic clot activator tube Serum Separator tubes (SST) 5. Plasma separator tubes (PST) Heparin tubes 6. EDTA tubes Plasma preparation tubes Oxalate/fluoride tubes

Yellow SPS Light blue Red Red Gold Plastic / Red-gray rubber Light green / Green-gray rubber Green Lavander / Pink Pearl Top Gray

Sterile Specimens
Blood Culture Tubes

Coagulation Tubes
Light Blue

Non additive
Light Green

SST
Gold or Red

Red

Green Lavender Gray

Orange
Additive: Thrombin Department: Chemistry

Yellow
Additive: ACD (maintain RBCs viability) Department: Blood Bank

Routine ETS Venipuncture

Supplies for Venipuncture

Routine ETS Venipuncture

1. Review Test Request

Manual requisition

Computer requisition printing at a terminal in the laboratory

Routine ETS Venipuncture

1. Review Test Request Patients name, DOB, medical record number Ordering physicians name Date and time test is to be done Type of test ordered Test status (timed, fasting, STAT) Patients location (if inpatient) Initials of phlebotomist

Routine ETS Venipuncture

2. Approach Identify and Prepare Patients

Determine the correct spelling of the patients last name:

Requisition form ID band Specimen label

Routine ETS Venipuncture

2. Approach Identify and Prepare Patients

Example of warning sign No blood pressure or venipuncture in the right arm

Routine ETS Venipuncture

3. Verify Diet Restrictions and Latex Sensitivity 4. Sanitize hands

5. Position Patient, apply tourniquet and ask patient to

make fist.

Routine ETS Venipuncture

6. Select vein, release tourniquet and ask to open fist

Selecting the Venipuncture Site Always examine the antecubital area first Ask the patient to hold the arm still and make a fist Select a vein that is large and does not roll Palpate the vein using the tip of your index finger

Routine ETS Venipuncture

7. Clean and air dry site 8. Prepare equipment and put on gloves

Cleansing the Site Cleaning the site with an antiseptic (70% isopropyl alcohol)

Cleanse the site using concentric circles

Allow alcohol to dry completely or use a gauze NEVER blow on the site

Routine ETS Venipuncture

9. Reapply tourniquet, uncap and inspect needle 10. Ask patient to remake a fist, anchor vein & insert needle

11. Establish blood flow, release tourniquet and ask patient

to open fist.

Routine ETS Venipuncture

12. Fill, remove and mix tubes in order of draw

Sharps Container

 Anchor the vein below the puncture site Insert the needle at a 15 to 30 angle Insert the evacuated tube and allow it to fill completely

Routine ETS Venipuncture

13. Place gauze, withdraw needle, activate safety features

and apply pressure 14. Discard needle in holder units

Sharps Container

Routine ETS Venipuncture

15. Label tubes 16. Observe special handling instructions

17. Check patients arm and apply bandage

Routine ETS Venipuncture

18. Thank patient, remove gloves and sanitize hands 19. Dispose used materials

20. Transport specimen to the lab

Must know

A tourniquet is place 3-4 inches above the antecubital are After removal from the holder, additive tubes must be inverted gently 3 8 times Tourniquet must not be left on the arm longer than 1 minute.

Trouble Shooting
1. Tube position 2. Lost

3. Bevel against the vein wall

4. Needle to deep 5. Needle not deep enough

6. Needle beside the vein

7. Collapsed vein 8. Undetermined needle position

A. B.
i.

Interacting with a child Immobilizing a child

ii.

Wrapped in a blanket Restrained while sitting on a parents lap

C.
i. ii.

Pediatric venipuncture equipment

23-gauge butterfly and tube holder Use of microtubes

A.
i.

Challenges
ii.

iii.
iv. v.

Arthritis Coagulation problems Hearing Loss Skin ad veins are less elastic Alzheimers, cataracts, Parkinsons and stroke

Problem Sites
1. Burns, Scars and Tattoos 2. Damaged Veins

3. Edema
4. Hematoma 5. Mastectomy

Vascular Access Devices

1. Heparin or saline lock 2. Intravenous line

3. Central vascular access device (CVAD)

Vascular Access Devices

1. Arterial Line 2. Arteriovenous (AV) shunt or fistula

Procedural Error risk

1. Hematoma 2. Iatrogenic anemia

3. Inadvertent arterial puncture

4. Infection of the site 5. Nerve injury 6. Reflux 7. Vein Damage

Hematoma

Patients Conditions and Complication

1. Allergies to supplies and equipment 2. Excessive bleeding

3. Fainting (syncope)
4. Nausea or vomiting 5. Obese patients 6. Pain 7. Petechiae 8. Seizures/convulsion

The blood is collected from a skin puncture made with a lancet or similar device. Collection site

Outer area of the bottom of the foot (heel stick) ii. The fleshy part of the last phalanx of the third/forth finger iii. Fleshy portion of the earlobe
i.

Material:
1. Alcohol, Gauze, Bandages 2. Lancets

3. Warming Devices
4. Microcollection Tubes 5. Microhematocrit Tubes 6. Sealants 7. Capillary Order of Tubes 8. Indication for Capillary Puncture

The blood is collected from a skin puncture made with a lancet or similar device.
1. Alcohol, Gauze, Bandages

The blood is collected from a skin puncture made with a lancet or similar device.
2. Lancets

The blood is collected from a skin puncture made with a lancet or similar device.
3. Warming devices (not to exceed 42C)

The blood is collected from a skin puncture made with a lancet or similar device.
4. Microcollection Tubes

5. Microhematocrit Tubes
6. Sealants

Capillary Order of Draw

1. EDTA specimens 2. Other additive specimen

3. Serum

Indications of Capillary Puncture

1. No accessible veins 2. Veins are fragile

3. Thrombotic tendencies
4. POCT (glucose monitoring)

Indications of Capillary Puncture

1. Small blood volume 2. Prevent Injury by restraining

3. New born screening

Neonatal Screening
1.

2.

Collected by heel puncture and placed within printed circles on filter paper First drop of blood is wiped away.

Routine handling
1. Mixing Tubes Mix tubes by inverting 3 to eight times 2. Transporting specimens Plastic bag with a biohazard logo, liquid tight closure and slip pocket for paperwork

Routine handling
3. Delivery time limits 45 minutes of collection Centrifuged within 1 hour or up to 2 hours
Minimize Glycolysis ( Glucose are lowered by 200 mg/ml per hour).

4. Special handling Maintained at 37C (heat block) Chilled (using crushed ice) Wrapped on foil
e.g. bilirubin decrease by 50% after 1 hour of light exposure

Certain specimens must remain cool, so they are placed in an icewater mixture

Specimens to be kept warm and protected from light can be wrapped in aluminum foil

Routine handling
5. Specimen Suitability i. Hemolyzed ii. Collection in the wrong tube iii. Failure to follow timing and handling requirements iv. Quantity not sufficient (QNS) v. Clotting in WB or plasma specimen

Routine handling
6. Centrifugation i. Specimens must be completely clotted (30-60 minutes at room temp.) before centrifugation. ii. Visually check
a. b. c. Lipemic Hemolyzed Icteric

Unacceptable Blood Specimens

a. Lipemic A cloudy turbid appearance, presence of lipid, indicates a non-fasting specimen. Interferes with colorimetric analysis in chemistry

Unacceptable Blood Specimens

b. Hemolyzed Destruction of RBC results in plasma or serum appearing red to pink due to hemoglobin release Affects potassium and enzyme testing

Unacceptable Blood Specimens

c. Icteric Specimen with a yellowish appearance due to increased bilirubin content

Routine handling
7. Stopper Removal Stopper removal devices Face Shield Splash Shield 8. Aliquot Preparation For multiple tests in a single specimen. Stored at 4C 20C for 8 hours