Renal: Blood Collection via Haemodialysis Access No. here
Guideline and
Procedure
Renal: Blood Collection via Haemodialysis Access
Sites where Guideline and Procedure applies:
HNE facilities that utilise HAPS pathology and where a
patient undergoes haemodialysis
Target audience:
Nephrology clinical staff, who provide care to
haemodialysis patients.
Description:
This document comprises part of the clinical information
package for care for Haemodialysis Dialysis patients.
This Guideline and Procedure applies to:
1. Adults
Yes
2. Children up to 16 years
No
3. Neonates – less than 29 days
No
Keywords:
Blood collection, pathology, haemodialysis
Replaces Existing Guideline and Procedure
and:
Yes
Registration Number(s) and/or name and of
Superseded Documents:
John Hunter Hospital SWP N.3.10
HNEH GandP 10_37 from 2nd December 2010
Relevant or related Documents, Legislation, Australian Standards, Guidelines etc:

NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
 NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
 NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf
 Hunter new England Local Health Net work Guidelines and Procedures:
Renal: Commencement of Haemodialysis using Central Venous Dialysis Catheters
(Permcath/Vascath) (HNELHD 11_28)
Registered or Endorsed Enrolled Nurses who have been deemed
Prerequisites (if required):
competent in the performance of haemodialysis
Guideline and Procedure
Note:
This document reflects what is currently regarded as safe and appropriate
practice. However in any clinical situation there may be many factors that
cannot be covered by a single document and therefore does not replace the
need for the application of clinical judgment in respect to each individual patient.
This guideline and procedure sets out the steps to be followed for withdrawing
blood from a central venous catheter. The procedural components of the
document such as, preparation of patient, preparation of equipment, technique,
cleaning up and documentation are considered mandatory.
Date authorised:
April 2012
Authorised by:
Contact Person:
Kelly Adams – Renal Stream Coordinator
Contact Details:
02 49048800
This Guideline and
Procedure contains advice
on therapeutics
No
Date of Issue:
Review due date:
April 2014
TRIM Number:
Version No. 2
April 2012
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Renal: Blood Collection via Haemodialysis Access No. here
OUTCOMES
1
Safe, sterile and accurate method of blood specimen collection via a haemodialysis access, eg.
AVF, AVG, Permcath or Vascath
ABBREVIATIONS & GLOSSARY
AVF
Arteriovenous fistula
AVG
Synthetic arteriovenous grafts
PPE
Personal Protective Equipment
INR
International normalized ratio
APTT
Activated Partial Thromboplastin Time
BFR
Blood Flow Rate
GUIDELINE
Haemodialysis patients often require rapid or repeated blood samples to monitor adequate
haemodialysis efficacy and patient wellbeing. Blood specimen collection from the haemodialysis
cannula is immediate and simple and eliminates the need for painful venipuncture thereby
reducing patient discomfort and stress. Furthermore, collection of routine blood samples from the
AVF or AVG also promotes vein preservation of the non fistula arm.
Multiple blood samples must be collected in specific order to avoid cross contamination of additives
between tubes and the potential for erroneous results being reported which can effect patient
management.
The blood sample is collected from the arterial needle before flushing with saline or heparin. If
obtaining blood sample after haemodialysis or unintentional flushing with saline or heparin a 10ml
discard specimen must first be collected.
Refer to the “order of draw” for multiple tube collections poster displayed in units to ensure
accurate collection of blood specimens
PROCEDURE
The procedure requires mandatory compliance.
Patient Preparation
It is mandatory to ensure that the patient has received appropriate information to provide informed
consent and, that patient identification, correct procedure and correct site process is completed
prior to any procedure.
Check patient medications if applicable (ie if collecting INR check Warfarin dose/time and
document on request form)
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection control,
moving safely/safe manual handling, and documentation practices.
Refer to the “order of draw” for multiple tube collections poster displayed in units to ensure
accurate collection of blood specimens
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Renal: Blood Collection via Haemodialysis Access No. here
Equipment Requirements





Personal Protective Equipment
Luer adapter and holder for vacutainer system
Appropriate vacutainer tubes
10cc normal saline syringe to flush cannula following last blood specimen collection
Pathology request form
Arteriovenous Fistula/Graft Collection
Procedure Steps
1.
2.
3.
4.
5.
6.
Wash hands
Identify correct patient, introduce yourself and explain procedure to patient.
Ensure pathology request form is complete and obtain correct blood tubes
Don PPE
Wash hands
Cannulate as per HNE Renal Stream Clinical Guideline and Procedure: Cannulation of an
Arteriovenous Fistula or Graft
7. When flashback is visible loosen cap and allow blood to prime cannula tube
8. Tighten cannula cap
9. Clamp cannula
10. Blood sample is collected from the arterial needle before flushing with saline or heparin
11. Remove cannula cap and attach vacutainer holder
12. Release cannula clamp
13. Attach blood collection tube to vacutainer holder and allow to fill before removing collection
tube (refer to Order of Draw for Multiple Tube Collections)
14. Repeat for multiple tube collections
15. Clamp cannula
16. Invert tubes gently. DO NOT SHAKE
17. Remove vacutainer adapter
18. Flush cannula with Normal Saline and clamp cannula
19. Discard blood collection equipment in the biohazard containers for disposal
20. Label tubes with patient name, medical number, date and time of collection
21. Dispose of PPE and equipment
Central Venous Catheter Collection
Procedure Steps for all blood sample EXCEPT coagulation values
1. Access lumens as per HNELHD Clinical Guideline and Procedure: Commencement of
haemodialysis using central venous dialysis catheter (Permcath/Vascath)
2. Remove 10ml of blood from one lumen (either arterial or venous) to avoid heparin
contamination
3. Clamp lumen and discard the syringe
4. Attach vacutainer holder and open lumen clamp
5. Attach blood collection tube to vacutainer holder and allow to fill before removing collection
tube (refer to Order of Draw for Multiple Tube Collections)
6. Repeat for multiple tube collections
7. Clamp lumen
8. Invert tubes gently. DO NOT SHAKE
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9. Remove vacutainer adapter and discard the biohazard containers for disposal
10. Continue with Central venous access procedure
Procedure Steps for coagulation values (eg. INR, APTT)
1. Access dialysis catheters as per Renal Stream Clinical Guideline and Procedure:
Commencement of Haemodialysis using Central Venous Dialysis Catheters
(Permcath/Vascath)
2. Commence haemodialysis at BFR of 200 ml/min for 1 minute (Do Not Administer heparin
bolus)
3. Remove grey cap of the green multi drawing needle adaptor and connect into vacutainer
holder
4. Clean arterial port of haemodialysis blood circuit with alcohol wipex1
5. Remove green cap of the green multi drawing needle adaptor and attach needle into the
arterial port
6. Attach blood collection tube to vacutainer holder and allow to fill before removing collection
tube (refer to Order of Draw for Multiple Tube Collections)
7. Remove blood tubes and invert gently. DO NOT SHAKE
8. Remove vacuette & vacutainer and dispose into a sharp bin immediately
9. Administer heparin bolus (or other anticoagulant medication as prescribed)
10. Adjust BFR and other dialysis parameter as prescribed
Note: If unable to remove catheter locking solution, the patient will require venipuncture to
obtain accurate coagulation blood samples. (Venipuncture should be obtained 2 hours post
dialysis)
Nursing Alert: Cross match pathology must be attended with a witness who will sign the
pathology request validating that the patient identification, time and date are correct on tube and
pathology form.
Nursing Alert: Blood tubes must be labelled at the patient bedside to minimise mislabelling errors
APPENDICES
Appendix 1: Five Moments for Hand Hygiene
Appendix 2: HAPS blood collection tube guide
REFERENCES
Boyd, A., Dunne, A., Townsend, K. & Pai, A.B. (2006) Sampling for International Normalized
Ration in Patients on Haemodialysis with Central Venous Catheters, Nephrology Nursing Journal,
July-Aug, Vol 33, No 4, p 408-411.
Hand Hygiene Australia 2008: Five Moments for Hand Hygiene
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Renal: Blood Collection via Haemodialysis Access No. here
Appendix 1
Adopted from the World Health Organization and Hand Hygiene Australia.
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Collection Tube Guide
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Order
of draw
Specimen
Volume
Tube Cap
Tube Type
Collect
first
Sterile sample
8-10mls/ bottle
Blood Cultures
Aerobic (1st)
Anaerobic
Then
In
following
order
2.ml
3.5mL
Sodium Citrate
(Coag tube)
Coagulation studies, PR, APTT, INR, D-Dimer. Clexane, anti Xa levels.
(Refer to handbook for all other coagulation tests.)
NB: Fill tube to completion (black line)
Gently invert tube to mix.
2ml
6mL
Clot Activator
(Serum tube)
Immunology, Iron Serology, B12, Ferritin, folate, pre albumin (pre
protein), VDRL, HIV, Hepatitis, Rubella. Serology.
Lithium & Vancomycin drug levels. Some Hormones BHcg, PTH.
If multiple tests are requested, more than one
tube will be required
(refer online handbook)
2ml
4mL
Lithium Heparin
(biochemistry)
2ml
4mL
EDTA
(haemayology)
2mL
Fluoride Oxalate
2mL
Seditainer
9mL
ACD
6mL
Sodium Heparin
7mL
Trace Metal
Determinations
Instructions
Equipment: Use butterfly cannula, vacutainer barrel and adaptor. Alcohol swab site and leave dry
(1-2 minutes) to reduce bacterial count on skin. Use sterile glove if need to re-touch site of insertion.
Biochemistry, LFT, UEC, Cardiac Enzymes, Lipids, Cholesterol,
Glucose, Troponin, Tumour markers, Most hormones TSH, T3, T4;
Progesterone; Drug levels (except Lithium)
ESR, FBC, Retics, Blood Group/Cross Match, HbAIC, Red Cell Folate,
Lead, HLAB27, BNP, Kleihauer, Cyclosporine, Manganese, fragile X,
Direct Coombes, Monospot, ,
On ice: Renin, ACTH, Ammonia
Kept Dark: Porphyrin
Gently invert tube to mix.
Gently invert tube to mix.
Glucose, Lactose
Lactate (on ice)
Gently invert tube to mix.
NB ESR – Used at upper Hunter; Lower Hunter; Calvary Mater
Gently invert tube to mix.
Tissue typing, Lymphocyte markers
Allow tube to fill to completion.
Gently invert tube to mix.
Chromosome studies
Gently invert tube to mix.
Trace metals, zinc, etc
Refer to trace and Toxic Element Assay Chart.
Gently invert tube to mix.
Hazard Warning: Never inject blood into the tube from needle and syringe.
To decant blood from syringe - Discard needle, remove tube cap and drip blood down side of tube. Ensure cap is secure when replaced.
HAPS CPCS (02) 49213573 Fax (02 49214400 Reference:HAPS Handbook HNE Intranet Site http://www.haps.nsw.gov.au/handbook/hh01.aspx /
Greiner /Vacuette Order of Draw http://www.vacuette.com/documents/980102_Handhabungsempfehlungen_07_0410_e_small.pdf
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