Phlebotomy Ch 7: Blood Collection

Front 1

Blood drawing station

Back 1

includes a table for supplies,
special chair for patient to sit during procedure,
a bed or reclining chair for patients with history of fainting, those donating blood, and other special situaitons,
a bed or padded table needed for heelsticks

Front 2

phlebotomy chair

Back 2

adjustable armerests that lock in place to prevent the patient from falling should fainting occur

Front 3

hand held equipment carriers

Back 3

convenient for "stat" or emergency situations or when relatively few patients need blood work

Front 4

phlebotomy carts

Back 4

commonly used for early morning hospital phlebotomy rounds when many patients need lab work and for scheduled "sweeps"
-bulky and potential source of nosocomial infections and are not normally brought into patient rooms; left outside, bring tray in
Important duty: keep stocked

Front 5

Gloves

Back 5

required by CDC/HICPAC standard precaustions and the OSHA bloodborne pathogen standard,
nonsterile, disposable latex, nitrile, neoprene, polythylene and vinyl exam gloves are acceptable

Front 6

Glove liners

Back 6

-glove powder can be a source of contamination, but makes them easier to slip on/off -->can help suspend latex particles in air and pose danger to those with allergies
-special glove liners available to those with allergies from gloves
-barrier hand creams help prevent skin irritation and are compatible with latex gloves
-FDA regulates glove quality

Front 7

antiseptics

Back 7

used to prevent sepsis, the presence of microorganisms or their toxic products in the bloodstream, but do NOT necessarily kill them.
-considered safe to use on human skin
- most common for blood collection is 70% isopropyl alchohol
-for a higher degree of antisepsis, povidone-iodine used for blood culture collection and blood gas collection
-does not sterilize the site

Front 8

Disinfectant

Back 8

EPA-regulated chemical substances used to remove or kill microorganisms on surfaces/instruments
-not safe for use on skin
-CDC/HICPAC - use of EPA registered sodium hypochlorite products is preferred
-1:10 dilution is applied prior to cleanup of blood spills and 10 mins of contact time is required for disinfectants to be effective

Front 9

Hand sanitizer

Back 9

CDC-use of alcohol based hand sanitizer for routine decontamination of hands as a substitute for hand washing provided the hands are not visibly soiled
-if soiled and hand washing facilities unavailable - use detergent-containing wipes followed by alcohol-based hand cleaner

Front 10

gauze pads

Back 10

used to hold pressure on site
-cotton balls not recommended - stick to site and reinitiate bleeding when removed

Front 11

sharps containers

Back 11

must be marked with biohazard symbol and be rigid, puncture resistant, leak proff, and disposable and have locking lids

Front 12

tourniquet

Back 12

properly applied is tight enough to restrict venous flow out of the area (makes them easier to see/stretches vein walls so they are thinner/easier to pierce), but not so tight as to restrict arterial flow into the area
-->restriction of flow can change blood components if its left in place for more than 1 minute
-blood pressure cuff may be used in place of tourniquet, maintains pressure below diastolic pressure

Front 13

needles

Back 13

multisample needles - ETS
hypodermic - syringe
winged infusion (butterfly) - used with ETS or syringe system
-discard if package is open, not sterile

Front 14

parts of needle

Back 14

bevel - slant, allows needle to slip into skin easily without coring (removal of a portion of the skin or vein)
shaft - long cylindrical portion
hub - attaches to the blood collection device
lumen - internal space of needle

Front 15

Needle gauge

Back 15

relates to the diameter of the lumen
-inverse - the larger the gauge, the smaller the actual diameter of the needle
-gauge - depends on: size/condition of vein, type of procedure, and equipment used
-appropriate for phlebotomy: 20-23, 21 gauge = standard
-too small of a gauge = may hemolyze the specimen
15-17 = special needle attached to collection bag, collection of donor units and therapeutic phlebotomy
18 = syringe - used primarily as a transfer needle, safety issues have diminished use
20 - multisample syringe - sometimes used when large volume tube are collected or large volume syringes are used on patients with normal-size veins
22 = multisample syringe - used on older children and adults with small veins or syringe draws on difficult veins
23 = butterfly - infants, kids and difficult adult veins

Front 16

Evacuated Tube system ETS

Back 16

most common, efficient, and CLSI preferred system
closed system - blood fows through needle directly into collection tube without exposure to outside contaminants
-3 components: needle, tube holder+needle, various types of evacuated tubes
-recommended to use different parts from the same manufacturer

Front 17

Multisample needles

Back 17

ETS needles
-allow multiple tubes of blood to be collected during a single venipuncture
-threaded in the middle, beveled point
-the end that pierces the vein is longer and has a longer bevel, shorter end penetrates the tube stopper
-when the tube is removed the sleeve slides back over the needle to prevent leakage of blood
-available with/without safety features

Front 18

evacuated tubes

Back 18

used with both the ETS and syringe
volumes ranging from 1.8-15 mL
-plastic strongly recommended
-fill automatically because there's a premeasured vacuum,
-they don't fill all the way to the stopper, always a consistent amount of headspace
-premature loss of vacuum: results from improper storage, opening tube, dropping the tube, advancing tube too far onto needle before venipuncture, or pulling needle bevel partially out of skin
-premature loss of vacuum can result in underfilled tube --> short draw
-short draw tubes - designed to partially fill when its difficult or inadvisable to draw larger quantities of blood

Front 19

additive tubes

Back 19

if additive prevents clotting: result is a whole blood specimen
-->some whole blood used directly for testing
-->some are centrifuged to separate cells from the fluid portion called plasma
if additive is a clot activator, blood will clot and specimen must be centrifuged to obtain the serum fluid portion
-underfilled additive tube = inaccurate additive-to-blood ratio

Front 20

Sympathomimetikum
a1-(a2) Adrenorezeptor Agonisten

Back 20

Xylometazolin - Olynth®, Otriven®

Front 21

Tube stoppers

Back 21

typically made of rubber
-plastic shield designed to protect personnel from blood drops on stopper after needle removed from tube, and from aerosol mists and sprays of specimen when stopper is removed from tube
rigidity of plastic - prevents removal of stopper using a thumb roll, a technique shown to cause aerosol formation
-color coding - indicates additive or special property of the tube

Front 22

expiration dates of additives/tube vaccum

Back 22

Reliability guaranteed by manufacturers if tubes are handled properly and stored between 4 and 25 degrees Celsius

Front 23

syringe system

Back 23

small or difficult veins
hypodermic needle, and a sterile plastic syringe with a Luer lock tip
syringe transfer device
-gauges 21-23, 1-1.5 inches long
-must have resheathing feature to allow needle to be removed for blood transfer
common volumes for phleb: 2, 5, and 10 mL
2 parts: barrel and plunber

Front 24

syringe transfer device

Back 24

allows safe transfer without using syringe needle
-has permanently attached needle
-reduces needle sticks and confines aerosol or spraying of specimen

Front 25

Winged infusion blood collection set (butterfly)

Back 25

small veins
pediatrics or elderly
more flexible/precision
1/2-3/4" needle
5-12" tubing with either a Luer attachment for syringe use or multisample Luer adapter for use with ETS
-the first tube collected with a butterfly will underfill because of the air in the tubing (affects blood-to-additive ratio)
-if an additive tube is the first to be collected, its important to draw a few mL of blood into a nonadditive tube or another additive tube of same type and discard it --> a clear or discard tube
-especially critical when collecting coagulation tubes
23 gauge

Front 26

S Monovette Blood Collection system

Back 26

a complete system for blood collection in which the blood collection tube and collection apparatus are combined in a single unit

Front 27

additive tubes

Back 27

-additives available in liquid, spray dried and powder forms,
-powdered - tap lightly prior to use
invert 3-8 times, depending on type, immediately after colelction
-never transfer blood from one additive tube to another additive tube

Front 28

anticoagulants

Back 28

prevent blood from clotting by either of 2 methods:
1. chelating (binding) or precipitating calcium so it's unavailable to the coagulation process
2. by inhibiting the formation of thrombin needed to convert fibrinogen to fibrin in the coagulation process
-if a test requires whole blood or plasma, specimen must be collected in an anticoagulant tube, mix immediately to prevent microclot formation
-Most common: EDTA, citrates, heparin, and oxalates

Front 29

EDTA

Back 29

anticoagulant,
-available in sodium or potassium-based salt
-prevents coagulation by binding or chelating calcium
- primarily used to provide whole blood specimens for hematology tests and blood bank tests
-spray dried EDTA recommended by CLSI, because liquid dilutes specimen and results in lower hemoglobin values
-8 inversions
-excess EDTA that results when tubes are underfilled causes RBCs to shrink and changes the CBC results
EDTA contained in:
lavender (purple)-top tubes
microcollection containers with lavender tops
pink pastic top tubes with a special blood bank patient ID
pearl top tubes w/thixotropic gel separator
royal blue top tubes w/lavender color coding on the label

Front 30

Citrates

Back 30

-prevent coagulation by binding or chelating calcium
-Sodium citrate - light blue - used for coagulation tests because it does best job of preserving the coagulation factors
-coagulation tests performed on plasma, so specimens must first be centrifuged to separate the plasma from the cells; during testing, calcium is added back to the specimen so the clotting process can be initiated and timed
-sodium citrate tubes: 9:1 ratio of blood to anticoagulant; underfilled tubes cause artificially prolonged clotting times
-3-4 inversions; prevents activation of coagulation process and microclot formation
-vigorous mixing or excessive amount can activate platelets and shorten clotting times

Front 31

Heparin

Back 31

-Prevents clotting by inhibiting thrombin formation (thrombin is an enzyme needed to convert fibrinogen into fibrin for clot formation)
-Heparinized plasma often used for STAT chem tests and other rapid response situations when a fast turn-around-time (TAT) for chem tests is needed
-Faster TAT possbile because time is eliminated that would normally be required for a specimen to clot before serum could be obtained
- 8 inversions
-heparinized plasma is preferred over serum for potassium tests because when blood clots, potassium is released from cells into the serum and can falsely elevate results.
-Heparin tubes: green stoppers and royal blue-top tubes with green on the label
-3 Heparin formulations: ammonium, lithium and sodium heparin

Lithium heparin - least interference in chemistry testing and is the most widely used anticoagulant for plasma and whole blood chemistry tests
-can't use lithium heparin to collect lithium levels
-sodium heparin must not be used to collect sodium specimens or electrolyte panels

Front 32

Oxalates

Back 32

prevent coagulation by precipitating calcium
Potassium oxalate - most widely used oxalate
--> it is commonly added to tubes containing glucose preservatives to provide plasma for glucose testing
-gray stoppers
-8 inversions
-if underfilled: excess oxalate causes hemolysis and release of hemoglobin into the plasma

Front 33

Special-use anticoagulants

Back 33

-combined with other additives and have additional properties for special use situations:
Acid citrate Dextrose (ACD)
Citrate-Phosphate-Dextrose (CPD)
Sodium Polyanethol Sulfonate (SPS)

Front 34

Acid citrate dextrose (ACD)

Back 34

-a special use anticoagulant
- available in 2 formulations (solutions A&B)
-for immunohematology tests such as DNA testingand human leukocyte antigen (HLA) phenotyping used in paternity tests and to determine transplant compatibility
-the acid citrate prevents coagulation by binding calcium,
-dextrose acts as a a red blood cell nutrient and preservative by maintaining red cell viability
-have yellow tops
8 inversions

Front 35

Citrate-phosphate-dextrose (CPD)

Back 35

used in collecting blood for transfusion
-citrate prevents clotting by chelating calcium
-phosphate stabilizes pH,
-dextrose provides cells with energy and helps keep them alive

Front 36

Sodium Polyanethol Sulfonate (SPS)

Back 36

-prevents coagulation by binding calcium
-used for blood culture collection, because it is an anticoagulant and it reduces the action of a protein called complement that destroys bacteria, slows down phagocytosis, and reduces the activity of certain antibiotics
-yellow stoppers
8 inversions

Front 37

Antiglycolytic Agents

Back 37

prevents glycolysis, the breakdown of glucose by blood cells
-if not prevented, the glucose concentration in the blood decreases at a rate of 10 mg/dL per hour
-glycolysis occurs faster in newborns and patients with leukemia
-most common: sodium flouride

Front 38

sodium flouride

Back 38

most common antiglycolytic agent
-preserves glucose for up to 3 days
inhibits growth of bacteria
commonly used in combination with the anticoagulant potassium oxalate to provide plasma specimens for rapid-response situations
-have gray stoppers
-8 inversions
-used to collect ethanol specimens to prevent either a decrease in alchohol concentration due to glycolysis, or an increase due to fermentation by bacteria

Front 39

Clot activator

Back 39

enhances coagulation
-includes substances that provide more surface for platelet activation, such as glass (silica) particles and inert clays like Celite, and clotting factors such as thrombin
-5 inversions for complete/rapid clotting

Front 40

Silica particles

Back 40

clot activators in serum separator tubes (SSTs) and plastic red-top tubes
-cause the blood to clot within 15-30 minutes
-5 inversion
-blood in a SST tube will eventually clot without mixing; however when its not mixed, glass particles may become suspended in the serum and interfere in testing process

Front 41

Thrombin tubes

Back 41

-clottting factor found in a clot activator tube
-blood clots within 5 mins
5 inversions

Front 42

Celite tubes

Back 42

clotting factor found in a clot activator tube
-used with some point-of-care coagulation systems
5 inversions

Front 43

thixotropic gel separator

Back 43

an inert (nonreacting) synthetic substance in the bottom or certain blood collection tubes
-the density of gel is between that of the cells and the serum or plasma
-specimen is centrifuged, the gel undergoes a change in viscosity and moves between the cells and the serum or plasma, forming a barrier
-prevents the cells from continuing to metabolize substances, such as glucose, in the serum or plasma
BD serum gel tubes: gold plastic or red/gray tiger tops, (called serum separators SSTs)
Griner serum gel tubes: red plastic stoppers with yellow tops
BD heparinized gel tubes: light green plastic or green/gray tiger tops(are called plasma separator tubes PSTs)
Greiner heparinized gel tubes: green plastic with yellow tops
EDTA gel tubes: pearl stoppers (PSTs)

Front 44

trace element free tubes

Back 44

royal blue stoppers
used for trace element tests, toxicology studies and nutrient determinations
-measure small quantity substances that would normal be contaminated by trace elements found in the glass/stopper material of other tubes
-Royal blue top tubes contain EDTA, heparin or no additive
-typically the labels indicate the additive

Front 45

Order of draw

Back 45

-special sequence of tube collection that is intended to minimize contamination by additive carryover, tissue thromboplastin or microorganisms
-varies with institution
-results in the least amount of interference should carryover occur

Front 46

carryover or cross contamination

Back 46

the transfer of additive from one tube to the next
-blood remaining on or within the needle can be transferred to next tube drawn or filled, contaminating that with additive from the previous tube and possibly affecting test results
-EDTA tubes have been the source of more carryover problems than any other additive
-Heparin causes the least interference in tests other than coagulation tests because it also occurs in blood naturally
-minimized by order of draw and ensuring the specimen tubes fill from the bottom up during collection and that the contents of the tube dont come in contact with the needle during the draw or when transferring blood into tubes from a syringe

Front 47

tissue thromboplastin

Back 47

-present in tissue fluid
-activates the extrinsic coagulation pathway and can interfere with coagulation tests
-it is picked up by the needle during venipuncture and flushed into the first tube during ETS collection, or mixed with blood collected in a syringe
- no longer considered a sig. problem for PT and PTT tests
-may compromise other coagulation tests
-any time a coag test other than PT(T) is the first or only tube collected, a few mL of blood should be drawn into a nonadditive tube or another coagulation tube (clear/discard)

Front 48

Microbial contamination

Back 48

blood cultures detect microorganisms in the blood and require special site cleaning measures prior to collection to prevent contamination
-blood culture tubes or bottles are sterile and collected first in the order of draw
-contamination of blood culture bottles can lead to false positive results and inappropriate or delayed care

Front 49

CLSI Order of Draw

Back 49

1. sterile tube (blood culture
2. blue top coagulation tube
3. serum tube with or without clot activator, with or without gel
4. heparin tube with or without gel plasma separator
5. EDTA tube
6. Glycolytic inhibitor tube

Front 50

Order of Draw: Memory Jogger

Back 50

Stop Light Red, Stay Put, Green Light Go.




(Sterile, light blue, red, SST, PST, Green, lavender, gray)

Front 51

Alternate syringe order of draw

Back 51

clotting process is activated the minute blood starts to fill a syringe, some institutions prefer to use a separate order of draw so that tubes most affected by microclot formation are filled as soon as possible
-this order assumes that the blood that entered the syringe last is the freshest and least affected by microclot formation
1. sterile specimens (blood cultures)
2. light blue tops (coagulation tubes)
3. lavendar top and plasma preparation tube (PPT)
4. Green top and plasma separator tube (PST)
5. Gray-top oxalate fluoride tube
6. Red top and serum separator tube (SST)

***collect whole blood specimens quickly to prevent clumping!
***to prevent carryover it's important to hold the syringe and trasfer device vertical while filling the tubes
-->will keep the transfer needle above the fill level of the tube so that it is not contaminated by blood mixed with additive

Front 52

Memory Jogger for alternate syringe order or draw

Back 52

Silly Ladies Love Green and Gray Roses



(sterile, light blue, lavendar, green/PST, Gray, Red/SST)