Phlebotomy 118 – Week 3 Comprehensive Notes

Motivational Context

• Opening quote by Thomas A. Edison: “Our greatest weakness lies in giving up … try just one more time.”
  • Emphasizes perseverance—relevant when repeat sticks or troubleshooting are required in phlebotomy practice.

Course & Source Framework

• Course: Phlebotomy 118, Week 3; slide deck accompanies “Pearson’s Comprehensive Medical Assisting: Administrative and Clinical Competencies, 3e.”
• Institution: Allen School of Health Sciences (est. 1961) – motto “Where Education Comes to Life.”

Sterile Syringe & Needle Method (Manual Draw)

• Intended for small, fragile, or collapsible veins.
• Advantages: control over suction; option when evacuated tubes create too much vacuum.
• Drawbacks:
  • Blood volume limited to syringe size.
  • Higher risk of needle-stick injury or specimen contamination vs. evacuated systems.
  • Requires manual transfer into tubes → ↑ risk of hemolysis & clot formation.
• Key Equipment Prep:
  • Secure needle to syringe; prime plunger several times to ensure free movement.
  • Depress plunger fully to expel air before venipuncture (prevents air embolus & specimen dilution).
• Patient Safety Pre-check:
  • Remove gum/candy to prevent airway obstruction in case of syncope.
• Venipuncture Technique:
  • Confirm no air bubbles; bevel up; insert at 15°–30° angle.
  • Pull plunger SLOWLY—do not force vacuum; rapid pull causes hemolysis & vein collapse.
• Transfer of Blood:
  • Preferred: attach sterile transfer device, engage needle safety; discard needle in sharps; let tube vacuum fill passively.
  • Alternate (no transfer device): place tube upright in rack; pierce stopper with needle while syringe remains vertical—hands off tube/rack for safety.
  • Never push plunger into tube; causes hemolysis.
• Order of Draw for Syringe (additive tubes first to avoid micro-clots):
  1. Yellow (SPS/ACD)
  2. Light Blue (citrate)
  3. Green (heparin)
  4. Lavender (EDTA)
  5. Gray (oxalate/fluoride)
  6. Red/Gray (tiger)
  7. Red (no additive)

Hemolysis – Causes & Impact

• Alters chemistry (notably elevates serum potassium).
• Etiologies:
  • Vigorous shaking vs. gentle inversion.
  • Mismatch: small-gauge needle + large vacuum tube.
  • Over-squeezing during capillary stick.
  • Alcohol not fully dried—entrains alcohol into specimen.
  • Pulling syringe plunger too fast.

Evacuated Tube System (ETS) – Comparative Links

• Video links:
  • Syringe demo: https://www.youtube.com/watch?v=7NSEFVbzTAU
  • ETS demo: https://www.youtube.com/watch?v=NjLKTTag07s

Standard Color-Code & Additives (ETS Reference)

• Yellow – anticoagulant (SPS/ACD)
• Light Blue – sodium citrate
• Red – none
• Red/Gray (Tiger) or Gold (SST) – clot activator + gel (no anticoagulant)
• Green – heparin
• Lavender – EDTA
• Gray – potassium oxalate / sodium fluoride

Venipuncture Complications & Management

• Physical: Hematoma, nerve damage, pain, nausea/vomiting.
• Circulatory: Vein collapse (high vacuum, wrong gauge, fast plunger).
• Hemodynamic: Inadvertent arterial puncture → hold pressure 5–10 min, notify MD, document.
• Stress-induced events:
  • Prolonged wait, fasting diabetic → risk of hypoglycemia; give sugar, alert physician.
  • Convulsions → remove needle, place patient side-lying, summon help/EMS.
• Syncope (fainting):
  • If predicted → supine/semi-Fowler before stick.
  • During stick → discard needle safely, lower head, recline.
  • Protect head post-episode.
• Reflux: Blood back-flows into vein; avoid by keeping arm downward angle.
• Petechiae: pinpoint red dots distal to tourniquet; sign of capillary rupture.

Hematoma Specifics

• Pathophysiology: blood leaks into tissues when vein wall breached & pressure not controlled.
• Causes: tourniquet >1 min, bad needle angle (too shallow/deep), probing, removing needle before tourniquet, fragile skin, anticoagulants.
• Prevention: adequate site pressure 2–3 min, cold compress for swelling.

Specimen Rejection Criteria

1. Improper Label: must include patient name, DOB, date/time, MR#, phlebotomist initials, and source (for micro).
2. QNS – Quantity Not Sufficient: citrate & EDTA tubes must be filled for correct additive ratio (e.g., CBC, ESR, coag studies).
3. Clotted Anticoagulant Tubes: yellow, light-blue, green, lavender, gray should be 100 % clot-free; immediate inversions BEFORE labeling.
4. Handling errors:
   • Light-sensitive analytes (bilirubin, vitamins B6, B{12}) → wrap in foil/brown bag/amber tube.
   • Temperature-sensitive:
   – Room Temp: EDTA CBC.
   – Chill on ice: ammonia, lactic acid, blood gases.
   – Frozen (dry ice): acid phosphatase.
   – Body-warm 37^{\circ}C: cold agglutinins, cryoglobulins.
5. Wrong Tube: inappropriate container for test ordered.

Troubleshooting – Needle Position

• Bevel against vein wall → increase angle.
• Bevel down → stop & completely re-draw.
• Through-and-through (both walls) → slowly retract.
• Partially in tissue (bleed/bruise) → advance or withdraw slightly while stabilizing skin.
• Valve occlusion (bevel sits on valve) → minor retraction.
• Missed vein → repalpate, pull skin, insert deeper.

Geriatric & Special Patient Considerations

• Skin: ↓ collagen, hydration; must traction skin firmly.
• Hearing: speak slowly, louder (no yelling).
• Vision: assist seating; show equipment.
• Cognitive impairment: explain respectfully, simple terms.
• Coagulation disorders / anticoagulants → ↑hematoma risk; extra pressure.
• Joint diseases (arthritis) → position comfortably.
• Diabetes: never puncture foot/ankle.
• Stroke, Parkinson’s, Dementia: allow time, anticipate tremors, comprehension limits.
• Dialysis/Chemo: avoid shunts, fistulas, ports—do not draw.

Anatomical Sites to Avoid

• Foot (unless ordered).
• Shunt/Fistula.
• Eczema, burns, scars.
• Same-side IV; if unavoidable draw below IV.
• Post-mastectomy arm → use opposite limb.

Collection Methods & Tube Sequences (ETS vs. Syringe vs. Capillary)

• Reference grid provided (slide 57); highlights differing priority.
• Capillary (Microtainer) principle: blood gas (green) first if ordered; otherwise follow additive first—green then lavender then gold etc.
• Examples:
  • CBC + STAT electrolytes → green then lavender.
  • CBC + blood gas → green (heparin) then lavender (EDTA).

Specimen Processing – Centrifugation

• Purpose: separate serum/plasma from cells.
• Protocol: \ge 10 min @ \approx 3000 rpm; ensure balanced buckets.
• Serum separator tubes (SST) contain gel to isolate serum post-spin.

Pediatric/Newborn Screening

• Dermal puncture (heel).
• State-mandated panels:
  • Cystic Fibrosis
  • Sickle Cell
  • HIV
  • PKU (phenylketonuria): screens for enzyme deficiency in amino-acid metabolism; positive → special diet.

Blood Donation & Therapeutic Phlebotomy

• Two categories:
  1. Transfusion Unit: 450–500 mL collected; can be fractionated into RBCs, plasma, platelets, factors, reagents, proteins.
  2. Therapeutic (polycythemia): reduce high RBC/PLT/Hb/Hct; not used for transfusion.
• Donor eligibility:
  • Age 17–66 y
  • Weight \ge 110\,\text{lb} (avoid hypovolemia).
  • Hb \ge 12\,\text{g·dL}^{-1}.
  • Acceptable BP per guidelines.

Therapeutic Drug Monitoring (TDM)

• Ensures efficacy/non-toxicity.
• Peak: draw 15–30 min after dose (usually morning).
• Trough: immediately prior to next dose; schedule depends on drug frequency.
• Common monitored drugs: Lithium, Theophylline, Heparin, anticonvulsants (phenobarbital, phenytoin).

Concept of Peaks & Troughs

• Highest (peak) and lowest (trough) serum concentrations across dosing interval determine safe therapeutic window; guide dose & timing.

Special Collection – Blood Culture & Alcohol Testing

• Blood Cultures:
  • Often timed relative to fever spikes or antibiotic therapy.
  • Strict asepsis: alcohol scrub followed by betadine/chlorhexidine.
  • Collect anaerobic bottle first (no air) then aerobic.
• Blood Alcohol:
  • Initiate Chain-of-Custody paperwork.
  • Do not cleanse site with alcohol; use povidone-iodine or soap-water.

Temperature-Controlled Transport

• Chilled (ice/water): blood gases, lactic acid, ammonia—prevent metabolism.
• Frozen (dry ice): acid phosphatase—enzymes stable only frozen.
• Warm 37^{\circ}C: cold agglutinins, cryoglobulins—prevent precipitation.

Light-Sensitive Specimens

• Bilirubin, vitamins B6,B{12},A, beta-carotene → wrap in foil, brown bag, or use amber tube.

Legal, Ethical & Regulatory Framework

• OSHA: employer must provide safe workplace; compliance includes sharps disposal, SDS availability.
• HIPAA: patient data confidentiality; discuss only in private, shield charts, elevator caution.
• Patient Rights:
  • May refuse phlebotomy; forced draw = battery (intentional tort).
  • Document refusal; notify physician.
• Civil vs. Criminal:
  • Assault = threat; Battery = unauthorized touch.
  • Negligence (unintentional tort) most common in healthcare.
  • Fraud = intentional deception.
• Patient chart = legal document—accurate entries critical.

Post-Exposure Protocol

• Needle-stick: wash with soap/water, report, seek medical evaluation.
• Splash to eyes: flush in eyewash station \ge 5 min.
• Blood spill on clothes: remove garments, decontaminate skin; clean surface with appropriate bleach solution.

MSDS/SDS (Material Safety Data Sheet)

• OSHA-mandated documentation for every chemical.
• Lists hazards, PPE, spill/first-aid procedures, storage & disposal.

Practical Take-Home Connections

• Always match needle gauge with tube vacuum to prevent hemolysis & collapse.
• Adhere strictly to order of draw—differs by method (ETS vs. syringe vs. capillary).
• Patient-centered care: anticipate stress, comorbidities, and consent.
• Quality specimens = correct label, volume, additive ratio, handling & transport conditions.
• Safety and legal adherence (OSHA, HIPAA, refusal rights) underpin professional phlebotomy practice.