Blood sample collection in children

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Blood sample collection in children Dos and
Don'ts
Dr Swati Bhave
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Preparation of Pediatric Patients

• Find out
• Is it the first time for the child?
• Find out about past experience. How did the child
  react ? How did the parents react ?
• Explain
• To parent and child about procedure (if
  possible with dolls or puppets)
• Explain need of second attempt if required

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Parental co-operation

• Assess - Parental ability to participate or
  assist you
• Decide - Whether parent should be present or not
• If present - Decide how will they assist
  physical restrain, distraction, emotional support
  , explanation

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How to relieve Anxiety Fear

• Collect blood away from other patients in a
  special room. Never in the hospital bed. This is
  a comfort zone
• Area should be child friendly. Uniforms should be
  colourful
• Keep equipment out of site
• Ask childs preference of hand
• Allow child to select comfort object
• Stop procedure if child combative
• Try later or another person

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Minimizing PAIN

• Topical anesthetic like AMETOP, EMLA
• Cost, time ( 10-60min)
• More than one site tried, allergy
• Sucrose or pacifier

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Selection of Site

• Very important to get adequate volume
• Will be decided by
• Age of the child heel or finger stick, IV
• Whether arterial or venous blood required
• Equipment available eg neonate capillary tubes,
  vacutainers, routine needle syringe etc

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Infants and Neonates HEEL stick puncture

• Lateral plantar bottom surface
• 3 - 5 min Pre-Warming gt blood flow
  (arterializes)
• Pediatric lancet New born 2.5mm L /1mm D,
  Preterm o.75 mm L / 0 .85 mm D
• Depth of major BV is 0.03 mm to 1.6 mm from skin
  to calcaneous
• gt 2.4 mm depth injury Osteomyelitis

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Infants and Neonates HEEL stick puncture

• Do not use anteromedial area or posterior curve
  of C
• Do not use alcohol swabs to stop bleeding
  stinging Use sterile gauze for pressure
• Do not use adhesive tapes maceration and
  bruising of skin
• Do not squeeze or milk excessively hemolysis or
  dilutes blood with tissue and interstitial fluid
  erroneous results
• Discard first drop
• Complications cellulitis, abscess, scarring,
  tissue loss, calcified nodules

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Older child gt one yr age finger prick

• Damaged veins, arm in cast or bandaged
• Do not use if edema, infection, lt circulation
• Skin to BV depth 1.5 -2.4 mm
• Should not go gt2.4 mm deep
• Pediatric lancet sizes 1.75/1.25/0.85 mm

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Intravenous blood collection

• Site selection
• Tourniquet not excessively tight
• Special precautions when
• Heparin lock or
• IV line collection

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What is required from the sample

• Does the test require whole blood , serum or
  plasma.
• How much is the volume required 2, 4, 5, ml
  etc. Pre-term 10 ml may be 5 of total volume
• What are the special bulbs or ready made tubes
  required e.g. fluoride bulb for sugar,
  chemistry bulb for urea , EDTA for hematology etc

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In What to collect blood ?
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ORDER of drawing

• This is important - so that additives in one tube
  will not contaminate specimen in subsequent tubes
• Blood culture
• Non Additive tube
• Coagulation tube
• Non Additive tube
• If using syringes minimize clotting by filling
  additive tubes before non additive

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When How to get Serum Plasma

• Serum sample
• blood collected without any anti-coagulant and
  centrifuged
• clear supernatant fluid devoid of any fibrin
  products
• Plain bulb
• Most enzymes,
• Biochemical LFT,KFT,
• S Electro.
• Serological Widal, VDRL

• Plasma sample
• blood collected mixed with anticoagulant and
  centrifuged
• clear supernatant fluid with thrombosis
  inhibited. Most satisfactory sample. No changes
  occur in blood
• Heparinized bulb
• PH, NH4, RBC levels, Plasma cortisol,
  testosterone, globin,cholinesterase

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For Special Testing

• PCR, Genetic, ammonia, blood gases, drug,
  antibiotic hormone levels etc.
• Before collection of sample ascertain that you
  know everything about the sample collection
• Confirm from lab how much volume, what bulb,
  procedure, timing etc
• Recollection of blood is distressing for
  everyone Child-parent- doctor adds to cost

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HEMOLYSIS OF SAMPLES

• Contact with water
• Excessive heat or cold
• Rigorous mechanical injury to RBS ( thin gauge )
• Prolonged storage
• Hemolyzed samples will give erroneous results

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PREVENTION OF HEMOLYSIS

• Equipment used to collect absolutely dry
• Minimum constriction of limb
• Use correct gauge
• Collect slowly and steadily
• Remove needle and put immediately into the bulb
• Easier if collection in Vacutainer

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Important steps before collection

• Identification of the patient
• Labeling correctly very very important
• Re-checking which test is required
• Keeping ready all the necessary equipment
  drawing of blood and bulbs for collection
• Clean up the area before and after collection

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Following safety precautions

• Do no harm to your patient
• Ensure use of safe and sterile equipment
• Do no harm to yourself
• Follow universal precautions
• Avoid needle stick injuries and splashing of
  blood into your eyes, skin or mucous membrane
• Do no harm to the community
• Ensure that you have safely and correctly
  disposed all equipment so that no other person
  can get exposure

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Transport Storage of samples

• Ideally the sample should be collected in the
  laboratory and immediately into the processing
• If it cannot be sent immediately one should
  follow instructions carefully for
• Storage
• where should it be kept ? room temp, cold
  storage-what temp
• Transport
• What are the precautions during transport

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Summary

• Blood collection in children is a traumatic and
  invasive procedure
• All efforts should be made to reduce the
  discomfort
• Care should be taken to avoid need for repeat
  puncture