Phlebotomy

Phlebotomy

Dr. Asela Kalinga
Neerogya Health Care Pvt Ltd

Neerogya Health Care Pvt Ltd Dr Asela

What is phlebotomy
• withdrawal of blood from a vein, artery, or the
capillary bed for lab analysis or blood
transfusion.


Who is a phlebotomist
• Collects blood and other specimens

• Prepares specimens for testing

• Interacts with patients & health care professionals
• plays a vital role in any health care system
Other medical professionals, including
doctors, nurses, technologists, and medical assistants
must also be trained to collect blood specimens.


Phlebotomist


Laboratory work flow cycle


What do you keep
• Professionalism
• Confidentiality
• Attitude
• Appearance
• Safety


Professionalism


Confidentiality
• All employees are responsible for maintaining
confidentiality of medical information


Attitude

• Tone of voice and facial expression will
determine how patients respond to you.
• Always be polite, friendly, calm, and
considerate.


• polite


• friendly


• calm


• considerate


Appearance
• Your personal appearance will also affect the
impression you make.
• Comply with your facility’s dress code and
personal appearance policies.


Safety


Anatomy &
Physiology


Anatomy is the branch of science concerned
with the study of the structure of the body.

Physiology is the branch of science concerned
with the study of the function of the body.


• The cardiovascular system consists of the
Heart, and Blood Vessels.
• Its main function is circulate oxygenated blood
from the lungs to various organs, and return
blood depleted of oxygen to the lungs, where
it is re-oxygenated.


Structure of capillary


How to select site for bleeding


• Vein should feel like spongy tube.


Blood
Components


• Circulating whole blood is a mixture of:
• Plasma (which contains fluid, proteins, and
lipids), and
• Formed elements, consisting of red
cells, white cells, and platelets.


Whole
Blood


RBC


WBC


Platelets


Blood Clot
• When a blood sample is left standing without
anticoagulant, it forms a coagulum or blood
clot.
• The clot contains coagulation
proteins, platelets, and entrapped red and
white blood cells.


Plasma


Serum
• Serum contains all the same substances as
plasma, except for the coagulation
proteins, which are left behind in the blood
clot.


Equipments


• Trays
• Blood Collection tubes
• Syringes
• Needles
• Lancets
• Tourniquets
• Sterilization
• Bandaging Material
• Gloves
• Sharp Disposal Container

• Marking Pen
• Washing material
• Cool box/ Refrigerator


Trays


• Trays should be sanitized daily using
appropriate disinfectant

• Kept Organized and well-stocked.


Blood Collection tubes
• glass or plastic tube with a rubber stopper.
• It has a vacuum so that blood will flow into
the tube.
• anticoagulants and/or other chemical
additives.
• Rubber stoppers of blood collection tubes are
color coded.
• Each type of stopper indicates a different
additive or a different tube type.


Green tube / Lavender

• EDTA to prevent clotting
• hematology studies.
• Should be completely filled
• Must be inverted after filling


“MCV is not influenced by K3EDTA
concentrations up to ten times normal, while
K2EDTA, at high concentrations, results in a
slight increase in MCV, as measured with three
of the instruments2”. In addition, it has also
been reported that “the difference in MCV
between K2EDTA and K3EDTA was more
marked under the condition of lower blood
pH4”.


Red tube
• No additives
• Blood bank tests, toxicology, serology
• Must not be inverted after filing


Light blue
• sodium citrate.
• coagulation (clotting) studies.
• must be completely filled
• must be inverted immediately after filling


Function of Sodium Citrate

Sodium citrate act as chelating agent to bind the
calcium in the blood.
Calcium need
* To make a Plt aggregation
* To form fibrin.


ESR tube


Gel & Clot activator


What is gel tube ?
• Gel tubes are Serum tubes, with presence of
clot activator and separator Acrylic gel for
automatic separation of clot and serum during
centrifugation.


Gel Advantages
• Gel forms Stable barrier between the Separated serum and clot.
– Prevents interference of substances released from blood clot into serum ( eg :
release of K+ / LDH from Lysed RBC’s).
– Gel Serves as excellent tube medium for transportation and storage of
Specimen.
• Allows use of primary tubes on analyzers.
• Allows storage of specimens in primary tubes.
• Eliminates time of serum transfer and aliquoting, Hence Improves
turnaround time.
• Reduces the risk of contamination and exposure of sample to atmosphere
during multiple transfers.
• Reduces waste and contamination
• Reduces labeling error, invited by repeated aliquoting.
• Eliminates cost of secondary aliquot assembly - Aliquot tubes, transfer
pipette tip , Multiple labels.


• Fluoride tube

• Inhibitor for glycolysis + anticoagulant
• Sodium Fluride +potassium oxalate.
• glucose levels.


See expiry date on tube


Syringes


Components of syringe


Types of syringe
• Luer lock syringe


• Slip tip syringe


• Eccentric tip syringe


• Catheter tip syringe


Needles


Components of needle


Colour code


Butterfly Needle


• Winged infusion set
• Difficult venupuncutre including pediatric
draws
• with a syringe or a holder and vacuum
collection tube system.
• 21, 23, or 25 gauge
• number-one cause of needlesprik injuries, so
proper use of their safety devices is critical.


Lancets


• Lancets are used for difficult
venupuncutre, including pediatric draws.


Tourniquets


• Vein easier to SEE, FEEL, and PUNCTURE


Sterilization


Bandaging Material


Gloves
• Gloves must be worn for all procedures
requiring vascular access.
• Non-powdered latex gloves are most
commonly used;


Collecting of
blood sample


Greeting
• Always greet patient in a professional, friendly
manner.
• A good initial impression will earn the patients
trust, and make it easier and more pleasant to
draw a good specimen.
• Knock on the patient’s door before entering.
• Identify yourself by name and department.
• Explain the reason for your presence.


• The more relaxed and trusting your
patient, the greater chance of a successful
atraumatic venupuncutre.
• Good verbal, listening, and nonverbal skills are
very important for patient reassurance


Identification of patient
• Make sure the name, medical record
number, and date of birth on your
order/requisition match those on the patient’s
armband.
• Verify the patient’s identity by politely asking
them to state their full name.
• Properly identifying patients and specimens is
probably the single most critical part of your
job.
• The consequences of misidentifying a
specimen can be life threatening.

• Never rely on the patient name on the door or
above the bed. Patients are frequently moved
from room to room.


Standard Precautions
01. Hand wash


Proper method


Applying gloves
Patients are often reassured that
proper safety measures are being
followed when gloves are put on in
their presence.


Positioning the Patient


• Comfortable position
• Turn the arm so that the wrist and palm face
upward, and the antecubital area is accessible
• When supporting the patient’s arm, do not
hyperextend the elbow. This may make vein
palpation difficult.


Applying the tourniquet
• Tie the tourniquet just above the elbow.


• The tourniquet should be tight enough to stop
venous blood flow in the superficial arm veins


• The tourniquet should be applied a maximum
of 1 – 2 minutes, approximately 2 to 3 inches
above the antecubital fossa


• After applying the tourniquet, you may ask
the patient to make a fist to further distend
the arm veins


• Patients often think they are helping by
pumping their fists
• This is an acceptable practice when donating
blood, but not in sample collection as this can
lead to haemoconcentration


Preferred sites
• The median cubital vein
• Cephalic vein, or the Basilic vein.


• Veins on the back of the hand.
• Use a much smaller needle for these hand
veins.


• Using the nondominant hand routinely for
palpation may be helpful when additional
palpation is required immediately before
performing the puncture.
• Often, a patient has veins that are more
prominent in the dominant arm.


Never draw from these areas
• Scarred, abraded, or inflamed skin


• Arms containing IV catheters


• Oedematous arms


• Occluded Veins
• Shunts


Cleansing the site
• Isopropyl alcohol swab
• Outward expanding spiral starting with the
actual venupuncutre site.
• Allow the alcohol to dry:-
1-disinfect the site
2-prevent a burning sensation


Hold vein in place


• Insert needle


• Gently push the tube onto the needle holder
so that the catheter inside the needle holder
penetrates the tube.
• Blood flow should be visible at this point.


Blood won’t flow
If you do not see blood flow, the tip of the
needle:

1. May not yet be within the vein.
2. May have already passed through the vein.
3. May have missed the vein entirely.
4. May be pushed up against the inside wall of
the vein.


Incomplete collection or no blood is
obtained
• Change the position of the needle. Move it
forward (it may not be in the lumen)


• or move it backward (it may have penetrated
too far).

• Adjust the angle (the bevel may be against the
vein wall).


• Loosen the tourniquet. It may be obstructing
blood flow.
• Try another tube. There may be no vacuum in
the one being used.
• Re-anchor the vein. Veins sometimes roll away
from the point of the needle and puncture
site.


Other Problems
• A hematoma forms under the skin adjacent to
the puncture site - release the tourniquet
immediately and withdraw the needle. Apply
firm pressure.


• The blood is bright red (arterial) rather than
venous. Apply firm pressure for more than 5
minutes


Removing the Needle
• Gently release the tourniquet before the last
tube of blood is filled
• Remove the last tube from the needle
• Withdraw the needle in a single quick
movement


• Quickly place clean gauze over the site, and
apply pressure.
• You may ask the patient to continue applying
pressure until bleeding stops.


• Apply pressure to the puncture site and
instruct the patient to keep the arm in a
straight position. Have the patient hold
pressure for at least 3 minutes.


• Take this time to invert any tubes that need to
have anticoagulant mixed with the blood.
• Label specimens.


Re-inspect the puncture site to make sure
bleeding has stopped, and apply a bandage.


Needle disposal
• Remove the needle from the holder if
appropriate, and properly discard it in an
approved sharps disposal container.
• Discard all waste and gloves in the appropriate
biohazardous waste container.
• Wash hands.


Specimen Labeling
• Label specimens at the bedside according to
your institution’s standard procedures, or
apply pre-printed labels.
• Proper labelling is the single most critical task
you are asked to perform


Proper labelling generally includes
• Patient’s first and last name
• Hospital identification number
• Date & time
• Phlebotomist initials
• Your institution may provide bar coded
computer generated labels that contain this
information.


Labeling Errors
• Labeling errors are the most common cause of
incorrect laboratory results.
• If detected, the incorrectly labeled specimen
will be rejected.
• If undetected, it will produce incorrect results
which might adversely affect your patient’s
care


Finger stick-Specimen collection


• A safety Lancet, which controls the depth of
incision
• Finger-sticks should not be performed on
children under one year of age.
• If possible, use the fourth (ring) finger or the
middle finger.
• Many patients prefer that you use fingers on
their nondominant hand.
• Choose a puncture site near the right or left
edge of the finger tip.
• Clean the site as you would for routine
venupuncutre.


• Select a safety lancet appropriate for the size
of the patient’s finger.
• You may warm the finger prior to puncture to
increase blood flow.
• Make the puncture perpendicular, rather than
parallel, to the finger print.
• Wipe away the first drop of blood using gauze
to remove tissue fluid contamination.


• Collect blood into an appropriate tube.
• Label specimens appropriately.
• Make sure bleeding has stopped. Apply an
adhesive bandage if necessary.
• Discard sharps appropriately.


Heel stick
• Veins of small children and infants are too
small for venupuncutre;
• Butterfly needles may be used to collect
venous blood in older children.


Heel stick neonatal blood collection
• These devices are designed to control the
depth of incision, since going too deep into an
infant’s heel could injure the heel bone, and
cause osteomyelitis (bone infection).


• Firmly grasp the infants foot.
• Do not use a tourniquet.
• The heel may be warmed with a cloth to help
increase blood flow.
• Wipe the collection site with an alcohol prep
pad, and allow the alcohol to dry.
• Wipe the site with sterile cotton or gauze, to
be sure all the alcohol has been removed.


• Puncture the left or right side (outskirt) of the
heel, not the bottom of the foot.
• Wipe away the first drop of blood since it may
contain excess tissue fluid or alcohol which
could alter test results.


• Collect the blood into the appropriate tube.
• Do not: Squeeze the infant’s foot too tightly
and wipe with alcohol during the collection


• After collection is completed, apply pressure
to the puncture site with a sterile gauze pad
until bleeding has stopped.
• Do not apply an adhesive bandage to an
infant’s foot since it may injure its delicate
skin.


Special
situations

• Patients refusing blood work
• Fainting
• Unsatisfactory Specimens
• Haemolysis
• Clots
• Insufficient volume
• Labeling Errors


Patients refusing blood work
• If someone hesitates to let you collect a blood
specimen, explain to them that their blood
test results are important to their care.
• Patients have a right to refuse blood tests
• If the patient still refuses, report and
document patient refusal


Fainting
• Rarely, patients will faint during
venupuncutre.
• It is therefore important that patients are
properly seated or lying in such a way during
venupuncutre so that if they do faint, they
won’t hurt themselves.
• self-limited


Signs and symptoms of fainting

• Weakness
• Lightheadedness
• Nausea
• Sweating
• Rapid breathing (hyperventilation)
• Dimming of vision
• Difficulty hearing or ringing in the ears


what to do

• Gently remove the tourniquet and needle
from the patients arm, apply gauze and
pressure to the skin puncture site.
• Call for help.
• If the patient is seated, place his head
between his knees.
• A cold compress on the back of the neck may
help to revive the patient more quickly.

If the patient is seated


Get him or her to lie down. (If they are in a situation or place where they really can't lie
down then sitting down is the next choice.)
Help restore blood flow to the brain by raising the person's legs above the level of the
head (about 30cm).
Once the victim is lying down, elevate his feet about 12 inches above the ground.


If someone faints:
– Check the ABCs (airway, breathing, circulation), and, if
necessary, begin CPR and call emergency medical services.
Continue CPR until help arrives or the person responds and
begins to breathe.
– If the person is breathing but unconscious, then put them
in the recovery position.
– Loosen constrictive clothing. The person should revive
quickly. If the person doesn't regain consciousness within
one minute, or if there are any serious injuries as a result
of falling from the faint, call for emergency medical
assistance. Also call immediately if there are symptoms of
stroke (e.g. slurred speech or difficulty moving a limb) after
fainting.
– Stay with the person while they are recovering. They may
feel tired or weak for several hours afterwards.


Recovery position


Unsatisfactory Specimens
• They can cause misleading laboratory results
• Must be rejected by the laboratory.
• The patient must then undergo another
venupuncutre to get a better specimen.
• It costs time & money to redraw the specimen.
• The credibility of the laboratory is reduced if too
many unsatisfactory specimens are drawn.


Haemolysis
• Haemolysis means the breakup of fragile red
blood cells within the specimen, and the
release of their hemoglobin and other
substances, into the plasma.
• A haemolyzed specimen can be recognized
after it is centrifuged by the red color of the
plasma.


Causes of Haemolysis
• Using a too small needle for a relatively bigger
vein
• Pulling a syringe plunger too rapidly
• Expelling blood vigorously into a tube
• Shaking a tube of blood too hard.


• Haemolysis can cause falsely increased
potassium, magnesium, iron, and ammonia
levels, and other aberrant lab results.


Clots
• Blood clots when the coagulation factors
within the plasma are activated.
• Blood starts to clot almost immediately after it
is drawn unless it is exposed to an
anticoagulant.
• Clots within the blood specimen, even if not
visible to the naked eye, will yield inaccurate
results.


Causes of Clots
• Inadequate mixing of blood and anticoagulant
• Delay in expelling blood within a syringe into a
collection tube
• Inadequate sample


Insufficient volume
• short draws will result in an incorrect ratio of
blood to anticoagulant, and yield incorrect
test results.
• Short draws can be caused by:
• A vein collapsing during phlebotomy.
• The needle coming out of the vein before the
collection tube is full.
• Loss of collection tube vacuum before the
tube is full.


Labeling Errors
• Labeling errors are the most common cause of
incorrect laboratory results.
• If detected, the incorrectly labeled specimen
will be rejected.
• If undetected, it will produce incorrect results
which might adversely affect your patient’s
care.


Causes
• Failure to follow proper patient identification
procedure.
• Failure to label the specimen completely and
immediately after collection.


Phlebotomy

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