Basic Principles of Phlebotomy Ricki Otten MT(ASCP)SC uotten@unmc.edu CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Objectives for Student Lab: Those objectives marked with ‘*’ will not be tested over during the student lab rotation CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Phlebotomy: Historical Practice CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Modern Phlebotomy Diagnosis and management of disease Remove blood for transfusions Therapeutic reasons: Polycythemia Hemochromatosis CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Blood Function: Supplies nutrients to tissues: O2, hormones, glucose Removes end-products of metabolism: CO2, urea, creatinine Provides defense mechanism: WBC, antibodies Prevents blood loss: platelets, coagulation proteins CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Blood Composition: Fluid component (~55%) Formed elements (~45%) RBC WBC Platelets Fluid component (~55%) Water (~92%) Protein (~7%) etc CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Coagulation: In vivo In vitro Blood is fluid Clot is formed to protect injured vessel In vitro Spontaneous reaction Triggered by glass or poor drawing technique CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Coagulation Reaction: Clotting factors + calcium  thrombin Fibrinogen + thrombin  fibrin strands CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Anti-coagulants: Remove calcium Neutralize thrombin Whole blood Plasma Serum CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Blood with anticoagulant: Clotting is prevented and irreversible Mix: completely invert 8-10x Whole blood Centrifuge  plasma Plasma contains fibrinogen CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Blood without anticoagulant: Spontaneous clotting occurs and is irreversible Fibrinogen  fibrin strands Fibrin strands entrap cells Centrifuge  serum Serum lacks fibrinogen CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Appearance Normal: clear and ‘yellow’ Abnormal: Hemolyzed = pink to red (ruptured RBC) Icteric = dark orange-yellow (bilirubin) Lipemic = cloudy (fat, triglycerides) CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Blood Collection Tubes: Contain a vacuum Used with Vacutainer and Syringe systems Stoppers universal color coded: indicates contents Have an expiration date CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Tubes containing no anti-coagulant CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Red-top tube: Glass Plastic No additive Glass surface activates clotting sequence Do not mix SERUM: use for TDM Plastic Contain additive to activate clotting sequence Contain inert gel  SST Do invert to mix additive and initiate clotting sequence SERUM CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Gold or Mottled-red-gray top tube: Contain clot activator and gel (SST) Invert to mix and initiate clotting sequence SERUM CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Royal blue-top tube: Trace metal-free Iron, copper, zinc Label color indicates contents: Red: no additive = serum Purple: EDTA = whole blood or plasma Green: heparin = whole blood or plasma CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Tubes containing anti-coagulant CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Blue-top tube: Anticoagulant = sodium citrate Binds calcium Must be full Blood:anticoagulant ratio critical Must be on ice if not analyzed within 30 minutes Coagulation studies PLASMA Whole blood CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Green-top tube: Anticoagulant = heparin Inhibits thrombin formation Three formulations: Lithium heparin Ammonium heparin Sodium heparin Inhibits thrombin formation Must be full and on ice if need pH, ionized Ca PLASMA Whole blood CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Green-top tube: Most chemistry tests, STAT lab (PST) Decreases time needed for blood to clot, Makes turnaround time better CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Purple-top tube: Anticoagulant = EDTA Binds calcium Hematology studies: CBC PLASMA Whole blood CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Grey-top tube: Anticoagulant = potassium oxalate Binds calcium PLASMA, Whole blood Antiglycolytic agent = sodium fluoride Maintains plasma glucose levels Limited use: glucose, lactic acid CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Fibrin-split Products tube Light blue top tube with 2 yellow bands on the label Contains soya bean thrombin which causes the blood to clot immediately CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Yellow-top tube: ACD = acid citrate dextrose Paternity testing DNA SPS = sodium polyanethol sulfonate Used for special blood culture studies Inhibits certain antibiotics Both bind calcium PLASMA, Whole blood CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Type and Amount of Specimen: Dependent upon Test Whole blood: EDTA or heparin? Plasma: EDTA or heparin? Serum: trace free? Separator gel interference? Amount of sample needed to perform test Multiple labs needing the same specimen at the same time CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Valid Test Results Require: Trained personnel Causes of pre-analytical error Invalid test results Quality control Quality assurance Sophisticated instruments CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Safety Practices:  For infection to spread: Infectious substance: HBV, HCV, HIV Mode of transmission Susceptible host  CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Modes of Transmission: Parenteral: any route other than the digestive tract Intramuscular Intravenous Subcutaneous Mucosal Ingestion Non-intact skin: chapped hands, cuts, cuticles Percutaneous: needles, sharps Permucosal: mouth, nose, eyes CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Safety Practices: Infection Control: stop the spread of infection CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Safety: Infection Control Hand washing Primary means of preventing spread of infection (especially nosocomial) Minimum 15 seconds, soap, friction Wash hands before and after each blood draw PPE Lab coat Gloves Mask Standard precautions at all times CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Safety: Engineering Controls PPE Sharps containers Safer medical devices CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Safer Medical Devices: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: PPE: gloves, lab coat, mask Cleaning agent Alcohol pads: routine Povidone iodine: blood culture collection and blood gases Soap and water: alcohol testing, allergies Cotton balls, gauze CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: Bandage, tape (use caution with children) Sharps container: Discard needles, lancets Biohazard marking Puncture resistant NEVER recap, bend break needles CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: 6. Tourniquets: Slows venous blood flow down Causes veins to become more prominent NEVER leave on for >1 minute AVOID rigorous fist clenching or hand pumping (potassium, lactic acid, LD) Latex allergy CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Tying on the Tourniquet: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: 7. Needles NEVER reuse a needle NEVER use if shield is broken NEVER recap, cut, bend or break Drop immediately into sharps container after venipuncture Size of needle is indicated by gauge: Larger gauge number indicates smaller needle diameter 21, 23 gauge needles routinely used for phlebotomy CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Needles: Used with syringe system Used with vacutainer system CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Multi-sample Needle: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Butterfly Needle: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Butterfly Needle: Most often used with syringe Expensive, thus not used for routine draws Used for small, fragile veins Increased risk of needle stick injury CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: 8. Tube holder/ vacutainer adapter Threaded Flanges CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: Syringe Black water proof pen CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Syringe Safety Device: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Labeling Blood Collection Tubes: Black indelible marker (water proof) Never pencil Legal document Print legibly Required information: 5 items Patient name Identification number Date of draw (mm,dd,yyyy) Time of draw (military time) Phlebotomist signature: first initial, last name CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Vacutainer or Syringe? Vacutainer Syringe Most often used Most economical Quick Least risk of accidental needle stick Syringe More control Reposition easily Will see ‘flash’ of blood in syringe hub when vein successfully entered CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

The Patient: Approach Communication Empathy Handling special situations Patient identification Arm band Legal document Prepare patient for blood draw Latex allergy? CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Selecting the Site: Antecubital area most often accessed Hand or wrist Remember: 2 arms Use tip of index finger on non-dominant hand to palpate area to feel for the vein CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Collection Site Problems: Veins that lack resiliency Extensive scarring Hematomas Edematous area Side of mastectomy CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Collection Site Problems: Intravenous line NEVER draw above an IV Draw from other arm Draw from hand on other arm Draw below the IV CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Draw Below IV site: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Collection Site Problems: Indwelling lines: Hickman catheters Heparin locks Used to administer medication Only nurse may access these lines Can obtain blood: called a ‘line draw’ Must clear line of heparin contamination by discarding first 5-10 cc of blood CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Hickman Catheter: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Inserting the Needle: Anchor the vein Grasp arm with your non-dominant hand Use thumb to pull skin taut Smoothly and confidently insert the needle bevel up 15-30 degree angle CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

No Needle Movement! You must anchor the blood-drawing equipment on the patient’s arm to minimize chance of injury CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Fill Tubes: Use correct order of draw: Blood cultures Red top Blue (baby blue) Green Purple Grey CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Be careful not to: Push needle further into vein when engaging evacuated tube Pull needle out of vein when disengaging tube Pull needle out of vein as you pull back on the plunger Pull up or press down when needle in vein Forget to mix additive tubes 8-10 times CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Withdraw Needle: First release tourniquet Disengage tube Place cotton directly over needle, without pressing down Withdraw needle in swift, smooth motion Immediately apply pressure to wound Do not bend arm CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Label Tubes Immediately: In sight of patient Patient name Identification number Date of draw Time of draw (military time) Your initials CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Recheck Draw Site: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Failure to Obtain Blood: Check tube position and vacuum Always have back up tubes near by Needle position Collapsed vein CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Needle Position: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

You should try again Look at alternate site Use clean needle Other arm Hand Use clean needle Use fresh syringe if contaminated Only try twice CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Poor Collection Techniques: Venous stasis Prolonged application of tourniquet (>1 min) Hemodilution Drawing above IV Short draw (blood to anticoagulant ratio) Hemolysis Traumatic stick Too vigorous mixing Alcohol still wet Using too small of needle Forcing blood into syringe CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Poor Collection Techniques: Clotted sample Inadequate mixing Traumatic stick Partially filled tubes Short draw Sodium citrate tube draw volume critical Using wrong anticoagulant CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Poor Collection Techniques: Specimen contamination Using incorrect cleanser Alcohol still wet Powder from gloves Drawing above IV Specimen handling Exposure to light Pre-chilled tube Body temperature CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Venipuncture Procedure Remain calm Organize yourself Organize your equipment: STICK TO ELEVEN CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Equipment: Stick to Eleven Gloves Lab coat Alcohol wipe Cotton ball Bandage/tape Sharps container Tourniquet Needle Syringe or vacutainer holder Collection tubes with backup tubes Water-proof marker CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Venipuncture Procedure: Wash hands Put on gloves Identify patient Latex allergy? Position arm Apply tourniquet CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Venipuncture Procedure: Locate vein Release tourniquet Cleanse site in outward rotation Allow to air dry CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Venipuncture Procedure: Reapply tourniquet Do not contaminate site Anchor vein Insert needle Fill tubes Quick mix additive tubes Release tourniquet Withdraw needle CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Venipuncture Procedure: Engage safety device Dispose of needle immediately Apply pressure to puncture site Label tubes Recheck puncture site Thank patient Remove gloves, wash hands CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Accidental Needle Stick: Remain calm Cleanse wound with alcohol Wash wound thoroughly Notify supervisor, instructor Follow site protocol Page OUCH hotline: 1-402-888-OUCH 1-402-888-6824 Complete incident report CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Syringe draw CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Syringe Safety Transfer Device CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Mark your spot CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Hand Vein Draw CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture: Method of choice for infants, children under 1 year Adults Scarred Fragile veins Hardened veins Home glucose monitoring (POCT) Patients with IV CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Capillary Blood Mixture of arterial, venous, capillary blood and fluid from surrounding tissues Fluid from surrounding tissues may interfere and/or contaminate the specimen Warming skin puncture site increases arterial blood flow to the area Reference ranges often differ from venous CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Equipment: PPE Cleaning agent Alcohol pads: routine Soap and water: alcohol testing, allergies DO NOT use providone iodine Cotton balls, gauze CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Equipment: Bandage/tape Sharps container Warming device Commercial warmer Warm wet washcloth CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Equipment: Lancet Always use standardized equipment NEVER use a surgical blade CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Equipment: Micro-specimen containers Capillary tubes Microtainers Capillary blood gas tubes Micropipet diluting system CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Equipment: Glass slides: used to prepare blood smears CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Procedure: Wash hands Approaching the patient Patient identification Latex allergy? Bedside manner Site selection Cleanse site: DO NOT use providone- idodine Perform puncture: Wipe away first drop of blood Label the specimen CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Site Selection: CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Procedure: Hold finger between your index finger and thumb Puncture the finger using a quick, smooth motion Wipe away the first drop of blood CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Procedure: Collect sample DO NOT touch collecting device to skin surface DO NOT scrape collecting device across skin surface DO NOT scoop blood into collecting device CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

Skin Puncture Procedure: Order of draw is critical: platelets accumulate at puncture site causing clot formation Blood smear EDTA Heparin Serum Apply pressure to puncture site Label specimen in sight of patient (indelible marker) CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture