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• These notes cover pre-analytical considerations in phlebotomy, vascular access, potential complications, capillary puncture techniques, special collections such as blood cultures, and point-of-care testing.

Assessing Health

• Pre-analytical phase includes procedures such as laboratory specimen handling and identification.
• Phlebotomists should be able to draw blood and identify factors affecting the process.
• Physicians compare results to a reference interval with high and low limits based on healthy individuals.
• Basal state, representing the body's metabolism in the early morning after fasting, is ideal for establishing reference ranges.

Problem Areas to Avoid in Site Selection

• Burns, scars, and tattoos are not ideal sites due to potential difficulty in examining veins and impaired blood circulation.
• Damaged veins can be difficult to puncture and produce inaccurate results.
• Edema, also known as Oedema, involves swelling from fluid accumulation in tissues.
• Hematoma is a solid swelling or blood mass in tissues, caused by leakage from vessels during venipuncture.
• Mastectomy involves breast removal surgery and may affect vein selection.
• Veins in obese patients may be deep and difficult to locate.

Vascular Access Sites and Devices

• Vascular access devices (VADs) are used for blood sampling, medication infusion, central venous pressure readings, and blood transfusions.
• Arterial lines are used in critically ill patients to obtain samples for arterial blood gas and lab studies via a thin catheter inserted into an artery.
• Arteriovenous shunt or fistula is a surgically created passageway, typically in the arm, connecting an artery and vein directly.
• Blood-sampling devices help avoid needle sticks, prevent infections, and reduce wastage of line draws.
• Heparin or saline lock is an IV catheter, attached to a stopcock or diaphragm.
• Intravenous (IV) sites use a thin plastic tube or catheter inserted into a vein to inject fluids into the bloodstream.
• Central Vascular Access Devices (CVADs), also known as indwelling lines, are inserted into main veins or arteries for blood collection, monitoring pressure, and administering fluids.

Three Types of CVADs:

• Central venous catheter is inserted into a large vein (subclavian) and advanced into the superior vena cava.
• Implanted port involves a surgically implanted disk-shaped chamber attached to an indwelling line.
• Peripherally inserted central catheter (PICC) is a flexible tube inserted into the veins of extremities and the central veins.

Handling Patient Complications Associated with Blood Collection

• For allergies to equipment, place gauze over the site and remove after 15 minutes.
• Excessive bleeding may occur longer in patients on aspirin or anticoagulants.
• Fainting is caused by insufficient blood flow to the brain.
• Discontinue procedure if patient experiences nausea or vomiting until they feel better.
• Warn the patient prior to needle insertion and avoid redirection of the needle to minimize pain.
• Petechiae involves small red or purple spots appearing on the arm when a tourniquet is applied.
• If a patient experiences seizures or convulsions, discontinue blood draw quickly and hold pressure over the site.

Avoiding and Handling Procedural Error Risks and Failure to Draw Blood

• After discontinuing blood draw, apply pressure to avoid hematoma formation.
• Apply a cold compress or ice pack to help address swelling.
• Hematoma formation is caused by excessive or blind probing.
• Inadvertent arterial puncture, small vein size, needle penetration, incomplete needle insertion, tourniquet left on, or inadequate pressure can trigger hematoma.
• Iatrogenic anemia results from blood loss due to blood draw, so collect only required specimen volume.
• Inadvertent arterial puncture results in rapid filling of the tube and hematoma formation on the site.
• Prevent infection by using sterile techniques and advising patients to keep the bandage on the site for 15 minutes.
• Nerve injury can occur due to improper site selection, rapid needle insertion, excessive redirection, and blind probing.
• Avoid reflux of anticoagulant by ensuring the patient's arm is downward, and the tube is just below the venipuncture site.
• Avoid vein damage by following proper technique and avoiding blind probing.

Specimen Quality

• Hemoconcentration is a decrease in fluid content or plasma volume, caused by tourniquet use, leading to increased concentration of red blood cells.
• Hemolysis refers to the rupture of red blood cells, releasing hemoglobin into the surrounding fluid.
• Partially filled tube or short draw occurs when the phlebotomist pulls a tube too early, which leads to incorrect blood-to-additive ratio.
• Specimen contamination results from incorrect handling, which includes allowing alcohol, powder, or other materials into the sample.
• Using the wrong or expired collection tube may compromise the quality of the seal and pressure.

Troubleshooting Failed Venipuncture

• Phlebotomists should ensure that the needle is properly inserted, the bevel is correctly positioned.
• Collapsed veins occur when conditions are less than ideal, resulting in insufficient blood flow.
• Ensure that the bevel is not partially out of the skin and the tube itself is not damaged to avoid failure due to loss of vacuum.

Capillary Puncture Equipment and Procedure

• Skin puncture is a method that uses a lancet to make a small incision into the capillary bed of the skin to obtain a small volume of blood specimen.
• Lancet / incision devices are sterile, sharp, and designed for single use only, utilized for finger or heel puncture.
• Laser lancet is a type of lancet that produces a small hole in the skin by vaporizing water in the skin.
• Microcollection container is a small plastic tube used to hold blood specimen collected in the capillary puncture, also known as microtube.
• Microhematocrit tubes and sealants are narrow bore tubes that are made of either plastic or glass, typically used for hematocrit determinations.
• Microscope slides are used for blood films for hematology determinations.
• Warming devices increase blood flow seven-fold by warming the puncture site.
• Capillary blood gas (CBG) equipment is special equipment used for collection of capillary blood gas (CBG) specimen.

Capillary Blood Specimen Composition

• Specimen consists of arterial blood, venous blood, capillary blood, interstitial fluid, and intracellular fluid.
• Arterial blood is bright red blood found in the pulmonary vein, left chamber of the heart, and the arteries, oxygenated blood of the circular system.
• Venous blood travels from the peripheral veins passing through the venous system then through the right chamber of the heart and is deoxygenated with a dark red color.
• Capillary blood is extracted from venules and arterioles found in the capillary bed and is the preferred specimen for infants, young children, elderly patients, and patients with severe burns.
• Interstitial fluid fills the spaces around the cells, filtered Blood from the blood capillaries, and drained away as lymph.
• Intracellular fluid is inside the cells, facilitates the movement of the fluid in the membrane and block the entrance of unwanted materials.

Indications for Performing Capillary Puncture

• Veins are fragile or inaccessible
• Veins are reserved for chemo or other procedures
• Patient has clotting tendencies or extreme fear of needles.
• Veins will be used for glucose monitoring or oral glucose tolerance test (OGTT).
• Health risks like anemia and cardiac arrest. Only small volume of blood is needed. Venipuncture could damage veins and tissues surrounding the site and result in hemorrhage, thrombosis, gangrene, and infection.
• Risks of injury because of the needed restraint.
• Capillary blood is preferred.

Capillary Puncture Precautions

• Not appropriate for Erythrocyte Sedimentation Rate, blood cultures, or large volume requirements

Order of Draw

• Refers to avoid cross-contamination of additives, and specifies Capillary Blood Gases, EDTA specimens, other additive specimens, and serum specimens.

Capillary puncture method.

1. Review accession test request
2. Identify and prepare patient
3. Check diet restrictions and latex sensetivity
4. Sanitize, glove hands
5. Position the patient
6. Select puncture site
7. Warmth for site, if needed
8. Clean; air dry
9. Equip, prepare blood gas
10. Puncture the site, discard lancet.
11. Wipe 1st Blood drops
12. Fill tubes and mix in order of draw
13. Apply pressure to the gauze and keep site elevated
14. Specimen label
15. Label, observe handling instructions
16. Check and bandage site
17. Dispose of materials and thank patient, sanitize and transport to lab

Uses for Smears

• Smear identifies blood cell abnormalities
• A thick smear prepares a malaria test
• Peripherial smear is used

Capillary Blood Gas Specimen

• Best for Capillary blood gas for infant or child

Newborn, Natal Bilirubin

• Tests help indicate liver disorder in infants
• Newborn/natal screening detects inborn disorders, heel pick
• Newborn screening detects baby's disability to prevent illness or death

Special Collections

• Determining blood type and Rh factor is called Blood bank- blood type and screen
• Check the capability between the donors and the recipients blood is called: Blood bank: cross match test
• Determining presence of infection and type of organism is called Blood culture
• Evaluates is called Coagulation test
• A Glucose tests screens metabolic disorers is called - 2 - hour postprandial glucose
• Diagnoses carbohydrate metabolism is called Glucose tolerance test (GTT) and Oral glucose tolerance
• Determines the lack of mucosal lactase called Lactose Tolerance test
• Verify patient likely to father child called - Paternity/parent age testing
• Drug levels determine dose/toxicity called - Therapeutic drug monitoring
• Treat polythemia by removing part of the process called Threapeutic phlembotomy
• Toxins detected called Toxicology test Checks is called Trace elements

Blood Bank Specimens

• Determine transfusion safe
• Collect in lavedender or pink top
• Provide all hospital labels, name information and initials of the Phlembotomist

Blood specimens

• Unit can be separated in RBC, plasma, platelets
• Notify a donar later when disease is diagnosed - Lookback Program
• Patient's own blood donar reduces risk
• Harvests residual hemoglobin - cell salvaging used in surgery

Blood Culture

• Detects toxins
• Determine fever origin to help micro-organism
• Requires clean collection/optimum results with anaerobic

Sterile Collection

• Prevents flora contamination with special bottles for 30 minutes
• Skin and air -crucial

Procedure

• Id patient
• apply/release tournquet quickly,
• Skin Clean bottle
• Inncoculate bottle
• invert specimen
• Label with sterile water

Blood medium

• Inoculate directly in a butterfly with safety device
• A syringe method safely transfers via syrine
• Lab transfer minimizes tamination but is not recommended

Coagulation

• Evaluates
• Tests are : evaluatimng pathwats and fibin

Time limit

• Must be handled prperly by inverting time
• Discard first
• Mix inversions
• Handle within 4 hrs
• adjust test

Oral Glucose Tolerance Test

• Time for testing glucose
• If Heprin the blood
• Adjust NA 555
• Transport to central test with frozen plasma

Sugar

• Evaluate body glucose measuring
• diagnose diabetes
• Sample is consistent

LTT

• Evaluats lactase for stomach problems

Parentage

• Performed to determine paternity

DNA for blood

• Provide photo ID or blood is not approved
• Swab interior cheek

Drug Monitering

• Monitored within therapeutic range
• Level must be maintained
• Presciption needs clinical state
• Blood must achieve level peak

Toxicities

• Red cell harmful, needing reduction
• Excess iron can lead to issues

Phlebotomy

• Tests for levels and is harmful

Toxicology

• Detects treatment

specimens

• Uses law enforcement specimens after death for breif
• All specimens are tracked and signed through the chain of command
• Legal witness might be assigned

Testing

• Alcohohol has legal issues
• Used for treatment if suspected
• The right container is vital
• Gray tubes prevent contamination

Tests and POC tests

• Must follow strict procedure

POC Testing

• Used during treatment plans
• QC ensures accurate results
• EQ ensure the best outomes

Bleeding tests

• Pre Surgical checks
• Requires the best technology
• Test patient with iodine/alchohol/bandages and provide quality test perameters

Blood gasses

• Electrolytes require quick check
• Test must reduce harm to patients
• Measure for o2/co2 and solution hydrogen
• Measure gas and oxygen with correct measure and o2

POC Multi Tests

• Measure electrolytes and gases;
• Can apply device or testing.
• Make sure test device meets tests properly for testing pregnant lady or HIV.
• POC requires all steps and checks
• POC lab tests

Handing specimens and lab tests

• Proper tests , proper equipment
• Proper test equipment
• Minimize time errors
• proper mixing is vital

Specimens

• Tubes placed in liquid containers to avoid mess
• Testing immediately is important

Light-Sensitive Specimen

• light testing affects test results
• Store tube wrapped in foil

Speciment is not correct.

• Improperly filled or contaminatued specimens - rejected
• Must be delivered /handled correctly
• Should centrifuged within hour
• EDTA (purple) tubes - cant be centrifuged
• Specimen must be balanced and tubes filled.
• Plasma tested immediately.
• Serum requires clotting.
• Safety during processing is paramount.

Aliquot Preparation

• Alquot is taken fo chemical analysis of the aliquot
• Must use protective wear and perform tests based on procedures.