PHLEBOTOMY

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PHLEBOTOMY

• Created By Michelle Huffman

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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

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SAFETY PRECAUTIONS

• In 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.

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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.

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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

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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

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Importance of correct specimen collection

• Laboratory testing of blood specimens is VITAL to
  the correct DIAGNOSIS, TREATMENT and MONITORING
  of a patients 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)

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Types of Specimens

• The 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.

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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.

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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.

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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.

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Most Common Tubes Drawn
Color 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
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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
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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 RBCs 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.

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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.

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Hemolysis

• Hemolysis is the breakage of red blood cells
  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

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• Must invert tubes
• 8-10 times
• to prevent hemolysis
• to ensure adequate mixing of blood with
  anticoagulant

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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
• ESRFibrinogen
• Hemoglobin
• Hematocrit
• PT
• PTT

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Redraw The Specimen
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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 patients
  veins.
• NOTE Each and every person has different veins
  (ex. Shape, size, and stability)

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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.

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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)

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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.

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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.

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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

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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 patients 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

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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.

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• Never draw blood from a FOOT!!!!!!
• PERIOD!!!!

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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.

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Phlebotomy Tips

• Bevel on Upper Wall rotate bevel slightly
• Needle slipped beside vein withdraw needle
  until
• The bevel is just under the skin and redirect
  needle into
• Vein.
• 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 tube
• Or pull more slowly on syringe plunger.)
• NOTE If unable to obtain specimen discontinue
• Phlebotomy and try again using appropriate
  actions.

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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.

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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.

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Pre-analytical Errors
https//www.youtube.com/watch?vPh4H1AuvOH0
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Blood Culture Collection

• Watch blood collection video

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QUESTIONS?????