1. Blood sample collection in children Do’s and Don'ts Dr Swati Bhave

2. Preparation of Pediatric Patients Find out – Is it the first time for the child? Find out about past experience. How did the child react ? How did the parents react ? Explain – To parent and child about procedure (if possible with dolls or puppets) Explain need of second attempt if required

3. Parental co-operation Assess - Parental ability to participate or assist you Decide - Whether parent should be present or not If present - Decide how will they assist : physical restrain, distraction, emotional support, explanation

4. How to relieve Anxiety & Fear Collect blood away from other patients in a special room. Never in the hospital bed. This is a comfort zone Area should be child friendly. Uniforms should be colourful Keep equipment out of site Ask child’s preference of hand Allow child to select comfort object Stop procedure if child combative Try later or another person

5. Minimizing PAIN Topical anesthetic like AMETOP, EMLA Cost, time ( 10-60min) More than one site tried, allergy Sucrose or pacifier

6. Selection of Site Very important to get adequate volume Will be decided by –Age of the child: heel or finger stick, IV –Whether arterial or venous blood required –Equipment available eg neonate capillary tubes, vacutainers, routine needle & syringe etc

7. Infants and Neonates HEEL stick puncture Lateral plantar bottom surface 3 - 5 min Pre-Warming > blood flow (arterializes) Pediatric lancet New born 2.5mm L /1mm D, Preterm o.75 mm L / 0.85 mm D Depth of major BV is 0.03 mm to 1.6 mm from skin to calcaneous > 2.4 mm depth injury: Osteomyelitis

8. Infants and Neonates HEEL stick puncture Do not use anteromedial area or posterior curve of C Do not use alcohol swabs to stop bleeding : stinging; Use sterile gauze for pressure Do not use adhesive tapes :maceration and bruising of skin Do not squeeze or milk excessively : hemolysis or dilutes blood with tissue and interstitial fluid : erroneous results Discard first drop Complications cellulitis, abscess, scarring, tissue loss, calcified nodules

9. Older child : > one yr age finger prick Damaged veins, arm in cast or bandaged Do not use if edema, infection, < circulation Skin to BV depth 1.5 -2.4 mm Should not go >2.4 mm deep Pediatric lancet sizes 1.75/1.25/0.85 mm

10. Intravenous blood collection Site selection Tourniquet not excessively tight Special precautions when –Heparin lock or –IV line collection

11. What is required from the sample Does the test require : whole blood, serum or plasma. How much is the volume required : 2, 4, 5, ml etc. Pre-term 10 ml may be 5 % of total volume What are the special bulbs or ready made tubes required : e.g. fluoride bulb for sugar, chemistry bulb for urea, EDTA for hematology etc

12. In What to collect blood ?

13. ORDER of drawing This is important - so that additives in one tube will not contaminate specimen in subsequent tubes Blood culture Non Additive tube Coagulation tube Non Additive tube If using syringes minimize clotting by filling additive tubes before non additive

14. When & How to get Serum & Plasma Serum sample –blood collected without any anti-coagulant and centrifuged –clear supernatant fluid devoid of any fibrin products Plain bulb –Most enzymes, –Biochemical LFT,KFT, –S Electro. –Serological :Widal, VDRL Plasma sample –blood collected & mixed with anticoagulant and centrifuged –clear supernatant fluid with thrombosis inhibited. Most satisfactory sample. No changes occur in blood Heparinized bulb –PH, NH4, RBC levels, Plasma cortisol, testosterone, globin,cholinesterase

15. For Special Testing PCR, Genetic, ammonia, blood gases, drug, antibiotic & hormone levels etc. Before collection of sample ascertain that you know everything about the sample collection Confirm from lab how much volume, what bulb, procedure, timing etc Recollection of blood is distressing for everyone: Child-parent- doctor & adds to cost

16. HEMOLYSIS OF SAMPLES Contact with water Excessive heat or cold Rigorous mechanical injury to RBS ( thin gauge ) Prolonged storage Hemolyzed samples will give erroneous results

17. PREVENTION OF HEMOLYSIS Equipment used to collect : absolutely dry Minimum constriction of limb Use correct gauge Collect slowly and steadily Remove needle and put immediately into the bulb Easier if collection in Vacutainer

18. Important steps before collection Identification of the patient Labeling correctly: very very important Re-checking which test is required Keeping ready all the necessary equipment : drawing of blood and bulbs for collection Clean up the area before and after collection

19. Following safety precautions Do no harm to your patient –Ensure use of safe and sterile equipment Do no harm to yourself –Follow universal precautions –Avoid needle stick injuries and splashing of blood into your eyes, skin or mucous membrane Do no harm to the community –Ensure that you have safely and correctly disposed all equipment so that no other person can get exposure

20. Transport & Storage of samples Ideally the sample should be collected in the laboratory and immediately into the processing If it cannot be sent immediately one should follow instructions carefully for Storage where should it be kept ? : room temp, cold storage-what temp Transport What are the precautions during transport

21. Summary Blood collection in children is a traumatic and invasive procedure All efforts should be made to reduce the discomfort Care should be taken to avoid need for repeat puncture