1. PHLEBOTOMY AND SPECIMEN CONSIDERATIONS
many errors can occur during these steps, such errors are
considered preanalytical errors and are known to contribute to delayed and suboptimal patient care.

2. Two classifications of preanalytical variables:
PHLEBOTOMY AND SPECIMEN CONSIDERATIONS
Two classifications of preanalytical variables:
1. Controllable variables relate to standardization
of collection, transport, and processing of specimens.
2. Uncontrollable variables are those associated with the
physiology of the particular patient (age, sex, underlying
disease, etc.)

3. PHLEBOTOMY The process of collecting blood
PHLEBOTOMY AND SPECIMEN CONSIDERATIONS
PHLEBOTOMY
The process of collecting blood
literally translated means “to cut a vein”

4. 2 main phlebotomy procedures:
PHLEBOTOMY AND SPECIMEN CONSIDERATIONS
2 main phlebotomy procedures:
Venipuncture- blood is collected through a needle inserted in the vein
2. 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 laboratory
An assured professional can put the patient at ease and facilitate a positive interaction

7. Appearance Attitude Communication Skills Bedside Manner
BLOOD COLLECTION PERSONNEL
PROFESSIONALISM
Appearance
Attitude
Communication Skills
Bedside Manner

8. PPE Hand hygiene Isolation INFECTION CONTROL
-lab coats, gloves are required for phlebotomy procedures and during specimen handling
-New gloves for each patient
-Masks
Hand 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 soiled
Isolation
- 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 pressure
Collapse more easily
Dark bluish red (oxygen poor)
Capillary
only one cell
Can easily be punctured to provide blood specimen
ARTERIES
Have thick walls to withstand the pressure of ventricular contraction, that creates a pulse
Normal systemic arterial blood is bright red.

11. M H 2 basic patterns of the veins
VASCULAR ANATOMY (phlebotomy related)
2 basic patterns of the veins M H

12. H PATTERN
VASCULAR ANATOMY (phlebotomy related)

13. M

14. OTHER VEINS: VASCULAR ANATOMY (phlebotomy related)
Veins on the back of the hand or at the ankle may be used, although these
are 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 BLOOD
Primarily reserved for blood gas evaluation and certain emergency situations
VENOUS BLOOD
affected by metabolic activity of the tissue it drains and varies by collection site
chloride, glucose, pH, CO2, lactic acid and ammonia levels differ may from arterial blood
CAPILLARY BLOOD
Contains arterial and venous blood plus tissue fluid
Capillary glucose is normally higher
Calcium, potassium and total protein are normally lower

16. TYPES OF BLOOD SPECIMENS
SERUM
PLASMA
WHOLE BLOOD

17. Venipuncture can be performed by 3 basic methods
VENIPUNCTURE EQUIPMENT
Venipuncture can be performed by 3 basic methods
I 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 blood
II Needle and syringe – used on small, fragile and damaged veins
III Winged infusion set (butterfly) – can be used with the ETS and syringe
Used 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 venipuncture
Distends the veins, making them larger and easier to find, stretches the wall so they are thinner and easier to find
Must 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 gauge
Gauge = number that relates to needle diameter or bore
Gauge 21-23
Gauge 21 – considered standard for routine venipuncture

20. 3. Evacuated Tube System 3 basic components
VENIPUNCTURE EQUIPMENT
3. Evacuated Tube System
3 basic components
A. 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 vacuum
tube and usually is covered by a rubber sheath

22. The bevel is the slanted opening at the end of the needle.
VENIPUNCTURE EQUIPMENT
The 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 end
The 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 label
Vacuum 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 draw
Are 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 SYSTEM
A short needle with butterfly wings and a length of tubing with a Luer fitting for syringe use or a Luer adapter for ETS use
Gauge 23 most commonly used
During 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 EQUIPMENT
6. Tube Additives
Anticoagulants
Prevent blood from clotting and include EDTA, citrates, heparin and oxalates
B. Antiglycolitic agents
Prevent glycolysis which can decrease glucose concentration by upto 10 mg/dl per hour
Sodium fluoride : most common antiglycolitic agent
Preserves glucose for upto 3 days, and inhibits bacterial growth
C. Clot activators
Are coagulation factors like thrombin
Glass particles (silica)
Inert clays ex. Diatomite (celite)
Enhance clotting by providing more surface for platelet activation

28. D. Thoxotropic gel separators
VENIPUNCTURE EQUIPMENT
D. 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 EQUIPMENT
7. Trace element free tubes
Contamination free
Used 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 microorganisms
Additive carry over
Affects chemistry test
Occurs 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 OVER
COMMON TESTS AFFECTED BY ADDITIVE CONTAMINATION
Citrate – ALP, Ca,Phosporus
EDTA ALP, Ca, CK,PTT,K,PT,Serum Iron, Na
Heparin – Activated CT, ACP, Ca, PT, PTT Na, Li
Oxalates- ACP, ALP, Amylase,Ca, LDH, PT, PTT, K, Red cell
Silica (clot activator) – PTT, PT
Sodium 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 requests
2. Approach, identify and prepare the patient
3. Verify diet restrictions and latex sensitivity test
4. Sanitize hands
5. Position patient, apply tourniquet and ask patient to make a fist
6. Select vein,release tourniquet and ask patient to open fist
7. Clean and air dry site
8. Prepare equipment and put on gloves
9 .Reapply tourniquet, uncap and inspect needle
10. Ask patient to remake a fist ,anchor vein and insert needle
11. 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 pressure
14. Discard needle and holder unit
15. Label tubes
16. Observe Handling Instructions
17. Check patient’s arm, apply bandage
18. Dispose of used materials
19. Thank Patient, Remove Gloves and Sanitize hands.
20. Transport Specimens to the lab.

35. Trouble shooting Failed Venipuncture
Tube position
Vacuum
Bevel against the vein wall
Needle too deep
Needle beside the vein
Collapsed vein
Blood cannot be replaced as quickly as it is drawn
Use a smaller tube or pull the plunger more slowly
If blood does not return, discontinue the draw
Undetermined 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 Venipuncture
Interaction with a child
Immobilizing a child
Geriatric Venipuncture
meaningful communication is important
Alzheimer’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 Tattoos
Damaged Veins
Edema
Hematoma
Mastectomy

39. Vascular Access Devices:
Arterial line
Arteriovenous shunt or fistula
Heparin or saline lock
Intravenous line
Central 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 tissues
Situations that can trigger hematoma formation?

41. 2. Iatrogenic anemia
3. Inadvertent arterial puncture
4. Infection of the site
5. Nerve injury
6. Reflux
7. Vein damage

42. Allergies to supplies or equipments Excessive bleeding
Patient Conditions and Complications
Allergies to supplies or equipments
Excessive bleeding
Fainting (syncope)
Nausea or vomiting
Obese Patients
Pain
Petechiae
Seizures/Convulsions

43. Capillary Specimen Collection
Useful in pediatrics where removal of larger quantities of blood can have serious consequences
Collection sites
Fingers – adults and children over the age of 2
Heels - infants

44. Materials:
Alcohol- 70 % alcohol
Gauze- to wipe the first drop of blood and excess tissue fluid
- hold the pressure after specimen collection
3. Bandage – to cover the site after collection
4. Lancets - sterile, disposable, sharp instruments used for capillary puncture
5. Warming devices – increases blood flow when performing heel sticks
ex. Towel or diaper dampend with warm water (<42C)
6. Microcollection Tubes – special small plastic tubes “bullets”
7. Microhematocrit tubes – used for manual hematocrit
8. Sealants – used to seal one end of microhematocrit tubes

45. Capillary Order of Draw
EDTA specimens – first because most affected by clumping
Other additive specimes
Serum specimens

46. Indications for capillary puncture:
Adults and Older Children:
There are no accesible veins
Available veins are fragile and must be saved for other procedure
Patient has clot-forming tendencies
Blood is to be obtained for POCT procedures
Infants and Very Young Children:
Infants have a small blood volume
Venipuncture is difficult and can damage vein and surrounding tissues
Preferred specimen for newborn screening test

47. Capillary Specimen Collection
Steps 1-4 same as venipuncture
5. Position patient
6. Select puncture/ incision site
7. Warm the site if applicable
8. Clean and air dry site
9. Prepare equipment
10. Puncture the site and Discard the lancet\
11. Wipe away first drop of blood
12.Fill and mix tubes in the order of draw
13. Place gauze and apply pressure
14. Label specimen and observe special handling procedures
15. Check the site and apply bandage
16. Dispose of used materials
17. Thank patient, Remove Gloves and sanitize hands
18. Transport specimen to the lab

48. Heel Stick procedure
Select 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 foot
Place 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

50. Wipe away the first drop of blood!!!!!

51. Neonatal Bilirubin Collection – must be protected from light
Neonatal Screening
screens for phenylketonuria, a disorder which could be managed by dietary adjustment if diagnosed early.

52. Mixing tubes – gentle inversion Transporting Specimens
Specimen Handling and Processing
Mixing tubes – gentle inversion
Transporting Specimens
Delivery time limits
- must be centrifuged within 1 hour if serum or plasma is needed
Why 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