Complications  of  Phlebotomy     Medical/Physiological  complications:                    Common  complications:     a.

) Syncope  (fainting)  –  results  from  insufficient   blood  flow  to  the  brain.   Causes:  fatigue,  a  sudden  decrease  in   blood  volume,  cardiac  arrhythmia,   hypoglycaemia,  hyperventilation     • For  individuals  who  are  having  their  blood   collected,  fainting  is  primarily  due  to   psychological  causes.   • If  a  patient  is  sitting  in  a  phlebotomy  chair  and   faints  before  venipuncture,  guide  the  patient’s   head  between  his/her  knees.   • A  cold  compress  placed  on  the  back  of  the  neck   is  also  helpful.   • It  is  also  a  good  idea  to  have  ammonium  salts   available,  but  these  can  be  very  strong  and   must  be  used  with  care.   • Once  the  patient  recovers,  have  him  lie  down.   • A  cool  drink  may  also  help.     b.) Hematoma     • Most  common  complication  from  phlebotomy.   • Occurs  when  the  needle  is  improperly  placed   in  the  vein,  allowing  blood  to  escape  from  the   vein  and  collect  under  the  skin.   • Primary  indication  is  swelling  around  the   venipuncture  site  while  the  needle  is  being   inserted.     c.) Short  Draw  or  No  Blood  Collected   • When  insufficient  blood  is  collected  in  a   given  tube  or  for  a  given  test.   • When  needle  is  in  the  vein  but  blood  flow  is   reduced  but  blood  flow  is  reduced,  the   needle  Bevel  may  be  against  the  vessel  wall.   Slight  manipulation  of  the  needle  will   remedy  this  problem.   • Suction  of  the  tube  vacuum  may  be  too   great,  causing  the  vessel  to  collapse.  In   these  cases,  smaller  tubes  or  syringes  may   be  used.   • Collapsed  veins  may  also  occur  if  the   syringe  plunger  is  withdrawn  too  quickly.   • Needle  is  not  inserted  far  enough.  Needle   may  be  below  the  skin  but  above  the  vein.  

Needle  may  have  been  inserted  through  the   vein.  

  Anticoagulated  tube  must  be  filled  to  the  proper  level.   Short  draw  will  alter  the  anticoagulant-­‐to-­‐blood  ratio,   producing  spurious  results.     Other  complications:     1. Petechiae  -­‐  small  red  dots  that  appear  on  the   skin  as  a  result  of  capillary  hemorrhage.   Capillaries  bleed  excessively  because  of  a   coagulation  problem,  generally  related  to   platelets.  Petechiae  can  also  be  the  result  of   tying  the  tourniquet  too  tight  and  leaving  it  too   long.  So  tourniquet  should  not  be  on  longer   than  1  min.       2. Edema  -­‐  results  when  excessive  fluid  collects  in   the  tissues  of  a  patient,  causing  swelling.     These  areas  should  be  avoided  because:   a.) It  is  often  difficult  to  locate  a  vein.   b.) Specimen  may  be  diluted  with  tissue  fluid,   which  could  adversely  affect  testing  results.     3. Excessive  bleeding  -­‐  phlebotomist  must  not   leave  a  patient  until  bleeding  has  stopped   following  venipuncture.     4. Intravenous  veins     5. Obesity  -­‐  veins  are  generally  deeper  and  cannot   be  seen.     6. Allergies     7. Damaged  or  scarred  veins  -­‐  look  for  alternative   site  and  if  none  can  be  located  microcapillary   procedure  should  be  considered.     8. Burned  areas  -­‐  should  be  avoided  as  they  are   very  susceptible  to  infection     9. Convulsions  –  rare,  simple  hysteria  causes  most   convulsions  in  phlebotomy  patients     10. Mastectomy  -­‐  venipuncture  should  be  avoided   in  the  arm  on  the  same  side  on  which  a   mastectomy  was  performed.  This  is  because  the   patient  may  be  susceptible  to  infection  on  that   1  

 

side  of  the  body  because  of  the  removal  of   lymph  nodes  with  the  breast.  In  double   mastectomy,  the  physician  or  nurse  should  be   consulted.     11. Nerve  Injury  -­‐  occasionally,  even  when  proper   technique  and  equipment  are  used,  a  patient   may  sustain  nerve  injury.  Signified  by  a   “shooting”  pain  in  the  forearm.  Nerves  may   overlie  the  vein  identified  for  phlebotomy.   Phlebotomy  should  be  discontinued   immediately.       The  following  may  increase  the  chance  of  nerve   injury:   1. Excessive  probing   2. Going  significantly  through  the  vein   3. Sudden  movement  by  the  patient  during   phlebotomy       Specimen  Collection  and  Processing  For  Hemostasis   Testing     A  nontraumatic  venipuncture  is  the  goal  any   time  blood  is  drawn,  but  probably  in  no  other  area  of   laboratory  testing  is  the  quality  of  the  sample  as   important  to  the  accuracy  of  test  results  as  in  studies   related  to  hemostasis.     Premature  activation  of  the  clotting  process  can  occur   before  the  sample  can  be  evaluated  in  the  test   procedures.     Causes:   1.) Contamination  with  tissue  thromboplastin  -­‐  It  is  a   potent  clot-­‐activating  substance  found  in  fluids   that  escape  from  injured  cells  and  tissue  spaces.   This  explains  why  capillary  blood  clots  faster.  It   activates  the  extrinsic  pathway  of  clotting  and   causes  erroneous  test  results.   2.) Contact  with  the  surface  of  an  inappropriate   specimen  container  -­‐  the  contact  factors   (prekallikrein  or  Fletcher  factor,  XII  and  XI)  will  be   activated  prematurely  by  contact  with  glass   causing  a  shortening  of  both  intrinsic  and  extrinsic   pathways.  Recommended  materials  are  plastic,   polystyrene  or  silicone-­‐coated  glass.     3.) Improper  temperature  -­‐  labile  factors  (V  and  VIII)   will  deteriorate  if  left  at  room  temp  for  an    

extended  period.  Cold  tends  to  activate  factors  VII   and  XI  prematurely.     4.) Hemolysis  -­‐  hemolyzed  red  cells  act  like  tissue   thromboplastin  in  activating  plasma  clotting   factors.  If  it  occurs  in  the  blood-­‐drawing  process,   technical  problems  are  usually  the  cause.     The  Effect  of  Hemolysis  on  Common  Tests   Test   Effect   Potassium   Increased  value   Magnesium   Increased  value   Chemistry   Aldolase   Increased  value   Lactate   Increased  value   dehydrogenase   May  invalidate   Blood  Bank   Antibody  screening   test;  specimen   rejected   Prothrombin  time   Increased  value  if   (PT)   severe   Hematology     Activated  partial   Increased  value  if   thromboplastin  time   severe     Causes  of  hemolysis:   1. Technical     • Vigorously  shaking  the  tube  of  blood   • Using  a  needle  that  is  too  small  (gauge  23)   • Drawing  too  hard  on  the  syringe  plunger  (this   collapses  the  vein,  creating  a  vacuum  and   causes  hemolysis  on  the  rbc)   • Expelling  blood  too  quickly  through  the  syringe   into  the  collection  tubes  (let  the  blood  flow  to   the  sides  of  the  tube)   • Allowing  the  specimen  to  overheat  (the  heat   causes  hemolysis   2. Physiological   • Transfusion  reaction   • Autoimmune  haemolytic  anemia   • Paroxysmal  nocturnal  hemoglobinuria   • Disseminated  intravascular  coagulation     Activated  Partial  Thromboplastin  Time  (APTT)  -­‐  used  in   monitoring  patients  with  anti-­‐coagulant  therapy.     Equipment:   1. Tourniquet   • Venous  stasis  occurs  if  it  is  applied  too  tightly   (>1  min)  

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  2. Needle   • Should  be  of  the  disposable  type  and  coated   with  polymeric  silicone.  (These  will  make  skin   penetration  and  vein  entry  smooth  and  easy   with  minimal  pain,  trauma  and  activation  of   coagulation  factors.     20  gauge  -­‐  most  commonly  used   19  gauge  -­‐  when  more  than  20  ml  is  to  be   drawn.   21  gauge  -­‐  pediatric  patients  or  those  with   narrow  or  small    veins.     3. Sample  containers   • Plastic  syringes  or  silicone-­‐coated  evacuated   tubes.   • Whenever  citrated  plasma  is  required  =  use   silicone-­‐coated  evacuated  tube  with  trisodium   citrate  (the  anticoagulant  of  choice)  ;  ratio  is   4:1  in  the  black  top  tube   • Samples  drawn  into  these  tubes  are   satisfactory  for  both  coagulation  and  platelet   function  studies     Anticoagulant  of  choice   • It  preserves  the  labile  clotting  factors  V  and  VIII   better   • The  most  satisfactory  for  platelet  aggregation   studies   • Citrated  plasma  samples  also  are  more  sensitive  to   the  effects  of  heparin;  therefore  they  are  preferred   for  tests  to  monitor  heparin  therapy.     Ratio  of  Anticoagulant  to  Blood   Standard  ratio  for  Citrate:   • Nine  parts  blood  to  one  part  anticoagulant  (9:1)   • This  ratio  is  satisfactory  for  specimens  with   normal  Hct.     • If  Hct  exceeds  0.50  L/L  (polycythemia;  normal  is   0.45)  or  there  is  incomplete  filling,  the  amount  of  

When  arterial  flow  or  venous  return  is   interrupted,  there  is  activation  of  the   fibrinolytic  system  and  clotting  factors.   To  minimize  such  stasis  and  the   hemoconcentration  that  also  develops.  The   tourniquet  should  be  released  as  soon  as  the   vein  is  entered  and  blood  appears  in  the   syringe  or  evacuated  tube.   Seraket  tourniquet  is  recommended.  

unbound  citrate  causes  a  false  prolongation  of   clotting  time,  especially  in  PT  and  APTT.     This  is  because  the  standard  amount  of  calcium  is   used  to  recalcify  the  plasma  must  inactivate   excess  unbound  citrate  in  addition  to  initiating   clotting  of  the  specimen.    The  same  can  be  said  for  underfilled  blood.  The   small  volume  of  plasma  also  contributes  to  excess   unbound  citrate.  

  3  remedies:   1.) Solve  for  the  correct  ratio  -­‐  Involves  repeat   extraction  and  recomputation  after  extraction.   2.) Increase  the  calcium  used  to  recalcify.   3.) Decrease  the  concentration  of  the   anticoagulant.     Most  practical  means  of  correction:  DECREASE  the   concentration  of  the  anticoagulant.     Under  normal  conditions,  the  citrate  in  the   evacuated  tube  is  enough  to  anticoagulate  half  of  the   normal  blood  volume.  If  you  have  high  Hct,  it  is   preferable  to  use  lesser  concentrations  of  citrate.     Coagulation  tests  are  more  sensitive  to  an   excess  of  citrate  in  the  plasma  (as  with  high  Hct.)and  an   underfilled  tube  than  to  an  excess  of  calcium  which   occurs  with  low  Hct  or  an  overfilled  tube.     Although  3.8%  (.29  molar)  Na  citrate  is  still   used,  3.2%  (.109  molar)  buffered  Na  citrate  has  been   adopted  as  the  standard  anticoagulant  for  coagulation   studies  by  the  NCCLS  (National  Committee  for  Clinical   Laboratory  Standards).  The  buffered  sodium  citrate  also   minimizes  the  effect  of  pH.     Buffering  of  the  citrate  solution  has  the  added   effect  of  stabilizing  the  pH  of  blood  samples  and   increases  the  stability  of  the  labile  clotting  factors.     • EDTA     o  Not  satisfactory  for  coagulation  testing   because  it  inhibits  the  fibrinogen-­‐thrombin   reaction.     o Also,  factor  V  is  not  stable  in  its  presence.     o Used  in  cell  counting  and  cell  morphology.           3  

 

Heparin     o An  organic  acid  (mucoitin  polysulfuric  acid)   that  acts  with  anti-­‐thrombin  III  and  inhibits   the  reactions  of  all  stages  of  coagulation.   o Not  used  for  collecting  blood  for  coagulation   studies  because  of  its  many  anticoagulant   actions   o But  it  may  be  the  anticoagulant  of  choice  for   platelet  retention  test.  

Testing  should  be  done  immediately  on  centrifuged   samples  because  the  buffering  effect  of  red  cells  is   lost  after  centrifugation.  Plasma  should  be  stored  at   4˚C  for  not  longer  than  2  hours.  

  Processing  and  Holding  Samples  before  Testing     Effects  of  pH:   1. Changes  in  pH  can  affect  values  by  causing   prolongation  of  clotting  times.   2. The  buffered  citrate  contained  in  evacuated  tubes   protects  samples  against  such  loss  also  red     3. Cells  have  a  buffering  effect  that  helps  to  stabilize   the  pH.   4. To  maintain  this  effect,  samples  should  remain  in   unopened  tubes  if  testing  is  not  done  immediately.   5. Normal  samples  collected  in  evacuated  tubes  and   stored  at  room  temperature  (unopened)  for  as   long  as  6  hours  show  no  significant  changes  in  PT   or  APTT.   6. If  you  separate  the  blood  sample  once  it  has  been   centrifuged,  you  have  to  use  it  within  2  hours.     Effect  of  Temperature:   1. If  samples  are  left  at  room  temperature  for  an   extended  time,  factors  V  and  VIII  are  likely  to   deteriorate.     2. Factors  VII  and  XI  tend  to  be  prematurely  activated   at  refrigerated  temperatures  (4˚C).       Centrifugation:   • For  most  coagulation  testing,  platelet-­‐free  plasma  is   required.       • Platelet-­‐poor  plasma  (PPP)  is  prepared  by   centrifuging  anticoagulated  blood  2000  x  g  for  10   min.     • Plasma  should  be  removed  immediately  with  a   plastic  or  siliconized  pipet  (glass  pipets  allow   premature  activation  of  contact  factors).     • Only  the  upper  ¾  should  be  aspirated  (do  not   disturb  ¼  plasma  portion).   • For  some  tests,  centrifugation  of  sample  at  2˚  to  4˚C   is  advisable.  Refrigerated  centrifuge  or  small   centrifuge  placed  in  a  ref  is  required.      

  Frozen  Samples:   • Samples  should  not  be  frozen  if  testing  can  be  done   within  2  hours  after  collection.  If  freezing  is   necessary,  it  should  be  done  rapidly  at  -­‐20˚C  or   lower  (rapid  freezing).   • Slow  freezing  can  cause  ice  particles  to  form  and   denature  the  clotting  proteins.  If  frozen  properly,   fibrinogen  is  stable  for  at  least  4  hours  after   thawing  and  survives  refreezing  and  thawing.        

Source:  Mrs.  Cinco   November  12,  2010       Encoded  by:     Manzano  and  Miro     Edited  by:   Yongco    

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