Venipuncture Equipment & Supplies

• The purpose is to list, describe, and explain the equipment and supplies needed to collect blood specimens by venipuncture, and define associated terms and abbreviations.
• It's important to list and describe evacuated tube system (ETS) and syringe system components, explain how each system works, and determine which system and components to use.
• Demonstrating knowledge of blood collection additives, identifying the chemical composition of specific additives, and describing how each additive works is essential.
• Describing the ETS tube stopper color coding to identify the presence or absence of an additive, connecting additives with stopper colors, and listing the order of draw with its importance is key.

General Blood Collection Equipment and Supplies

• A blood-drawing station includes a table, special chair, and a bed or reclining chair for patient comfort.
• Phlebotomy chairs should be comfortable, have adjustable armrests, prevent falling, recline, have adjustable heights, and should be helpful for ergonomics.
• Handheld phlebotomy equipment carriers vary in sizes, contain supplies for multiple draws, are ideal for STAT or emergencies, and are best for when you don't need to collect numerous samples.
• Phlebotomy carts contain more supplies for more draws and are used for sweeps.
• Easy to maneuver and can be useful, but can be bulky and are a potential source of nosocomial infections.
• Gloves are required by CDC/HICPAC and OSHA, using a new pair for each patient.
• Acceptable nonsterile, disposable materials: latex, nitrile, neoprene, polyethylene, and vinyl.
• Powdered gloves aren't recommended due to associated lung problems, allergies, and hypersensitivities.
• Hand decontamination is essential before putting on and after removing gloves.
• Use hand sanitizers if your hands are not visibly soiled.
• Wash with soap and water if visibly soiled.
• Antiseptics prevent or inhibit the growth of microorganisms to prevent sepsis.
• 70% isopropyl alcohol is most common for routine blood collection.
• Solutions like iodine, benzalkonium chloride, chlorhexidine gluconate, and hydrogen peroxide can also be used.
• Antiseptics are safe on human skin.
• Disinfectants remove or kill microorganisms on surfaces/instruments but aren't safe for skin.
• Hand sanitizers, which are alcohol-based rinses, gels or foams, can replace handwashing if hands are not visibly soiled.
• Clean 2 x 2-inch gauze pads are used to administer pressure over the blood collection site.
• Use paper, cloth, or knitted tape over folded gauze instead of self-adhesive bandages on infants under 2 to avoid choking hazards.
• Permanent pens are used for labeling tubes and initialing forms.
• Patient identification equipment: Barcode readers are used to print the labels at the patient's bedside.
• Any needle, lancet, or other sharp objects need to be disposed of in a sharps container immediately after use; never overfill.
• Biohazard bags are leak-proof bags marked with a biohazard label used to transport blood and other specimens, and often feature an external pouch for needed paperwork.

Venipuncture Equipment

• Vein-locating devices use transillumination, which shines high-intensity LED or infrared light to highlight veins in subcutaneous tissue; hemoglobin absorbs the light highlighting the veins.
• Tourniquets are applied to restrict blood flow and inflate veins.
• Stretchable disposable straps are used for securing a tourniquet.
• Should restrict venous flow, but not arterial flow to inflate veins.
• Tourniquets shouldn't be left for over 1 min, it can alter blood components and lead to false results.

Needles

• Needles should be sterile, disposable, and for single use only and will always be stored in a sharps disposal container
• Types of needles include multisample and winged fusion (butterfly).
• Needle parts include bevel, shaft, hub, and lumen.
• Gauge indicates the diameter of the lumen, the most common needle for phlebotomy is a 21 gauge 1 ½ inch needle.
• 1- and 1.5-inch lengths are most common for venipuncture.
• Ensure the correct needle is selected because using too big of a needle may collapse a vein, and a needle that is too small can hemolyze a sample.
• Tube holders (hubs) or attached to needles have safety features.

Evacuated Tube System ETS

• ETS is a closed system where blood flows though a needle into the vein, preventing exposure to air or contaminants.
• Allows for a single venipuncture to collect numerous tubes
• ETS components: multisample needle, tube holders with safety features, and evacuated tubes.
• Multisample needles allow multiple tubes to be collected in a venipuncture.
• The needles are double-pointed, have a threaded part that screws into the holder, a retractable sleeve, and are available with/without safety features.

Needle and Holder Units

• Follow OSHA standards for the use of disposable needles because holders with needles must be disposed of as a unit.
• Evacuated tubes can be used with both ETS and syringe method, available in different sizes/volumes (depending on age, volume of blood needed, and the size/condition of the patient's vein) in glass/plastic.
• Tubes used are often made of plastic for safety during usage and transportation
• Evacuated tubes are vacuumed with negative pressure artificially to draw an exact volume of blood.
• Additive tubes contain a substance (e.g., anticoagulant).
• Nonadditive tubes contain no substance.
• Stoppers are made of rubber or rubber with plastic covering.
• The color coating of the stopper usually indicates the type of additive.
• Tubes include expiration information.
• Color coding is used for additives for easy use and multiple samples.
• Multiple tube sizes are dependent on the blood required for each test
• If a tube losses it's vacuum blood will no longer flow into the tube; this often occurs due to incorrect storage, if the tube has been dropped/opened, damage to the needle or needle position, or not allowing tubes to fill fully.

Syringe System

• Syringe system is an alternative for patients with small/difficult veins.
• It's no longer used for phlebotomy.
• Needle lengths will often be 1- to 1.5-in with a resheathing feature to draw blood.
• Components : Barrel and Plunger
• Blood must be promptly transferred to the correct tube using a syringe transfer device and must never be transferred from the syringe to the tubes manually..

Blood Collection Sets

• Winged infusion set, known as a butterfly, is effective for small/difficult veins (hands, and for elderly/pediatric patients) with automated in-vein retraction.
• They can be attached to a holder (left) or syringe (right), and shorter lengths allow for shallower angles.
• Common gauges range from 25-21.
• VANISHPOINT offers a blood collection set using automated in-vein retraction to eliminate exposure.
• Combination systems are complete and combine blood collection tube and apparatus in one unit. The specimen is collected by an evacuated tube or syringe, available in regular/butterfly-style needles with safety devices.

Blood Collection Additives

• Additives are anything added to a tube other than the stopper or a silicone coating and are not always interchangeable.
• Tubes contain an additive to prevent, encourage clotting, or preserve components
• An anticoagulant additive results in whole blood samples and is centrifuged to obtain plasma for testing.
• Clot activator additive requires the tube to be centrifuged to obtain serum for testing

Anticoagulants

• Anticoagulants are substances that prevent blood clotting in a whole blood or plasma sample.
• Two methods for this include precipitating calcium and inhibiting the formation of thrombin.
• Types: Ethylene-diaminetetraacetic acid (EDTA), Citrates, Oxalates, Heparin (tubes must be mixed immediately and gently prevent hemolysis).
• EDTA comes in the form of K2 and K3, binds with calcium, and is commonly found in lavender/purple tubes as well as pink, tan, royal blue, or white tubes.
• EDTA is used for hematology, blood banking, and preserves cell morphology.
• Citrates bind with calcium, preserve clotting factors, and is commonly used in light blue (or blue, or black) tubes for coagualtion.
• Oxalates bind to calcium, will often be found with an antiglycolytic, and fill the top of grey tubes.
• Heparin inhibits thrombin, is used for blood chemistry tests requiring faster turnaround time (TAT), and is often included in green top tubes (green and grey, royal blue, grey and black).
• Light blue-top tubes used for coagulation testing contain a 9:1 ratio of blood with sodium citrate and must be filled to within 90% of that volume.

Special-Use Anticoagulants

• ACD (acid citrate dextrose) for blood banks, maternity, and transplants.
• CPD (Citrate phosphate dextrose) for blood banks.
• SPS (sodium polyanethol sulfonate) for microbiology and blood culters.
• Antiglycolytic agents prevent glycolysis (glucose breakdown by blood cells).
• Sodium fluoride is most common, preserves glucose for up to 3 days, and inhibits bacterial growth.
• It is paired with potassium oxalate (anticoagulant) for rapid response.
• Clot activators are substances that enhance coagulation in serum-separator tubes (SSTs).
• Glass or Silica, and Inert clays (Celite) are substances providing more surface for platelet activation.
• Examples include clotting factors like thrombin.
• PST (plasma separator tubes) and SST (serum separator tubes) contain thixotropic gel to separate cells and serum/plasma; when centrifuged, the gel moves between cells and serum/plasma.
• Trace element-free tubes are made of materials free of trace element contamination, used for trace element tests, toxicology studies, and nutrient determinations and use royal-blue stoppers.
• Non gel serum or plasma separator has emerged as an alternative using more flexible material (elastomer) that gel which can used for more tests instead of gel base tubes.

CLSI Order of Draw

• Specific Order: Blood culture tube or bottles, Sodium citrate tube, Serum tube with or without gel, Heparin tube with or without gel, EDTA tube with or without gel separator, Sodium fluoride/potassium oxalate glycolic inhibitor.
• Prioritization minimizes risk for interference due to cross-contamination from additive transfer between tubes, therefore, filling specimen tubes from the bottom up minimizes carryover.
• Tissue thromboplastin, found in tissue fluid, activates the extrinsic coagulation pathway.
• For coagulation tests (other than PT or PTT), draw a few milliliters of blood into another tube before collecting coagulation specimen to prevent interference with coagulation tests.
• Microorganisms on the skin can contaminate blood specimens so blood cultures are collected first when sterility of site is optimal. Key venipuncture steps: Receive/review/accession test request, approach/greet/identify patient, explain/obtain consent, verify requirements/identify sensitivities/potential problems,sanitize hand, apply gloves,select vein/release tourniquet/open fist, clean/dry site, prepare equipment,reapply tourniquet/inspect needle, and anchor-vein/ insert needle.