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Basic Principles of Phlebotomy

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1 Basic Principles of Phlebotomy
Ricki Otten MT(ASCP)SC CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

2 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

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

4 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

5 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

6 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

7 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

8 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

9 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

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

11 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

12 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

13 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

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

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

16 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

17 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

18 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

19 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

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

21 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

22 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

23 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

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

25 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

26 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

27 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

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

29 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

30 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

31 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

32 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

33 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

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

35 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

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

37 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

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

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

40 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

41 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

42 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

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

44 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

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

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

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

48 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

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

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

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

52 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

53 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

54 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

55 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

56 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

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

58 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

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

60 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

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

62 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

63 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

64 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

65 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

66 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

67 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

68 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

69 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

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

71 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

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

73 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

74 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

75 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

76 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

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

78 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

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

80 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

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

82 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

83 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

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

85 Syringe draw CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

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

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

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

89 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

90 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

91 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

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

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

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

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

96 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

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

98 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

99 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

100 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

101 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

102 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

103 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

104 CLS 424 Phlebotomy Student Lab Rotation: Phlebotomy Lecture

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