Presentation on theme: "PHLEBOTOMY AND SPECIMEN CONSIDERATIONS"— Presentation transcript:
1 PHLEBOTOMY AND SPECIMEN CONSIDERATIONS many errors can occur during these steps, such errors areconsidered preanalytical errors and are known to contribute to delayed and suboptimal patient care.
2 Two classifications of preanalytical variables: PHLEBOTOMY AND SPECIMEN CONSIDERATIONSTwo classifications of preanalytical variables:1. Controllable variables relate to standardizationof collection, transport, and processing of specimens.2. Uncontrollable variables are those associated with thephysiology of the particular patient (age, sex, underlyingdisease, etc.)
3 PHLEBOTOMY The process of collecting blood PHLEBOTOMY AND SPECIMEN CONSIDERATIONSPHLEBOTOMYThe process of collecting bloodliterally translated means “to cut a vein”
4 2 main phlebotomy procedures: PHLEBOTOMY AND SPECIMEN CONSIDERATIONS2 main phlebotomy procedures:Venipuncture- blood is collected through a needle inserted in the vein2. Capillary puncture –blood is collected from a skin puncture made with a lancet or similar device
5 individuals trained in blood collection techniques
6 BLOOD COLLECTION PERSONNEL Plays an important role in public relations in the laboratoryAn assured professional can put the patient at ease and facilitate a positive interaction
8 PPE Hand hygiene Isolation INFECTION CONTROL -lab coats, gloves are required for phlebotomy procedures and during specimen handling-New gloves for each patient-MasksHand hygiene-most important means of preventing the spread of infection-Hands must be decontaminated frequently , including after glove removal-Alcohol based antiseptic can be used if hands are not visibly soiledIsolation- separates certain patients from others and limit their contact with personnel and visitors-Required precaution is posted on patient’s door
10 THE VASCULAR SYSTEM VEINS have thinner walls because blood in them is under less pressureCollapse more easilyDark bluish red (oxygen poor)Capillaryonly one cellCan easily be punctured to provide blood specimenARTERIESHave thick walls to withstand the pressure of ventricular contraction, that creates a pulseNormal systemic arterial blood is bright red.
11 M H 2 basic patterns of the veins VASCULAR ANATOMY (phlebotomy related)2 basic patterns of the veinsMH
14 OTHER VEINS: VASCULAR ANATOMY (phlebotomy related) Veins on the back of the hand or at the ankle may be used, although theseare less desirable and should be avoided in diabetics and other individuals with poor circulation.Leg, ankle and foot veins are sometimes used but not without permission of the patient’s physician due to potential medical complications
15 SOURCE AND COMPOSITION OF BLOOD SPECIMENS ARTERIAL BLOODPrimarily reserved for blood gas evaluation and certain emergency situationsVENOUS BLOODaffected by metabolic activity of the tissue it drains and varies by collection sitechloride, glucose, pH, CO2, lactic acid and ammonia levels differ may from arterial bloodCAPILLARY BLOODContains arterial and venous blood plus tissue fluidCapillary glucose is normally higherCalcium, potassium and total protein are normally lower
16 TYPES OF BLOOD SPECIMENS SERUMPLASMAWHOLE BLOOD
17 Venipuncture can be performed by 3 basic methods VENIPUNCTURE EQUIPMENTVenipuncture can be performed by 3 basic methodsI Evacuated tube system (ETS) – most preferred because blood is collected directly from the vein in the tube, minimizing the risk of specimen contamination and exposure to the bloodII Needle and syringe – used on small, fragile and damaged veinsIII Winged infusion set (butterfly) – can be used with the ETS and syringeUsed to draw blood from infants and children, hand veins and other difficult to draw situations
18 1. Tourniquet VENIPUNCTURE EQUIPMENT Applied to a patient’s arm during venipunctureDistends the veins, making them larger and easier to find, stretches the wall so they are thinner and easier to findMust not be left on longer than 1 minute because specimen quality may be affected
19 2. Needles VENIPUNCTURE EQUIPMENT Sterile, disposable and sized by length and gaugeGauge = number that relates to needle diameter or boreGauge 21-23Gauge 21 – considered standard for routine venipuncture
20 3. Evacuated Tube System 3 basic components VENIPUNCTURE EQUIPMENT3. Evacuated Tube System3 basic componentsA. Multisample needle – allows collection of multiple tubes during venipuncture
21 VENIPUNCTURE EQUIPMENT The Vacuum collection needle is pointed at both ends, with one end shorter than the other.The long end of the needle is used for insertion into the vein, the shorter end is used to pierce the rubber stopper of the vacuumtube and usually is covered by a rubber sheath
22 The bevel is the slanted opening at the end of the needle. VENIPUNCTURE EQUIPMENTThe bevel is the slanted opening at the end of the needle.bevel of the needle must face upward when the needle is inserted into the vein.
23 B. Tube holder VENIPUNCTURE EQUIPMENT Plastic cylinder with a small opening for a needle at one end and a large opening for tubes at the other endThe tube end has flanges to help place and remove tubes
24 C. Evacuated tubes VENIPUNCTURE EQUIPMENT Have a premeasured vacuum that automatically draws the volume of blood indicated on the labelVacuum loss can occur if tubes are stored improperly, opened, dropped or advanced too far onto the needle before draw, or if the needle bevel backs out of the skin during drawAre color coded to identify a type of additive, absence of additive or special tube property
25 4. SYRINGE SYSTEM VENIPUNCTURE EQUIPMENT Syringes are customarily used for patients with veins from which it is difficult to collect blood and for blood gas analysis.
26 VENIPUNCTURE EQUIPMENT 5. BUTTERFLY SYSTEMA short needle with butterfly wings and a length of tubing with a Luer fitting for syringe use or a Luer adapter for ETS useGauge 23 most commonly usedDuring use , the plastic wings are held with the thumb and index finger, allowing the user to achieve the shallow needle angle needed to access small veins
27 6. Tube Additives Anticoagulants B. Antiglycolitic agents VENIPUNCTURE EQUIPMENT6. Tube AdditivesAnticoagulantsPrevent blood from clotting and include EDTA, citrates, heparin and oxalatesB. Antiglycolitic agentsPrevent glycolysis which can decrease glucose concentration by upto 10 mg/dl per hourSodium fluoride : most common antiglycolitic agentPreserves glucose for upto 3 days, and inhibits bacterial growthC. Clot activatorsAre coagulation factors like thrombinGlass particles (silica)Inert clays ex. Diatomite (celite)Enhance clotting by providing more surface for platelet activation
28 D. Thoxotropic gel separators VENIPUNCTURE EQUIPMENTD. Thoxotropic gel separators-inert substances contained near the bottom of certain tubes-during centrifugation the gel lodges between cells and fluid, forming a physical barrier that prevents the cells from metabolizing substances in the serum or plasma
29 7. Trace element free tubes VENIPUNCTURE EQUIPMENT7. Trace element free tubesContamination freeUsed to collect specimens for trace elements, toxicology, nutrient
30 ORDER OF DRAW AND ADDITIVE CARRY OVER is a special sequence of tube collection that reduces the risk of specimen contamination by microorganismsAdditive carry overAffects chemistry testOccurs when blood in an additive tube touches the needle during venipuncture or during transfer from a syringe
31 COMMON TESTS AFFECTED BY ADDITIVE CONTAMINATION ORDER OF DRAW AND ADDITIVE CARRY OVERCOMMON TESTS AFFECTED BY ADDITIVE CONTAMINATIONCitrate – ALP, Ca,PhosporusEDTA ALP, Ca, CK,PTT,K,PT,Serum Iron, NaHeparin – Activated CT, ACP, Ca, PT, PTT Na, LiOxalates- ACP, ALP, Amylase,Ca, LDH, PT, PTT, K, Red cellSilica (clot activator) – PTT, PTSodium fluoride – Na, BUN
32 STOP, LIGHT RED, STAY PUT, GREEN LIGHT, GO S (Sterile)L (Light Blue)R (Red)S (Serum Separator Tube)P (Plasma Separator tube)G (green)L (lavender)G (gray)
33 VENIPUNCTURE PROCEDURES 1. Review and accession of test requests2. Approach, identify and prepare the patient3. Verify diet restrictions and latex sensitivity test4. Sanitize hands5. Position patient, apply tourniquet and ask patient to make a fist6. Select vein,release tourniquet and ask patient to open fist7. Clean and air dry site8. Prepare equipment and put on gloves9 .Reapply tourniquet, uncap and inspect needle10. Ask patient to remake a fist ,anchor vein and insert needle11. Establish blood flow, release tourniquet and ask patient to open fist
34 12. Fill, remove and mix tubes in order of draw 13. Place gauze, withdraw needle, activate safety feature and apply pressure14. Discard needle and holder unit15. Label tubes16. Observe Handling Instructions17. Check patient’s arm, apply bandage18. Dispose of used materials19. Thank Patient, Remove Gloves and Sanitize hands.20. Transport Specimens to the lab.
35 Trouble shooting Failed Venipuncture Tube positionVacuumBevel against the vein wallNeedle too deepNeedle beside the veinCollapsed veinBlood cannot be replaced as quickly as it is drawnUse a smaller tube or pull the plunger more slowlyIf blood does not return, discontinue the drawUndetermined needle position
36 Multiple venipuncture attempts: Try again below the first site, on the other arm or on a hand or wrist vein.If the second attempt is unsuccessful, ask someone to take over.
37 Interaction with a child Immobilizing a child Pediatric VenipunctureInteraction with a childImmobilizing a childGeriatric Venipuncturemeaningful communication is importantAlzheimer’s disease, arthritis, coagulation problems, clouding of lens or catarcts, hearing loss, skin are less elastic, parkinson’s disease and stroke
38 Preanalytic Considerations Problem sites:Burn, Scars and TattoosDamaged VeinsEdemaHematomaMastectomy
39 Vascular Access Devices: Arterial lineArteriovenous shunt or fistulaHeparin or saline lockIntravenous lineCentral Vascular access device (CVAD) or indwelling line
40 PROCEDURAL ERROS RISKS Hematoma formation- rapid swelling near the venipuncture site due to blood leaking into the tissuesSituations that can trigger hematoma formation?
41 2. Iatrogenic anemia3. Inadvertent arterial puncture4. Infection of the site5. Nerve injury6. Reflux7. Vein damage
42 Allergies to supplies or equipments Excessive bleeding Patient Conditions and ComplicationsAllergies to supplies or equipmentsExcessive bleedingFainting (syncope)Nausea or vomitingObese PatientsPainPetechiaeSeizures/Convulsions
43 Capillary Specimen Collection Useful in pediatrics where removal of larger quantities of blood can have serious consequencesCollection sitesFingers – adults and children over the age of 2Heels - infants
44 Materials:Alcohol- 70 % alcoholGauze- to wipe the first drop of blood and excess tissue fluid- hold the pressure after specimen collection3. Bandage – to cover the site after collection4. Lancets - sterile, disposable, sharp instruments used for capillary puncture5. Warming devices – increases blood flow when performing heel sticksex. Towel or diaper dampend with warm water (<42C)6. Microcollection Tubes – special small plastic tubes “bullets”7. Microhematocrit tubes – used for manual hematocrit8. Sealants – used to seal one end of microhematocrit tubes
45 Capillary Order of Draw EDTA specimens – first because most affected by clumpingOther additive specimesSerum specimens
46 Indications for capillary puncture: Adults and Older Children:There are no accesible veinsAvailable veins are fragile and must be saved for other procedurePatient has clot-forming tendenciesBlood is to be obtained for POCT proceduresInfants and Very Young Children:Infants have a small blood volumeVenipuncture is difficult and can damage vein and surrounding tissuesPreferred specimen for newborn screening test
47 Capillary Specimen Collection Steps 1-4 same as venipuncture5. Position patient6. Select puncture/ incision site7. Warm the site if applicable8. Clean and air dry site9. Prepare equipment10. Puncture the site and Discard the lancet\11. Wipe away first drop of blood12.Fill and mix tubes in the order of draw13. Place gauze and apply pressure14. Label specimen and observe special handling procedures15. Check the site and apply bandage16. Dispose of used materials17. Thank patient, Remove Gloves and sanitize hands18. Transport specimen to the lab
48 Heel Stick procedureSelect a site on the medial or lateral plantar surface of the heel that is warm, normal color, free of cuts, bruises, infection, rashes, swelling or previous punctures
49 Encircle the heel with the index finger around the arch, thumb around the bottom and other fingers around the top of the footPlace the lancet against the skin on the medial or lateral plantar surface of the heel using enough pressure to keep it in place without deeply compressing the skin
51 Neonatal Bilirubin Collection – must be protected from light Neonatal Screeningscreens for phenylketonuria, a disorder which could be managed by dietary adjustment if diagnosed early.
52 Mixing tubes – gentle inversion Transporting Specimens Specimen Handling and ProcessingMixing tubes – gentle inversionTransporting SpecimensDelivery time limits- must be centrifuged within 1 hour if serum or plasma is neededWhy is prompt separation important?
53 Cellular glycolysis lowers glucose levels in a specimen at a rate of up to mg/L per hour until the serum or plasma is physically separated from the cells