2024 MLA 1119 Module 4 Venipuncture Equipment PDF

RDP MLA 1119 Module 4 Venipuncture Equipment and Procedures  Module 4: Venipuncture Equipment and Procedures Venous blood may be obtained by using one of three methods: Capillary (micro) collections Vacutainer method - most commonly used Butterfly needle method whic...

RDP MLA 1119 Module 4 Venipuncture Equipment and Procedures  Module 4: Venipuncture Equipment and Procedures Venous blood may be obtained by using one of three methods: Capillary (micro) collections Vacutainer method - most commonly used Butterfly needle method which incorporates the Vacutainer or syringe method The differences in the procedures will be explained further in this Module. Part 1: Capillary Punctures (Micro-collections) Rationale Capillary punctures or “finger pokes, micro-collections” may be utilized to collect a blood specimen when obtaining the specimen via venipuncture is unsuitable. There are various reasons for performing a capillary puncture on adult patients, such as inaccessible veins or patients with severe burns. However, the most common application for capillary puncture is the collection of blood from infants or young children, both in terms of ease of collection as well as promoting the overall well-being of our young parents. Utilizing proper equipment and procedure to perform a capillary puncture on an appropriate site will produce a quality blood specimen suitable for analysis with minimal trauma to the patient. Learning Objectives To complete this module successfully, you should be able to: 1. Describe and discuss the reasons for performing a capillary puncture on young children and adults, including advantages/disadvantages and the difference between capillary and venous blood. 2. Describe and discuss the equipment used for capillary puncture with regard to types, proper use, limitations, disinfection and/or disposal, advantages and/or disadvantages. 3. Discuss the sites commonly used for capillary punctures and describe how to select the best puncture area, areas unsuitable for puncture and the proper placement of the lancet to obtain a good poke. 4. Describe the procedure for capillary puncture from a finger and list all required steps for the procedure in the correct order. 5. Describe and discuss the performance of a heel puncture and specimen collection from an infant, including patient preparation, site selection, collection procedure, documentation, and use/handling of NMS cards to obtain a suitable blood specimen. 6. Describe problems that may be encountered during capillary puncture and discuss methods used to prevent/resolve the problems. Connection Activity Following a number of successful venipunctures, you select the next requisition for blood collection and discover that your patient is under two years of age! You look into the waiting area and see a tiny girl sitting on her mom's lap. Imagine some of the questions you might have: Will she cooperate during the collection procedure? Will her mom be able to help during the procedure? Will you find a suitable vein for collection in such a tiny arm? When a blood specimen is required from an infant or young child, the venipuncture procedure may not be an appropriate choice for the collection. This Module will introduce an alternate procedure useful for obtaining blood from young patients as well as adults whose veins are not accessible: the capillary puncture. PART ONE- Capillary Punctures Objective 1 Describe and discuss the reasons to perform a capillary puncture on young children and adults, including advantages/disadvantages and the difference between capillary and venous blood. Blood specimens obtained by capillary or skin puncture (also known as micro collections) are especially important in pediatrics because small but adequate amounts of blood for lab tests can be obtained. They are also referred to as “micro-collections,” because we collect small amounts into tubes called microtainers. Obtaining blood by venipuncture on infants is not only difficult (veins very small) but potentially hazardous. Puncturing deep veins in children may cause: cardiac arrest hemorrhage venous thrombosis reflex arteriospasm and gangrene of an extremity damage to surrounding tissues or organs infection injury from restraining the infant during the procedure Taking large quantities of blood may result in anemia. It is also advantageous to perform capillary punctures on the following adult patients: severely burned patients extremely obese patients patients with thrombotic tendencies patients whose veins are being reserved for therapeutic purposes patients whose veins are not accessible or are very fragile, i.e. geriatric patients Capillary blood is a mixture of blood from arterioles, venules and capillaries and contains interstitial and intracellular fluids. It usually resembles arterial blood more closely than venous blood. Objective 2 Describe and discuss the items of equipment used for capillary puncture with regard to types, proper use, limitations, disinfection and/or disposal, advantages and/or disadvantages. Equipment Antiseptics Antiseptics are used to cleanse the skin before venipuncture. Generally, we use a pre-prepared swab moistened with 70% isopropyl alcohol. Special collections, for example, blood cultures or legal specimens require disinfection with an antiseptic that does not contain alcohol. The most common antiseptics used in more specialized collections are iodine or chlorhexidine. We must familiarize ourselves with the specific cleansing requirements for each collection Gauze Pads Gauze pads (2x2 in, or 3x3 inches) are used for capillary punctures; cotton balls tend to leave fibres that “stick” to the site and increase the risk of dislodging the platelet plug post-venipuncture. Some sites may recommend sterile gauze for newborns/infants. During capillary collections, we use 2 gauze pads: one dry swab to wipe away the 1st drop of blood following the puncture one dry swab is applied with pressure once the collection is complete Lancets Lancets are small, sterile, disposable devices designed to penetrate a predetermined distance into the skin. There is a vast array of types or models available, but all are for single use and should be discarded appropriately into a Sharps container following a puncture. The penetration depth and length of incision varies with the type of lancet. Color coding is used to denote the blade or needle and depth of puncture Quick Heel Lancets Figure 4.1 Assorted Lancets Note: CLSI recommends that lancet depth should NOT exceed 2.0 mm. Figure 4.2 Blade Depth Advantages of Safety Flow Lancets: Blade is recessed, allowing precise placement of lancet on site prior to puncture. “Semi-automatic” puncture mechanism eliminates “stabbing” action, resulting in a more controlled puncture. Blade retracts automatically after use, reducing the risk of accidental pokes. Color-coded based on different blade widths and depths. Figure 4.3 Safety Flow Lancet  Advantages of BD Microtainer® Contact-Activated Lancet: user comfort is enhanced with an ergonomic design for a more comfortable grip. activates only when positioned and pressed against the skin, resulting in a consistent puncture depth for easier sampling. The lancet covers a very small area at contact point, therefore, improving visibility of the puncture site. These are the lancets we use here at RDP. The colour coding applies as follows: Blue- Penetrates to a depth of 2.0mm with a blade width of 1.5mm. This lancet is most preferable in situations requiring high blood flow. Its design is suitable for obtaining larger blood samples, which might be necessary for certain tests that require more volume. Pink- The pink BD Microtainer® contact-activated lancet has a penetration depth of 1.8 mm and uses a 21-gauge needle. The use of a 21-gauge needle in the pink BD Microtainer lancet is primarily for achieving a balance between sufficient blood flow and minimizing discomfort during blood sampling. Purple- The purple BD Microtainer® contact-activated lancet has a needle depth of 1.5 mm and a gauge of 30. It is designed for low-flow applications, enhancing user comfort and ensuring consistent puncture depth. This is finer and shallower compared to the pink (21-gauge, 1.8 mm depth) and blue (16.5 gauge, 2.0 mm depth) lancets, which are designed for medium and high flow, respectively. The purple lancet is specifically designed for low flow, which is ideal for situations where minimal blood is required or for patients with fragile skin. Capillary Tubes These are small, glass or plastic, disposable tubes (about 1 mm in diameter) used to collect blood by capillary action. Capillary action, also known as capillarity, is the ability of a liquid to flow in narrow spaces without the assistance of, or even in opposition to, external forces like gravity. This phenomenon occurs due to the combination of cohesive forces (the attraction between molecules of the liquid) and adhesive forces (the attraction between the liquid molecules and the walls of the container or tube) They may or may not contain an anticoagulant, which is indicated by a color-coded tip. One or both ends of the tube must be sealed using a plastic stopper or clay sealant following collection, so the blood does not flow out of the tube during transit. These tubes are no longer commonly used as a collection method but are of great use in the lab for other purposes. For example, we use these capillary tubes to draw blood from an EDTA tube when making blood smears. Capillary tubes can be used to collect specimens for blood gas analysis. To collect a blood specimen into these tubes, hold the tube horizontally to the finger and just touch the blood drop, allowing the blood to flow into the tube. Keep the tube horizontal so that air bubbles do not become trapped in the tube, as these interfere with blood gas analysis. Once the tube is approximately ¾ full, hold a finger over the end to prevent blood flow and seal the tube using the clay sealant. Micro Collection Tubes There are several plastic micro-collection tubes available, with or without additives. They have color-coded stoppers and a “flo scoop,” which helps to funnel the blood into the tube during collection. Most of these tubes hold approximately 0.5mL of whole blood. Optional features include: etched lines on tubes - indicate minimum and maximum fill volumes. separating gel- to separate plasma or serum from the cellular components dark brown-coloured tubes - used to protect light-sensitive blood constituents such as bilirubin The order of collection of these micro collection tubes differs from that of the routine Vacutainers, with the EDTA and other anticoagulated tubes collected before the serum tubes. The order of draw is different because platelets begin to aggregate, and clotting begins soon after the puncture. This will affect the results of tests performed on EDTA specimens. Order of Draw for Micro-collection tubes: Blood Gases (capillary tubes) EDTA Heparin or Heparin Gel Sodium Fluoride/Potassium Oxalate SST (clear or amber) Sharps Disposal Container All used blades, lancets, needles, discarded glass slides and capillary tubes are potentially very dangerous if they puncture a second person. They should immediately be put into a proper puncture-proof container after use. Warming Devices Warming the site before skin puncture increases blood flow to the area and can dramatically affect the volume of blood you are able to collect. Several commercial devices are available, or a cloth/diaper dampened with warm water can be used to wrap around the hand or foot prior to puncture. To avoid scalding the skin, ensure that the temperature of the warming medium does not exceed 42°C.  Figure 4.7- Heel Warmers Objective 3 Discuss the sites commonly used for capillary punctures and describe how to select the best puncture area, areas unsuitable for puncture and the proper placement of the lancet to obtain a good poke. Fingers The fleshy surface of the distal portion (side) of the second or third fingers can be used for the puncture. The other digits are not advised as the thumb has a pulse, the index finger tends to have thicker, callused skin and the fifth finger tends to have less soft tissues overlying the bone. Usually the middle or ring finger are chosen, as it is generally the largest and has the best flesh pad for puncturing. Use the fleshy pad of the finger, avoid the side or tip of the finger. The puncture should involve a firm, deep puncture across the fingerprints, not parallel to them. A puncture that is parallel to the print allows the blood to run along the print, so a discreet blood drop does not form, and the result is a difficult and messy collection. Children that are less than one year old have fingers that are too small to use so the large toe or heel is a much better site. Heels or Toes If an infant's large toe is fairly large, it may be chosen if they are at least one year old. The more common site, especially for newborns, is the medial or lateral sections of the plantar or bottom surface of the heel. The least hazardous sites are shaded in the diagram below. If other areas are punctured, the possibility of hitting bone is increased, which may in turn, result in an infection and osteomyelitis. Do NOT puncture sites that are: edematous scarred bruised inflamed/infected have open wounds The chart below provides information for the infant and preemie heel stick lancets. Note that these are to be used for heel sticks only. Figure 4.10- Quikheel Preemie Lancets Objective 4 Describe the procedure for capillary puncture from a finger and list all required steps for the procedure in correct order. Capillary Collection Procedure Patient Approach and Identification Perform NOD (name, Occupation, Duty) and wash your hands thoroughly with soap and water or hand sanitizer Assemble Equipment make sure you have gathered all of the necessary equipment and supplies and ensure all the equipment is within reach before you perform the venipuncture gauze pads 70% isopropanol swabs lancet receptacles for blood which may include: micro-collection tubes or capillary tubes/sealer (if applicable) apply a flo scoop onto the micro-collection tube, if necessary gloves  Band-Aids (for adults and older children only, as small children and infants may aspirate them) Choose and Disinfect the Puncture Site The site should be free from calluses, edema, bruising and cyanosis do not puncture through previous punctures warm the site to increase blood flow. This can be done by covering the area for three minutes with a towel that has been soaked in warm water (42oC) or by using a commercial warmer. Warming the site may increase blood flow sevenfold. For older children and adults, you can ask them to rub their hands together, sit on their hands or place them under their arms to help warm them up. disinfect the site with 70% alcohol and allow to air dry. Any residual alcohol will sting the patient and hemolyze the blood specimen. Puncture Site Make sure the site is held firmly, even adults will have a tendency to pull away. Make the puncture in one continuous deliberate motion. A deep puncture hurts no more than a superficial one. It is better to spare the patient from a second puncture by performing a good first one. Give the patient a brief warning immediately before the puncture, then reassure them the worst is over after you have punctured the skin. Check that your placement is in the fleshy part of the finger pad and the blade will puncture ACROSS the fingerprint lines, not parallel to. Press the lancet firmly on the finger. Do not pull the lancet off the site when you depress the trigger as this will result in a poor poke. Give it a second or 2 and discard the lancet into a Sharps container. Blood Collection Always wipe away the first drop with a gauze pad as this drop will contain tissue fluids. If blood does not flow freely, gently squeeze the area around the site, allowing the capillaries to refill between scoops. Excessive pressure (“milking”) will dilute the blood specimen and cause it to clot faster or hemolyze. If the site becomes messy, wipe away the blood with a clean gauze, then carry on with the collection. If the finger becomes too messy, the blood will not pool well enough to catch the drops. If an anticoagulated specimen is being collected, it may be necessary to mix the blood in the tube a few times during the collection by gently tapping the tube. Avoid introducing air bubbles into the specimen. It should be possible to collect 0.5 mL of blood from a single puncture site. Blood and Patient Handling After Collection Press a clean gauze pad to the puncture site and elevate it until the bleeding has stopped. Place a Band-Aid on older children and adults only.  Cap the specimen and mix gently by either inverting the tube or gently tapping on a hard surface. Label all specimens and complete the collection information on the requisition. Ensure all equipment has been disposed of and no items are left behind in the patient’s bed or collection area. Check that the bleeding has stopped, and the patient is comfortable. Thank your patient and dismiss them. Objective 5 Describe problems that may be encountered during capillary puncture and discuss methods used to prevent/resolve the problems. Collection Problem Solution/Prevention Puncture which is greater than Use only recommended blades for newborns. A 2.0 mm on newborns deeper puncture may pierce the bone which could lead to bone deformities and/or infection. Puncture site will not bleed If site is too cold, the capillaries contract resulting in a very minimal blood flow. Warm the site with a commercial warmer or warm towel, but make sure site is dry before attempting the puncture. This will also occur if the puncture is not deep enough. Remember a shallow puncture hurts as much as a deep puncture but may not bleed adequately. Do not puncture the same site more than once to obtain the specimen. Using first drop of blood This drop is always discarded (wiped away) because it contains blood which is diluted with tissue fluids. Painful punctures The alcohol must be dry before the puncture is attempted, or it will sting. Excessive squeezing (milking) This will dilute blood with tissue fluids. Use firm to obtain sample pressure, not excessive squeezing.  Puncturing through previous Never puncture through a wound, this may cause an sites infection, and will delay the healing process. Accidental puncture Always dispose of used lancets and other sharps immediately in a puncture-proof container. Anticoagulated specimens Complete mixing of blood and anticoagulant within which contain clots minutes of starting collection whether in an anticoagulated collection tube or an anticoagulated capillary tube. Blood hemolyzed This is most likely caused by residual alcohol at the site or excessive squeezing of the tissue surrounding the site. Newborns have an increased red blood cell fragility and high hematocrit; thus hemolysis is more prone to occur. Summary Proper selection, preparation, handling, maintenance and/or disposal of capillary puncture equipment is required to ensure collection of a suitable blood specimen using a capillary puncture procedure. Utilizing good techniques, performing the capillary puncture and collection procedure in their proper sequence, and working efficiently are all crucial to ensuring that a quality specimen is obtained as well as ensuring that the patient experiences minimal trauma during the collection. Part 2- Collection Tubes, Additives and Order of Draw Collection Tubes and Additives Rationale Various types of collection tubes are used to collect blood specimens. These tubes may contain different additives that are important in providing an appropriate blood specimen for specific analysis. This Module will introduce various types of tubes and their additives and provide information that will enable you to select the appropriate collection tube for the type of analysis requested. Learning Objectives To complete this Module, you should be able to: Describe and discuss the following types of anticoagulants with regard to the mechanism of action, primary uses, advantages/disadvantages, adverse effects on results and colour of tube stopper: heparin, EDTA, citrates, oxalates, SPS. Describe and discuss the following types of tubes and additives used to produce serum specimens with regard to the mechanism of operation, primary uses, advantages/disadvantages, limitations and colour of tube stoppers: SST and red stopper tubes. Describe the appropriate handling of collection tubes that contain additives immediately after filling and indicate what type of blood specimen is obtained for the various types/colours of collection tubes. Determine the correct order of collection of the various tubes according to CLSI guidelines and explain the rationale for the order of draw. Describe and discuss the adverse effects that additives may have on blood specimen results, which must be considered when selecting an appropriate collection tube. Connection Activity You are preparing a sweet and sour teriyaki sauce; however, the sauce will not thicken and runs like water. You realize that you forgot to add a crucial ingredient that causes a change in consistency, making a suitable sauce (recognize that ingredient?). Blood specimens also can be altered by the use of specific additives "ingredients" put into the blood collection tubes. Different additives have specific functions that produce a desired change/effect on the blood specimen. This Module will identify different types of additives and how the use of these additives in collection tubes can affect changes in blood specimens that make them suitable for specific analysis. Objective 1 Blood collection tubes contain additives that either prevents or accelerates clotting. Describe and discuss the following types of anticoagulants with regard to the mechanism of action, primary uses, advantages/disadvantages, adverse effects on results and colour of tube stopper: SPS, citrates, Serum, heparin, EDTA, and oxalates. 1. Sodium Polyanethol Sulphonate (SPS) chelates calcium. inactivates antibiotics and inhibits phagocytosis. Provides a nutrient-rich environment for bacteria to grow is used exclusively in microbiology for the collection of blood cultures. in STERILE PALE YELLOW stoppered tubes and blood culture bottles. be careful not to confuse these tubes with the ACD tubes. Most commonly these will be in the form of bottles that are collected in sets- 1 Aerobic bottle/1 Anaerobic bottle Produces WHOLE BLOOD specimens 2. Citrates a. Sodium Citrate (NaCit) prevents coagulation by precipitating calcium. CRITICAL Fill- means that the blood must drawn to meet the fill line etched on the tube to ensure the ratio of anticoagulant to blood is correct. available as a 3.2% solution; A 1:9 (anticoagulant to blood) ratio is critical for correct test results in coagulation tests. The most commonly used volume is 0.5 mL of liquid sodium citrate mixed with 4.5 mL of blood. colour-coded by a light BLUE stopper. Improperly filled tubes will not give accurate results, and therefore, must be recollected. although sodium citrate is mainly used for coagulation, it can be used for an ESR  (erythrocyte sedimentation rate) as well. These tubes have a BLACK stopper and also have a critical fill volume. The anticoagulant to blood ratio for these tubes is 1: 4. Produces WHOLE BLOOD specimens Advantage: preserves coagulation factors. Disadvantage: tubes must be filled to capacity. excessive inversions can activate platelets and falsely shorten clotting times. b. Acid Dextrose Citrate (ACD) this anticoagulant is used to collect blood for immunohematology (e.g. tests done for DNA testing and HLA typing). is colour-coded by a PALE YELLOW stopper. (Be careful not to confuse with an SPS tube as they can look very similar). acid citrate prevents clotting dextrose provides nutrients for RBC’s 3. Serum Separating Tubes (SST) Serum tubes have 2 essential components: Clot Activator- additive that speeds up the clotting mechanism so that the specimen can be centrifuged, and the serum separated from the clot in 30 minutes from the time of collection. Silicone Gel layer- (“thixotropic gel”) occupies about 1 mL of the tube, which because of its viscosity and density, moves to form an inert barrier between the cells and serum when the specimen is centrifuged. colour-coded by a GOLD stopper. although SST specimens do not contain anticoagulants, they DO require mixing by gentle inversion 5 – 8 times. This is necessary to mix the clot activator (which coats the walls of the Vacutainer) with the blood specimen, which enables faster clot formation. used when the desired specimen is serum, (e.g. routine chemistry tests, serology, endocrinology). Produces a SERUM specimen Advantages: they give a higher yield of serum. faster processing since the clot forms quicker.  the serum may remain in the original tube indefinitely, thus eliminating labelling a separate serum tube (“aliquot”). 4. Red No-Additive Tubes Red stoppered tubes are available plain (glass tubes), without any additives, or with a clot activator and no gel (plastic tubes). These tubes can be used for chemistry, serology or immunology. The plain red glass tube is the only tube that does NOT require mixing Blood will naturally clot once inside this tube as there are no anticoagulants in it to prevent clotting. Therefore, this tube will also produce a SERUM specimen 5. Heparin Tubes There are 2 types of Heparin tubes, both containing Lithium heparin as the anticoagulant. One contains a separating gel to isolate the plasma, the other does not. Prevents blood from clotting by inactivating thrombin and thromboplastin. Heparin is a complex acid mucopolysaccharide. Heparin is found in most body tissues; therefore, is considered a natural anticoagulant. Available as an ammonium, lithium or sodium salt. Is usually coated onto the inside wall of Vacutainer tubes or capillary tubes. In Vacutainer tubes, has a DARK GREEN stopper. Plasma separator tubes (PST) contain heparin and a separating gel and have a pale green stopper. Is mainly used for stat chemistry tests such as electrolytes, glucose, creatinine, and urea. Is also used for capillary blood gases and red blood cell fragility tests Dark Green stoppered tube produces a WHOLE BLOOD specimen Mint/pale green (PST) stoppered tube produces a PLASMA sample Advantages: Causes the least amount of hemolysis. Interferes the least with chemistry tests. Disadvantages: expensive Anticoagulant properties last only for 24 hours; therefore, blood collected in heparin will eventually clot. Cannot be used for blood smears because it will cause a blue background when the smears are stained. 6. EDTA (Ethylene diamine tetra acetic acid) is available as a dipotassium or tri-potassium salt chelates (binds) calcium, making it unavailable for coagulation. Colour-coded by a PURPLE (mauve or lavender) stopper. is the routine anticoagulant for the majority of hematology tests. E.g.,CBC, differential, WBC, hemoglobin, platelet.  is also the routine anticoagulant for transfusion medicine tests such as type and screen, ABO/Rh typing, DAT and prenatal testing. Produces a WHOLE BLOOD sample Advantages: Have excellent abilities to prevent platelets from clumping which makes platelets easier to count (CBC test- Hematology). Causes minimal white and red cell distortion; therefore, is the ideal anticoagulant for blood smears (used for manual differentials). Disadvantage: Binds many divalent ions making EDTA unsuitable for most chemistry tests. Destroys Factor V, so is unsuitable for coagulation tests 7. Oxalates functions by precipitating the calcium thus making it unavailable for coagulation. available as sodium, potassium, ammonium or lithium salts. are almost exclusively used in combination with a glycolytic inhibitor, such as sodium fluoride. present in a dry, powder form. is colour coded by a GREY stopper. is mainly used for lactate and ethanol specimens and can also be used for glucose. This testing is performed in chemistry. Produces a WHOLE BLOOD specimen Disadvantages: Unsuitable for hematology because of the distortion of the blood cells. Sodium fluoride acts as an enzyme inhibitor, so cannot be used for enzyme determinations. Specialty Draw Tubes Other types of collection tubes with different coloured stoppers are available and are usually used for specific tests and/or departments. Some of these include: ROYAL BLUE or NAVY blue stopper- these may contain heparin, EDTA or no additive and are used for the analysis of trace elements. The tubes are tested for trace elements. TAN stopper- may contain heparin or EDTA and is used for the analysis of lead. ORANGE or YELLOW BLACK stopper- contains thrombin and is used for clotting a specimen very quickly. The following chart provides a summary of the most common types/colours of collection tubes, their additives and the type of specimen that is produced by each tube: STOPPER COLOUR ADDITIVE SPECIMEN TYPE Green Heparin Plasma Pale green/Mint Heparin and separating Plasma gel Purple EDTA Whole Blood Light blue and Black Trisodium citrate Whole blood Grey Potassium oxalate and Whole blood sodium fluoride Pale Yellow SPS or ACD Whole blood Gold Clot activator and gel Serum separator Red Glass/Red Plastic No additive or clot Serum activator Objective 2 Describe the appropriate handling of collection tubes that contain additives immediately after filling and indicate what type of blood specimen is obtained for the various types/colours of collection tubes. All blood specimens must be handled and labelled appropriately immediately following collection. All tubes that contain an additive must be inverted gently to ensure that the additive and the blood are completely mixed without causing trauma to the specimen, such as hemolysis of the red blood cells. The tubes are labelled correctly once the specimens are mixed, and the collection is documented appropriately on the requisition or collection/draw list. Special handling procedures may be required for some specimens, such as keeping the specimen chilled or protecting it from light. All tubes containing an additive, whether an anticoagulant or a clot activator, must be inverted to ensure the additive and blood have adequately mixed. The chart on the following page illustrates how to properly invert the tubes and the recommended number of inversions for each tube. It is important to note that the two most common errors that affect specimen integrity are: Underfilling of the tubes Inadequate mixing after collection  Figure 4.11- Vacutainer inversion guide Take notice that the citrate tubes only require 3-4 inversions. This is because the clotting factors in the blood that we are trying to preserve are unstable and fragile and excessive or aggressive mixing may cause erroneous testing results. Overmixing of the serum tubes (Gold and red stoppered tubes) is less of a concern because serum doesn’t contain those clotting factors. Question: Do I wait until I have collected all of the tubes before I invert them? - No, the tubes must be inverted as soon as they are removed from the back end of the needle right away to ensure the integrity of the specimen. This, however, can prolong the time that the needle is in the patient’s arm. So, the recommendation is that once you remove a tube from the needle, perform 2 gentle inversions before setting the tube down and moving to the next one. Once the collection is complete and the patient is comfortable and holding gauze to the puncture site, you may complete the remaining inversions and then move on to labelling and completing the collection information on the requisition. Objective 3: Determine the correct order of collection of the various tubes according to CLSI guidelines and explain the rationale for the order of draw. Order of Draw To avoid possible cross-contamination of additives between tubes, they must be collected in a particular order; this is referred to as the “order of draw”. The order of draw when using a vacutainer system is as follows: Figure 4.12- Order of Draw (reproduced with permission from BD) Rationale for the Order of Draw This sequence for blood collections was developed to reduce the contamination from carryover as we move from tube to tube, as the different additives can affect the testing results. 1. SPS/Blood Culture bottles Must be collected first to avoid introducing bacteria from the outside environment. Tube tops are not sterile so as we move from tube to tube, bacteria or contaminants have the chance to enter the tube. We avoid this by cleaning the tops of these tubes/bottles so we know that the only bacteria present in the sample is from the patient. 2. Coagulation tubes (light blue, black)  Prevents clotting by chelating (binding) calcium, making it unavailable for the clotting process. All other additives would have a detrimental effect on the clotting factors, causing erroneous results. The anticoagulants in citrate tubes are very gentle. Just strong enough to preserve the coagulation factors. 3. Serum tubes (gold, red) These tubes follow the coagulation tubes for 2 reasons: if these were collected first (after blood cultures) the clot activator would affect coagulation results carryover of other anticoagulants would affect serum formation. Therefore, we collect it after the coagulation tubes, and before the heparin tubes. This is because Heparin is a natural anticoagulant, meaning that it is found in the human body and therefore acts as a buffer between clot activator and anticoagulant. I like to think of the heparin tubes as a bit of a palette cleanser. If there is any carryover of heparin to the tubes following, the heparin will have little effect on the sample or testing integrity. 4. Heparin (dark green, mint/light green) Heparin would compromise all coagulation testing but causes the least amount of interference in most other testing Naturally occurring substance Prevents clotting by inhibiting thrombin formation 5. EDTA (purple/lavender/mauve) EDTA chelates the calcium needed for coagulation, thus keeping the sample from clotting It also chelates most of the divalent ions needed for chemistry testing, so it is important to collect this tube after the Chemistry tubes (serum and heparin) Carryover from heparin will not adversely affect platelets or cell morphologies 6. Oxalate/glycolytic inhibitor (fluoride) Acts as an enzyme poison which affects many tests done on serum and heparinized blood. Objective 5 Describe and discuss the adverse effects that additives may have upon blood specimen results which must be considered when selecting an appropriate collection tube. Adverse Effects of Additives When blood is drawn into Vacutainer tubes, the tube additives used must not alter the blood constituents being tested. The following are some considerations when using tubes with additives: The additives must not add to the substance being determined. An example would be the use of sodium heparin when sodium levels are to be determined. The additive must not remove the substance being analyzed. An example would be using EDTA sample to measure the amount of ++ calcium. EDTA removes Ca. The additive may alter enzyme reactions. For example, the use of sodium fluoride in an enzyme determination. Fluoride destroys many enzymes. The additive may alter cellular components. Using oxalates would distort cellular morphology. Heparin causes background staining of blood smears. An adequate amount of anticoagulant must be used for the amount of blood drawn. If there is insufficient anticoagulant, small clots will form in the specimen, which not only invalidate cell counts but will also plug instrument lines. This could happen if 7 mL of blood is added to a 5 mL draw tube. Too much anticoagulant for the amount of blood drawn. This occurs when the Vacutainer tubes are NOT properly filled to capacity. If the anticoagulant is liquid, it will dilute the sample. In the case of coagulation testing, too much anticoagulant will cause false result(s).  All tubes with additives must be mixed completely and thoroughly immediately after collection. Invert the tube gently five to eight times. Summary Identification of the various coloured blood collection tubes and the type of additives contained in those tubes is critical for the collection of suitable blood specimens for laboratory analysis. Additives in blood collection tubes may cause changes in the blood specimen which are desirable (such as preventing clot formation) but may also interfere with and/or alter test results. The type of additive and its effects must be considered when collecting blood specimens for analysis to ensure/maintain specimen integrity. Part 3- Straight Needle Collections Learning Objectives To complete this part of the module, you should be able to: 1. Define and discuss the items of equipment used for venipuncture with regard to types, proper use, limitations, disinfection and/or disposal, advantages and/or disadvantages. 2. Discuss the commonly used antecubital fossa area and alternate venipuncture sites and describe how to select an appropriate vein for venipuncture. 3. Describe the procedure for venipuncture using a Vacutainer method and list all required steps for the procedure in the correct order. 4. Describe and discuss the procedure for venipuncture using a syringe method, including differences, advantages and disadvantages of this procedure compared to the routine Vacutainer method. 5. Describe and discuss various factors to consider when selecting a vein for venipuncture. 6. List the laboratory tests that require special handling techniques to maintain specimen integrity and describe methods used to keep a blood specimen chilled, at 37°C, or to protect it from light. Connection Activity You have invited friends for a summer evening barbeque, and you plan to grill steaks. In order to marinate the steaks, cook them medium-rare and be ready to eat at 6:30 pm, you must prepare and perform several steps in a particular order or sequence. For example, you should ensure that the propane tank is adequately filled to cook your steaks; you would not want to run out of fuel just as you put the steaks on the barbeque. In order to marinate the steaks, it would not be logical to prepare the marinade after the steaks have been grilled. Likewise, attempting to light the barbeque before opening the gas line to the propane tank would be unsuccessful. What steps are required (in proper sequence) to successfully accomplish the task of marinating and barbequing your steaks? To successfully collect a blood specimen by venipuncture also requires the performance of the procedure in a logical order. This part of the module will address the equipment required for venipuncture and the steps in the venipuncture procedure which must be performed in proper sequence in order to successfully collect a blood specimen. Objective 1 Define and discuss the items of equipment used for venipuncture with regard to types, proper use, limitations, disinfection and/or disposal, advantages and/or disadvantages. Equipment 1. Blood Collection Trays / Collection Carts Collection trays should be lightweight and easy to handle and yet provide enough space and compartments to carry the various supplies that are needed. Each phlebotomist is responsible for the care, restocking, and regular cleaning of his/her tray. They should be disinfected with an appropriate solution (e.g. 1% bleach, oxivir) as scheduled or whenever there is blood or other contamination noted. Trays may be carried or may be attached to a rolling cart for ease of use and to provide a clean workspace for the collector. Figure 4.13 Blood Collection Trays (Fisher Scientific) 2. Gauze / Alcohol Swabs For routine venipuncture, gauze and a prepared swab with 70% isopropyl alcohol are required. The 70% alcohol is used to disinfect the collection site by removing bacteria, soap, residue lotion and oil from the skin surface. This is done to prevent infection and to eliminate contamination of the specimen which may interfere with test results. To clean the site, use the 70% alcohol swab, apply pressure, and rub back and forth with friction (some sites may prefer a circular motion). Regardless of whether you use  a back-and-forth or circular motion, the important part is applying enough friction to remove contaminants from the skin. Allow the alcohol to air dry before the puncture is performed. Failure to allow the alcohol to dry completely will cause discomfort to the patient, may cause hemolysis or have an adverse effect on testing results. If the site is touched again, it must be re-cleansed before puncture. The dry gauze is applied to the site after the needle is withdrawn from the vein. It is used to apply firm pressure to stop bleeding from the puncture site. You only need to use 1 or 2 squares of gauze for this. 3. Tourniquets When the tourniquet is placed on the arm about 10 cm above the elbow, venous flow is obstructed and the veins become more prominent, so they are easy to visualize and feel. Obstruction of blood flow can alter the balance of blood components if the tourniquet is left in place for more than 1 minute, so the tourniquet must be fastened in a way that is easy to release with one hand during the blood collection procedure. Latex Free Tourniquet – most common type of tourniquet in use. These tourniquets are made of a non-latex alternative such as nitrile and tied using a slip knot that can be undone with one hand). Advantages of latex-free tourniquets: disposable/single-use only reduce the spread of nosocomial infections good for patients with latex allergies Disadvantages of latex-free tourniquets: take up more space on blood collection trays come in one size and width only  Tying a tourniquet: *It is important to check that the tourniquet has not rolled up once you have it tied as this can be very uncomfortable for patients. If you notice that it has rolled up, please remove and retie the tourniquet.* Indications that the tourniquet is too loose include: easily slips off veins fail to become full and distended Indications that the tourniquet is too tight include: patient complaint skin appears white around the tourniquet patient's hand/arm becomes red/purple in colour appearance of petechiae (pinpoint bruises) on patient’s arm 4. Needles Needles are made of a lightweight stainless steel designed to be used once and then properly discarded. They must be sharp and sterile. Each needle is covered with a protective sheath that shields the point and cannula (shaft and hub of the needle) until the moment of use to ensure sterility. Protective sheath The basic needle is composed of 3 parts: the bevel, shaft and hub. Bevel Hub Shaft The bevel is the slanted sharp end of the needle. This is the portion that punctures the skin and contains the opening for the blood to flow in to. The shaft determines the gauge size (size of bore or lumen of the needle) and the needle length. The hub is the portion which attaches the needle to a syringe, or a vacutainer holder. Needles are available in several gauges and lengths. Generally, the larger the gauge number, the smaller the needle bore (size). The most commonly used in venipuncture are 21, 22 and 23 gauge in a 1” or 1.5” length. Most needle manufacturers use a standard color code indicating the gauge of the needle. Light Blue = 23 gauge Black = 22 gauge Green = 21 gauge Yellow = 20 gauge Pink = 18 gauge The 18 gauge needle is the LARGEST in size and is used when collecting donor blood for transfusion purposes. Syringe Needles - have one sharp end, hub screws onto syringe. Collection with a syringe and needle is no longer an acceptable practice in Alberta. The use of syringes for blood collection is used in combination with a butterfly needle (as per APL/Dynalife policy). Vacutainer Needles – These are the needles most commonly used for venipunctures. They have two sharp ends, one of which fits into a Vacutainer holder in order to pierce the evacuated collection tube (back end). The other end, of course, contains the bevel, shaft and hub and is the “patient end”. These are used in tandem with a vacutainer holder that screws onto the hub of the needle. Colour-coded hub Rubber Sleeve Double pointed ends Vacutainer needles are packaged with a tamper-evident seal to ensure sterility. Multiple sample needles have a rubber sleeve (or valve) which keeps blood from dripping into the holder as one tube is pulled out and another tube put in. Colour-coded cap 5. Vacutainer Holder The vacutainer holder is a plastic device designed for use with evacuated collection tubes and Vacutainer needles. Holders come as single use holder. A disposable needle screws into a holder and the Vacutainer tube is then inserted in the holder. After the needle is in the vein, the tube is pushed into the holder (via the back end needle), the vacuum is broken and blood flows into the tube. The blood will stop flowing when the vacuum in the tube has been exhausted. 6. Syringes Although not used extensively for routine blood collections, syringes are especially useful for patients who have small, fragile or damaged veins. The force of the vacuum from a Vacutainer tube may “collapse” the vein by drawing it against the bevel of the needle. By using a syringe, the vacuum force can be regulated to prevent this collapse. The syringe is generally made of disposable plastic and consists of 2 parts: a barrel and a plunger. When the plunger is drawn back it creates a vacuum which draws blood into the barrel. It is important to exercise the plunger and ensure it is flush with the nozzle of the barrel before use. If this was not done and air was pushed into a patient's vein, an air embolism could cause death. Syringes are available in a variety of sizes; 5 mL and 10 mL are most used. 7. Vacutainer Blood Collecting Tubes These are evacuated sterile plastic tubes with a rubber stopper used for taking blood specimens. These tubes contain a vacuum that draws blood from the vein, through the double-ended Vacutainer needle. When the rubber stopper is pierced, the vacuum is engaged. Tubes come in a variety of sizes, draw capacities and additive formulations. They are colour-coded for additive identification and labelled with information regarding the type of additive, expiration date, and lot number. Use only in-date tubes, as expired tubes may not have an appropriate vacuum and sterility is not assured. The usual sizes used are 5 and 7 mL for adult samples or 2 and 3 mL for pediatric samples. Soft draw or pediatric tubes are distinguished by their transparent lids. 8. Needle Disposal Unit (Sharps Container) Once needles have been used, they should be placed in a puncture-resistant container designed solely for disposal marked with a biohazard label. These containers are designed so that a needle can be removed from the holder without the phlebotomist touching it. Never bend or break the needle or reinsert it into the original sheath. Breaking the needle creates aerosols. Reinserting needles back into their original sheath is a common cause of needle-stick accidents. Once the fill line is reached, the unit is permanently closed for disposal. 9. Gloves Gloves provide a protective barrier between the patient and the phlebotomist. Remember that many cuts and abrasions through which an infectious agent could enter the body are often invisible. In the event of a needlestick, the presence of a glove is thought to reduce the amount of inoculum as some of the blood is wiped off of the outside of the needle by the glove material. According to Health Canada, “Gloves will protect from any blood spills to the hands and reduce the volume of blood from a needlestick injury by 50%.” Gloves routinely used for phlebotomy are not sterile. Choose gloves that fit well and are free of perforations. There are three main materials used for gloves – vinyl, nitrile and latex. Vinyl gloves have the benefit of being non-allergenic, but in the past have been found not to fit as well as latex. Nitrile gloves fit well and feel comfortable, but they are more expensive. This is the most common type in use as they are latex-free and fit better than vinyl. Latex fit nicely, conforming to the wearer’s hand quite well. However, many people (both staff and patients) have developed allergies to latex. Latex allergies result in rashes and abrasions of the skin, which makes the individual even more susceptible to infection by blood-borne pathogens, should exposure occur. Gloves should be disposed of, and hands washed after each patient. 10. Tape/Band-Aids Before leaving the patient, inspect the puncture site and apply a band-aid or tape over the gauze to secure it. In most cases, the patient can be instructed to remove it in about 15 minutes. If the patient is on anticoagulants, it may be wise to have them leave it on for longer. Use hypoallergenic band-aids or tape if the patient is allergic to the adhesives regularly used or has latex allergies. Generally, most sites prefer that you dress the puncture site after collection by taping a piece of two of gauze over the puncture site. This is because Band-Aids are quite adhesive. Patients may have a skin reactive to the adhesive and they may cause pain during removal, especially for elderly patients. Here at RDP, we permit the use of Band-Aids for capillary collections. For venipunctures, we prefer you get used to the process using tape and gauze. Objective 2 Discuss the commonly used antecubital fossa area and alternate venipuncture sites and describe how to select an appropriate vein for venipuncture. Venipuncture Sites The most commonly used site is the antecubital fossa area which is located on the inside surface of the elbow. The following veins are located in this area: median cephalic vein median cubital vein median vein basilic vein (least desirable vein because of its proximity to internal cutaneous nerve and brachial artery) cephalic vein (often small and tends to roll) The veins chosen for venipuncture are those at or near the elbow, such as the median cubital or median cephalic. The best veins are those which are flat, "full" appearing, and well supported by subcutaneous tissue to prevent "rolling" and "dimpling" while the needle begins to penetrate the vein wall. Prominent veins may not always be the easiest to enter. In elderly people, they often "roll" away from the needle. This "rolling" can be prevented by holding the vein in place with one hand (“anchoring”). In people who have had a lot of blood taken, the vein may be particularly difficult to enter because of the scar tissue. A little bit more force must be applied to enter the vein. Other sites include the back of the hand, ankle or foot veins. While the back of the hand is a relatively common site for venipuncture, the ankle and foot veins are not choice sites. These veins are often thin, small and prone to hemorrhage, and the procedure is likely to be more painful to the patient. The needle used should be sharp, short and have a small lumen (#22 or #23 gauge). Syringes are often preferred to Vacutainers because of controlled pressure as blood is being drawn. Please note that collection from sites other than the arm and foot may require special permissions. This policy will be site-specific. Antecubital Fossa Area- #1, 2, and 3 are preferred sites for venipuncture Objective 3 Describe and discuss various factors to consider when selecting a vein for venipuncture. Factors that must be considered when choosing a vein for venipuncture: 1. Scarred veins - avoid, if possible. These veins will be more difficult to penetrate and will take longer to heal. 2. Mastectomy - collect from other side because of lymphostasis (pooling of lymph fluid due to removal of lymph nodes). Patients without lymph flow are highly susceptible to infection and some chemical constituents may be altered, causing erroneous test results. 3. Bruises (Hematomas) - avoid, if possible. The vein will be more difficult to locate and the procedure more painful to the patient. 4. Edema (Swelling) - avoid, if possible. The extra accumulation of tissue fluid may dilute the blood specimen, causing erroneous test results. 5. Thrombosed veins - avoid, if possible. These veins are damaged and will be more difficult to penetrate. 6. IV running – avoid, as the IV fluid will dilute the blood specimen, causing erroneous test results. If possible, collect from the other arm. If you must draw from an arm which has an IV: - request permission and have a nurse shut off the IV - shut IV off for at least 2 minutes (minimum time specified by CLSI) - draw specimen from below the IV; try to select a vein other than the one with the IV line - discard initial 5 to 7 mL of blood drawn - document on the requisition the contents of IV fluid. 7. Thin, fragile veins - may collapse. Consider using a larger gauge needle and a syringe method or soft draw tubes. 8. Deep veins - increase the angle between the needle and the arm to minimize the amount of tissue being penetrated. 9. Surface veins - will more likely roll, thus keep well anchored until the needle is in the vein. Decrease the angle between the needle and the arm. 10. Veins that run across the arm - position needle so it will be inserted in the same direction as the vein is running. 11. Arms with fistulas - whenever possible draw specimens from the opposite arm. Fistulas are permanent and are reserved for dialysis. 12. Burns – do not poke a fresh burn site as this is painful to the patient and has a high risk of infection. Healed burn areas may be scarred and difficult to penetrate. 13. Abrasions/Lesions/Tattoos – these are susceptible to infection, so avoid them. Objective 4 Describe the procedure for venipuncture using a vacutainer method and list all required steps for the procedure in the correct order. PROCEDURE – Straight Needle (VACUTAINER) METHOD 1. Patient Approach and Identification Greet the patient in a friendly, professional manner. Explain you are from the lab and you are here to collect their blood. Ask for their consent. “Hi, I’m __________ from the lab and I’m here to collect your blood. Is that OK?” Identify hospital patients by the following: ▪ Asking them to state and spell their FULL name and give their date of birth. Compare this to the requisition/collection list and labels. ▪ Compare the requisition/collection list and labels to the patient’s ID bracelet which must be attached to the patient. Verify the FULL name, DOB and PHN are correct. Identify outpatients by the following: ▪ Asking them to state and spell their FULL name and give their date of birth. Compare this to the requisition/labels. Verify the FULL name and DOB are correct.  Patients who are unable to communicate i.e. infants, senile, unconscious, or speak another language; should be identified by someone who knows them or can communicate for them. If diet restrictions were necessary, check to make sure they were adhered to. In Alberta, a 9-digit Personal Health Number. (PHN) is issued to each individual. This number is unique and identifies the individual throughout the province. Wash/disinfect your hands before you begin the procedure. This should be done in sight of the patient. 2. Position the Patient put on gloves if the patient is seated, the chair should have side supports and the patient's arm should be extended to form a straight line from the shoulder to the wrist and inclined in a downward position. The arm and elbow should be supported. for patients in bed, their arm should be extended to form a straight line from the shoulder to the wrist. A pillow may be placed under the elbow if additional support is required. the patient's arm should be easily accessible to the blood collector. 3. Vein Selection and Assessment Place the tourniquet on the patient's arm. Use the index finger to palpate the veins (you should be able to feel the vein compress and then have it bounce back as the pressure is released, like an elastic tube). Preferably this should be done with the index finger of your non-dominant hand. Assess the vein’s size, depth, movability, and direction. The fullest, most central, and most anchored vein should be chosen.  You may have to assess both arms. You may have to move the arm or rotate it slightly to give you easy access to both equipment and vein. The patient may be able to tell you where others were successful. The tourniquet should not be left for more than one minute to prevent hemoconcentration. Release the tourniquet after locating the most appropriate vein and assemble/gather your equipment. 4. Assemble the Required Equipment All equipment should be placed within easy reach, on the opposite side of the hand that you will hold the needle with. (Note: no needles on the bed) Required Vacutainer tubes placed in the correct collection order (you may want to keep a few spares in your pocket). Vacutainer holder with a multi-sample needle attached and first Vacutainer tube resting in the holder. Gauze, alcohol swabs – alcohol swab for disinfection and a dry gauze to place on the site after collection. The dry gauze should be placed within easy reach for use after the collection is complete. Needle disposal unit. (Sharps container) 5. Re-apply Tourniquet Re-palpate site. Note: you have only palpated the vein at this point. No disinfection has occurred, so you may retouch the site again to palpate one more time. 6. Cleanse the Venipuncture Site Use an alcohol swab wet with 70% isopropyl alcohol to cleanse the site by moving the swab back and forth with friction (or in a circular motion).  Allow the site to dry. Any remaining alcohol will hemolyze the blood specimen and make the procedure more painful for the patient. do not retouch the site. The site has now been cleaned so you cannot touch it without having to cleanse again. 7. Needle Insertion The vein should be anchored by pulling the skin taut below the site of entry using the thumb of the hand you are not holding the needle in. Make sure your thumb position will not obstruct your access to the vein. The bevel of the needle should be in an upward position. The needle should follow the vein (insert in the same direction as the vein runs in the arm). The angle between the needle and the arm should be between 15 to 30o. The deeper the vein, the larger the angle of approach should be. The hand holding the vacutainer holder should be positioned so that you have easy, unobstructed access to the specimen tube in the holder. The holder should be firmly grasped so that it can be totally immobilized. Placing your index finger against the front of the holder will help to reduce movement as you change collection tubes. Resting the small finger on the arm will help to immobilize the holder. Use verbal instructions to indicate when you are ready to insert the needle, such as “Take a deep breath.” Insert the needle into the vein in a smooth, quick motion. When the needle enters the vein, with experience, you should be able to detect a difference in the ease of penetration of the needle.  When the tip of the needle is totally in the vein, the patient should not feel any pain. Repositioning a needle should only be done if the collector is experienced and the patient feels no pain. 8. Withdrawing the Blood Use the hand that was anchoring the vein to push the Vacutainer tube onto the back end of the needle Use the flange on the holder to brace two of your fingers and push the tube on with your thumb (this counter-pressure helps to prevent movement of the needle). The holder must be immobilized, or the needle will be pushed through the vein. Keeping your needle-holding (dominant) hand pressed down on the patient’s arm will help to prevent movement. Allow the tube to fill until the vacuum stops drawing blood. When blood starts to enter the first tube, the tourniquet should be removed. Brace your thumb on the flange of the holder, cup your fingers around the tube and slip it out of the holder. Push on the next tube to be collected. Keeping your eyes focused on the needle tip will help you minimize its movement. Fill all tubes. Filled tubes should be mixed with your free hand while filling the remaining tubes. Remove the last tube from the holder. 9. Removing the Needle from the Arm A few squares of gauze should rest loosely on the site and the needle should be withdrawn quickly and in the same direction as it was inserted. DO NOT press down on the gauze until the needle has been completely removed. Doing so can cause a lot of pain. DO NOT pull up on the needle or tilt it downward, as this will be painful to the patient. Once the needle is out of the arm, ask the patient to apply pressure on the site with the clean, dry gauze. Employ the needle safety device to cover the needle point. Instruct patient to keep their arm extended while they continue to apply pressure. Dispose of the used needle immediately into the disposal unit. 10. Blood Specimen Handling All tubes which require mixing should be gently inverted about eight times in total. All tubes must be labelled at the patient’s bedside. This ensures the blood tubes will not be mistaken for another patient or arrive in the lab unlabeled. The label must include: - the patient's full name - an I.D. number (Here at RDP we use the PHN) - date and time of collection - initials of phlebotomist - tests ordered Some specimens require special handling, such as keeping the specimen either chilled or at 37°C, or protected from light (see table on p.3-21). All blood-soiled swabs, etc. should be disposed of appropriately 11. Patient Recheck the patient's arm, to ascertain if the venipuncture site has stopped bleeding. If it has not, reapply pressure to the site. Apply tape over the gauze once the bleeding has stopped. Thank the patient for their cooperation; remove your gloves and wash your hands (this should be done in view of the patient). Objective 4 Describe and discuss the procedure for venipuncture using a syringe method, including differences, advantages and disadvantages of this procedure compared to routine Vacutainer method. SYRINGE METHOD This method is used in conjunction with a butterfly needle. A syringe is attached to the butterfly needle (instead of the vacutainer holder) and the blood is drawn into the syringe Note: It was once acceptable to use a syringe and straight needle to collect the blood and then use a transfer device to add the blood from the syringe into the appropriate tubes. As per APL and Dynalife, this is no longer an acceptable method. This method differs in the following ways: The plunger should be checked to see if it rides smoothly in the barrel of the syringe. Do this by pulling the plunger out and in a few times (“exercising” the plunger). There should be no air left in the syringe; the plunger must be flush with the nozzle of the syringe. This is to ensure that we don’t introduce any air into the patient’s vein, as this could cause an air embolus. To draw the blood into the syringe, the plunger is pulled back slowly. Use the flange on the barrel of the syringe as a brace. The blood in the syringe must be distributed into appropriate tubes. This should be done after the needle has been removed, but quickly to avoid clotting in the syringe. The pressure exerted on the vein by the blood removal is controlled by the speed with which the plunger is pulled. Using a syringe technique and a smaller needle enables the collector to obtain a sample from patients whose veins tend to collapse. Blood is then transferred to the appropriate collection tubes using a transfer device. Attach the transfer device to the syringe and tip the syringe so it is completely upright. The vacuum in the tubes will draw the blood out of the syringe. **DO NOT APPLY PRESSURE TO THE SYRINGE WHEN TRANSFERRING THE BLOOD. This will result in hemolysis and will greatly affect the testing results. ** Syringes must not be used for trace element collections that include testing for cobalt and chromium because the plunger tip contributes such elements to the specimen. Venipuncture Procedure Using Butterfly Needle and Syringe If it is necessary to use a syringe, proceed with the following recommendations: 1. Follow appropriate patient identification procedures. 2. Remove the syringe from the packaging and exercise the plunger a few times. Ensure the plunger rides smoothly in the barrel of the syringe and that the plunger is flush with the nozzle. 3. Attach the butterfly needle to the syringe. 4. Assemble all other venipuncture equipment ▪ 70% alcohol swab ▪ Gauze ▪ Tourniquet ▪ Transfer device ▪ Vacutainer tubes in the correct order of draw ▪ Tape 5. Perform venipuncture. Keep the needle as stable as possible in the vein. 6. Release the tourniquet as soon as blood begins to flow. 7. Slowly withdraw the desired amount of blood. 8. Transfer blood to venous collection tubes: ▪ remove and discard the needle from the filled syringe ▪ attach a transfer device to the syringe ▪ pierce the stopper of the tube and allow the tube to fill. Do not apply any pressure to the plunger. This technique helps to maintain the correct ratio of blood to tube additive and reduces damage to the red blood cells. 9. Mix tubes by gentle inversion 10. Label tubes and complete the collection information on the requisition. 11. Check the patient’s venipuncture site to ensure bleeding has stopped and apply tape over the gauze. 12. Perform hand hygiene and thank and dismiss your patient. Part 4- Butterfly Collections Objective 1 Describe and discuss the procedure for venipuncture using a butterfly method, including differences, advantages and disadvantages of this procedure compared to the routine Vacutainer method. This is also known as a winged infusion set. Blood can be withdrawn using either a syringe or an adaptor and Vacutainer assembly. The method differs from a routine Vacutainer collection in the following ways: The “wings” are held together with your thumb and forefinger. angle of insertion is decreased. A greater portion of the needle is slipped into the patient’s vein. The wings or tubing may be taped down to stabilize the needle. (This is not a commonly acceptable practice) Once the blood has been collected, carefully dispose of the needle and attached tubing into an appropriate sharps container and process specimens appropriately. The steps of the venipuncture procedure are the same as straight needle collections. There are 2 things that you must keep in mind when using a butterfly that will affect testing results: 1. The tubing attached to the butterfly needle contains potassium and may falsely increase potassium levels. Therefore, when collecting specimens to be tested for potassium (K+), the butterfly should not be your first choice in collection equipment. 2. When collecting, if a citrate tube (light blue, black) is ordered and will be collected first (this means there are no blood cultures to collect) you must collect a “Discard tube”. This is because citrate tubes have a very specific ratio and the presence of the air in the tubing may alter the blood to additive ratio. *It is recommended that you use a citrate tube as a discard to prevent carryover into the citrate tube that will contain the specimen for testing. Once you see blood enter your discard tube you may remove it and continue with your collection. Discard tubes do not get labelled and can literally be discarded. Resources https://www.surgo.com/universal-lancets--3/bd-microtainer-contact-activated-lancet-blue-1-5-m m-x-2-0-mm-200-bx--1 Clinical and Laboratory Standards Institute: GP41, 7th edition- Collection of Diagnostic Venous Blood Specimens. Figure 4.1- 4.10, RDC MLA 119 Module 4 (old version) Figure 4.11- Tube inversions https://www.youtube.com/playlist?list=PLEkT9vGBjSP1xj3xIwTo5FTYbR6vBlgA8 Figure 4.13- Fisher Scientific https://www.fishersci.ca/shop/products/heathrow-scientific-blood-collection-tray/22267050