Specimen Collection 4.

Hemolysis due to
incorrect technique
• Integrity of laboratory results are highly (e.g., forcing blood
dependent on the quality of specimen through needle,
collected draw via intravenous
• Therefore, it is crucial that good practices line)
and knowledge towards proper specimen After 1. Inadequate (mix
collection to be observed. collection immediately)
mixing/clots
3 stages of Testing Process 2. Mislabeling of
specimen
• Pre-Analysis 3. Improper transport
• All the complex steps that must take to lab: Exposure to
place before a sample can be light/extreme
analyzed temperatures or
• Specimen collection is included delayed delivery
• 70% of errors that occurs in the 4. Processing errors:
laboratory are attribute in the Pre- incomplete
analytical stage. centrifugation,
incorrect log-in,
• Pre-analytical stage should be error
improper storage or
free aliquoting prior to
• Analytical analysis
o Actual testing Erythrocyte Sedimentation
• Post-analytical Rate (ESR)- dependent on
o Results released fresh sample, process 2 hours.

Common Preanalytical Errors Physiologic Factors Affecting Test Results

Phase Error
Before 1. Incorrect test • Posture
Collection ordered o Changing from a supine (lying)
2. Inadequate patient to a sitting or standing position
preparation (e.g., not results in a shift of body water
fasting, recent heavy from inside the blood vessels to
meal-lipemia) or the interstitial spaces.
improper timing o Upright position= ^hydrostatic
(e.g., trough drug pressure= ˅plasma volume
level drawn too
(hemoconcentration)= ^proteins
early)
o In hematology:
3. Misidentification of
patient ▪ ˅Hemoglobin after bed
During 1. Wrong rest, amplified by
collection container/wrong intravenous fluid
additive administration.
2. Short draws/wrong
anticoagulant/blood
ratio
3. Hemoconcentration
from prolonged
tourniquet time
• Diurnal Rhythm • Age
o Timing of extraction o 4 age groups
o Daily body fluid fluctuations that ▪ Newborn
occur with some constituents of ▪ Childhood to puberty
the blood ▪ Adult
AM PM ▪ Elderly adult
Cortisol, Increase Decrease o Newborn
TSH, iron 6:00 ▪ Hgb F
(best) ▪ 20 g/dl (normal)
Eosinophil Decrease Increase o Adult
count ▪ Hgb A
▪ 20 g/dl (Polycythemia
• Exercise Vera )
o Increase various constituents in o Newborn has the highest
the blood such as creatinine, total hemoglobin value and age
protein, creatine kinase, affects WBC count
myoglobin, aspartate o Newborn can have high WBC
aminotransferase, white blood count due to the process of
cell count, and HDL- nucleated RBC
cholesterol
Tests Affected by Diurnal Variation,
o May activate coagulation, Posture, and Stress
fibrinolysis, and platelets. Cortisol Peaks 4-6 AM;
▪ Inflammatory reaction lowest 8pm-
• Stress 12am; 50%
o Anxiety and excessive crying lower at 8pm
can cause a temporary increase than at 8am;
in the white blood cell count increased with
o Hyperventilation affects acid- stress
base balance and elevates Adrenocorticotro Lower at night;
leukocyte counts, serum lactate, pic hormone increased with
or free fatty acids. stress
Plasma renin Lower at night;
• Diet
activity higher standing
o Fasting means no food or than supine
beverages except water for 8 to Aldosterone Lower at night
12 hours before a blood draw. Insulin Lower at night
o LIPEMIA Growth hormone Higher in
▪ Affecting some tests that afternoon and
require photometric evening
measurement, such as Acid phosphatase Higher in
the hemoglobin afternoon and
concentration and evening
coagulation tests Thyroxine Increases with
performed on optical exercise
detection instruments. Prolactin Higher with
o Chronic alcohol abuse high stress; higher
MCV levels at 4 and
8am and at 8am
▪ Megaloblastic anemia
and 10pm
 Iron Peaks early to ▪ Most common needle size for adult
late morning; venipuncture is 21 gauge with a length
decreases up to of 1 inch.
30% during the ▪ It provides better control during
day venipuncture.
Calcium 4% decrease
supine Gauge Needle Type Typical Use
15-17 Special Collection of
needle donor units,
Blood Collection Equipment and Supplies attached to autologous
collection blood
▪ Blood-drawing station
bag donation, and
▪ Phlebotomy chairs
therapeutic
▪ Handheld Carriers/Phlebotomy Carts phlebotomy
▪ Gloves and glove liners 18 Hypodermic Used
▪ Antiseptics primarily as a
o 70% isopropyl alcohol transfer
o 70% isopropyl alcohol + 1%- needle rather
10% povidone-iodine pads, than for blood
tincture of iodine, chlorhexidine collection;
(not blood culture) safety issues
▪ Gauze pads/cotton balls have
▪ Bandages diminished
▪ Needle and sharps disposal containers use.
▪ Slides 20 Multisample Sometimes
Hypodermic used when
▪ Pen
large-volume
▪ Watch
tubes are
Tourniquet collected or
large-volume
▪ A device that is applied or tied around a syringes are
patient’s arm prior to venipuncture to used on
restrict blood flow patients with
▪ Elastic strap, a heavier Velcro strap, or a normal-size
blood pressure cuff veins
▪ Applied 3 to 4 inches above the 21 Multisample Considered
venipuncture site Hypodermic the standard
venipuncture
▪ Left on for no longer than 1 minute
needle for
(Rodaks)
routine
Needles venipuncture
on patients
▪ Sterile, disposable, and designed for a with normal
single use only veins or for
▪ Multisample needles, hypodermic syringe blood
needles and winged infusion (butterfly) culture
needles collection
▪ 1- or 1.5-in. lengths 22 Multisample Used on older
Hypodermic children and
adult patients
 with small Anticoagulants
veins for
syringe draws ▪ Substances that prevent blood from
on difficult clotting (coagulating)
veins ▪ By chelating (binding) or precipitating
23 Butterfly Used on the calcium so it is unavailable to the
veins of coagulation process or by inhibiting the
infants an formation of thrombin needed to
children and convert fibrinogen to fibrin in the
on difficult or coagulation process.
hand veins of ▪ Clotted-serum
adults. ▪ Whole blood- sample to use in hema
▪ The gauge number of a needle is
inversely related to the bore size: the ▪ Ethylenediaminetetraacetic acid
smaller the gauge number, the larger (EDTA)
the bore. o Anticoagulant of choice for
hematology cell counts and cell
morphology
o Lavender (purple)- top tubes
o K2EDTA- plastic, spray-dried
▪ Recommended for
blood cell counts
o K3EDTA- glass, liquid form
▪ Tendency to dilute
sample
▪ 1% to 2%- dillution
o Removes ionized calcium (Ca2+)
through a process referred to as
chelation
o Excess EDTA, which results
when tubes are underfilled, can
cause RBCs to shrink and thus
change CBC results
microhematocrit
▪ Excess happens if Short
Draw
o Pink top tubes
▪ spray-dried K2EDTA;
immunohematology
(ABO grouping, Rh
typing, and antibody
screening)
o White top tubes
▪ EDTA and gel;
molecular diagnostic
testing of plasma.
▪
▪ Citrates
o For coagulation testing (aPTT
and PT testing)
o Light blue-top tube
o Containing 0.105M or 0.129M
(3.2% or 3.8%, respectively)
▪ 3.8 not preferred bcz it
can prolong or falsely
increase clotting time
o Contain a 9:1 ratio of blood to
anticoagulant
o Precipitating calcium into an
unusable form
o Citrated tube inverted for 5
times
o Vigorous mixing or an excessive
number of inversions can
activate platelets and shorten
clotting times.
o Black-top tubes
▪ Buffered sodium citrate;
ratio of blood to
anticoagulant is 4:1; for
Western sedimentation
rates
▪ Heparin
o Used as an in vitro and in vivo
anticoagulant
o Green-top tubes
o Lithium heparin (LiHep) and
sodium heparin (NaHep)
o Prevents clotting by inhibiting
thrombin formation
o Used to coat capillary blood
collection tubes
o An appropriate anticoagulant for
many hematology tests,
including Wright-stained blood
smears.
o Do not use it in hematology
o Lithium heparin
▪ Most chemistry tests
except for lithium and
folate levels
o Sodium heparin
▪ Recommended for trace
elements, leads, and
toxicology but not for
SODIUM assays
▪ The injectable form used
for anticoagulant
therapy
o Heparinized plasma is preferred
over serum for potassium tests
because when blood clots,
potassium is released from cells
into the serum and can falsely
elevate results.
Antiglycolytic Agent
▪ Sodium fluoride
o Used for glucose measurements
o Gray-top tubes
o Prevents glycolysis for 3 days
o ANTICOAGULANT:
Potassium oxalate
▪ Prevents coagulation by
precipitating calcium
o Used to collect ethanol
specimens to prevent either
decrease in alcohol
o Glycolysis occurs faster in
newborns because their
metabolism is increased, and in
patients with leukemia because
of high metabolic activity of
WBCs.
Clot Activators
▪ A substance that enhances coagulation
in tubes used to collect serum
specimens
▪ Glass (silica) particles and inert clays
like Celite
▪ Silica particles are the clot activators in
serum-separator tubes (SSTs) and
plastic red-top tubes.
▪ Used for most chemistry, blood bank,
and immunology assays.
Thixotropic Gel Separator Environmental Factors Associated with
Evacuated Blood Collection Tubes
▪ An inert material that undergoes a
temporary change in viscosity during ▪ Ambient Temperature
the centrifugation process o Decrease Temperature=
▪ This enables it to serve as a separation decrease pressure = increase
barrier between the liquid (serum or draw volume
plasma) and cells. ▪ Altitude
o Higher altitude = lower draw
Order of Draw
volume
▪ Sterile tube (blood culture) o Affects hemoglobin
▪ Blue-top coagulation tube concentration
o Usually start nowadays ▪ Humidity
▪ Serum tube with or without clot activator, o Very high humidity =
with or without gel vaporization
▪ Heparin tube with or without gel plasma o Low humidity = drying out
separator ▪ Sunlight
▪ EDTA tube o CTAD
▪ Glycolytic inhibitor tube ▪ Citrate-Theophylline,
Adenosine,
Dipyridamole
▪ Minimize platelet
activation
Venipuncture
▪ The process of collecting or “drawing”
blood from a vein
▪ Most common way to collect blood
specimens for laboratory testing
▪ Phlebotomist
▪ Step 1: Review and Accession Test
Request
o The form on which test orders
are entered is called a
requisition
o Accession is the process of
recording in the order received.
▪ Step 2: Approach, Identify, and
Prepare Patient
o Approaching the Patient
▪ Looking for Signs
▪ Entering a Patient’s
Room
▪ Physicians and Clergy
▪ Family and Visitors
▪ Unavailable Patient
▪ Identifying Yourself
▪ Obtaining Consent
▪ Bedside Manner
o Patient Identification
▪ Verifying Name and
Date of Birth
▪ Ask the patient to state
his or her full name and
date of birth
▪ Checking Identification
Bracelets
▪ 3-way ID
▪ Sleeping Patients
▪ Unconscious patients
▪ Identification of Young,
mentally incompetent,
or non-english-speaking
patients
▪ Neonates and other
infants
▪ Outpatient ID
▪ Never collect a Fist
specimen without some
way to positively
connect that specimen to
the patient
o Preparing the Patient
▪ Explaining the
Procedure
▪ Addressing Patient
Inquiries
▪ Handling Patient
Objections
▪ Handling difficult
patients
▪ Addressing needle
phobia
▪ Addressing objects in
the Patient’s Mouth
▪ Step 3: Verify Diet Restrictions and
Latex Sensitivity
o Diet Restrictions
o Latex Sensitivity
▪ Step 4: Sanitize Hands
o Some phlebotomists prefer to put
on gloves immediately after
hand sanitization; others prefer
to wait until after vein selection
because they find it easier to feel
veins without gloves on. Follow
facility protocol.
▪ Step 5: Position patient, apply
tourniquet, and Ask patient to make a
fist
o Because of the possibility of
fainting, a patient should never
be standing or seated on a high or
backless stool during blood
collection.
o If a patient has prominent,
visible veins, tourniquet
application can wait until after
the site has been cleaned and you
are ready to insert the needle.
o Obese patients
▪ BP cuff
▪ Step 6: Select Vein, Release
Tourniquet, and Ask Patient to Open
o Ideal vein- Median Cubital Vein
▪ Step 7: Clean and Air-Dry the site
o 2-3 inches in diameter of the area
o Dry naturally for 30 seconds-1
minutes. Let the alcohol air dry.
o The evaporation and drying
process helps destroy microbes,
prevents specimen hemolysis
from alcohol contamination, and
 avoids a burning sensation when
the needle is inserted.
o If it is necessary to repalpate the
vein after the site has been
cleaned, clean it again or
decontaminate the gloved
finger used to palpate and touch
only above or below the
expected needle entry point.
▪ Step 8: Prepare Equipment and Put on
Gloves
▪ Step 9: Reapply tourniquet, uncap and
inspect needle
▪ Step 10: Ask patient to remake a fist,
anchor vein, and insert needle
o Bevel up
o Angle is 15-300
▪ Step 11: Establish blood flow, release
tourniquet, and ask patient to open fist
▪ Step 12: Fill, remove, and mix tubes in
order of draw or fill syringe
o Do not vigorously shaking of
blood specimens
▪ Step 13: Place gauze, remove needle,
activate safety feature, and apply
pressure
o Do not press own on the gauze,
while the needle is in the vein.
▪ Step 14: Discard collection unit,
syringe needle, or transfer device
▪ Step 15: Label tubes
▪ Step 16: Observe special handling
instructions
▪ Step 17: Check patient’s arm and
apply bandage
▪ Step 18: Dispose of contaminated
materials
▪ Step 19: Thank patient, remove gloves,
and sanitize hands
▪ Step 20: Transport specimen to the lab
Special Site Selections
▪ Five specific situations that can create
the potential for a difficult
venipuncture
o Edema of the extremities
▪ Common pregnant
women,
▪ Hemodialysis
o IV lines
o Scarring or burn patients
o Dialysis patients
o Post-mastectomy patients
Edema
▪ The abnormal accumulation of fluid in
the intracellular spaces of the tissue
▪ SHOULD BE AVOIDED for
venipuncture because the veins are hard
to find and the specimens may become
contaminated with tissue fluid.
IV Lines
▪ A limb with an IV running SHOULD
NOT BE USED for venipuncture
because of contamination to the
specimen
▪ If there is no alternative, blood should be
drawn below the IV with the
tourniquet also places below the IV
site.
▪ The IV infusion should be shut off for 2
to 3 minutes before the sample is drawn
Scarring or Burn Patients
▪ Very difficult to palpate
▪ More susceptible to infection
▪ Painful for the patient
Dialysis Patients
▪ Blood SHOUD NEVER BE DRAWN
from a vein in an arm with a cannula
(temporary dialysis access device) or
fistula (a permanent surgical fusion of a
vein and an artery).
▪ A hand vein or a vein away from the
fistula on the underside of the arm
 ▪ Ensure that the dialysis patient does not o Caused by leaving the
bleed from the venipuncture site tourniquet on the patient’s
arm for too long
Postmastectomy Patients
o If it is left on for a longer time
▪ Other arm on the side without a because of difficulty in finding a
mastectomy should be used vein, it should be removed for 2
▪ The pressure on the arm that is on the minutes and reapplied before
same side as the mastectomy from a the venipuncture is performed.
tourniquet or blood pressure cuff can ▪ Hemolysis
lead to pain or lymphostasis o Rupture of red blood cells with
▪ Patient is much more susceptible to the consequent escape of
infections hemoglobin
o Can cause the plasma or serum
Complications Encountered in Venipuncture to appear pink or red
▪ Ecchymosis (Bruise) ▪ The phlebotomist used
o Caused by leakage of small too small a needle
amount of blood in the tissue during a difficult draw
around the puncture site ▪ Drew the blood through
o Apply direct pressure on the an existing hematoma
site ▪ Pulled back too quickly
▪ Hematoma on the plunger of a
o When leakage of large amount syringe
of blood around the puncture ▪ Forced blood into a tube
site causes the area to rapidly from a syringe by
swell pushing the plunger
o Remove the needle immediately ▪ Mixed a tube too
and apply pressure to the site vigorously
with a gauze pad for at least 2 ▪ Contaminated the
minutes specimen with alcohol
▪ Fainting (Syncope) or water at the
o Before drawing blood, the venipuncture site or in
phlebotomist should always the tubes
ask the patient whether he or ▪ Petechiae
she has had any prior episodes o Small red spots indicating that
of fainting during or after blood small amounts of blood have
collection escaped into the skin epithelium
o Remove and discard the needle o Indicate a possible hemostasis
immediately, apply pressure to abnormality and should alert
the site with a gauze pad, lower the phlebotomist to be aware of
the patient’s head, and loosen possible prolonged bleeding
any constrictive clothing. ▪ Allergies
▪ Hemoconcentration o Allergic to skin antiseptic
o Increased concentration of substances and adhesive
cells, larger molecules, and bandages and tape
analytes in the blood as a result ▪ Nerve damage
of a shift in water balance o If a nerve has been affected, the
patient may complain about
 shooting or sharp pain,
tingling, or numbness in the arm.
o Immediately remove and discard
the needle, apply pressure with a
gauze pad, and collect the blood
from the other arm.
▪ Seizures
o The phlebotomist should
immediately remove and
discard the needle, apply
pressure with a gauze pad, and
notify the nurse or designated
first-aid providers at the facility
▪ Vomiting
o The phlebotomist should
provide the patient an
appropriate container and
tissues, notify the nurse or
designated first-aid providers at
the facility, and ensure the
patient’s head is positioned so
that he or she does not aspirate
vomit.
Skin Puncture
▪ The technique of choice to obtain a
blood specimen from newborns and
pediatric patients
▪ Patients who are severely burned and
whose veins are being reserved for
therapeutic purposes
▪ Patients who are extremely obese
▪ Elderly patients with fragile veins.
Collection sites
▪ Infants under 1 year of age
o Lateral (outside) or medial
(inside) plantar (bottom) surface
of the heel
▪ In children older than 1 year of age
and in adults
o The palmar surface of the distal
portion of the third (middle) or
fourth (ring) finger on the
nondominant hand
o A puncture no deeper than
2.0mm
▪ A puncture no deeper than 2.0mm
▪ Puncture in the middle
o Bone injury- osteomyelitis
▪ Warm the site with a commercial heel
warmer or a warm washcloth to a
temperature no greater than 420C and
for no longer than 3 to 5 minutes
▪ Should not puncture an area that is
swollen, bruised, infected, or already
has been punctured.