PHLEBOTOMY
Created By: Michelle Huffman
Introduction to Blood Collection
Objectives
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Recognize the Importance of Correct Blood Collection
Factors That Influence Integrity of Blood Specimen
Safety Precautions Related to Blood Collection
Differentiate Between Whole Blood, Plasma and Serum
Actions of Anticoagulants, to Prevent Blood Coagulation
Describe the Appearance of Hemolyzed, Icteric, and Lipemic Specimen
Differentiate Between Arterial, Venous and Capillary Blood
Special Specimen Handling Procedures
Purpose of Quality Assurance in Blood Collection
SAFETY PRECAUTIONS
In addition to safety precautions specifically associated with blood
collection. Personnel must observe all STANDARD precautions
required in Patient Care .
• Wearing appropriate personnel protective equipment
• Observation of Isolation Practices
• Hand Washing (15-20 secs.) and BETWEEN Patients
• Using ONLY Needles with Safety Devices in the Intended Manner
• Using only the recommended transfer devices to transfer blood from
syringes to evacuated tubes
• Disposal of Entire Assembled Tube Holder and Needle After Use
• Recording All Accidental Needlesticks and Exposures as Required
• Disposal of Contaminated Materials in Designated Biohazard Containers
• Decontamination of Surfaces Using an Approved Disinfectant.
NOTE:
Blood Collection poses a serious risk for
exposure to blood borne pathogens (ex. HIV,
hepatitis B, hepatitis C,
Most blood-borne pathogen exposures
associated with blood collection occur as a
result of accidental puncture with a
contaminated needle.
Types of Patient Isolation
• Strict Isolation – required for a patient with highly contagious
diseases that can be spread by direct contact and through the air. (ex.
Chicken pox, diphtheria) GLOVES, GOWN and MASK
• Contact Isolation - indicated for highly transmissible disease that is
spread primarily by direct contact, such as influenza and infections with
antibiotic-resistant bacteria. GLOVES, GOWN and MASK
• Respiratory Isolation – Patient with infection that can be spread via
droplets or through the air, such as whooping cough (pertussis),
meningicoccal meningitis and Haemophilus influenza. GLOVES and
MASK
• AFB-TB Isolation – (acid-fast bacillus) Patient with active
tuberculosis. N95 Respirator Mask, GOWN and GLOVES
What Does Being A Phlebotomist
Mean??
Factors that are the responsibility of the collector and include:
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Monitoring of Specimen Ordering
Correct Patient Identification
Patient Communication and Patient Safety
Patient Preparation
Timing of Collections
Phlebotomy Equipment
Collection Techniques
Specimen Labeling
Specimen Transportation to the Laboratory
Specimen Processing
Importance of correct specimen collection
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Laboratory testing of blood specimens is VITAL to the correct DIAGNOSIS,
TREATMENT and MONITORING of a patient’s condition.
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Although the primary concern of personnel collecting blood specimens is
understandably to obtain the specimen, failure to adhere to the collection procedure
can compromise the integrity of a successfully collected specimen.
Note: approximately 56% of laboratory errors occurs during the preanalytical phase (process that occurs
before testing)
Types of Specimens
The laboratory refers to blood specimens in terms of WHOLE BLOOD,
PLASMA and SERUM.
WHOLE BLOOD - A whole blood specimen contains erythrocytes (red blood cells),
leukocytes (white blood cells), and thrombocytes (platelets) suspended in plasma and
essentially represents blood as it circulates through the body. (CBC, blood typing)
Note: Majority of laboratory tests are performed on the liquid portion of blood (plasma or serum) which
contain substances, such as proteins, enzymes, organic and inorganic chemicals and antibodies.
PLASMA –
Plasma is the liquid portion of blood that has not clotted. Plasma is often
defined as the liquid portion of blood that contains fibrinogen and other clotting
factors. Plasma is obtained by centrifugation of unclotted specimens.
SERUM
- Serum is the liquid portion remaining after clotting has occurred. Serum does
not contain fibrinogen and other clotting factors. Serum is obtained by centrifugation
of clotted specimens.
NOTE:
• The presence or absence of anticoagulants in the tubes
into which blood specimens are placed determines the
type of specimen available for testing.
• WHOLE BLOOD and PLASMA – require an
anticoagulant to prevent clot formation
• SERUM – is obtained from tubes that DO NOT contain
and anticoagulant.
EVACUATED TUBES AND
ORDER OF DRAW
• Evacuated tubes come in a variety of sizes,
volumes and colors. The tubes are labeled
with the type of anticoagulant or additive, the
draw volume, and the expiration date.
• Evacuated tubes have color coded rubber
stoppers or plastic shields covering the
stoppers.
• Evacuated tubes fill automatically because of
the premeasured vacuum present in the tube.
Why Does It Matter!?!?!?
• The order in which the tubes are drawn is one of the MOST
IMPORTANT considerations when collecting blood specimens.
• Tubes MUST be collected in a specific order to prevent invalid test
results caused by contamination of the specimen by
microorganisms, tissue thromboplastin, or carryover of additives or
anticoagulants between tubes.
• The order of draw changes when collecting a capillary specimen
due to how quickly the blood can clot. In order to achieve maximum
quality for a specimen the microtainer tubes need to be collected
purple then green.
Most Common Tubes Drawn
Color of Tube
Main Tests Run
Serum/Plasma
Blood Cultures
Microbiology
Red
Send out
serum
No Clot activator
No gel
Blue
Coagulation
plasma
Sodium Citrate
Gold
chemistry
serum
Clot activator
Green
chemistry
plasma
Lithium heparin
Pink
Blood bank
plasma
K2 EDTA
Purple
hematology
plasma
K2 EDTA
Gray
chemistry
plasma
PotassiumOxalate/
Sodium Fluoride
NA
Anticoagulant
medium
ADDITIVES
Gels are found in green and gold top evacuated and microtainer tubes. Most commonly used for separating
Plasma and serum from the red blood cells.
SODIUM CITRATE
BINDS CALCIUM
MOST COMMONLY USED FOR COAGULATION
STUDIES
GOLD
CLOT ACTIVATORS – INITIATES OR ENHANCES
COAGULATION
LITHIUM HEPARIN
INHIBITS THROMBIN
MOST COMMONLY USED FOR CHEMISTRY
DETERMINATIONS
K2 EDTA
(ETHYLENEDIAMINETETRAACETIC ACID)
BINDS CALCIUM
MOST COMMONLY USED FOR HEMATOLOGY
STUDIES
POTASSIUM OXALATE/ SODIUM FLUORIDE
BINDS GLUCOSE
OFTEN USED FOR GLUCOSE TESTING
Special Requirements
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Drug Levels – Usually ordered as a timed study (should be treated as a STAT) and
required to be drawn as close to the time requested as possible due to the peak and
trough levels of medication that has been given to the patient.
Cold Agglutinins – Because cold agglutinins in serum attach to the RBC’s when the
blood cools below body temperature, the specimen must be kept warm until the
serum can be separated from the cells.
Specimens Sensitive to Light – Exposure to light will decrease the concentration of
bilirubin, beta-carotene, folate, vitamins A, B12, and B6 and Porphyrins.
Chilled Specimens – Specimens for tests such as lactic acid and ammonia as well
as many others need to be placed on ice (chilled) immediately after collection to
prevent deterioration.
Cortisol Stimulation – These tests are ordered by Chemistry after the nurse has
dosed the patient. These tests MUST be done on time with NO EXCEPTIONS. If a
patient receiving cortisol is not drawn on time the patient must wait 3 days before
being able to repeat the test.
Appearances of Blood
• Normal serum and plasma appear clear and pale yellow.
• Variations in the normal appearance can indicate that certain tests
results may be adversely affected. (ex. results can be severely
decreased or increased.)
• Hemolyzed – Pink to red color, indicating red blood cell destruction
• Icteric – Dark yellow color indicating the presence of increased
bilirubin
• Lipemic – Cloudy, milky appearance indicating the presence of
increased lipids.
Hemolysis
Hemolysis – is the breakage of red blood cell’s membrane, causing the release of the hemoglobin
and other internal components into the surrounding fluid.
Which can be caused by a variety of factors including but not limited to:
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Rapidly pulling back on the plunger of a syringe
Forcing blood from syringe into tubes
Capillary draws that are not free flowing
Improper choice in venipuncture site
Prolonged tourniquet time
Cleansing the venipuncture site with alcohol and not allowing the site to dry
Improper venipuncture indicated by slow blood flow
The use of a small bore needle resulting in a large vacuum force applied to the blood, causing
stress on the red blood cells which may cause them to rupture
Vigorous mixing or shaking of a specimen
Prolonged contact of serum or plasma with cells
Test results from all laboratory disciplines can be affected by hemolysis.
The only corrective action is to…………………
Must invert tubes
8-10 times:
• to prevent
hemolysis
• to ensure adequate
mixing of blood
with anticoagulant
Tests Affected By Hemolysis
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Acetone
Alcohol
Ammonia
AST
C-Peptide
CK
CEA
Cortisol
Direct Bilirubin
Free T4
Folate
FSH
Glucose
Iron
Lactic Acid
LDH
LH
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Lipase
Magnesium
Phosphorus
POTASSIUM
Protein Electrophoresis
PSA
Testosterone
Total Protein
Total T4
TSH
Vitamin B12
D-Dimer
ESR
Fibrinogen
Hemoglobin
Hematocrit
PT
PTT
Redraw
The
Specimen
Which Way do I Collect the
Blood??
• Venipuncture can be performed using an evacuated
tube system, a syringe system, or a winged blood
collection (butterfly) set. Each of these systems requires
its own unique equipment.
• The system that is chosen for venipuncture is ALWAYS
based on the assessment of the patient’s veins.
NOTE: Each and every person has different veins (ex.
Shape, size, and stability)
VENIPUNCTURE
EQUIPMENT
• Differentiate between evacuated tube, syringe, winged blood collection
set for collection of blood by venipuncture.
• Differentiate various needle sizes, length, guage and purpose.
• Safely disposing of contaminated needles.
• Identify types of evacuated tubes by color, types of anticoagulants,
additives present, mechanism of action, special characteristics, and
purpose of each.
• List correct order of draw for various types of blood collection tubes.
• Purpose of tourniquet
• Substances used to clean skin prior to venipuncture.
• Quality Control of Venipunture.
Evacuated Tube System
(Vacutainer)
• The evacuated tube system is the most frequently used method for
performing venipuncture.
• Blood is collected directly into the evacuated tube.
• This system allows for the collection of numerous tubes from a single
venipunture.
• This system is usually chosen when a patient has a large median cubital
vein, or other large veins in the antecubital area that are easily
palpated. (15 to 30 degree angle)
SYRINGES
• Syringes – may be preferred over an evacuated tube
system at times when drawing blood from patients with
poorly anchored, rolling veins that will NOT support a
vacuum. (10 to 15 degree angle)
• The advantage of this system is that the amount of
suction pressure on the vein can be controlled by slowly
pulling back on the syringe plunger.
NOTE: blood drawn in a syringe must be immediately transferred to
appropriate evacuated tubes to prevent the formation of clots.
WINGED BLOOD COLLECTION SETS
(BUTTERFLY)
• WINGED BLOOD COLLECTION SETS – or butterflies
as they are routinely called are used for:
• Performing venipuncture from very small veins (10-15
degree angle)
• Obtaining specimens from children and elderly.
WHAT SIZE NEEDLE WOULD YOU USE?
• Needle sizes are determined by the number on
the package. The BIGGER the number the
SMALLER the (gauge) needle.
• Therefore the SMALLER the number the
BIGGER the (gauge) needle.
Ex: 23’ gauge
22’ gauge
21’ gauge
Where Are the Veins?
• Proper positioning is important for succesful
Venipuncture. Patients should not stand or sit on
High stools because of possiblity of fainting
• Slight rotation of the patient’s arm is necessary
or vein exposure.
• As a rule of thumb, the tourniquet should not be left
On the patient for more than 1 minute at a time
Because of discomfort, However the tourniquet is left on
During the blood draw.
• Tourniquets – are used to allow the veins to fill to
Capacity
Hand Veins & Nerve Damage
• The Posterior surface of the wrist
Should be used for hand venipunctures.
• The hand is full of nerves and the
venous Network. EXTREME caution
needs to be used when selecting
a vein in the hand or wrist for
venipuncture.
• Nerve Damage can also occur with
Excessive needle punctures.
• Never draw blood from a FOOT!!!!!!
PERIOD!!!!
Capillary Specimens
• Capillary specimens are to be drawn only
when necessary.
• When a patient has no discernable veins
in hands or arm and you need a CBC.
• Always be sure that the test required can
be done from a capillary specimen before
drawing the patient if there is no other way
to obtain the specimen.
Phlebotomy Tips
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Bevel on Upper Wall – rotate bevel slightly
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Needle slipped beside vein – withdraw needle until
The bevel is just under the skin and redirect needle into
Vein.
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Needle Position cannot be determined – withdraw
Needle until bevel is just under the skin, relocate vein,
and redirect into vein.
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Needle too deep and penetrated through vein –
Withdraw needle slightly
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Needle Not Deep Enough – push needle gently
into vein
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Collapsed Vein – Vein disappears when entered
due to vacuum, or pressure caused by pulling on
syringe plunger. (try again using smaller tube
Or pull more slowly on syringe plunger.)
NOTE: If unable to obtain specimen discontinue
Phlebotomy and try again using appropriate actions.
Is it Venous, capillary or arterial?
• VENOUS blood is the specimen of choice for clinical laboratory testing.
• ARTERIAL blood is the required specimen for arterial blood gas
determinations.
• CAPILLARY blood is a mixture of arterial and venous blood and is
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collected by dermal puncture. (ex. fingerstick, heelstick) When properly
collected capillary blood is suitable for some lab tests Therefore it should
always be indicated on the label whether a specimen is venous or
capillary.
This information must accompany the results for interpretation by the
physician.
QUALITY ASSURANCE
• As you can see many factors related to
blood collection can affect laboratory
Quality Assurance. Remember that
Laboratory Personnel are available to
answer questions and should be consulted
whenever NEEDED.
Pre-analytical Errors
https://www.youtube.com/watch?v=Ph4H1AuvOH0
Blood Culture Collection
• Watch blood collection video
QUESTIONS?????