Blood Collection: Equipment & Supplies

• Objectives include understanding equipment, systems, additives and order of draw

General Blood Collection Equipment and Supplies

• A blood-drawing station includes a table, special chair, and sometimes a bed or reclining chair for patient comfort and safety.
• Phlebotomy chairs should be comfortable, have adjustable armrests and height and prevent patients from falling.
• Phlebotomists often visit patients in busy hospital settings.
• Handheld phlebotomy equipment carriers come in various sizes and are useful for multiple draws, STAT requests, or when not collecting many samples.
• Phlebotomy carts hold more supplies and are better for collecting many samples, often used for "sweeps"
• Carts are a potential source of nosocomial infections and are ideally left outside rooms with equipment brought in via a tray.
• Gloves are required by the CDC/HICPAC and OSHA, and a new pair should be used for each patient
• Acceptable glove materials include nonsterile, disposable latex, nitrile, neoprene, polyethylene, and vinyl.
• Powdered gloves are not recommended due to lung problems, allergies, and hypersensitivities.
• Hand decontamination is essential before putting on and after removing gloves.
• Hand sanitizers should only be used if hands are not visibly soiled; otherwise, wash with soap and water.

Antiseptics and Disinfectants

• Antiseptics prevent or inhibit microorganism growth and prevent sepsis, 70% isopropyl alcohol is the most common for routine blood collection, and are safe for use on human skin.
• Disinfectants remove or kill microorganisms on surfaces, disinfectants do not kill spores, reusable medical equipment must be sterilized and are not safe for use on human skin.

Gauze, Bandages, Slides, Pens, Watches and Patient ID

• Clean 2x2 inch gauze pads, that can be fluid proof, are used to apply pressure to the collection site.
• Bandages are applied to the blood collection site after bleeding has stopped, with paper, cloth, or knitted tape used
• Ensure to check for patient allergies to adhesives
• Self-adhesive bandages should never be used on infants under 2 due to choking hazards
• Slides are needed to prepare blood smears.
• Pens for labeling tubes must be permanent and smear-proof.
• Watches should have a second hand or portable clock and be easy to disinfect
• Patient identification equipment includes barcode readers to print correct labels.

Needle and Sharps Disposal

• Needles, lancets and other sharp objects should be disposed of in a sharps container immediately after use.
• Sharps containers should be rigid, puncture-resistant, leakproof, disposable and clearly labelled with the biohazard symbol, and have locking lids.
• Sharps containers should be disposed of when they are 2/3 full.

Biohazard Bags

• Biohazard bags are leakproof, used to transport blood and other specimens, and marked with a biohazard label.
• Bags often have an external pouch to keep paperwork free of contamination, while keeping paperwork and sample together in transit

Vein-Locating Devices

• Vein-locating devices use transillumination with high-intensity LED or infrared light to highlight veins in subcutaneous tissue
• Hemoglobin absorbs the light highlighting the veins

Tourniquets

• A tourniquet is a device applied to restrict blood flow, inflating veins without stopping arterial flow and should be stretchable and disposable.
• Tourniquets should not be left on longer than 1 minute to prevent alterations in blood components and inaccurate test results.

Needles

• Needles must be sterile, disposable and designed for single use only
• Needle types include multisample, hypodermic and winged infusion (butterfly) needles
• Needle parts include the bevel, shaft, hub, and lumen
• Needle gauge refers to the diameter of the lumen, so a larger gauge indicates a smaller diameter.
• Needle gauge color coded by depends on the size of the needle.
• In phlebotomy, a 21-gauge 1-1½ inch needle is typically used.
• Needle length is most commonly 1- to 1.5 inches for venipuncture.
• If a needle is too big it might collapse the vein, and if a needle is too small it could hemolyze a sample.

Evacuated Tube System (ETS)

• The ETS is a closed system where blood flows into a collection tube through a needle inserted into a vein, preventing exposure to contaminants.
• The ETS allows for the collection of multiple tubes with a single puncture including a multisample needle, tube holders, needle and holder units with safety attached to the needle, and evacuated tubes
• Multisample needles allow collection in a single venipuncture and have a retractable sleeve to avoid leakage
• Multisample needles are double pointed with threaded part that screws into a holder

Needle and Holder Units

• In Needle and Holder Units, the needle and plastic holder may or may not be permanently attached.
• Evacuated tubes are used with both ETS and the syringe method, and come in multiple sizes, where OSHA requires tube holders with needles to be disposed of as a unit after use.

Evacuated Tubes (cont.)

• Evacuated tubes have a vacuum, artificially created when air is pulled from the tube which designed to draw an exact volume of blood.
• Additive tubes contain a substance, like an anticoagulant, whereas nonadditive tubes do not.
• Rubber or plastic-covered stoppers usually are color coded to indicated is in tube.
• Expiration dates for additive and vacuum are printed on the label of evacuated tubes.
• Evacuated tubes are color coded for convenient use, allows for easy collection of many samples, are commonly used for routine blood collection in phlebotomy testing and come in multiple sizes.
• Though tubes were originally made of glass, now they are mostly plastic.
• If a tube loses vacuum, blood no longer flows into the tube, due to incorrect storage, it may have been dropped or opened, or have incorrect needle position or tubes not allowed to fill fully.
• Vacuum level in ETS tubes is pre-measured for correct blood-to-additive ratio.

Syringe System

• The Syringe System is an alternative for patients with small or difficult veins, but is no longer used for phlebotomy typically.
• Syringe needles are 1- to 1.5-in long and must have a resheathing feature if used to draw blood with a barrel and plunger.
• Syringe transfer devices allow safe blood transfer into tubes without a syringe needle or removing the tube stopper.
• Syringes do not contain additives, therefore blood must be transferred to the correct tube immediately and the transfer devices greatly reduce the chance of needle sticks.

Blood Collection Sets

• Blood collection sets are most commonly known as a butterfly needle with automated in-vein retraction, which is effective for small or difficult veins.
• Butterfly needles can be attached to an evacuated tube holder or syringe, short allowing for a shallower angle, where common gauges range from 25-21.
• One type of collection is the Nonwinged blood collection set.

Blood Collection Sets (cont.)

• Combination systems allow specimen to be collected by evacuated tube or syringe with regular or butterfly-style needles where safety devices are available and the blood collection tube and collection apparatus are combined in single unit.

Blood Collection Additives

• Additives are anything, outside of the stopper, added to collection tubes, usually to to prevent/ encourage or preserve blood.
• Additives are not interchangeable, so it is important to pick the correct tube for the test, where anti-coagulants result in whole blood, and some whole blood samples are used to obtain plasma.
• Additives that activate the coagulation of blood are centrifuged to obtain serum for testing.

Anticoagulants

• Anticoagulants are substances which prevent clotting in whole blood or plasma samples, that use the methods of precipitating calcium, or inhibiting formation of thrombin.
• Types of anticoagulants include Ethylenediaminetetraacetic acid (EDTA), Citrates, Oxalates and Heparin.
• Ethylenediaminetetraacetic acid (EDTA) comes in 2 forms - k2 and k3, which bind with calcium, purple tubes are most commonly used, with specialty tubes available in pink tan, tan, royal blue and white used for hematology.
• Citrates also bind with calcium, and preserve clotting factors, where light blue tube or blue and black tubes are used in coagulation.
• Oxalates bind to calcium, and are often found with an antiglycolytic and are generally in grey top tubes.
• Heparin inhibits thrombin, is in green tubes and used for blood chemistry, and tests requiring TAt, where green and grey, royal blue, grey and black less common.
• Anticoagulant specimens must be mixed immediately via gently inverting with no shaking.

Light Blue-Top Tubes

• Light blue-top tubes are used for testing coagulation with a 9:1 ration of blood, are contain Sodium Citrate and must be filled 90% of the way.

Blood Collection Additives

• Special-Use Anticoagulants include Acid citrate dextrose (ACD): which are blood banks, paternity, transplants
• 2 types A and B, Citrate phosphate dextrose CPD, and Sodium polyanethol sulfonate SPS

Antiglycolytic Agents

• Antiglycolytic Agents are substance that prevent glycolysis, that are Sodium fluoride, potassium oxalate, glucose

Clot Activators

• Clot Activators are substances which enhance coagulation in serum-separator tubes (SSTs) where types are substances that provide more surface for platelet activation
• (Inert Clays, Glass), Clotting factors (Thrombin)

Serum or Plasma Separator Tubes

• The Thixotropic gel separator located in tube comes in PST or SST format, has density between cells and serum or plasma, and when centrifuged, forms gel which moves between cells and either and serum or plasma to prevent cells from continuing to metabolize,
• There are trace element free tubes, which are made of materials free of contamination, are used for testing for these trace elements, and feature royal-blue stoppers, that the user must double check labels.
• Non Gel separator or BD Barricore or those with non-gel tubes with flexible elastomers that can be used for more serum testing found in many hospitals.

CLSI Order of Draw

• The order of draw is:
• Blood culture tube or bottles first
• Sodium Citrate tube
• Then Serum tubes
• Then Heparin tubes
• EDTA tubes
• Then Sodium fluoride/potassium oxalate glycolic inhibitor.

Order of Draw Considerations

• Carryover/Cross-Contamination involves transfer of additive from one tube to the next, when blood in additive tube touches needle, is transferred from syringe into ETS tubes,
• Order of draw minimizees sequence risks and tubes being filled from bottom up minimizes carryover as well.
• Tissue Thromboplastin Contamination involves draw a minimal amount of blood to avoid tests in blood plasma.
• Microbial Contamination is when blood cultures are collected first when is optimal to prevent contamination of needle.
• In Venipuncture Steps Overview, the key components include:
• Receive, review, and accession test request
• Approach, greet, and identify the patient
• Explain the procedure and obtain consent
• Verify collection requirements, identify sensitivities and potential problems
• Sanitize hands and put on gloves
• Position patient, apply tourniquet, and ask patient to make a fist
• Select vein, release tourniquet, and ask patient to open fist
• Clean and air-dry the site
• Prepare collection equipment
• Reapply tourniquet, uncap and inspect needle
• Ask patient to remake a fist, anchor vein, and insert needle