Journal Reading Phlebotomy
Laboratory QA
Blood Collection From Intravenous Lines:
Is One Drawing Site Better Than Others?
Giuseppe Lippi, MD,1* Paola Avanzini, PhD,1 Rosalia Aloe, PhD,1 Gianfranco Cervellin, MD2
Lab Med Spring 2014;45:172-175
DOI: 10.1309/LM2XCV5SQML1ONTM
ABSTRACT
Objective: Establish whether hemolysis in samples collected from
intravenous lines is influenced by catheterization site.
Methods: Blood was collected from all patients (67 total) admitted to
the emergency department the same morning, through a 20-gauge
catheter placed in a vein of the upper limb directly into an evacuated
blood tube. Serum was tested for hemolysis index by multi-wavelength
photometric readings.
Results: The frequency of hemolyzed specimens was 30% (20/67).
Hemolysis rate in median cephalic and basilic veins (17%) was
Spurious hemolysis, also known as in vitro hemolysis,
is the leading cause of unsuitable samples referred for
routine and urgent laboratory testing. Among the vari-
ous sources of spurious erythrocytes injury, collection of
blood specimens from intravenous lines (ie, catheters) is
commonplace in short-stay units such as the emergency
department (ED), where this practice is virtually unavoid-
able for a variety of organizational reasons, including faster
collection of blood and less discomfort due to additional
venipuncture procedures in alternative sites, especially
when serial testing is required (eg, for assessing the kinet-
ics of cardiac biomarkers).1 Several lines of evidence now
attest, however, that this practice is associated with a
nearly 6-fold higher risk of hemolysis.2 The catheter place-
ment site has been proposed as a factor associated with
the risk of hemolysis. In a study involving 204 blood speci-
mens collected in an ED, Burns and Yoshikawa found that
Abbreviations
ED, emergency department; HI, hemolysis index; RR, relative risk
Laboratory of Clinical Chemistry and Hematology, and 2Emergency
1
Department, Academic Hospital of Parma, Parma, Italy
*To whom correspondence should be addressed.
E-mail: glippi@ao.pr.it
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Nama : Ni Putu Sukma Sumantri Prabandari
Pembimbing : dr. Ida Ayu Putri Wirawati, Sp. PK (K)
Hari/tanggal : Jumat, 24 Mei 2019
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comparable to that of median anterobrachial vein but lower than
cephalic vein (29%; P =0.01), basilic vein (33%; P <0.01), and
metacarpal plexus veins (75%; P <0.01). Compared with median
basilic and cephalic veins, the relative risk of hemolysis was 1.4 from
median anterobrachial vein, 1.6 from cephalic vein, 1.9 from basilic
vein, and 4.3 from metacarpal plexus veins.
Conclusion: Drawing blood frocm catheters placed distally from
median veins carries higher hemolysis risk.
Keywords: preanalytical variability, hemolysis, sample quality,
catheter
hemolysis in samples collected from the antecubital fossa
was lower than in those collected distally to the antecubital
fossa (4% vs 18%), but no distinction was made according
to the type of collection (ie, straight needle venipuncture
versus collection from a catheter).3 In a study by Dugan et
al, blood was collected from 100 randomly chosen patients
through freshly placed peripheral venous access devices,
and the hemolysis rate was nearly 4 times lower in sam-
ples collected from veins of antecubital fossa than in those
drawn distally (ie, 9% versus 35%).4 However, the authors
used a heterogeneous set of venous access devices. To
clearly elucidate whether hemolysis in samples collected
from intravenous lines may be influenced by the catheter
site, we determined the rate of hemolysis in samples col-
lected from various catheterization sites in ED patients.
Materials and Methods
This investigation was conducted in a large urban ED at
the Academic Hospital of Parma, Italy. The study popula-
tion consisted of all patients admitted during the morning
of a single working day who required blood collection for
diagnostic purposes. Blood was collected by the 2 nurses
on duty the day of the study through a 1.0 mm x 3.2 mm,

Figure 1
Sites of catheter placing (n=67).
20-gauge catheter (Neo DELTA VEN, Viadana, MN, Italy;
ref. no. 1331), placed in a vein of the upper limb. Two 13
mm x 100 mm, 5.0 mL Vacutainer® SST II Plus serum
tubes (Becton Dickinson Italia S.p.A., Milan, Italy; ref. no.
367955) were collected using a conventional Becton Dick-
inson (BD) tube holder (BD Vacutainer One Use Holder,
Becton Dickinson). The investigation was specifically
planned on a single working day to eliminate daily varia-
tions in sample collection, handling, and analysis in the
central laboratory. The first tube filled was discarded; the
second filled tube was rapidly transported to the central
laboratory and centrifuged according to manufacturers’
specifications (1300 g for 10 min at room temperature).
Serum was tested for hemolysis index (HI) by bichromatic
readings at 410/480 and 600/800, along with the other
parameters requested by the physician, on a Beckman
Coulter DxC chemistry analyzer (Beckman Coulter Inc.,
Brea CA, USA). Hemolysis was defined as the presence
of a value of cell-free hemoglobin greater than 0.5 g/L.1
The statistical analysis, including Wilcoxon-Mann-Whitney
test (for continuous variables) and a Chi-squared test (for
categorical variables), was performed with Analyse-it for
Microsoft Excel (Analyse-it Software Ltd, Leeds, UK). The
relative risk (RR) was calculated using MedCalc Version
12.3.0 (MedCalc Software, Mariakerke, Belgium). All ED
patients provided an informed consent for participating
in this study, which was performed in agreement with the
ethical standards established by the institution in which the
www.labmedicine.com Spring 2014  |  Volume 45, Number 2  Lab Medicine 173
Laboratory QA
Median Median
Cephalic Basilic
(n=17; 25%) (n=6; 9%)
Median
Anterobrachial
(n=16; 24%)
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Cephalic
(n=14; 21%)
Basilic
(n=6; 9%)
Metacarpal
Plexus
(n=8; 12%)
experiments were performed and the Helsinki Declaration
of 1975.
Results
The study population consisted of 67 patients (36 females
and 31 males; mean age 56±8 years). Overall, 17 samples
were collected from median cephalic vein (25%), 6 from
median basilic vein (9%), 16 from median anterobrachial
vein (24%), 14 from cephalic vein (21%), 6 from basilic vein
(9%), and 8 from veins of metacarpal plexus (12%) (Figure
1). The overall frequency of hemolyzed specimens was
30% (20/67). The mean concentration of cell-free hemoglo-
bin was 0.1 g/L (95% CI, 0.0–0.2 g/L) in samples collected
from median cephalic vein, 0.1 g/L (95% CI, 0.0–0.3 g/L)
from median basilic vein, 0.2 g/L (95% CI, 0.0–0.5 g/L)
from median anterobrachial vein, 0.1 g/L (95% CI, 0.0–0.3
g/L) from cephalic vein, 0.8 g/L (95% CI, 0.0–2.5 g/L) from
basilic vein, and 1.5 g/L (95% CI 0.2–2.8 g/L) from veins of
metacarpal plexus.
The concentration of cell-free hemoglobin in samples
collected from the 2 median (ie, cephalic and basilic)
veins (n = 23; 0.1 g/L; 95% CI, 0.0–0.2 g/L) did not differ
significantly from that of samples collected from median
anterobrachial (P= 0.11) or cephalic veins (P= 0.22), but
Laboratory QA
4.5
4.0
Cell-Free Hemoglobin (g/L)
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
–0.5
Median Median
Cephalic Basilic
Figure 2
Concentration of cell-free hemoglobin in serum samples drawn from intravenous catheters placed in different veins of the upper limb.
The dotted line is drawn at the threshold of significant sample hemolysis.
was significantly lower than that of samples collected from
basilic vein (P= 0.02) and from veins of metacarpal plexus
(P< 0.01). Similarly, the frequency of hemolysis in samples
collected from median cephalic and basilic veins (4/23,
17%) was comparable to that of samples collected from
median anterobrachial vein (4/16, 25%; P= 0.08), but was
lower than that of samples collected from cephalic vein
(4/14, 29%; P= 0.01), basilic vein (2/6, 33%; P< 0.01) and
from veins of metacarpal plexus (6/8, 75%; P< 0.01) (Fig-
ure 2). As compared with samples collected from the two
median cephalic and basilic veins, the RR of obtaining he-
molyzed specimens was 1.4 (95% CI, 0.4 to 4.9; P=0.56)
in samples collected from median anterobrachial vein, 1.6
(95% CI, 0.5 to 5.5; P= 0.42) from cephalic vein, 1.9 (95%
CI 0.5 to 8.1; P = 0.38) from basilic vein and 4.3 (95% CI,
1.6 to 11.5; P< 0.01) from veins of metacarpal plexus.
Discussion
Several preanalytical activities, especially those directly re-
lated to collection of venous blood, play a substantial role
in decreasing the quality of the testing process.5 Among
the various causes of specimen rejection, spurious hemo-
lysis has been reported as the most common reason in
studies conducted in several different countries healthcare
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Median Cephalic Basilic Metacarpal
Anterobrachial Plexus
Catheter Placing
settings.1,6 Blood collection through intravenous lines is
commonplace in the ED and other inpatient care settings,
due to the efficiency associated with the use of a single ve-
nous access for both infusion of therapeutic solutions and
necessity for collecting multiple blood specimens. Never-
theless, this practice carries a high risk of erythrocyte dis-
ruption, reflected in the high rate of hemolysis.1,2
In our study, the rate of hemolysis was 30%. Although the
study included a limited number of samples collected from
the different veins of the upper arm, we found that the site
of catheter placement influenced the rate of hemolysis. Our
results suggest that healthcare providers and laboratory
professionals should be aware that collecting blood from
intravenous lines placed distally from the 2 median basilic
and cephalic veins may produce a higher rate of hemo-
lyzed specimens. Furthermore, collecting blood specimens
from veins of the metacarpal plexus should be avoided due
to the extremely high risk of erythrocyte disruption, which
is probably attributable to the large pressure differential
that may be exist between small veins, large needles, and
evacuated tube systems.1 Unlike many other studies,3,4 this
investigation involved blood specimens collected by only
2 nurses within a limited time period, which enabled us to
reliably compare the hemolysis rate among specimens col-
lected from different catheter placement sites, eliminating
many variables that may be introduced by technique. LM

Acknowledgments
The authors acknowledge nurses Maria Pia Carpi, Caterina
Colombo, and Davide Caputo for the skill assistance dur-
ing blood collection in the ED.
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Laboratory QA
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