Phlebotomy Guide: History, Techniques, and Equipment PDF

PHLEBOTOMY Prepared by: Leo Teophane B. Sinco, RMT, MLS (ASCPi) Lera C. Almendral, RMT, MSPH THE BLOOD VESSELS The blood vessels transport blood throughout the human body. Five types of blood vessels: 3 main types of your blood vessels 1. arteries, carry th...

PHLEBOTOMY Prepared by: Leo Teophane B. Sinco, RMT, MLS (ASCPi) Lera C. Almendral, RMT, MSPH THE BLOOD VESSELS The blood vessels transport blood throughout the human body. Five types of blood vessels: 3 main types of your blood vessels 1. arteries, carry the blood away from the heart; 2. arterioles, small branches of an artery leading into capillaries; 3. capillaries, where exchange of water and chemicals between the blood and the tissues occurs; smallest 4. venules, small branches of veins that lead to the capillaries 5. veins, carry blood from the capillaries back towards the heart. THREE MAJOR LAYERS OF THE BLOOD VESSELS Both the vein and artery are composed of three major layers. These are: ▪ Tunica intima ▪ Tunica media ▪ Tunica externa 1. Tunica intima ▪ Innermost and thinnest layer for easy diffusion of nutrients ▪ Composed of simple squamous epithelial cells interlaced with several circularly arranged elastic bands called the internal elastic lamina. unique structure 2. Tunica media widstand the pressure ▪ Thickest layer in the arteries ▪ Consists of circularly arranged elastic fiber, connective tissue, polysaccharide substances ▪ Separated from tunica externa by another thick elastic band called external elastic lamina. 3. Tunica externa ▪ Outer layer and the thickest layer in veins ▪ Entirely made of connective tissue ▪ Contains nerves that supply the vessel as well as nutrient capillaries (vasa vasorum) in the larger blood vessels.  VESSEL SIZE Ranges from a diameter of about 25 mm for the aorta to only 8 um in the capillaries. BOTH ARE THE CHANGE OF DIAMETER; THEY HAVE 2 EFFECTS BAD OR GOOD Vasoconstriction is the narrowing of blood vessels by contracting the vascular smooth muscle in the vessel walls. bad effect: nasal decongestant Vasodilation is the widening of blood vessels due to relaxation of the blood vessel’s muscular walls. THE BLOOD FLOW reason why mo agto sa lungs: unloading of co2 and loading of oxygen priority pinky finger thumb MAJOR ARM & LEG 1. Antecubital fossa VEINS FOR  Also known as the elbow pit VENIPUNCTURE  Triangular area on the anterior of the elbow, which is a site of major veins  First choice for routine venipuncture because there are several major veins called antecubital veins 3 types of antecubital fossa: median cubital vein, sephalic, basilic  MAJOR ARM & LEG VEINS FOR VENIPUNCTURE 2. H-shaped antecubital vein Median cubital vein is the preferred venipuncture site; easiest to access and least painful for the patient - well anchored; - stable vein Cephalic vein is the second choice; harder to palpate but is movable ang usually better when drawing blood cephalic and from an obese patient basilic Basilic vein is the last choice-vein; not well anchored and punctures are more painful near brachial artery MAJOR ARM & LEG VEINS FOR VENIPUNCTURE 3. M-shaped antecubital veins The intermediate antebrachial veins, which include the median, median cephalic, and median basilic veins. Median vein-intermediate antebrachial vein; first choice vein; safest and less painful Median cephalic vein – intermediate cephalic vein; 2nd choice for venipuncture; less likely to roll Median basilic vein – intermediate basilic vein; last choice vein because it is more painful  MAJOR ARM & LEG VEINS FOR VENIPUNCTURE butterfly method or wing infusion; bony area; decrease needle angle 4. Other arm and hand veins Used only if the antecubital veins are not accessible Veins at the back of the hand that can be used are smaller and thus more painful Underside of the wrist is never used as a venipuncture site  put the torniquet 3-4 inches above the site both arm or hand and leg MAJOR ARM & LEG VEINS FOR VENIPUNCTURE thrombosis can be present 5. Leg, ankle, and foot veins must not be used in venipuncture without the permission of a physician due to complications such as thrombosis. 6. Arteries are not used for routine blood collection and are limited to the collection of arterial blood gas. Special training is needed, and the procedure is risky for the patient. VEINS FOR VENIPUNCTURE HISTORY OF PHLEBOTOMY Phlebotomy Teimien - to make a cut or puncture From the Greek word “phlebos”, meaning vein and “-tomia”, meaning cutting Act of drawing or removing blood from the circulatory system through a cut or puncture to obtain a sample for analysis and diagnosis Also done as part of the patient’s treatment for certain blood disorders Egyptians – first to perform bleeding by scarification they want to cure the patient kay belief na nila nga ma okay ang person if kwaan dugo HISTORY OF PHLEBOTOMY In Greece, a prominent Greek physician known as Galen of Pergamon, discovered that arteries as well as veins had blood. Previously it was thought that arteries were filled with air. ▪ He developed a complex system for the quantity of blood which should be removed and from what specific areas of the body. iyahang gi determine pila ang amount of volume kwaon sa person og ahang dapita; 1 liter HISTORY OF PHLEBOTOMY The Pilgrims uses lancet ▪ Credited for bringing phlebotomy to the United States in the 18th century. ▪ It was common at this time to use lancets that were fired into veins at multiple locations, withdrawing up to four pints of blood (1 pint = 473 mL) ▪ Over time, other instruments were developed to improve the technique. Bloodletting was a popular service for almost one hundred years, although it went out of fashion as many harmful incidents came to light HISTORY OF PHLEBOTOMY Bleeding as a standard treatment in the 18th century: For fever such as putrid fevers (typhus and typhoid fever) For hypertension, cases of comas, and drowsy headaches. Recommended to reduce inflammation of the lungs according to the amount of pain, the pounding of the pulse, and the difficulty in breathing. As much as 210 ounces were bled over a 6‐day period (210 ounces = 6, 210 mL). 4.4-6 ang rbc both male and female HISTORY OF PHLEBOTOMY On December 13, George Washington (1799) was taken ill with a ‘cold’ and ‘mild hoarseness’. A total of 2, 365 mL of blood was taken over 12 hours. James Craik, an Edinburgh trained physician, doctor Brown offered no explanation for this. Washington’s blood eventually became viscous and flowed slowly, reflecting dehydration and hypovolemia. George Washington in his last illness, attended by Doctors Craik and Brown; During the American Civil War (1861–1865), military doctors, unable to cope with widespread disease and infection, bled Union soldiers and civilians alike. Early instruments included anything sharp, such as horned stones, quills, thorns or animal teeth. The thumb lancet was introduced in the 15th century. It was a double‐edged instrument, often with ornate handles made from turtle shells. Louis Pasteur (1822–1895) and Robert Koch (1843–1910) proved conclusively that inflammation resulted from infection and thus was not susceptible to bloodletting. They offered a scientifically legitimate way of thinking about the cause and treatment of the patient’s illness disapproved nga kwaan og dugo if ma infected; need to drink medication dili kay ibleed American Civil War Lancets HISTORY OF PHLEBOTOMY hospital in india As recently as April 2008, three Kashmiri hospitals were reported to be using leeches, primarily to bleed patients as treatment for heart problems, arthritis, gout, chronic headaches, and sinusitis. The leeches are for single use to avoid transmission of disease!  HISTORY OF PHLEBOTOMY we do bleeding to help the person heal or cured; therapeutic phlebotomy Phlebotomy is used every day to diagnose health problems and introduce medication intravenously. It’s also used in life- saving procedures like blood transfusions. Today, trained professionals called phlebotomists withdraw blood in clinics and hospitals all over the world. viscous ila blood; specific volume lang; discard the blood collected sickle cell anemia Therapeutic phlebotomy HISTORICAL PRACTICE QUALITY IN PHLEBOTOMY The role of the phlebotomist has never been more important. In the United States, it is estimated that more than 1 billion venipunctures are performed annually, and errors occurring within this process may cause serious harm to patients, either directly or indirectly. Critical areas include: Appropriateness of the test request role of the doctor to order appropriate test Patient and sample identification medtech's role becasue we deal with the patient and after we collect we identify the samples Criteria for acceptance and rejection of specimens not all collected are accepted in laboratory; pre-ana Communication and interpretation of results involves the lab and pathologist of the patient; there should be open and transparent communication RATIONALE Specimen collection is the first step in most laboratory analysis. Test results are therefore said to be as good as sample collection and handling. Quality assessment in phlebotomy includes: preparation of a patient for any specimens to be collected, collection of valid samples, proper specimen transport. especially if collected from ward  The only laboratory staff member that a patient sees. Expected to deliver unexcelled customer satisfaction Should understand and know the patient’s expectations, manage unrealistic collects the sample; the direct interaction with the patient expectations PHLEBOTOMIST AS A through patient education, and be LABORATORY diplomatic with AMBASSADOR customer complaints. THE FIRST STEP: PATIENT IDENTIFICATION PROCEDURES Ambulatory patients; they shouldnt answer yes or no; you can ask for patient's ID 1. Conscious in-patients – verbally ask their full names, verify using the identification bracelet which includes first and last name, hospital number/unit number, room/bed, and physician’s name. dont collect if the patient is sleeping, they must be awake; identified same way sa conscious patient 2. Sleeping patients – they must be awakened before blood collection. Identified same as conscious patients. treat the same way sa imong conscious patient 3. Unconscious patients/Mentally challenged patients – identified by asking the attending nurse or relative; ID bracelet THE FIRST STEP: PATIENT IDENTIFICATION PROCEDURES ask for assistance sa parents 4. Infants and children – nurse or relative may identify the patient or by ID bracelet 5. Outpatient patient – verbally ask their full name, DOB and countercheck with driver’s license or ID with photo. If the patient has ID card or bracelet, same manner as with hospitalized patients.  Be gentle and treat them with compassion, empathy, and kindness. Attempt to interact with the pediatric patient Acknowledge the parent and the child. Be friendly, courteous, and responsive. Allow PEDIATRIC enough time for the PATIENTS procedure.  When obtaining a blood specimen from an adolescent, it is important to be relaxed and perceptive about any anxiety that he or she may have. General interaction techniques include allowing enough time for the procedure, establishing eye contact, and allowing ADOLESCENT the patient to PATIENTS maintain a sense of control. make sure your voice is loud; speak slowly but loud enough to be audible; their veins naay tendency na mo move gyapon Treat geriatric patients with biskan sa stable na imoa kwaan dignity and respect. Do not GERIATRIC demean the patient. It is best to PATIENTS address the patient with a more formal title such as Mrs., Ms., or Mr. rather than by his or her first name. Senior patients may enjoy a short conversation. Keep a flexible agenda so that enough time is allowed for the patient. Speak slowly and allow enough time for questions. The elderly have the right of informed consent. Too many times this fact is lost in dealing with any patient, but it seems more prevalent in dealing with aging patients. CATEGORIES OF ADDITIVES USED IN BLOOD COLLECTION Evacuated tubes are color coded meaning naay specific additives source of energy 1. Antiglycolytic agent – inhibits the use of glucose by blood cells. Example: sodium fluoride can be found in grey top tube 2. Anticoagulant agent – prevents blood from clotting. The mechanism by which clotting is prevented varies with the they binds to calcium or chelation of calcium anticoagulant. EDTA, lavendar citrate, and oxalate light blue 3.2 & black 3.8 remove calcium by grey the only different; doesnt bind; green forming insoluble salts, whereas heparin prevents the conversion of prothrombin to thrombin. these four prevents coagulation the material itself na ang clotting process; red or yellow stoppers; plain tube or serum tube 3. Clot activator – helps initiate or enhance the clotting mechanism. Examples: glass (silica) particles and inert clays (celite) that provide increased surface area for platelet activation and clotting factor such as thrombin.  CATEGORIES OF ADDITIVES USED IN BLOOD COLLECTION gel if unused you can find it at the bottom but if it is spin in centrifuge it will move in between the liquid portion and your cells 4. Thixotropic Gel Separator – inert SST - Serum Separator Tube material that undergoes a temporary seprated jd kay it will affect the change in viscosity during the result centrifugation process which enables it to serve as a separation barrier between the liquid (serum and plasma) and cells. 5. Trace element-free tubes royal blue for toxicology; if naay trace element mo false increase sa result ▪ Made of materials that are free of trace element contamination ▪ Have royal-blue stoppers ▪ Used for trace element tests, toxicology studies, and nutrient determination SPECIAL-USE ANTICOAGULANTS Immunohematology and blood banking 1. Acid Citrate Dextrose (ACD) anticoagulant inside your blood bank  Acid citrate: prevents coagulation binding calcium, with little effect on cells and platelets  Dextrose: acts as an RBC nutrient and preservative by maintaining RBC viability source of energy sa imo rbc; ma ensure ang sruvival  Used for immunohematology tests such as DNA testing and human leukocyte antigen (HLA) phenotyping DNA; Paternity; Compatibility of HLA  ACD tubes have yellows tops SPECIAL-USE ANTICOAGULANTS during blood donation (banking) 2. Citrate Phosphate Dextrose (CPD) Citrate: prevents clotting by chelating calcium Phosphate: stabilizes pH Dextrose: provides cells with energy and keep them alive Used in collecting units of blood transfusion 3. Sodium Polyanethol Sulfonate (SPS) used in microbiology blood culture tubes Prevents coagulation by binding calcium inactivates the complement system which can be seen in immune system once activated Used for blood culture collection mapatay ang bacteria SPS tubes have yellow stoppers slows down phagocytosis the wbc reduces the activities of certain antibiotics COLOR CODING FOR TUBE CAPS Cap Color Specification Red No additive Orange Coagulant promotes clotting Yellow Coagulant and Separation Gel Green Sodium heparin Light Green Lithium heparin Purple EDTA blood Light Blue Sodium Citrate (1:9) 1 part; 9 parts of blood ratio of anticoagulant sa blood Black Sodium Citrate (1:4) 1 part; 4 parts of blood Grey Potassium Oxalate Monohydrate anticoagulant and Sodium Fluoride antiglycolipid agent  RED-TOP TUBE Glass – No additive – Glass surface activates clotting sequence – Mixing of sample by inversion is not required 0a inversion needed for red top tube but if it is plastic need sha i invert for 5 times – SERUM: use for TDM (Therapeutic Drug Monitoring) Clinical Chemistry Test Plastic mix for inversion; need sha i invert for 5 times – Contains clot activators to initiate clotting sequence – Must be inverted to mix sample with additive and initiate clotting sequence – SERUM Blood clotting time: 60 minutes wait for the sample to clot; room temp for 30mins; patindog Laboratory use: Serum determinations in chemistry, routine blood donor screening (crossmatching), and diagnostic testing for infectious diseases Immunoserology section; Clin. Chem; Blood Bank 40 GOLD OR MOTTLED-RED-GRAY TOP TUBE Contains clot activator and gel (SST) Inverted to mix and initiate clotting sequence 5 inversions SERUM Blood clotting time: 30 minutes room temp; upright position Laboratory use: serum determination in chemistry, blood donor screening (crossmatching), and serum testing for infectious diseases Clin Chem; Blood Bank; Immunoserology 41 LIGHT BLUE-TOP TUBE best in preserving the coagulation factors; no microcontainer tube Anticoagulant: 3.2 % sodium citrate Specimen: Plasma centrifuge right after the collection Binds calcium 3-4 full gentle inversion gentle kay dili pedi naay microclots and hemolize (result nis rigorous inversion) Blood: anticoagulant ratio (9:1) Laboratory use: Clot-based studies/coagulation studies (PT and APTT), mixing studies, and ethanol gelation test 42 GREEN-TOP TUBE arterial blood Anticoagulant: heparin Three formulations: Lithium heparin Plasma pro- before Ammonium heparin Whole Sodium heparin blood Inhibits thrombin formation Requires 8 full inversions all top with anticoagulant kay 8 except sa blue top Must be full and transported on ice if needed for pH, pO2, and ionized calcium analysis Laboratory use: plasma determinations in chemistry 43 PURPLE-TOP TUBE Anticoagulant: Spray-coated K3EDTA (glass) or liquid K2EDTA (plastic) Sample: Can either be plasma or whole blood Binds calcium through chelation Requires 8 full inversionsadd 2 more; kay dugay shang naka upright unya basin didto ra ktubo sa liquid portion; redistribute the cells Laboratory use: Hematology determinations (CBC),whole blood routine immunohematology testing, and blood donor screening (crossmatching) 44 GRAY-TOP TUBE Anticoagulant: potassium oxalate – Prevents coagulation by precipitating calcium – Plasma and Whole blood or Antiglycolytic agent: sodium fluoride – Maintains plasma glucose levels – Preserves glucose for up to 3 days and inhibits growth of bacteria Requires 8-10 full inversions Laboratory use: glucose determinations and lactic acid level determination 45 YELLOW-TOP TUBE ACD: acid citrate dextrose – Blood bank studies – HLA phenotyping – Paternity testing – DNA SPS : sodium polyanethol sulfonate – Used for special blood culture studies – Inhibits certain antibiotics Both bind calcium Requires 8 full inversions Sample: Plasma and Whole blood 46 no gel clot activator or anticoagulant blood banking section ORDER OF DRAW (EVACUATED TUBES) 1- dont want/prevent cross contamination by aditive; the anticoagulant kay mabalhin sa pikas ma error ang test;2- prevent tissue thromboplastin;3- contamination of microorganism Blood Culture or sterile tubes (yellow stopper) di pedi ma contaminate Coagulation tube (light blue stopper) Serum tube with or without clot activator or gel (red, gold, or red gray marbled) Heparin Tube (green or light green stopper) next sa heparin Black Top Tube EDTA tube (lavender stopper) Oxalate/fluoride tube (gray stopper) GENERAL BLOOD COLLECTION EQUIPMENT AND SUPPLIES Antiseptics Used to prevent sepsis and are used to clean the site prior to blood collection Antiseptics used in blood collection 70% ethyl alcohol 70% isopropyl alcohol (isopropanol) Benzalkonium chloride (e.g. Zephiran chloride) Chlorhexidine gluconate Hydrogen peroxide Povidone-iodine if for blood culture Tincture of iodine venipuncture kay left to right; skin puncture kay inside to outside GENERAL BLOOD COLLECTION EQUIPMENT AND SUPPLIES Gauze pads/Cotton balls Clean 2-by 2-inch gauze pads folded in fourths are used to hold over the site following blood collection procedures Cotton ball can also be used but not recommended Sharp Disposal Containers To contain used needles, lancet, and other harp objects used in blood collection procedures Pen dili dapat sign pen Carried by the phlebotomist; must be with indelible (permanent) nonsmear ink to label tubes and record other patient information Watch Preferably with a sweep second hand or timer to accurately determine specimen collection times and time certain tests  VENIPUNCTURE EQUIPMENT Vein-locating devices Also known as portable transillumination devices Used to locate easily veins that are difficult to see or feel The use of high-intensity LED or infrared red light through the patient’s subcutaneous tissue to highlight the veins absorb by the hemoglobin ang light Venoscope II Transilluminator VENIPUNCTURE EQUIPMENT Tourniquet restrict venous flow; not so tight na maka restrict og arterial flow A device that is applied or tied around a patient’s arm prior to venipuncture to restrict blood flow Must be fastened in a way that is easy to release with one hand during blood collection or in emergency situations Most common type is the strap tourniquet Elastic tourniquet Buckle quick release Velcro tourniquet tourniquet VENIPUNCTURE EQUIPMENT Needles Phlebotomy needles are sterile, disposable, and designed for single use only evacuated tube system They include: multisample needles, hypodermic needles, and winged infusion (butterfly) needles Needles are color coded by gauge for easy identification yellow- 20 gauge gauge number and the size of the lumen of the needle kay the bigger ang green- 21 gauge black- 22 gauges COMMON VENIPUNCTURE NEEDLE GAUGE WITH NEEDLE TYPE AND TYPICAL USE Gauge Needle Type Typical Use 15-17 Special needle Collection of door units, autologous blood attached to donation and therapeutic phlebotomy collection bag 20 Multisample Sometimes used when large-volume tubes Hypodermic are collected, or large-volume syringes are used on patient with normal-sized veins 21 Multisample Considered the standard venipuncture Hypodermic needle for routine venipuncture on patients with normal veins or for syringe blood culture collection criteria for needle gauge to be used: 1. size and condition of the patients vein 2. type of blood collection procedure to be performed 3. equipment being used COMMON VENIPUNCTURE NEEDLE GAUGE WITH NEEDLE TYPE AND TYPICAL USE Gauge Needle Type Typical Use 22 Multisample Used on older children and adult patients Hypodermic with small veins or for syringe draw on difficult veins 23 Butterfly Used on the veins of infants and children and on difficult or hand veins of adults NEEDLE LENGTH Multisample needles Hypodermic needles Butterfly needles evacuated 1- or 1.5-inch 1- or 1.5-inch ½ to ¾ inch PARTS OF A SYRINGE slanted part; bevel up indicator nga na hit ang vein aspirate  PARTS OF AN EVACUATED TUBE SYSTEM cant be and indicator kay diman mo sulod ang blood iri  WINGED INFUSION SET Also known as butterfly Used for small or difficult veins such as hand veins of elderly and pediatric patient 23-gauge needle is most commonly used 25-gauge needle is used specifically to collect blood from scalp or other tiny veins of premature infants and other neonates PARTS OF A WINGED INFUSION SET VENIPUNCTURE EQUIPMENT Tube holder A clear, plastic, disposable cylinder with a small threaded opening at one end (often called a hub) where the needle is screwed into it and a large opening at the other end where the collection tube is placed  VENIPUNCTURE EQUIPMENT Evacuated Tubes Used with both ETS and the syringe method to obtain blood specimens Come in various sizes and volumes ranging from 1.8 to 15 mL Can be made of plastic or glass Fill with blood automatically because of vacuum which is artificially created by pulling air from the tube PREMATURE LOSS OF THE VACUUM 1. improper storage of blood collection tubes 2. opening of the tube 3. dropping the tube 4. advancing the tube too far onto the needle before venipuncture 5. needle bevel partially out the skin during venipuncture ORDER OF DRAW FOR CAPILLARY SPECIMENS (MICROTAINER TUBES) Tubes Inversions Blood Gases Rotate between palm to mix Slides & Smears/EDTA specimens 10 Lithium heparin 10 Lithium heparin with gel separator 10 Sodium fluoride/Potassium 10 oxalate Serum- with clot activator 5 Serum- No additive 0 Recommended to be collected Newborn Blood Spot Card sa circle sa card daw ni separately DI PEDI SKIN PUNCTURE or MICROTAINER 1. ESR - Black Top Tube 2. Coagulation Studies that requires plasma spicemen 3. Blood Culture CAPILLARY PUNCTURE EQUIPMENT Lancets/Incision Devices A sterile, disposable, sharp-pointed or bladed instrument that punctures or makes an incision on the skin to obtain capillary blood specimen Microcollection Containers Also called microtubes used to collect tiny amounts of blood obtain through capillary puncture Often referred as “bullets” CAPILLARY PUNCTURE EQUIPMENT Microhematocrit tubes Disposable, narrow-bore plastic or glass capillary tubes that fill by plain capillary action and typically hold 50-70 uL of blood Used for manual hematocrit pr packed cell volume determinations Can be heparinized or non- anticoagulated CAPILLARY PUNCTURE EQUIPMENT Clay sealant Used to seal one end of microhematocrit tubes og aha kutob ang band diha ra kutob ang iseal Warming devices Increases blood flow as much as seven times The device provides a uniform temperature that does not exceed 42 °C SPECIAL CAPILLARY PUNCTURE PROCEDURES very prone to contamination 1. Capillary blood gases (CBGs) new borns; infant or young children Capillary puncture blood is less desirable for blood gas analysis due to its composition and temporarily exposed to air during collection Rarely collected in adults Usually performed on infants and young children CBG specimens are collected from the same sites as routine capillary puncture specimens Warming the site for 5-10 minutes is necessary SPECIAL CAPILLARY PUNCTURE PROCEDURES 2. Neonatal bilirubin collection Done to newborns to detect and monitor increased bilirubin levels caused by overproduction or impaired excretion of bilirubin. Bilirubin breaks down in the presence of light Collection is done quickly by heel puncture, protected from light during transportation and handling. Sample is collected in amber-colored micro collection tubes. para dili mo breakdown SPECIAL CAPILLARY PUNCTURE PROCEDURES 3. Newborn/Neonatal Screening Testing of newborns for the presence of certain genetic, metabolic, hormonal , and functional disorders that can cause severe mental handicaps or other serious abnormalities Sample collected through blood spot collection ▪ Sample is obtained through heel puncture ▪ Blood drops are collected by absorption onto circles printed on a special type of filter paper FINGER PUNCTURE PRECAUTIONS 1. Do not puncture fingers of infants and children under 1 year of age. 2. Do not puncture fingers on the same side as mastectomy without consulting with the patient’s physician. 3. Do not puncture parallel to the grooves or lies of the fingerprint. 4. Do not puncture the fifth or the pinky finger. 5. Do not puncture the index finger. 6. Do not puncture the side or very tip of the finger. 7. Do not puncture the thumb. SPECIMEN QUALITY CONCERNS Clotted - failure to mix or inadequate mixing of samples collected into an additive tube. The red cells clump together making the sample unsuitable for testing. Hemolysis - usually caused by a procedural error: ▪ using too small of a needle ▪ pulling back too hard on the plunger of a syringe used for collecting the sample pink or red sha after ma centrifuge meaning na hemolysis na SPECIMEN QUALITY CONCERNS short draw Insufficient sample (QNS) - certain additive tubes must be filled completely. Incorrect blood to additive ratio will adversely affect the laboratory test results. When many tests are ordered on the same tube be sure to know the amount of sample needed for each test. Wrong or expired collection tube – must consult the procedure manual before collecting the specimen if unsure of the type of tube required for a test; additive in an expired tube may not work properly Improper transport and storage - certain tests must be collected and placed on ice, protected from light, or be kept warm after collection. SPECIMEN QUALITY CONCERNS Specimen contamination Can be a result of improper technique or carelessness such as: a. Allowing alcohol, fingerprints, glove powder, baby powder, or urine from wet diapers to contaminate NBS forms or specimens b. Getting glove powder on blood films (slides) or in capillary specimens c. Unwittingly dripping perspiration into capillary specimens during collection d. Using the correct antiseptic but not following the proper procedure e. Using the wrong antiseptic to clean the site prior to specimen collection  COMPLICATIONS ENCOUNTERED IN BLOOD COLLECTION Ecchymosis (Bruise) – most commonly encountered complication in obtaining a blood specimen. It is caused by leakage of a small amount of fluid around the tissue. Syncope (fainting) – second most common complication. Before drawing blood, the collector should ask if he/she had prior episodes of fainting. Hematoma – when leakage of a large amount of fluid around the puncture site causes the area to swell. Most commonly occurs when the needle goes through the vein, bevel is partially inserted in the vein, and if the collector fails to apply enough pressure after venipuncture.  COMPLICATIONS ENCOUNTERED IN BLOOD COLLECTION Failure to draw blood – due to improper needle positioning, excessive pull of the plunger, piercing the other pole of the vein, incorrect bevel positioning, and absence of vacuum. Petechiae –small red spots indicating that small amounts of blood have escaped into the skin epithelium. tightly attach torniquet CORRECT AND INCORRECT NEEDLE POSITIONING hematoma CORRECT AND INCORRECT NEEDLE POSITIONING  COMPLICATIONS ENCOUNTERED IN BLOOD COLLECTION Edema – swelling caused by an abnormal accumulation of fluid in the intracellular spaces. cephalic vein Obesity – veins may be neither readily visible nor easy to palpate can use of a blood pressure cuff in locating the vein. The cuff should not be inflated any higher than the patient’s diastolic pressure and should not be left on the arm for longer than 1 minute.  COMPLICATIONS ENCOUNTERED IN BLOOD COLLECTION prolong torniquet apllication Hemoconcentration – is an increased concentration of larger molecules and analytes (potassium) in the blood as a result of a shift in water balance. Can be caused by leaving the tourniquet on the patient’s arm too long. Prolonged tourniquet application - Primary effect is hemoconcentration. The hydrostatic pressure causes some water and elements to leave the extracellular space. Other complications includes - Burned, damaged, scarred and occluded veins, seizure and tremors, vomiting and choking, allergies, and mastectomy patients. if naay IV ang patients ipakuha sa sa nurse para maka collect ka; discard tube saka before collecting ang sample na imoa gamiton sa lab do not collect above the IV line, dapat below the IV line  COMPLICATIONS ENCOUNTERED IN BLOOD COLLECTION Hemolysis – rupture of red blood cells with the consequent escape of hemoglobin. Can cause the plasma or serum to appear pink or red. To prevent hemolysis: Mix tubes with anticoagulant additives gently Avoid drawing blood from a hematoma Avoid drawing the plunger of the syringe back too forcefully and avoid bubbles on the sample Make sure the venipuncture site is dry Avoid a probing, traumatic venipuncture  COMPLICATIONS ENCOUNTERED IN BLOOD COLLECTION IV Therapy – fluid may dilute the specimen, so collect from the opposite arm if possible. Otherwise, samples may be drawn below the IV by following these procedures: Turn off the IV for at least 2 minutes before venipuncture Apply the tourniquet below the IV site. Select a vein other than the one with IV Perform the venipuncture. Draw 5 mL of blood and discard before drawing the specimen tubes for testing PHYSIOLOGIC FACTORS AFFECTING TEST RESULTS Posture – changing from a supine (lying) to a sitting or standing position results in a shift of body water from inside the blood vessels to the interstitial spaces. Diurnal Rhythm – levels of certain hormones such as cortisol and adrenocorticotrophic hormone decreases in the afternoon. Other test values, such as iron and eosinophil levels increases in the afternoon. Exercise- muscle activity elevates creatine, protein, creatine kinase, AST and LDH. Exercise activates coagulation and fibrinolysis and increases platelet and white blood cells. Stress – anxiety can cause a temporary increase in white blood cells. PHYSIOLOGIC FACTORS AFFECTING TEST RESULTS Diet – if a patient has eaten recently (less than 2 hours earlier), there will be a temporary increase in glucose and lipid content in the blood. Serum may appear cloudy or turbid. Smoking – patients who smoke before blood collection may have increased white blood cell counts and cortisol levels. Long term smoking can lead to decrease pulmonary function and result in increased hemoglobin levels. POOR COLLECTION TECHNIQUES: Venous stasis potassium affected  Prolonged application of tourniquet (>1 min) Hemodilution  Drawing above IV  Short draw (blood to anticoagulant ratio) Hemolysis  Traumatic stick  Too vigorous mixing  Alcohol still wet  Using too small of needle  Forcing blood into syringe 86 POOR COLLECTION TECHNIQUES: Clotted sample Inadequate mixing Traumatic stick Partially filled tubes Short draw Sodium citrate tube draw volume critical Using wrong anticoagulant 87 POOR COLLECTION TECHNIQUES: Specimen contamination Using incorrect cleanser Alcohol still wet Powder from gloves Drawing above IV Specimen handling Exposure to light Pre-chilled tube Body temperature 88  REFERENCES Bishop, Michael L,. Et.al. Clinical Chemistry– Principles, Procedures and Correlations. 6th ed. Lipincott Williams and Wilkins. 2010 McCall, R.E. & Tankersley, C.M. (2012). Phlebotomy Essentials (5th ed.) Lippincott Williams and Wilkins. Rodak, B.F. et al. (2012) (Eds).Hematology: Clinical principles and applications (4th ed.) Singapore: Saunders. Rodriguez, M.T. Clinical Chemistry Review Handbook for Medical Technologists. Cattleya Star Copy Center and Book Binding. 2014