Basic Principles of Phlebotomy

Ricki Otten MT(ASCP)SC

uotten@unmc.edu

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Objectives for Student Lab:Those objectives marked with

‘*’ will not be tested over during

the student lab rotation

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Phlebotomy: Historical Practice

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Modern Phlebotomy

• Diagnosis and management of disease

• Remove blood for transfusions

• Therapeutic reasons:– Polycythemia– Hemochromatosis

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Blood Function:

1. Supplies nutrients to tissues:

O2, hormones, glucose

2. Removes end-products of metabolism:

CO2, urea, creatinine

3. Provides defense mechanism: WBC, antibodies

4. Prevents blood loss:

platelets, coagulation proteins

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Blood Composition:

Formed elements (~45%)– RBC– WBC– Platelets

Fluid component (~55%)– Water (~92%)– Protein (~7%)– etc

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Coagulation:

• In vivo– Blood is fluid– Clot is formed to

protect injured vessel

• In vitro– Spontaneous reaction– Triggered by glass or poor drawing technique

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Coagulation Reaction:Clotting factors + calcium thrombin

Fibrinogen + thrombin fibrin strands

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Anti-coagulants:

• Remove calcium• Neutralize thrombin

• Whole blood• Plasma• Serum

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Blood with anticoagulant:• Clotting is prevented and

irreversible

• Mix: completely invert 8-10x

• Whole blood

• Centrifuge plasma

• Plasma contains fibrinogen

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Blood without anticoagulant:• Spontaneous clotting occurs

and is irreversible

• Fibrinogen fibrin strands

• Fibrin strands entrap cells

• Centrifuge serum

• Serum lacks fibrinogen

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Appearance

• Normal: clear and ‘yellow’

• Abnormal:– Hemolyzed = pink to red (ruptured RBC)– Icteric = dark orange-yellow (bilirubin)– Lipemic = cloudy (fat, triglycerides)

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Blood Collection Tubes:• Contain a vacuum

• Used with

Vacutainer and

Syringe systems

• Stoppers universal

color coded: indicates contents

• Have an expiration date

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Tubes containing no anti-coagulant

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Red-top tube:• Glass

– No additive– Glass surface activates clotting sequence– Do not mix– SERUM: use for TDM

• Plastic– Contain additive to activate clotting sequence– Contain inert gel SST– Do invert to mix additive and initiate clotting sequence– SERUM

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Gold or Mottled-red-gray top tube:

• Contain clot activator and gel (SST)

• Invert to mix and initiate clotting sequence

• SERUM

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Royal blue-top tube:

• Trace metal-free

• Iron, copper, zinc

• Label color indicates contents:– Red: no additive = serum– Purple: EDTA = whole blood or plasma– Green: heparin = whole blood or plasma

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Tubes containing anti-coagulant

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Blue-top tube:

• Anticoagulant = sodium citrate

• Binds calcium

• Must be fullBlood:anticoagulant ratio critical

• Must be on ice if not analyzed within 30 minutes

• Coagulation studies

PLASMA

Whole blood

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Green-top tube:• Anticoagulant = heparin

– Three formulations: Lithium heparin

Ammonium heparin

Sodium heparin

• Inhibits thrombin formation

• Must be full and on ice if need pH, ionized Ca

PLASMA

Whole blood

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Green-top tube:

• Most chemistry tests, STAT lab (PST)

Decreases time needed for blood to clot,

Makes turnaround time better

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Purple-top tube:

• Anticoagulant = EDTA

• Binds calcium

• Hematology studies: CBC

PLASMA

Whole blood

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Grey-top tube:

• Anticoagulant = potassium oxalate– Binds calcium– PLASMA, Whole blood

• Antiglycolytic agent = sodium fluoride– Maintains plasma glucose levels

• Limited use: glucose, lactic acid

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Fibrin-split Products tube

• Light blue top tube with 2 yellow bands on the label

• Contains soya bean thrombin which causes the blood to clot immediately

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Yellow-top tube:

• ACD = acid citrate dextrose– Paternity testing– DNA

• SPS = sodium polyanethol sulfonate– Used for special blood culture studies– Inhibits certain antibiotics

• Both bind calcium

• PLASMA, Whole blood

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Type and Amount of Specimen:• Dependent upon

– Test

Whole blood: EDTA or heparin?

Plasma: EDTA or heparin?

Serum: trace free? Separator gel interference?

– Amount of sample needed to perform test

– Multiple labs needing the same specimen at the same time

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Valid Test Results Require:

• Trained personnel– Causes of pre-analytical error– Invalid test results

• Quality control• Quality assurance• Sophisticated

instruments

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Safety Practices:

For infection to spread:

1. Infectious substance: HBV, HCV, HIV

2. Mode of transmission

3. Susceptible host

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Modes of Transmission:

• Parenteral: any route other than the digestive tract– Intramuscular– Intravenous– Subcutaneous– Mucosal

• Ingestion

Non-intact skin: chapped hands, cuts, cuticles

Percutaneous: needles, sharps

Permucosal: mouth, nose, eyes

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Safety Practices:

Infection Control: stop the spread of infection

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Safety: Infection Control• Hand washing

– Primary means of preventing spread of infection (especially nosocomial)

– Minimum 15 seconds, soap, friction– Wash hands before and after each blood draw

• PPE– Lab coat– Gloves– Mask

• Standard precautions at all times

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Safety: Engineering Controls

• PPE• Sharps containers• Safer medical devices

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Safer Medical Devices:

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Equipment:

1. PPE: gloves, lab coat, mask

2. Cleaning agent– Alcohol pads: routine– Povidone iodine: blood culture collection and

blood gases– Soap and water: alcohol testing, allergies

3. Cotton balls, gauze

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Equipment: 4. Bandage, tape (use caution with children)

5. Sharps container: – Discard needles,

lancets– Biohazard marking– Puncture resistant

– NEVER recap, bendbreak needles

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Equipment:

6. Tourniquets:– Slows venous blood flow down– Causes veins to become more prominent– NEVER leave on for >1 minute – AVOID rigorous fist clenching or hand

pumping (potassium, lactic acid, LD)– Latex allergy

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Tying on the Tourniquet:

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Equipment:

7. Needles– NEVER reuse a needle– NEVER use if shield is broken– NEVER recap, cut, bend or break

– Drop immediately into sharps container after venipuncture

– Size of needle is indicated by gauge:• Larger gauge number indicates smaller needle diameter• 21, 23 gauge needles routinely used for phlebotomy

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Needles:

Used with syringe system Used with vacutainer system

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Multi-sample Needle:

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Butterfly Needle:

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Butterfly Needle:• Most often used with

syringe

• Expensive, thus not used for routine draws

• Used for small, fragile veins

• Increased risk of needle stick injury

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Equipment:

8. Tube holder/

vacutainer adapter

– Threaded– Flanges

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Equipment:

9. Syringe

10. Black

water proof

pen

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Syringe Safety Device:

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Labeling Blood Collection Tubes:

• Black indelible marker (water proof)– Never pencil– Legal document– Print legibly

• Required information: 5 items– Patient name– Identification number– Date of draw (mm,dd,yyyy)– Time of draw (military time)– Phlebotomist signature: first initial, last name

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Vacutainer or Syringe?

• Vacutainer– Most often used– Most economical– Quick– Least risk of accidental needle stick

• Syringe– More control– Reposition easily– Will see ‘flash’ of blood in syringe hub when

vein successfully entered

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The Patient:

• Approach• Communication• Empathy• Handling special situations• Patient identification

– Arm band– Legal document

• Prepare patient for blood draw– Latex allergy?

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Selecting the Site:

• Antecubital area most often accessed

• Hand or wrist• Remember: 2 arms• Use tip of index finger

on non-dominant hand to palpate area to feel for the vein

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Collection Site Problems:• Veins that lack

resiliency

• Extensive

scarring

• Hematomas

• Edematous

area

• Side of mastectomy

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Collection Site Problems:

• Intravenous line– NEVER draw above

an IV

– Draw from other arm

– Draw from hand

on other arm

– Draw below the IV

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Draw Below IV site:

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Collection Site Problems:

• Indwelling lines:– Hickman catheters– Heparin locks

• Used to administer medication

• Only nurse may access these lines

• Can obtain blood: called a ‘line draw’

• Must clear line of heparin contamination by discarding first 5-10 cc of blood

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Hickman Catheter:

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Inserting the Needle:

• Anchor the vein– Grasp arm with your

non-dominant hand– Use thumb to pull skin

taut

• Smoothly and confidently insert the needle bevel up– 15-30 degree angle

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No Needle Movement!

• You must anchor the blood-drawing equipment on the patient’s arm to minimize chance of injury

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Fill Tubes:• Use correct order of draw:

– Blood cultures– Red top– Blue (baby blue)– Green– Purple– Grey

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Be careful not to:

• Push needle further into vein when engaging evacuated tube

• Pull needle out of vein when disengaging tube

• Pull needle out of vein as you pull back on the plunger

• Pull up or press down when needle in vein

• Forget to mix additive tubes 8-10 times

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Withdraw Needle:

• First release tourniquet

• Disengage tube

• Place cotton directly over needle, without pressing down

• Withdraw needle in swift, smooth motion

• Immediately apply pressure to wound

• Do not bend arm

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Label Tubes Immediately:

• In sight of patient

• Patient name• Identification

number• Date of draw• Time of draw

(military time)• Your initials

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Recheck Draw Site:

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Failure to Obtain Blood:

• Check tube position and vacuum– Always have back up tubes near by

• Needle position

• Collapsed vein

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Needle Position:

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You should try again

• Look at alternate site– Other arm– Hand

• Use clean needle• Use fresh syringe if

contaminated

• Only try twice

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Poor Collection Techniques:• Venous stasis

– 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

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Poor Collection Techniques:• Clotted sample

– Inadequate mixing– Traumatic stick

• Partially filled tubes– Short draw– Sodium citrate tube draw volume critical

• Using wrong anticoagulant

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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

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Venipuncture Procedure

• Remain calm

• Organize yourself

• Organize your equipment:

STICK TO ELEVEN

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Equipment: Stick to Eleven

• Gloves• Lab coat• Alcohol wipe• Cotton ball• Bandage/tape• Sharps container• Tourniquet

• Needle• Syringe or vacutainer

holder• Collection tubes with

backup tubes• Water-proof marker

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Venipuncture Procedure:

• Wash hands

• Put on gloves

• Identify patient

• Latex allergy?

• Position arm

• Apply tourniquet

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Venipuncture Procedure:

• Locate vein• Release

tourniquet• Cleanse site in

outward rotation– Allow to air dry

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Venipuncture Procedure:

• Reapply tourniquet– Do not contaminate

site

• Anchor vein• Insert needle• Fill tubes

– Quick mix additive tubes

• Release tourniquet• Withdraw needle

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Venipuncture Procedure:

• Engage safety device• Dispose of needle

immediately• Apply pressure to

puncture site• Label tubes• Recheck puncture

site• Thank patient• Remove gloves,

wash hands

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Accidental Needle Stick:

• Remain calm• Cleanse wound with alcohol• Wash wound thoroughly• Notify supervisor, instructor• Follow site protocol• Page OUCH hotline: 1-402-888-OUCH

1-402-888-6824• Complete incident report

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Syringe draw

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Syringe Safety Transfer Device

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Mark your spot

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Hand Vein Draw

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Skin Puncture:

• Method of choice for infants, children under 1 year

• Adults– Scarred – Fragile veins– Hardened veins– Home glucose monitoring (POCT)– Patients with IV

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Capillary Blood• Mixture of arterial, venous, capillary blood

and fluid from surrounding tissues

• Fluid from surrounding tissues may interfere and/or contaminate the specimen

• Warming skin puncture site increases arterial blood flow to the area

• Reference ranges often differ from venous

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Skin Puncture Equipment:

1. PPE

2. Cleaning agent– Alcohol pads: routine– Soap and water: alcohol testing, allergies– DO NOT use providone iodine

3. Cotton balls, gauze

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Skin Puncture Equipment:

4. Bandage/tape

5. Sharps container

6. Warming device– Commercial warmer– Warm wet washcloth

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Skin Puncture Equipment:

7. Lancet – Always use

standardized equipment

– NEVER use a surgical blade

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Skin Puncture Equipment:8. Micro-specimen

containers– Capillary tubes– Microtainers– Capillary blood gas

tubes– Micropipet diluting

system

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Skin Puncture Equipment:

9. Glass slides:

used to prepare

blood smears

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Skin Puncture Procedure:1. Wash hands

2. Approaching the patient

3. Patient identification

4. Latex allergy?

5. Bedside manner

6. Site selection7. Cleanse site: DO NOT use providone- idodine

8. Perform puncture: Wipe away first drop of blood

9. Label the specimen

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Skin Puncture Site Selection:

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Skin Puncture Procedure:• Hold finger between your index finger and thumb

• Puncture the finger using a quick, smooth motion

• Wipe away the first drop of blood

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Skin Puncture Procedure:• Collect sample

– DO NOT touch collecting device to skin surface– DO NOT scrape collecting device across skin surface– DO NOT scoop blood into collecting device

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Skin Puncture Procedure:• Order of draw is critical: platelets accumulate at

puncture site causing clot formation– Blood smear– EDTA– Heparin– Serum

• Apply pressure to puncture site

• Label specimen in sight of patient (indelible marker)

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