EFFECT OF SQUEEZING ON THE FINGERTIP DURING CAPILLARY BLOOD

COLLECTION TO THE LABORATORY ANALYSIS RESULTS

James Perdinan Simanjuntak, Suzana Rahmatia, Rati Ruzlia Septi Giarti

Akademi Analis Kesehatan Provinsi Jambi, Indonesia
james.p.simanjuntak@gmailcom; suzanatia96@gmail.com

ABSTRACT
Introduction: Repeated finger prick is usually avoided for the patient’s convenience.
Therefore, excessive squeezing is often done in capillary blood collection to obtain a
sufficient number of specimens that may lead to changes in analyte concentration due to
dilution by the tissue fluid. The study aims to see the effect of squeezing treatment on
fingertip to the results of laboratory analysis. Platelet count and blood glucose level
were used in this study due to both are the most frequently performed test on capillary
blood.
Method: Platelet counts were performed on 10 participants, while blood glucose strip
test on 15 participants. Each test was carry out to five drops of blood from the same
punctured fingertip which were repeatedly squeezed to stimulate blood flow. The
measurements values resulting from the first blood drop are used as control. Data were
analyzed by Repeated Measures ANOVA and continued by an apropriate comparison
test.
Results: Up to the fifth drops, platelet count have decreased by 23.7%, whereas for the
glucose determination by 11.0%. The first drop results were significantly different
compared to the third drop for the platelet count, whereas on the fifth drop for the
blood glucose strip test.
Conclusion: The study concluded that the more repetitions of the squeezing treatment,
the results tend to decreased as well (p <0.01). The count of platelet cells should only
be performed on a second drop of capillary blood, while the determination of glucose
levels can still be done to the fourth drop of blood from the same punctured finger.

Key words: capillary blood, platelet, glucose level, blood dilution, milking

INTRODUCTION also been increasingly using this specimens

The examination of the capillary
blood has several advantages compared
with venous blood as it requires less
volume and the procedure can be done
easily and quickly. The factor of the
action taken is also the reason for
choosing this type of specimen, as it is less
invasive and causes less pain (1,2).
Some parameters of laboratory
analysis that apply both manual and
conventional methods have long been
using capillary blood as a test material,
especially in hematological analyzes such
as blood cell count and blood smear
examinations (3). Moreover, this method is
still use in some developing country,
especially in low-resource laboratories
and health care units around the world (4).
Currently, laboratory examination has
195
for the purpose of screening and diagnosis
of diseases. Along with the increasing
application of the Point-of-Care testing
(POCT) technique that is widely used in
many fields of medical laboratories, such
as immunoserology, parasitology and
clinical chemistry (5,6).
As well as venous blood
specimens, the application of capillary
blood collection procedures should also
be considered in order not to cause errors
in the analyzes performed. Deterioration
of these specimens may occur due to non-
adherence to procedures properly.
Excessive and repeated squeezing of the
fingers (milking) is not uncommon in
capillary blood collection. This action
should be avoided because it can cause
haemolysis and tissue fluid contamination.
 ASEAN Conference of Clinical Laboratory Sciences (ACCLS) 2018
Repeated squeezing on one fingertip is
often done to avoid re-puncturing on the
other fingertip if the number of blood
specimens obtained is not sufficient for
analysis requires (6,7,8).
Contaminated tissue fluid may
lead to changes in dilution of blood
specimens. This will obviously have an
impact on the change in the
concentration of some analytes in the
specimen, thus causing the results of the
analyzes to be inaccurate and unreliable
(6,9,10). However, other studies suggest
that dilution of blood, especially the
first drop, may result in contact with
alcohol that has not completely
vaporized (16). Meanwhile, some others
also stated that there was no difference
between the first and the second drop
in the determination of blood glucose
level (13,14).
There is no previous study have
observed the difference in the result of
blood cell examination based on the
number of blood drops. The authors
assume that the phenomenon will not
be the same if the two examination are
observed together. Knowing that the
metabolites are dissolved in plasma,
which is completely different to the
blood cells that insoluble and floating in
plasma.
The current study is aimed to
show changes in analytical
concentrations due to repeated
squeezing treatment, as described
above, to the results of laboratory
analysis. Based on the author’s
observation, in clinical laboratory
practicesand other health services,
platelet count examination and blood
glucose determination of striptest
method (glucometer) are examinations
that often use capillary blood as a test
material. Additionally, both of these
parameters have also been selected
because it is assumed to represent the
tests of two different medical laboratory
fields that generally apply quantitative
analysis, i.e. blood cell count
(haematology) and determination of
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metabolite concentration (clinical
chemistry).
METHODS
The study was carried out in
Hematology Laboratory and Chemical
Clinical Laboratory of Health Analyst
Academy of Jambi Province in August
2017. The examination was conducted
on blood samples obtained from 25
healthy participants who are staffs and
students of the Academy. All
participants were voluntarily involved
in the study and each required to sign a
consent form prior to perform blood
collection. Examination of platelet count
using tube method was carried out on
10 participants, while the other 15
participants were examined the blood
glucose level by strip test method.
Capillary blood collection
Dermal puncture is done on the
tip of the ring finger using safety lancet
devices after each participant was asked
to wash hands with soap and the tip of
the finger was disinfected using alcohol
swab (11). Each partisipant performed a
singel skin puncture and then five blood
drops were drawed by giving a
squeezing treatment at the fingertip to
obtain each drop of blood. Each
squeezing treatment was performed to
get a certain drop size about 5 mm in
diameter.
The first blood drop is directly
used as an examination specimen, not
wiped away as usually in routine
procedures, taken with a thoma pipette
or blood glucose test strip, according to
the test performed. The remaining
blood at the fingertips of the first
treatment is wiped using tissue paper.
The subsequent blood drops are
obtained and treated in the same
manner by repeating the squeezing on
the same fingertip until a fifth drop of
blood is obtained.
Platelet count
Platelet counts were performed
using tube method by diluting 10 L
 ASEAN Conference of Clinical Laboratory Sciences (ACCLS) 2018
capillary blood with 1990 L Rees Ecker
diluent solution. The blood that came
out from each treatment was taken
using a 10 L micropippete and dilution
was performed in five serological tubes
for each specimen. The number of
platelet cells microscopically observed in
Improved Neubauer counting chamber
in 25 group squares. Platelet count is
calculated by multiplying the number of
cells observed with an appropriate
dilution factor (x50). For each drop of
blood, the procedure is performed in
duplicate (duplo) using different set of
hemocytometer devices and the results
are reported as mean value of both
observations (103cells/mm3).
Blood glucose level
Determination of blood glucose
levels for each blood droplet was also
performed using two different blood
glucose monitoring deviceswith
appropriate test strips and coding chips.
Nesco Multycheck GCUHb Meter
(Nesco Medlab) and Accu-Chek active
(Roche Diagostic GmbH) are used in this
study. Each of these devices was
calibrated with a calibration strip from
each container prior to use with strips
from the same container, as outlined in
the manufacturer’s user manual. The
measurement results are calculated and
Table 1. Platelet count of capillary blood specimensobtained from repetition of
squeezing the punctured fingertips
T1 T2
Mean 164 159
SD 43 37
% Decreasing - 2,81
T = number of drop, unit = 10 cells/mm , n = 10, * p<0,01
3 3
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reported in the mean values of the two
devices (mg/dL).
Statistic analysis
Data of the examination results
are analyzed and descriptively presented
in tables form and graphs based on the
average value of each drop of blood, so
is the average and percentage of
decrease that occurs from each test and
each treatment. The hypotheses were
evaluated using ANOVA Repeated
Measures with 5% significance level (p
<0.05) and continued by comparison
test adjusted by the obtained coefficient
of variation value. The correlation
between each given treatments with the
observed values is interpreted based on
the Pearson correlation test value.
Statistical analysis is done by using
Minitab 17 software.
RESULT AND DISCUSSION
The resulting platelet counts in
this study showed a significant difference
according to each of the squeezing
treatment (p <0.01). The more
frequency of treatment given, the
platelet count for each drop of blood
also tends to decrease (Table 1). In
accordance to the comparison test
(DMRT test), the difference was
significantly found in the third blood
droplet if compared to the first.
T3 T4 T5
126 114 100
21 23 18
22,83* 30,28* 38,95*
 ASEAN Conference of Clinical Laboratory Sciences (ACCLS) 2018

250

200

T1
150
T2
T3
100
T4
T5
50

0
1 2 3 4 5 6 7 8 9 10

Figure 1. Bar graph for platelet count result of each participant

Of the 10 participants, according to the blood droplets, the result is entirely

results of each subject (Figure 1.),
although some subjects showed
fluctuating examination results, but
there appeared to be a decrease in
overall examination results. In the first
blood droplet there were only 2
subjects indicating the condition of
thrombocytopenia (<150 x 103cell
/mm3). The frequency of
thrombocytopenia increases by the
increase in the amount of blood drop
oozing out from the prick after repeated
squeezing treatment. In the second
blood droplet, the condition of
thrombocytopenia increased to 4
subjects; third drop of blood into 8
subjects; as well as the fourth and fifth
.
thrombocytopenia.
The mean values of blood
glucose levels measured in this study
also indicate a significant difference
from each treatment (p <0.01) (Table
2). Blood drops obtained from higher
frequencies also tend to decrease,
although not as much as the decreasing
occured in platelet count values. By
comparingthe results with the first blood
(DMRT test), the results on the second,
third and fourth blood drops have not
shown any significant difference in
results. Comparison test showed that the
only difference is found in the fifth drop
of blood resulting from the squeezing of
the same punctured fingertip

Table2. Glucose level of capillary blood specimens obtained from repetition of

squeezing the punctured fingertips

T1 T2 T3 T4 T5
Mean 135 128 124 121 109
SD 69 74 71 67 52
% decreasing - 4,98 8,04 10,16 19,63*
T = number of drop, unit = = mg/dL, n = 15, * p<0,01

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 ASEAN Conference of Clinical Laboratory Sciences (ACCLS) 2018

350

300

250
T1
200 T2
T3
150
T4
100 T5

50

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Figure 2. Bar graph for blood glucose determination results of each participant

Because of there are only 2 participants blood drop (Fig. 2). However, other
who have abnormal levels hyperglycemic subject (15th participant)
(hyperglycemia), the results in this study showed overall results from blood drops
can not be used to interpret as in the that remained in the hyperglycemia
observation of platelets. By investigating category. For 13 other participants,
data from one of hyperglycemic subject some of their blood glucose levels were
(14th participant), the hyperglycemic still in the normal category for random
status became normal when glucose (<200 mg/dL7 p.13).
examination is performed to the fifth
200

180
y = -17,26x + 184,5
160

140
y = -6,0067x + 141,65
120

100

80
T1 T2 T3 T4 T5

Platelet (10^3sel/mm3) Glucose (mg/dL)

Figure3.Line graph of the mean values decreasing of each parameter

The tendency of the graphic lines in
Figure 3 formed to look different and
can be used to illustrate the difference
changes in analytical concentration
199
obtained of test results. The decrease of
graphic lines formed from the results of
platelet count appears to decline
sharply, especially at the third blood
 ASEAN Conference of Clinical Laboratory Sciences (ACCLS) 2018
drop, while for the decline graph line of
glucose level tends to look not too
sharp, even it seems tend to be more
horizontal. This study was designed
to investigate the relationship between
the squeezing treatment of the fingertip
and the result of laboratory analysis,
represented by both examination
performed. From the interpretation of
the r value of the Pearson correlation
test (performed by Minitab 17
software), it is known that the
repetition of squeezing the fingertip
have a very weak correlation (r = -
0.129) to the determination of blood
glucose levels, whereas for the platelet
count can be interpreted that there is a
strong correlation between the
treatments and the test results (r = -
0.644).
The results differ from those of
Hortensius J, et.al (12), who reported that
the glucose levels from second blood
droplets gave significantly lower results
than the first blood drops. The
squeezing (milking) treatment on
capillary blood collection was also
carried out in the study and is believed
to be cause of thechanges in measuring
glucose levels. While in the study
conducted by the authors, the difference
results between first blood drops and
second blood drops were not signifant
in the measurements of these two
examination. Even for the measurement
of glucose levels, the difference was
only discovered in the fifth blood drop
drawed from the same fingertip after
repeated squeezing treatment.
In accordance with research by
Foos, JE (13) and Saini S, et.al (14), the
authors also concluded that the number
of blood drops did not cause differences
in the results of the glucose
determination. But the two studies only
do a comparison of glucose levels
resulting from the first blood drops and
the second blood drops alone. The
authors in this study proved that the
results were similar to previous studies
are still found until the fourth blood
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droplet for the determination of blood
glucose levels.
In addition, the study also showed
that the results of the platelet count also
did not show a significant difference
between first blood drops and second
blood drops. But unlike the
determination of blood glucose levels,
the platelet count proved to give
different results if done against a third
blood droplet. There were no previous
similar studies in the field of hematology
to compare with the results obtained by
the authors, but these results are
assumed to be the same if applied to
other hematological test parameters,
especially in blood cells count.
Generally, procedure of capillary
blood collection is always
recommended to wipe the first drop of
blood and using the second drop as a
laboratory test specimens. The use of
the first blood droplet is not
recommended because of the possibility
of haemolysis due to contact between
the first blood out with alcoholic liquid
which may still remain from the
disinfection process of the punctured
site. Ferreti J, and Martin KD (15) in their
study reported that the use of alcohol
remaining at the punctured site causes
the capillary blood glucose value to be
lower.
Haemolysis may also occur in
capillary blood specimens and may
cause changes in analytic concentration
in the blood. Unlike venous blood,
hemolysis in capillary blood is very
difficult to detect. Hemolysis can also be
caused by excessive and repeated
squeezing (milking) at the punctured
site. This milking action can also lead to
dilution of blood samples by
extracellular fluids (6,9,10).
The reason for not using the first
blood droplet as a test material is due to
the first blood comes out after the
punctured is more diluted by the tissue
fluid, albeit in very small amounts. As
described above, the first drop of blood
from punctured fingertip also tend to be
contaminated with alcohol, so it should
 ASEAN Conference of Clinical Laboratory Sciences (ACCLS) 2018
be diluted as well (16). But in this study
we found the result of both
examinations showed that all of the first
drops give a higher mean values than
the subsequent drops.
Nonetheless, the glucose levels in
the blood are similar to the levels of
glucose in the tissue fluid, so as not to
cause a change in the results of blood
glucose levels (10). It explains how in this
study the authors have just found the
significant differences at the fifth drop
for blood glucose examination. But not
for platelet count, the third drop has
already shown a significally lower result
due to dilution by tissue fluid that may
lead to a decreasing impact in the ratio
of cells and plasma. The leakage of
tissue fluid is oozed by the action of
squeezing and milking and even more
over if it is repeated.
A strength of our study is on the
treament of squeezing or milking the
fingertip. Compared to those previous
studies, we do more treatment to obtain
at least five drops of blood from a single
punctured finger. The main investigation
is at the subsequent drops after the
second. As we know, in the medical
practice, sometimes health care
professionals (physician, nurse,
phlebotomist or laboratory personnel)
preferred not to re-prick the finger if the
second drop of blood is insufficient for
the test, but they squeezed the fingertip
to stimulate the blood flow.
The result and conslussion can
only be stated for the specific methods
and devices that used in this study. As
well as the level of blood glucose and
platelet count which were generally at
the certain ranges. Squeezing treatment
was only standardized by diameter size
of blood drop obtained individually
which not really measured properly.
The tense of squeezing may vary
depend on the thickness of fingertip and
the depth of pricking.
CONCLUSION AND IMPLICATION
Based on the results of this study
it can be concluded that repeated
201
squeezing on the fingertips may affect
the results of analytical examination in
capillary blood specimens primarily due
to dilution by tissue fluid. However,
some blood droplets may still be
drawed to obtain the examination
sample, but it must be adjusted to the
type of examination performed. In the
examination of capillary blood samples
the use of fourth blood droplet is still
recommended for the determination of
blood glucose levels, but platelet count
should only be done to the second
blood droplets only.
Capillary blood collection has
many sources of pre-analytic error.
Squeezing the fingertip has been shown
to have an impact on the blood testing
result that may cause another unwanted
errors in diagnostic. Furthermore, it may
creat over investigation or inadequate
treatment that can lead to more
uncomfortable to the patient. In medical
practice, especially in laboratory service,
to increase patient safety is the target of
quality goal, but it is also important to
be aware of any changes that may
increase laboratory errors.
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