Considerations in Blood Collection 1. The “X” indicates stopper colors that may be drawn.

IF MORE THAN ONE STOPPER COLOR IS INDICATED CHECK WITH YOUR CLINICAL FACILITY FOR PROPER TUBE. 2. More than one test can be done on a tube. For example if a CBC and Retic count are ordered BOTH can be done on the same tube of blood. 3. The order of the draw MUST be followed to prevent additive carry over which will severely compromise the results of laboratory tests sterile blood cultures, light blue, red, purple, green, gray. IF ONLY A LIGHT BLUE NEEDS COLLECTING AND YOU ARE USING A BUTTERFLY A DISCARD TUBE MUST BE DRAWN SO THAT TUBE WILL NOT BE UNDERFILLED. 4. Correct Specimen Volume: a. All blood collection tubes need to be filled to the correct volume this will ensure the proper amount of blood for the amount of additive in the tube (blood to additive ratio). b. For example, if a 5 mL draw heparin tube is only filled with 3 mL of blood, the heparin concentration is erroneously high and may potentially interfere with some chemistry analytes. c. Expiration dates should also be checked on the evacuated tubes. d. Expired tubes should not be used, as they may have a decreased vacuum, as well as potential changes in any additives in the tubes. e. Light blue and black tubes MUST be completely filled. These tubes require a specific blood to additive ratio, failure

to completely fill WILL cause the sample to be REJECTED as accurate results CANNOT be obtained.. 5. Tourniquet Application and Time a. The tourniquet should be applied approximately three to four inches above the venipuncture site. The tourniquet should be on the arm no longer than one minute. b. A good rule of thumb to determine the one-minute tourniquet time is to remove the tourniquet when blood starts to flow into the first tube of blood being drawn. c. Prolonged tourniquet time can lead to an false increase in various chemistry analytes, including serum protein, potassium, total protein, aspartate aminotransferase (AST), total lipids, cholesterol, iron and lactic acid due to hemoconcentration of blood at the puncture site. 6. Maintain microtainers and vacuum tubes in an upright, vertical position. This is done to for two purposes: a. Promote clot formation, if required and b. Reduce possibility of hemolysis. 7. Each lab department will establish their own guidelines for rejection of samples for the laboratory taking into consideration the following factors: a. Discrepancy between specimen and lab requisition, mislabeled samples CANNOT be accepted. b. Failure to write date, time and/or initials of phlebotomist - NEVER LABEL SOMEONE ELSE’S TUBES, your initials verify that YOU collected the sample. If any lawsuit is filed based on the results from the tubes the person whose

initials appear on the tube WILL BE THE ONE SUED. c. Unlabeled tubes -DO NOT BEG TO COME AND LABEL TUBE, once tube leaves bedside the legal chain of custody has been broken and the tube MAY NOT BE LABELED OR CORRECTED. d. Hemolyzed specimens - usually do to IMPROPER COLLECTION TECHNIQUE, too small of a needle, drawing from a line, pulling too hard on the plunger of the syringe - HEMOLYSIS ADVERSELY AFFECTS LABORATORY RESULTS AND CANNOT BE USED. e. Wrong tube collected. f. Outdated supplies used. g. Contaminated specimens. h. Quantity Not Sufficieint (QNS)-inadequate volume i. Anticoagulated samples that are clotted- GENTLY mix as soon as the tube is filled, transfer blood from a syringe IMMEDIATELY, do not lay it down and do other things. j. Improper transport i. time-some samples must be tested or separated IMMEDIATELY after collection ii. temperature-some samples MUST be kept cool or warm after collection iii. light exposure-some samples MUST be protected from the light to prevent false decrease in analyte. k. Timed sample drawn at wrong time 8. Many tests require special handling requirements. Refer to the following chart. Handling Tests ordered Chilled samples $ place in ice slurry IMMEDIATELY upon

collection, failure to do so will result in REJECTION of blood sample. $ Some tests require collection vial to be chilled prior to collecting. $ If not chilled the results of the test will be invalid and patient may not be properly treated. $ blood gases, $ gastrin, $ ammonia, $ renin $ angiotenson $ lactic acid, $ catecholamine, $ parathyroid hormone, $ ACTH $ glucagon. Warmed samples- samples which require warming that are submitted at room temperature MUST be rejected $ cold agglutinins and $ cryoglobulin. Protect from light $ Failure to protect from light will result in falsely decreased values

$ Collect in amber tube to protect from light. $ If amber tube unavailable place in box, wrap on foil $ bilirubin, $ vitamin B12, $ carotene, $ folate $ urine samples for porphyrin determina tion. Test Yellow Lt. Blue Red Green Lavender Gray Black Tan Royal Blue Blood Culture X Coagulation Tests Prothrombin Time (PT) X Partial Thromboplastin Time (PTT) X Thrombin Time (TT) X Fibrinogen X Fibrin degradation products (FDP) X Activated clotting time (ACT) X D-dimer X Cryofibrinogen - Whole blood must be drawn in a prewarmed (37C) syringe and kept at 37C. Immediately after collection, transfer blood to pre-warmed (37C) 3.5 mL (sodium citrate) light blue top tube. Keep at 37C until separated from cells.

X Factor Assays X Test Yellow Lt. Blue Red Green Lavender Gray Black Tan Royal Blue Hematology Complete Blood Count (CBC) X Hemoglobin X Hematocrit X White blood cell (WBC) count X Red blood cell (RBC) X Platelet Count X Differential X Erythrocyte Sedimentation Rate (ESR) X Reticulocyte (Retic) Count X X Hemoglobin A1C X Eosinophil count X Sickle cell test X Chemistry Glucose Levels X Blood Alcohol Levels X Lactate X Bicarbonate X Comprehensive Metabolic Panel (CMP) Old name Chem 12, SMA 12, SMA 20, SMAC Include the following tests. Glucose level, electrolyte and fluid balance, kidney function, and liver function. http://www.labtestsonline.org/understanding/analytes/cmp/cmp.html

$ Glucose X X $ Calcium X X $ Albumin X X $ Total Protein X X Electrolytes * Sodium * Potassium * CO2 (carbon dioxide, bicarbonate) * Chloride XX $ Blood Urea Nitrogen (BUN) X X $ Creatinine X X $ ALP (alkaline phosphatase) X X $ ALT X X $ AST X X Test Yellow Lt. Blue Red Green Lavender Gray Black Tan Royal Blue $ Total Bilirubin-Protect specimen from light. X X Basic Metabolic Panel Old Name Chem 7, SMA 7 Include the following tests: glucose level, electrolyte and fluid balance, and kidney http://www.labtestsonline.org/understanding/analytes/bmp/bmp.html $ Glucose X X $ Calcium X X Electrolytes * Sodium * Potassium function.

* CO2 (carbon dioxide, bicarbonate) * Chloride XX $ Blood Urea Nitrogen (BUN) X X $ Creatinine X X Other Chemistry Tests Uric Acid X X Lactate Dehydrogenase (LD or LDH) X X Gamma-Glutamyltransferase (GGT or GGTP) X X Amylase X X Triglycerides X X Cholesterol X X Low Density Lipids (LDL) X X High Density Lipids (HDL) X X Iron X X Total Iron Binding Capacity (TIBC) X X Creatine Kinase (CK) X X LD Isoenzyme Panel X X Albumin X X Digoxin-Collect 5-7 hours after administration of last dose. X Dilantin -Collect immediately prior to next dose. X X Vancomycin X X Gentamycin X Phenobarbital X X Theophylline X Lithium X X Theophylline X X

Tobramycin X X X Test Yellow Lt. Blue Red Green Lavender Gray Black Tan Royal Blue Cyclosporin - Draw just prior to morning dose for trough level or two hours post dose. XX Hemoglobin Electrophoresis X Lead ACTH - *PLACE IN ICE SLUSH* X ADH X Alcohol- Prepare venipuncture site with betadine or soap and water. XXXX Aldosterone - Patient must be in upright position (sitting or standing) for 30 minutes prior to blood draw. XX Aluminum Red Ammonia -*PLACE IN ICE SLUSH* X X Arsenic Lav Lead X Lav B Type Natriuretic Peptide (BNP) X Carotene (FASTING) X X Glucagon -*PLACE IN ICE SLUSH* X Catecholamines-*PLACE IN ICE SLUSH* Because venipuncture stress elevates catecholamine levels, for truly basal levels, samples should be collected a minimum of 30 minutes after resting with the patient supine. Patient

preparation: 12-14 hour fast prior to collection. X Carcinoembryonic Antigen (CEA) X Ceruloplasmin X Chromium Red Cold Agglutinin (KEEP WARM) - NO Gel X Copper Lav Zinc-Do not let specimen come in contact with glass, metal or rubber. Lav Manganese X Lav Platinum Red Selenium Lav Cortisol - Optimal blood collection times to evaluate diurnal variation are 8:00 AM or 4:00 PM X Cryoglobulin - Keep Warm -The accuracy of this test is greatly compromised if blood is at < 37 degrees during 90 minute period after collection. X Test Yellow Lt. Blue Red Green Lavender Gray Black Tan Royal Blue Renin Activity-Cannot test patients that have received radioisotopes within the past 48 hours. Renin levels are affected by high sodium diet. Patient should be in upright (sitting or standing) or supine position for 30 minutes prior to blood draw. Patient's posture during blood draw (upright

or supine) should be noted. Stability: No more than 4 hours on cells at ambient temperature; NEVER refrigerate. X Estrogen X X Angiotensin X Folate, Serum X Folate, RBC X X Follicle Stimulating Hormone (FSH) X Progesterone X X Testosterone T3 Triiodothyronine X X T4 Thyroxine X X thyroglobulin X X Thyroid Antibodies X Parathyroid Hormone *PLACE IN ICE SLUSH* X Thyroid Stimulating Hormone (TSH) X X X Gastrin-10 hour fast and no radioactive isotopes therapy 48 hours prior to collection. X HBsAb (Hepatitis B Surface Antibody) X X HBsAg (Hepatitis B Surface Antigen) X X HCG X X HCV Antibody (Hepatitis C Antibody) X X Herpesvirus 6 Human IgG & IgM Abs X X X X HIV 1 & 2 Antibody Screen X X X X X HIV Viral Load White Ketones X X

Lipase X X Magnesium X X Myoglobin, Serum X X Osmolality X X Phosphorus X X Porphorins - Protect specimen from light. X X Test Yellow Lt. Blue Red Green Lavender Gray Black Tan Royal Blue Porphobilinogen - Protect specimen from light. X Serotonin-patient should avoid avocados, bananas, eggplant, pineapple, plums, tomatoes or walnuts for a 48 hour period prior to collection. X Serology C-Reactive Protein X X Cytomegalovirus CMV X Epstein Barr Virus (EBV) X Lyme Antibodies, IgG, IgM X Rheumatoid Factor X RPR X X Rubella X Streptozyme X Mono test X Blood Bank - Tube drawn will depend on clinical site, some sites have special armband ABO/D Type (ABO/Rh) X Pink Type and Screen (Indirect Coombs Test) X Pink

Crossmatch X Pink Direct Coombs Test or Direct Antiglobulin Test (DAT) X Elution X Kleihauer Betke Stain X References 1. http://uh.edu/admin/hc/Blood_Chem.html 2. http://www.webmd.com/hw/lab_tests/tu6207.asp 3. Activated Clotting Time http://enw.org/Research-ACT.htm 4. Phlebotomy Services

http://som.ucdavis.edu/departments/pathology/clinical/phlebotomy_services ORDER OF DRAW IS INCORRECT 5. Test Directory - Excellent reference for looking up tests by alphabetical order http://referencelab.clevelandclinic.org/DBSearch/Search.htm 6. ARUP Guide to Clinical Laboratory Testing Excellent reference for looking up tests by alphabetical order http://www.aruplab.com/testing/lab_testing.jsp 7. Pre-Analytical Considerations in Blood Collection http://www.columbia.edu/itc/hs/medical/selective/AdvClinicalPathology/2005/lect ure/PreAnalyticalLectureColor_Fink.pdf 8. Preanalytical Variables in the Chemistry Laboratory

http://www.bd.com/vacutainer/labnotes/Volume15Number1/ 9. BLOOD COLLECTION: ROUTINE VENIPUNCTURE AND SPECIMEN HANDLING http://medlib.med.utah.edu/WebPath/TUTORIAL/PHLEB/PHLEB.html GENERAL BLOOD COLLECTION

TUBE REQUIREMENTS TEST TUBE TEST TUBE TEST TUBE TEST TUBE ABO Type *** Pink Cortisol R or Y HCG screen & quant R or Y PSA Y, R (only) Acid Phosphatase R or Y FDP or D-dimer B HIV (signed consent) R or Y PT, APTT (PTC & PTV) B AFP R or Y C-Reactive Protein (CRP) R or Y IgG, IgM, IgA, IgE R or Y Progesterone R or Y Albumin LG or Y Ca19, Ca 125 R or Y Iron Profile (Fe, TIBC, %sat) LG or Y Rast or Allergy R or Y Alcohol (!use non-alcohol wipe) R or G Crossmatch*** R & L Lactic Acid G Reticulocyte Count L Alkaline Phosphatase R, LG or Y Cytomegelovirus (CMV) R or Y Lead L Rheumatoid Arthritis R or Y Ammonia L (on ice) Drug Levels* - all types R or LG LDH LG or Y RPR R Amylase LG or Y Drug Screen R Legionella Y or R Rubella Screen R or Y ANA R Electrolytes R, LG or Y Lipase LG or Y Sed Rate (ESR) L Anticardiolipin Ab R or Y Epstein Barr Ab R or Y Lipid Profile or Coro (Chol, Trig, HDL, LDL) LG or Y Serum Electrophoresis (SPEP)

R or Y ASO R Ferritin R, LG or Y Lithium R or Y Serum Immunoelectrophoresis (SIEP) R or Y Bilirubin (Total & Direct) R, LG or Y Fibrinogen Levels B Liver Profile LG or Y SGOT (AST) or SGPT (ALT) LG or Y BUN, Creatinine R, LG or Y Folate (Folic Acid) Y or R Lupus Type Anticoagulant* LTA 3B & R or Y (pediatric tubes 6B) BNP L Calcium R, LG or Y Comprehensive Metabolic Panel – CMP or General Chem R, LG or Y Lyme (Progressive) R or Y TSH, T3, T4 R or Y Carboxyhemoglobin LG/Do not spin GGT R, LG or Y Magnesium LG or Y Free T4 R or Y Cardiac Enzyme Profile (CK,CKMB,Troponin) LG Glucose LG, G or Y Mononucleosis Screen R Total Protein

LG or Y CBC L Glycohemoglobin (HbA1C) L Osmolality R, LG or Y Testosterone R or Y CEA R or Y Hemoglobin & Hematocrit (H&H) L Phosphorus LG or Y Troponin I LG Cholesterol, Triglycerides LG or Y Hemoglobin Electrophoresis L Platelet Count L Type and Screen*** Pink CD4/CD8**** Rm Temp/Same Day/Before 2:30 1 10ml GR and IL Heparin Assay (XA) Freeze/Deliver to Lab within 1 hour B (on ice) OB Panel 2L,2R,2Y Uric Acid LG or Y Cold Agglutinin (keep warm) R Hepatitis Profiles – All R or Y Basic Metabolic Panel - BMP or Profile 7 (consists of: BUN, CR, CA,Glu,Lytes and Bicarb) LG, Y Vitamin B-12 Y or R

CODES AND ORDER OF THE DRAW B - Light BlueTop (Tube must be full!) R - Red-Top Tube Y – Yellow Top Tube (Corvac)** LG – Light Green Top Tube GR – Green Top Tube L – Lavender or Pink Top Tube G – Grey Top Tube *Refer to lab manual for special instructions. **Can substitute Red Top for Yellow Top. ***Date, Time, User’s Initials on tubes and #13 BB Slip ****Obtain tube from Lab

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