PRE-ANALYTICAL CONSIDERATIONS

IN PHLEBOTOMY
 LEARNING OUTCOMES
At the end of this lesson, the students must be able to:
1. Enumerate the physiological variables that influence
laboratory test results and identify the tests most affected
by each one;
2. Identify problem areas to avoid in site collection, give causes
for concern, and describe the procedure to follow when a
difficult situation occurs;
3. Specify the various vascular access sites and devices and
illustrate what to do when they are encountered;
4. Explain how to handle patient complications associated with
blood collection;
5. Spell out how to avoid or handle procedural error risks, and
reasons for failure to draw blood; and
6. Discuss appropriate specimen quality.
OVERVIEW OF PRE-ANALYTICAL PHASE OF TESTING
✓ The pre-analytical testing phase includes procedures such
as laboratory handling and identification which takes
place prior to any laboratory testing.
✓ It is in this phase where proper control measures are
placed to avoid subsequent issues. This starts when the
doctor's order is given and ends when the laboratory
testing has officially commenced.
OVERVIEW OF PRE-ANALYTICAL PHASE OF TESTING
✓ the phlebotomist should also possess the skill of being
able to identify factors that affect the process and
address the same as needed.
✓ The laboratory test is used by physicians to diagnose and
monitor the presence of a disease.
✓ In phlebotomy, the basal state is ideal in establishing
reference range since it represents the condition of the
metabolism of the body early in the morning or after
approximately 12 hours of fasting.
PHYSIOLOGICAL VARIABLES

Listed are some of the factors that affect blood collection:

Variable Effect
Age Red Blood Cells (RBC), White Blood Cells (WBC), creatinine clearance
Altitude Red Blood Cells (RBC)

Hemoconcentration, Red Blood Cells (RBC), enzymes. Iron (FE), Calcium (Ca), Sodium
Dehydration
(NA)

Diet Glucose, lipids, electrolytes

Diurnal Variation (Thyroid Stimulating Hormone) TSH, cortisol, Iron (Fe)
Drug Therapy Enzymes, hormones

(Potential of Hydrogen) pH, Carbon Dioxide Partial Pressure (PCO2 ), Creatinine Kinase
Exercise/IM Injection
(CK), Lactic Acid Dehydrogenase (LDH), glucose

Fever Hormones, cortisol

Gender Red Blood Cells (RBC), Hemoglobin (HgB), Hematocrit (Hct)
Jaundice Yellow color interfaces due to increased Biliburin
Intramuscular Injection Creatine Kinase (CK) and the skeletal muscle fraction of LDH
Position Protein, Potassium (K)
Pregnancy Red Blood Cells (RBC)
Smoking Chol, cortisol, glucose, GH, triglyceride, White Blood Cells (WBC)

White Blood Cells (WBC), Iron (Fe), Adrenocorticotropic Hormone (ACTH), catecholamine,
Stress
cortisol

Temperature and Humidity Hemoconcentration

PROBLEM AREAS AND TROUBLESHOOTING IN THE
SITE SELECTION
1. Burns, Scars, & Tattoos - a site which has burns, scars or
tattoos is not recommended because veins in the area
may be difficult to examine and blood circulation maybe
impaired. Burns may be too painful to touch and tattoos
may also be susceptible to infection due to the dyes used
that may interfere with the process.
PROBLEM AREAS AND TROUBLESHOOTING IN THE
SITE SELECTION
2. Damaged Veins -aside from encountering difficulty in
puncturing the site when veins are damaged another
problem is the possibility of getting inaccurate results. Veins
could be Sclerosed or hardened or Thrombosed or clotted.
PROBLEM AREAS AND TROUBLESHOOTING IN THE
SITE SELECTION
3. Edema - which is also known as Oedema, is an abnormal
swelling caused by accumulation of fluid in the tissues. The
tissues become fragile, making the task of locating the veins
harder. This condition maybe due to reactions from
medications, pregnancy, infections and other medical
problems.
PROBLEM AREAS AND TROUBLESHOOTING IN THE
SITE SELECTION
4. Hematoma - a solid swelling or mass of blood in the
tissues which is caused by the leakage of blood from the
vessels during venipuncture. This is not only painful because
it obstructs the blood flow it could also lead to the
contamination of blood sample.
PROBLEM AREAS AND TROUBLESHOOTING IN THE
SITE SELECTION
5. Mastectomy - a treatment for breast cancer that requires
removal of the breast through surgery. Blood drawing
becomes a challenge since the lymph flow is obstructed, and
there maybe swelling and infection after the surgery. In
addition, tourniquet cannot be applied because it can cause
injury. It should also be noted that it could also change the
blood composition.
PROBLEM AREAS AND TROUBLESHOOTING IN THE
SITE SELECTION
6. Obesity - the individual is grossly overweight. Patients that
are obese have veins are deep and they are harder to locate.
A solution is to use a longer tourniquet or try locating the
cephalic or cubital vein.
VASCULAR ACCESS SITES AND DEVICES
There are cases when a patient require the use of Vascular
Access Devices (VADs) for blood sampling, infusing
medication, central venous pressure readings and blood
transfusion. The choice of vascular access sites is based on
the needs of the patient, the purpose and length of time it
needs to remain in the body. Listed are vascular access sites
and devices used in phlebotomy:
VASCULAR ACCESS SITES AND DEVICES
Arterial Line
To obtain samples for arterial blood gas and laboratory
studies, critically ill patients require arterial lines where a thin
catheter is inserted into an artery. This also used to monitor
blood pressure continuously. Neither tourniquet nor
venipuncture are allowed in the arm with an arterial line.
VASCULAR ACCESS SITES AND DEVICES
 Arteriovenous Shunt or Fistula
An arteriovenous shunt or fistula is a passageway created
thru surgery which is usually in the arms with the intention
of connecting the artery and a vein directly. This maybe
created for hemodialysis treatment or pathological process
such as erosion of arterial aneurysm.
VASCULAR ACCESS SITES AND DEVICES
Blood Sampling Device
A blood sampling device is used to avoid the use of needle
sticks, reduce infections, and reduce wastage from line
draws. The device collects blood from the arterial or central
venous catheter where it is connected.
VASCULAR ACCESS SITES AND DEVICES
The heparin or saline lock,
which is commonly called a "hep-lock," is an intravenous (IV)
catheter attached to a stopcock or cap with diaphragm. The
basic function is to provide access for administering medicine
or drawing blood from the patient. This is threaded in the
peripheral vein which is in the lower arm above the wrist for
up to 48 hours. It is usually flushed with heparin or saline (to
prevent clogging) and capped for future use.
VASCULAR ACCESS SITES AND DEVICES
 Intravenous (IV) Sites
An IV line is a thin plastic tube or catheter inserted into a
vein in the forearm to inject a volume of fluids into the
bloodstream. The phlebotomist should avoid collecting blood
from the arm with IV because the blood collected could be
contaminated with IV fluid. If blood collection is necessary,
collection site should be below the IV. Take note that
collection of blood from known previously IV sites should be
avoided for 24 to 48 hours.
 Central Vascular Access Devices (CVADs)
✓ also known as indwelling lines which is a tubing inserted
to the main vein or artery used for blood collection,
monitoring the patient's pressures and administering
medications and fluids.
✓ There are three (3) types of CVADs which include the
Central Venous catheter lines, implanted port, and
peripherally inserted central catheter.
A. CENTRAL VENOUS CATHETER is also known as a central
line inserted into the large vein (subclavian) and advanced
into superior vena cava.

Figure 6.6 Central Vascular Access Device

B. IMPLANTED PORT is a surgically implanted disk-shaped
chamber attached into the indwelling line. This is usually
placed on the upper chest just below the collarbone.

Figure 6.7 Port a catch

C. PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) is
a flexible tube inserted into the veins of extremities and
the central veins.

Figure 6.8 Peripherally Inserted Central Catheter

HANDLING PATIENT COMPLICATIONS ASSOCIATED
WITH BLOOD COLLECTION
1. Allergies to Equipment and Supplies
When the patient has adhesive allergy, a gauze should be
placed over the site and should be removed after fifteen
minutes. The alternative is to ask the patient to apply
pressure for five minutes. For Antiseptic allergy, simply use
a different antiseptic. And for latex allergy, look for a sign
to indicate the allergy and use a non-latex alternative for
gloves, tourniquet and bandages.
HANDLING PATIENT COMPLICATIONS ASSOCIATED
WITH BLOOD COLLECTION
2. Excessive Bleeding
When a patient is on aspirin or anticoagulant, the bleeding
may take a longer time. The pressure should be applied to
the site until the bleeding stops. The attention of the
authorized personnel should be called when the bleeding
continues after five minutes.
HANDLING PATIENT COMPLICATIONS ASSOCIATED
WITH BLOOD COLLECTION
3. Fainting
Fainting is a temporary loss of consciousness which is
caused by the insufficient flow of blood to the brain. If the
patient is prone to fainting during venipuncture, they are
asked to lie down during the procedure.
HANDLING PATIENT COMPLICATIONS ASSOCIATED
WITH BLOOD COLLECTION
4. Nausea and Vomiting
When the patient feels nauseous and has the tendency to
vomit, the phlebotomist has to discontinue the procedure
until the patient feels better or until the feeling subsides.
An emesis basin or wastebasket should be provided, and a
cold damp washcloth should be applied in the forehead.
HANDLING PATIENT COMPLICATIONS ASSOCIATED
WITH BLOOD COLLECTION
5. Pain
The patient should be warned before the needle insertion,
and the phlebotomist should avoid redirection of the
needle. If the patient complains of extreme pain or
numbness, remove the needle and apply ice to the site
because this could indicate nerve involvement. The
phlebotomist needs to document the incident if the
condition persists.
HANDLING PATIENT COMPLICATIONS ASSOCIATED
WITH BLOOD COLLECTION
6. Petechiae
This condition involves the appearance of small red or
purple spots that look like rashes, which appears on the
arm when tourniquet is applied.
HANDLING PATIENT COMPLICATIONS ASSOCIATED
WITH BLOOD COLLECTION
7. Seizures/Convulsion
When seizures or convulsions occur, the blood draw
should be discontinued immediately. Hold pressure over the
site but make sure that movement is not restricted, the
mouth is free from any obstruction and the patient is
protected from self-injury. Call the attention of the first-aid
personnel.
AVOIDING AND HANDLING PROCEDURAL ERROR
RISKS AND FAILURE TO DRAW BLOOD
Hematoma Formation
The phlebotomist should hold pressure on the site
immediately after discontinuing the draw. A cold compress or
ice pack maybe offered to help address the swelling.
Factors that trigger Hematoma are:
1. Excessive or blind probing
2. Inadvertent arterial puncture
3. Size of the vein - too small
4. The needle penetration - all through the vein
5. Needle is not completely inserted
6. Tourniquet is still on when the needle was removed
7. Pressure - not adequate
Iatrogenic Anemia
This results from blood loss due to blood draw. It is
important to ensure to collect only the required specimen
volume because if 10% of the blood volume is removed at
once from the body, the patients could face a threat.
Inadvertent Arterial Puncture
This happens when blood is filling up the tube rapidly
and there is a rapid formation of hematoma on the site.
Infection
Infection can be avoided by making sure that tapes or
bandages are not opened ahead of time, needles are not
preloaded into the tube holders, insertion site of the needle
is not touched after sterilization, cap is removed just before
venipuncture, and patients are advised to keep the bandage
on the site for at least 15 minutes.
Nerve Injury
Nerve injuries happens when there is improper site selection,
rapid needle insertion, excessive redirection of the needle
and blind probing.
If the initial attempt is not successful, the phlebotomist
should try to redirect the needle by using a slightly forward
or backward movement. The next step is to remove the
needle and look for an alternative site.
Reflux of Anticoagulant
To avoid blood that has already been drawn to flow back into
the vein from the collection tube, which may cause adverse
reaction because of the presence of tube additives, make
sure to keep the arm of the patient in a downward position
and the tube just below the venipuncture site.

Vein Damage
Damaging the vein could be avoided by following the proper
technique and avoiding blind probing.
Troubleshooting failed venipuncture
The phlebotomist should ensure that the following
does not happen:
1. Needle not inserted far enough
2. Bevel partially out of skin
3. Bevel partially into vein
4. Bevel partially through vein
5. Bevel completely through vein
6. Bevel against vein wall
7. Needle beside vein
8. Undetermined position
Please visit the portal to check
the illustrations on:

Proper Needle Position

Collapsed Vein
The collapsed veins usually occur when conditions are less
than ideal, which leads to the veins being blocked, resulting
to insufficient blood flow. This happens when there is a
strong pressure in the vacuum of the tube or plunger, the
tourniquet is too close to the site or it is too tight, or when
the tourniquet was removed during the draw.
Tube Vacuum
To avoid failure due to loss of vacuum, the phlebotomist
should make sure that the bevel is not partially out of skin
and the tube itself is not damaged.
SPECIMEN QUALITY
1. Hemoconcentration is a decrease in the fluid content or
plasma volume which is usually caused by tourniquet that
stagnates the normal flow of blood, leading to the
increase in concentration of red blood cells and other
nonfilterable large molecules. Hemoconcentration can cause
falsely elevated results for glucose, potassium, and protein-
based analytes such as cholesterol.
2. Hemolysis, which is also called haemolysis, refers to the
rupture of the red blood cells. The hemoglobin is then
released to the surrounding fluid.
3. Partially Filled Tubes, or short draw, happens when the
phlebotomist pulls a tube before reaching the required
volume which may lead to the incorrect blood-to-additive
ratio.
4. Specimen Contamination means that the specimen is
compromised due to incorrect handling, which includes
allowing alcohol, powder or other materials into the
sample.
5. Wrong or Expired Collection Tube should not be used
because the manufacturer could not warrant the quality of
the seal and pressure after the expiration date declared in
the tube.