NHA CCMA PHLEBOTOMY

Hemoconcentration

Blood pooling at the venipuncture site, leading to falsely elevated results for analytes, discomfort

Tourniquet left on for > 60 seconds

Vasovagal response

Fainting because the body overreacts to certain triggers (the sight of blood, extreme emotional distress)

Hemolysis

Rupture or destruction of red blood cells

Potentially because of tourniquet being tied too tightly

Affects potassium tests

Typically avoided with appropriate needle (21-22 gauge)

What information needs to be verified against the requisition with every phlebotomy procedure?

Provider order

Patient identity

Labeling of the specimens

Identification number of the specimens

First step in routine blood collection?

Obtain requisition form from provider

NEVER do procedure without this!

Verifying quality of venipuncture supplies

Inspect integrity of needle's seal to ensure sterility

Order of draw for phlebotomy

1. Yellow

2. Light Blue

3. Red

4. Gold or Tiger Top

5. Green

6. Lavender

7. Gray

Yellow stopper additive

Sodium polyanethol sulfonate (SPS)

Yellow stopper lab use

Blood culture specimen collections in microbiology

Light blue stopper additive

Sodium citrate (anticoagulant)

Light blue stopper lab use

Coagulation studies

PT/INR

PTT

TT

Fibrinogen

D-dimer

Red stopper additive

Plastic: clot activator

Glass: no additive (plain)

Red stopper tube lab use

Serum determinations in chemistry

Glass tube may be used for routine blood donor screening and dx testing of serum for infectious diseases:

Lipid panel

Complete metabolic panel (CMP)

Drug test

Plastic tube (clot activator) used for sodium determinations

Gold or tiger top (red-grey) additive

Serum separator tube (SST), clot activator, thixotropic gel (creates barrier)

Gold or tiger top (red-grey) lab use

Serum determinations in chemistry

May be used for routing blood donor screening and dx testing of serum for infectious diseases

Green top tube additives

Sodium or lithium heparin

Green top tube lab uses

For plasma determinations in chemistry

STAT/routine chemistry test

Ammonia

Troponin

Electrolytes

Arterial blood gases

Lavender top tube additive

EDTA (anticoagulant)

Lavender top tube lab use

Whole blood hematology determinations, routine immunohematology testing, blood donor screening

CBC, RBC, WBC, platelet counts

Hgb A1c

Hct

ESR

Sickle cell test

Blood bank

Grey top tube additive

Potassium oxalate and sodium fluoride (anticoagulant)

Grey top tube lab use

Glucose testing (GTT)

Fasting blood sugar (FBS)

Blood alcohol/ETOH

Lactate

Royal blue top tube lab use

Toxicology

Trace elements

Methods of selection for phlebotomy

Warm the site

Use tourniquet and palpation

Infrared vein scanner

Venipuncture for newborns to 12 months

Heel stick and capillary blood specimen

Venipuncture for 12 months to 2 years

Capillary samples from fingerstick or phlebotomy

Venipuncture for > 2 years

Regular phlebotomy

Site restrictions for phlebotomy

Fistulas

Ports

Mastectomy

Thromboses

Preferred vein for venipuncture

Median cubital vein is preferred over cephalic or basilic veins

Position for phlebotomy (normal and hx of syncope)

Seated with feet flat on the floor and good posture, arm extended to form straight line from shoulder to wrist with palm upward and using the opposite hand to make a fist and placing it behind the elbow

If hx of syncope, place in Semi-Fowler's or laying down

Cleansing the site for phlebotomy

70% alcohol pads, move in concentric circles of increasing diameter

Allow to AIR DRY, and do NOT blow or wave hands b/c this recontaminates the skin

Needle gauge for evacuated tube method

21-22 gauge

Where to apply tourniquet

3-4 in above the venipuncture site

Length of time to leave on a tourniquet

No more than 1 minute

Can lead to discomfort, accumulation of platelets, nerve damage

If this time is reached, wait 2 minutes before trying again

Once the skin has been cleaned for phlebotomy, can you reconfirm the vein location?

NO, must disengage tourniquet and start over

How to anchor a vein

Grasp firmly with the thumb 1 inch below the draw site and holding the skin taut

Degree of needle insertion for phlebotomy

15° (30° maximum) with bevel facing upward and no hesitation

When to remove the tourniquet during venipuncture

Once flow of blood has been established in the last tube

When to place gauze over the draw site

After the last tube has been filled and before removing the needle

When to discard a needle

Immediately after removal

How long to keep pressure on the venipuncture site and how to position arm post-venipuncture

Apply pressure to site and elevate arm for 2 mins, remaining extended (slightly bent at the elbow) to minimize bruising

When to label tubes

Immediately following the procedure

Syringe method

Needle, sterile syringe (3-20 cc), blood transfer system, vacuum tubes

Ensure that plunger system works

Must use test tube rack for transfer and new needle for transfer

What can happen if blood is drawn too quickly or too forcefully?

Collapsed vein

Butterfly method/winged infusion

Used for smaller/fragile veins in the dorsal hand or antecubital area

Smaller gauge needles with "butterfly wings" and long tubing that minimizes pressure on the vein from the suction in a vacuum tube

Needle gauge for butterfly method/winged infusion

25-26 gauge

Degree of insertion for butterfly needle

10-15 degrees

Hold needle by its wings

Tube inversions

For tubes with additive

Completely turn upside down and return upright

3-10x according to manufacturer's instructions

DO NOT shake or forcefully invert b/c leads to hemolysis

Capillary puncture location for adults

Middle (3rd) or ring (4th) finger of the nondominant hand

Perform slightly off-center

Capillary puncture location for infants

Outer edge on underside of heel

Preparing the site for capillary puncture

Warm the pt's hands, run under warm water, sit on them for a few mins

How to hold the patient's finger and lancet for capillary puncture

Hold between your thumb and forefinger

Lancet should be placed at a right angle to the finger

During capillary puncture, why should you wipe away the first drop of blood?

Contaminated with tissue fluids

What should you do if blood is slow to flow during a capillary puncture?

Apply gentle pressure

Wipe the site

DO NOT milk the finger

Order of draw for microcapillary tubes

1. Blood gases

2. EDTA tubes

3. Other additive tubes

4. Serum tubes

How long to leave a bandage post-venipuncture

At least 15 mins

Time for serum specimens to clot prior to centrifugation

30-60 mins

Time for red tube or SST to stand before centrifuge

20-30 mins

How to balance a centrifuge

Insert tubes across from each other; even number is essential for balance

Using a centrifuge

Never open when it is in operation

Cap tubes to prevent emission of aerosols

What to do if a patient faints during injection or phlebotomy

Supine position with legs elevated above heart

Cool compress to forehead

No food/drink

Pt stays in office for at least 15 mins

Cannot drive for 30 mins

Percentage of formed elements of blood

45%

Percentage of plasma in the blood

55%

Second choice vein for venipuncture

cephalic vein

If patient is high risk for venous thrombosis, what type of procedure do you use?

Dermal puncture

Infants should not have greater than what % of their blood volume removed in an24-hr period?

5%

In blood culture, when would you need to draw aerobic tube before anaerobic tube?

Butterfly method because this prevents oxygen from the tubing getting into the anaerobic tube