California Association
for
Medical Laboratory Technology
Distance Learning Program
UPDATED REVIEW OF
BLOOD COLLECTION EQUIPMENT
Course # DL-954
by
Patricia L. Fawkes, CLS
Kaweah Delta Medical Care Transfusion Service
Visalia, CA
&
Rebecca Rosser, CLS
Education & Development Consultant
Kaiser Permanente Regional Reference Laboratories
North Hollywood, CA
Approved for 1.0 CE
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COURSE # DL-954
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UPDATED REVIEW OF BLOOD COLLECTION EQUIPMENT
Course #DL-954
1.0 CE
Level of Difficulty: Basic
Patricia L. Fawkes, CLS
Kaweah Delta Medical Care Transfusion Service, Visalia, CA
Rebecca Rosser, CLS
Kaiser Permanente Regional Reference Laboratories, North Hollywood, CA
OBJECTIVES:
1)
List the equipment and supplies needed to collect blood by venipuncture.
2)
List the various types of anticoagulants, their mechanism for preventing blood from
clotting, and the color coding associated with each additive.
3)
Discuss the principle behind the order of draw.
4)
Name the various types of needles used in the syringe system.
INTRODUCTION:
Phlebotomy is the practice of drawing blood. The word phlebotomy is derived from
Greek: phlebo- means vein and –tomy means to make an incision.
Some authorities believe phlebotomy dates back to the last period of the Stone Age when
crude tools were used to puncture vessels to allow excess blood to drain out of the body. There is
evidence of bloodletting in Egypt around 1400 B.C. in a painting in a tomb showing the
application of a leech to a patient. Even in the Middle Ages barber-surgeons flourished by
performing bloodletting, wound surgery, cupping, leeching, shaving, extraction of teeth, and
administering of enemas. The familiar stripes on the barber pole symbolized red for blood and
white for bandages.
Early phlebotomy equipment consisted basically of a bleeding bowl, leech jar, cupping
glass, evacuating pump, and lancets called fleams.
During the 17th and 18th centuries, phlebotomy was considered a major therapeutic
treatment process and anyone willing to claim medical training could perform phlebotomy. The
practice of phlebotomy continues today, however principles and methods have dramatically
improved. Phlebotomy now has certain characteristics that balance knowledge and theory with
practical expertise.
Today the main purpose of phlebotomy is to obtain blood for diagnostic testing, to
remove blood for transfusion purposes, and in therapy of patients with polycythemia (a disease
involving overproduction of red blood cells) or hemochromatosis (a rare disease characterized by
excess iron deposits throughout the body). It involves highly developed and rigorously tested
procedures and equipment to ensure the safety and comfort of the patient and the integrity of the
sample collected.
Phlebotomy skills and responsibilities are performed in a variety of healthcare settings
ranging from hospital care units to home health settings. Furthermore, phlebotomy practice is
more widely performed by all types of health care professionals including nurses, respiratory
therapists, emergency medical technicians (EMTs), and clinical laboratory professionals.
This continuing education unit will review the primary duties of the phlebotomist and the
equipment necessary to collect a sample from an adult patient, using safety techniques.
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GENERAL BLOOD COLLECTION EQUIPMENT:
The standard phlebotomy cart or tray contains the following blood collection equipment:
gloves, antiseptics and disinfectants, gauze pads, bandages, evacuated blood collection tubes,
needles and sharps disposal containers, safety goggles (when needed), arterial puncture
equipment (when needed), skin puncture equipment, venipuncture equipment, a tourniquet, and
pen. A vein locating device is an optional but useful tool in locating veins that are difficult to see
or feel. One such transilluminator device, called the Venoscope, shines a bright light through the
patient’s skin. When it is positioned properly, veins are visible as dark lines within the tissue.
This works especially well for finding veins in the hand and foot.
The most commonly used tourniquet is a flat strip of stretchable latex, 15-18 inches long,
and disposable. A blood pressure cuff may be used in place of a tourniquet for those familiar
with its operation. Other available types of tourniquets are Velcro-closure and buckle-closure.
One disadvantage to these types of tourniquets is that they are not easily cleaned if contaminated,
and they are not useful for obese or very thin arms. Disposable, OSHA approved, non-latex
tourniquets are also available and may be a good option to reduce the risk of latex sensitivity
reactions.
Latex gloves have proved effective in preventing transmission of infectious diseases to
health care workers. However, exposures to latex can result in an allergic reaction in some
individuals. Since reports of allergic reactions to latex have increased among health care workers
in recent years, the National Institute for Occupational Safety and Health has developed steps to
protect the worker from latex exposure. Some suggestions are to use powder-free gloves with
reduced protein content, try other brand of gloves, or wear cotton gloves underneath the latex
gloves. Many facilities have converted to nitrile gloves, which do not contain powder and come
in a variety of colors.
EVACUATED (VACUUM) TUBE SYSTEMS:
Evacuated tubes can be used with both the evacuated tube system and with the syringe
method of obtaining blood specimens. It is the most direct and efficient method for obtaining a
blood specimen. With the evacuated tube system, the blood is collected directly into the tube
during the venipuncture procedure. With the syringe method, the blood from the syringe must be
transferred into the tubes after collection.
The evacuated tube system requires three components: the evacuated sample tube, the
double-pointed needle, and a special plastic holder. One end of the double-pointed needle enters
the vein and the other end pierces the top of the tube, and the vacuum aspirates the blood. The
evacuated tubes fill with blood automatically because of a vacuum that exists inside the tube.
The amount of vacuum is pre-measured so that the tube will draw a precise amount of blood. A
tube that has lost its vacuum will not fill with blood. Although the tube vacuum is guaranteed by
the manufacturer until the expiration date printed on the label, premature loss of vacuum can
occur from opening the tube, dropping the tube, advancing the tube too far onto the needle holder
prior to venipuncture, or pulling the needle bevel partially out of the skin during venipuncture.
This convenient system eliminates the need for syringes in many cases and consists of
disposable needles and tubes. Evacuated tubes are made mostly of plastic (some glass) and come
in various sizes, ranging from 2 to 15 mL. The size is selected according to the age of the patient,
the amount of blood needed for the test, and the size and condition of the patient’s vein. Some
evacuated tubes are coated on the inside with silicon to help prevent destruction of red blood
cells, keep the blood from sticking to the sides of the tube, or prevent activation of clotting
factors. Evacuated tubes may or may not contain additives. Blood collected in tubes without
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additives will clot and yield serum upon centrifugation. Tubes that contain additives may or may
not clot, depending on the type of additive they contain. Many tubes are specifically designed to
be used directly with chemistry, hematology, or microbiology instrumentation. In these cases, the
tube of blood is identified by its bar code label and is pierced by the instrument probe. Some
sample is aspirated into the instrument for analysis. Use of this type of closed system minimizes
laboratory personnel’s risk of exposure to blood.
Blood can be transferred from a syringe into evacuated tubes. After the safety device is
activated and the needle is removed from the syringe, a transfer device is used to attach the
syringe to the evacuated tube. This method ensures that the person transferring the blood is safe
from needle stick injury and exposure to the patient’s blood.
Several manufacturers have developed needle removal systems with safety in mind. One
safety needle holder allows the user to release the needle into the needle container without
unscrewing it from the holder. This prevents injuries associated with needle disposal and allows
the holder to be reused. Other holders have protective devices that cover the needle after use.
Most are designed to be used with special disposal equipment that accommodates the particular
features of the adaptor. Despite the fact that there may be manufacturers that allow the reuse of
needle holders, the Clinical and Laboratory Standards Institute (CLSI) document H3-A6 requires
that safety needles be discarded without disassembly from the holder.
Whether one chooses the evacuated tube system or the syringe system for collecting
blood, the safety holders (preferably disposable) and shields are mandatory parts of the
technique.
ANTICOAGULANTS:
Traditionally, serum, plasma, or whole blood has been used to perform the various assays
in most clinical laboratories. More recently heparinized whole blood has become the specimen of
choice for the latest clinical laboratory instruments used in stat and urgent situations. Using
whole blood as a specimen decreases the time involved in acquiring test results because it is not
necessary to wait for the specimen to clot before centrifuging the sample, which adds another 510 minutes to the turn-around time. Whole blood is achieved in a sample by drawing the blood in
a tube with an anticoagulant.
An anticoagulant is a substance that prevents blood from coagulating or clotting. There
are two methods to prevent coagulation: 1) chelating (binding) or precipitating calcium and
making it unavailable for the coagulation process or 2) inhibiting formation of the thrombin
needed to convert fibrinogen to fibrin. In addition to using the correct anticoagulant for a specific
laboratory assay, using the correct amount of anticoagulant in the blood specimen is important. If
an insufficient amount of blood is collected in a tube with anticoagulant, the laboratory test
results may be erroneous because of an incorrect blood-to-anticoagulant ratio. The blood
collection vacuum tubes have been designed for a certain amount of blood to be drawn into the
tube by vacuum according to the amount of pre-filled anticoagulant in the tube.
The most common anticoagulants include:
• EDTA (Ethylenediaminetetraacetic acid) – prevents coagulation by binding or
chelating calcium in the form of a potassium or sodium salt. It is the
anticoagulant of choice for whole blood hematology studies such as the CBC
(Complete Blood Count) because it preserves cell morphology and inhibits
platelet aggregation or clumping. EDTA is contained in lavender stopper tubes,
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•
•
•
•
•
royal blue tubes with lavender labels, pink-topped tubes for Blood Bank, and
pearl-white tubes for molecular studies.
Heparin (Ammonium, Lithium, Sodium Heparin) – prevents coagulation by
inhibiting the conversion of prothrombin to thrombin by inactivating blood
clotting substances, thrombin, and thromboplastin. Heparin is the anticoagulant of
choice for plasma chemistry determinations and is often used for stat or urgent
chemistry determinations. Heparin is contained in green stopper tubes and royal
blue tubes with green labels.
Sodium Citrate – prevents coagulation by binding calcium. Sodium citrate is the
anticoagulant of choice for coagulation studies such as Prothrombin Time (PT)
and Partial Thromboplastin Time (PTT) because it preserves the coagulation
factors. The tests are performed on plasma and this anticoagulant is contained in
tubes that have light blue stoppers. Blood to anticoagulant ratio is extremely
important for coagulation studies and should always be 9:1. This ratio can be
achieved by filling the tube until the vacuum is completely exhausted.
Potassium or ammonium oxalate – prevents coagulation by precipitating calcium.
Oxalate, along with an antiglycolytic agent such as sodium fluoride, is often used
to collect plasma for glucose testing. Oxalate/fluoride tubes have gray stoppers.
ACD (Acid Citrate Dextrose) – prevents coagulation by binding calcium. The
solution is used for certain immunohematology tests such as paternity and
transplant compatibility testing where the dextrose acts as both a red blood cell
nutrient and a preservative by maintaining red cell viability. ACD-containing
tubes have yellow stoppers.
Thrombin – ensures complete clotting usually in five minutes or less. The tube
stopper is orange-colored.
There are a series of other agents used in conjunction with or without the anticoagulant.
They are antiglycolytic agents, clot activators, and thixotropic gel separators. The antiglycolytic
agent is a substance that inhibits glycolysis or metabolism of glucose by the cells of the blood.
The most common agents are sodium fluoride and lithium iodoacetate. A clot activator is a
substance that initiates or enhances coagulation and provides increased surface for platelet
activation such as glass or silica particles. Thixotropic gel separator is an inert (non-reacting)
synthetic substance that forms a physical barrier between the cells and the serum or plasma. This
physical separation prevents the cells from continuing to metabolize substances, like glucose, in
the serum or plasma. Gel separator serum tubes have yellow plastic or mottled red/gray rubber
stoppers (aka: tiger-topped or SST) and gel separator plasma tubes have light green plastic or
mottled gray/green rubber stoppers (PST). All tubes with additives and/or anticoagulants should
be inverted gently the number of times recommended by the manufacturer immediately after the
specimen is drawn.
CLEANING AND PROTECTING THE PUNCTURE SITE:
Antiseptics and disinfectants are used to reduce the risk of infection. Antiseptic refers to
an agent used to clean living tissue. Disinfectant refers to an agent used to clean a surface other
than living tissue. Antiseptics are used to clean the patient’s skin before routine venipuncture
collection in order to prevent contamination by normal skin bacteria. The most commonly used
antiseptic is 70% isopropyl alcohol. Isopropyl alcohol (rubbing alcohol) is bacteriostatic, which
means it inhibits growth of bacteria but does not kill them. For the antiseptic (70% isopropyl
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alcohol) to be effective, it must be allowed to air dry on the skin. Prepackaged alcohol “prep
pads” are the most commonly used product.
Stronger antiseptics are used when more stringent infection control is needed, such as for
blood cultures or arterial punctures. Betadine (povidone-iodine solution) is commonly used for
these cases. For patients who are allergic to iodine, chlorhexidine gluconate or benzalkonium
chloride (Zephiran Chloride) is available. These antiseptics are harsher to the skin so they should
be washed off with alcohol after collection. Bleach is too toxic to use on human skin but is a
good disinfectant for cleaning equipment.
After drawing blood, the phlebotomist takes care to stop the bleeding by applying
pressure to the puncture site. This is done by using a 2-by 2-inch gauze pad folded into quarters.
When the bleeding stops, gauze is taped over the puncture site with paper tape or an adhesive
bandage.
Cotton balls are no longer recommended by CLSI (Clinical and Laboratory Standards
Institute) because the cotton sticks to the platelet plug and may dislodge it when the cotton is
removed, thus starting the bleeding process again.
NEEDLES:
There is a variety of safety needles used for phlebotomy. The gauge of the needle
indicates the size of the needle and refers to the diameter of the lumen (internal space) or “bore”
of the needle. The diameter of the needle and the gauge number have an inverse or opposite
relationship. The larger the gauge number, the smaller the actual diameter of the needle. Gauge
selection depends upon the size and condition of the patient’s vein.
Multiple-sample needles are used with vacuum collection tubes and the holder to allow
for multiple tube changes without blood leakage within the plastic holder. This needle has a
plastic cover over the tube-top puncturing portion of the needle. This cover creates a leakage
barrier. Evacuated tube system needles come in two lengths: 1 inch and 1½ inches. Length
selection depends primarily upon user preference and the depth of the vein. Evacuated tube
system needles are available in sizes 20 to 22 gauge, with the 21 gauge most commonly used for
routine venipuncture. The single-sample needle is used for collecting blood with a syringe when
a patient presents with difficult veins. These needles come pre-packaged in a wide range of
gauges and in 1 inch and 1½ inch lengths.
The butterfly needle, also referred to as a winged infusion set, is most commonly used for
patients with small or difficult veins such as geriatric patients, cancer patients, and pediatric
patients. It is a stainless steel beveled needle and tube with attached plastic wings on one end and
a Luer fitting attached to the other end. Although they generally come with attachments that
allow them to be used with syringes, a special multiple-sample Luer adaptor allows them to be
used with evacuated tube systems. The most common butterfly needle sizes are 21, 23, and 25
gauges. They are not used routinely as the small bore needle can cause hemolysis.
All safety needles should be activated immediately after withdrawal from the patient’s
vein.
ORDER OF DRAW:
Remembering which tests are affected by the various additives can be difficult. The order
of draw eliminates confusion by presenting a collection sequence that results in the least amount
of carryover from one sample tube to the other. Carryover can also be minimized by making
certain that specimen tubes fill from the bottom up during collection and that the contents of the
tube do not come in contact with the stopper puncturing needle during the draw. EDTA causes
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more carryover problems than any other additive. Tests affected by EDTA contamination are
Calcium, PTT, Potassium, Prothrombin Time, Serum Iron, and Sodium. Heparin contamination
affects the activated clotting time, Partial Thromboplastin Time (PTT), and Prothrombin Time
(PT). Potassium oxalate contamination affects the Potassium result and red blood cell
morphology.
When collecting multiple tubes, a specific order of draw is used to prevent additive
carryover. This order applies to glass and plastic tubes as well as syringe draws.
The order is as follows:
1) Blood culture tubes (yellow top), or blood culture vials or bottles
2) Coagulation tube (light blue top)
3) Serum tube with or without clot activator, with or without gel (red top)
4) Heparin tube with or without gel plasma separator (green top)
5) EDTA tube with or without gel separator (lavender, royal blue, or pearl top)
6) Glycolytic inhibitor (gray top)
7) Thrombin (orange top)
Please note that if you are using a winged infusion set, you must use an approved
discard tube prior to the light blue coagulation tube in order to maintain the required 9-1
ratio of blood to anticoagulant.
SAFETY & NEEDLE DISPOSAL SYSTEM:
We have discussed safety shields for needles, and safety needle holders. There are also
needle disposal systems available for needle removal with safety in mind. Needles and syringes
must be discarded in a puncture resistant plastic container, which reduces the possibility of
needle sticks for the phlebotomist. There are several sizes of needle-disposal containers for use
in carts, phlebotomy trays, at the bedside, in surgery, or home health situation. Make sure to
properly dispose of needles after each patient draw.
CONCLUSION:
This exercise is a review of blood collection equipment and procedures necessary for the
collection of blood. Emphasis is placed on anticoagulated and non-additive blood collection
tubes, the use of color coding on tubes, the use of gloves, syringes, needles, and other supplies
needed for safe and effective collection procedure. Anticoagulant types and mechanisms of
action of anticoagulants, as well as order of draw of various tubes are also discussed.
REFERENCES:
1. Becan-McBride K, & Garza D. Phlebotomy Handbook, Blood Collection Essential. 6th ed.
New Jersey: Prentice Hall; 2002:183-227, 257.
2. McCall RE, Tankersley M. Phlebotomy Essentials. 5th ed. Philadelphia: Lippincott, Williams
and Wilkins; 2012:191-224.
3. Clinical and Laboratory Standards Institute, H3-A6, Procedures for the collection of
diagnostic blood specimens by venipuncture. 6th ed. Wayne, PA: CSLI; 2007.
4. Scranton PE. Practical Techniques in Venipuncture. Baltimore; Williams & Wilkins; 1977:
66.
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Review Questions
Course #DL-954
Choose the one best answer
1. The gauge number of the needle indicates the:
a. length
b. diameter
c. bevel
d. sharpness
2. In the multiple vacutainer system order of draw, carryover from which tube affects the
results of the most number of tests?
a. glycolytic inhibitor
b. potassium oxalate
c. heparin
d. EDTA
3. Butterfly needles are also known as:
a. winged infusion sets
b. plunger
c. multi-sample needle
d. single-sample needle
4. From the listed needle gauges, which one has the largest diameter?
a. 19
b. 20
c. 21
d. 23
5. Which of the following substances works by inhibiting the metabolism of glucose?
a. EDTA
b. citrate
c. heparin
d. fluoride
6. Which blood collection tube is used for glycolytic inhibition tests?
a. green-topped
b. yellow-topped
c. black-topped
d. gray-topped
7. Which blood collection tube is used mainly for hematology testing?
a. red-topped
b. royal-blue topped
c. purple-topped
d. brown-topped
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8.
An antiseptic stronger than 70 % alcohol is used for
a. blood cultures
b. coagulation studies
c. glucose determination
d. chemistry tests
9.
Needles should be disposed into:
a. the trash can
b. rigid plastic containers
c. red bags
d. the dirty lab coat bin
10. Blood collection tubes containing an anticoagulant should be:
a. inverted gently and repeatedly after blood collection
b. shaken aggressively after blood collection
c. allowed to sit for 30 minutes before centrifugation
d. centrifuged immediately
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