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 ofPhlebotomyThe Art ofPhlebotomy
“The quality of laboratory results is critically dependent on the specimen presented for analysis.”
“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 phlebotomistRole of the phlebotomist
PRO for the laboratoryPatient’s “window” to the laboratoryCritical link between patient, patient’s
physician & clinical laboratoryDelivers quality laboratory services & over-all
patient care through correct blood collection practices.
PRO for the laboratoryPatient’s “window” to the laboratoryCritical link between patient, patient’s
physician & clinical laboratoryDelivers quality laboratory services & over-all
patient care through correct blood collection practices.
SCOPE OF PHLEBOTOMY
Skin punctureVenipunctureArterial punctureBleeding 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 Gauge # = bore
size For evacuated
systems, use w/ a syringe, single draw or butterfly system
Holder/ Adapter (vacutainer)
Tourniquet Wipe off with
alcohol & replace frequently
Alcohol Wipes 70% isopropyl
alcohol
EQUIPMENT
Povidone-iodine wipes/ swabs (blood culture)
Gauze sponges- Apply 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 order of draw is:
1st- blood culture tube (yellow-black stopper)
2nd- non-additive tube (red stopper or SST)
ORDER OF DRAW
3rd- coagulation tube (light blue stopper)
NEVER the first tube drawnIf 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
Re-anchor the vein
It may be obstructing 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 pulled out of the vein when switching tubes
Hold equipment 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 collectionCommon adverse reactions to blood collection
RXN SYMPTOMS FIRST AID
Fainting Dizziness, pallor, Rx tourniquet
sweating, & needle, apply
unconsciousness pressure on site &
elevate arm, spirit
of ammonia, orange
drink when conscious
RXN SYMPTOMS FIRST AID
Nausea/
vomiting Same Ask patient to take deep breath; cold
compress on nape & forehead
Hematoma Swelling; Remove tourniquet, needle.
purple color Apply pressure & elevate
at site arm. Cold compress after
5 min. if needed
Common adverse reactions to blood collection
RXN SYMPTOMS FIRST AID
Tetany Muscular
twitches Inhale &
& spasms exhale into
paper bag
placed around
mouth & nose
Common adverse reactions to blood collection
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 CaUSES: 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 (required to fulfill physician orders)
Adults (required to satisfy order & where venous access is limited)
For certain Point-of-Care (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 lacerates venules, arterioles & capillaries (mixture of venous & arterial blood + intracellular/ interstitial fluids)
Due to Arterial 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
for neonates/ infants (small/ premature)
Fingers (large infants, children & adults)
Plantar surface of great toe (larger infant)
Others: Adults & 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 be used for cleansing site
Site must be air dried or wiped w/ sterile gauze (w/ alcohol hemolysis unreliable results)
DO NOT use Betadine 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