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L1 lab CP _ Basic Lab Knowledge
Optimal treatment of patient and his samples is defined as the gold standard
Outlines
1- Safety 2- Responsibility of The Phlebotomist in Infection Control
3- Factors Affecting Test Results 4- Venipuncture

1. Safety
- Standard precautions must be followed in the collection of blood, and all
specimens must be treated as potentially infectious for blood-borne pathogens.

- Regulations of the Occupational Safety and Health Administration (OSHA) 1992

, outlined in detail what must be done to protect health care workers from
exposure to blood-borne pathogens

Blood-borne pathogens may enter the body

I- Direct transmission :
- Through an accidental injury by a sharp object, such as a contaminated needle
, a scalpel, broken glass, or any other object that can pierce the skin.

- Cuts, skin areas with dermatitis or abrasions, and mucous membranes of

the mouth, eyes, and nose may also provide a portal of entry.

II- Indirect transmission :

- Can occur when a person touches a contaminated surface or object and then
touches the mouth, eyes, nose, or non-intact skin without washing the hands.
- Hepatitis B virus can survive on inanimate or dried surfaces for at least 1 week

Chain of Infection

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 Wearing Gloves Hand Washing

- Essential personal protective equipment. - The most important practice to prevent the
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of infectious diseases. spread

- Must be worn during blood collection procedures.
- When gloves are removed, no blood from the
soiled gloves should come in contact with
the hands.
- The phlebotomist should wash his or her hands
with soap and running water between patients
and
every time gloves are removed.
- An alcohol-based hand rub may be used if hands
are not visibly contaminated.
Most important measures

- Antimicrobial wipes or

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towelettes are less effective
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for hand sanitation.

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infectious materials. indicates that a container holds potentially

resistant containers. should be placed in designated puncture-
Using Puncture-resistant Containers

easily accessible and should not be overfilled.

- Contaminated sharps and infectious wastes

- The red or red-orange biohazard sign

- Biohazard containers should be

2- Responsibility of The Phlebotomist in Infection Control

Because phlebotomists interact with patients and staff throughout the day
, they potentially can infect numerous people.
Knowledge
You must be familiar with and observe infection control and isolation policies
An idol
Reporting Violations of the policies should be reported

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3- Factors Affecting Test Results
1- Intrinsic Factors
2- Influences that can vary (Changing habits)
3- Factors related to sampling technique

Intrinsic Factors
1- Age 2- Race 3- Gender 4- Pregnancy

Age Race

Gender Pregnancy

1- Urine volume
2- Thyroid hormones
3- Metabolites (amino acids↑, urea↓)
4- Electrolytes
Serum Iron Level (calcium↓, magnesium↓, iron↓,
zinc↓,copper↑)
5- Proteins
(especially acute phase proteins↑)
6- Some diagnostically important lipids
CK & Creatinine (triglycerides↑, cholesterol↑)
7- Factors of the plasma coagulation system
and components of the fibrinolytic
system.
8- The sedimentation rate is increased
five-fold during pregnancy

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Influences that can vary (Changing habits)
3- Altitude 2- Exercise 1- Diet & Starvation

1- Diet & Starvation

- Distinguish between acute effects from those observed over a longer period.
- Percentage of change in analytes concentration as a result of food intake or
starvation Clinically relevant
May I take a coffee, smoke or drink
Change of the serum concentration of different before blood sampling?
analytes two hours after a standard meal
- Smoking
Rise in white blood cell count,
cortisol and glucose

- Caffeine
Blood glucose, Hormones
- Alcohol & Addictive drugs

Acute Chronic

2- Exercise

- Acute changes of analytes during exercise are due to:-

1- Volume shifts between the intravasal and interstitial compartments

2- Volume loss by sweating
3- Changes in hormone concentrations

Ephinephrine, Norepinephrine, Glucagon, Somatotropin, Cortisol, ACTH

Insulin
Total Leukocytic Count , Serum Calcium Level , Blood Glucose Level

In order to avoid misinterpretation of laboratory results, sampling after 12 h fasting -

and reduced activity is recommended as a standard procedure.

3- Altitude Hemoglobin

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Factors related to sampling technique
1- Time of sampling 2- Sampling during infusion therapy
4- Tourniquet 3- Posture

1- When to test ?
1- Influence of circadian rhythm (cortisole test)

For this reason, reference intervals are actually obtained between 7 and 9 a.m.

2- Influence of menstrual cycle

- Aldosterone
- Renin
- Cholesterol
- Iron
- Phosphate

2- Sampling during infusion therapy

Contamination of laboratory samples by infusion solutions is the commonest and

often the most relevant form of preanalytical interference in the hospital

1- Blood should never be collected proximal to the infusion site.

2- Specimens should be collected from the opposite arm.
3- A certain period of time should be allowed to elapse following infusion therapy.
4- It is recommended that the laboratory be informed of when and what type
of infusions were carried out and when blood samples were taken
5- If samples are to be taken from intravenous and intraarterial infusion catheters,
the cannula should be rinsed with isotonic saline commensurate with the
volume of the catheter.
- The first 5 mL of blood should be discarded before a blood sample is taken.

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3- Sampling in the supine or upright position?
Increase (%) of plasma concentration of various analytes
when changing from supine to an upright position

4- Tourniquet
- What happens when a tourniquet is kept on during sampling?
Using a pressure below the systolic pressure maintains
the effective filtration pressure inside the capillaries.

Fluid and low molecular compounds are moved from the intravasal space to the interstitium.

Macromolecules, compounds bound

to protein and blood cells, The concentration of low
do not penetrate the capillary wall molecular substances is unchanged.

- Their concentration apparently increases

Change (%) in serum concentration of various analytes after a tourniquet application time of 6 min

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Mental Stress
- anxiety prior to blood sampling
- preoperative stress

Secretion of hormones (aldosterone, angiotensin, catecholamines, cortisol,

prolactin, renin, somatotropin, TSH, vasopressin).

Concentrations of albumin, fibrinogen, glucose, insulin, lactate and cholesterol.

Standardized Sampling Procedure The same body position, daytime and

A preceding phase of rest and fasting
The tourniquet application time should
not be longer than one minute.
tourniquet application time,
avoidance of repeatedly clenching
and unclenching a fist.
During a running infusion the
phlebotomy should be performed on
the opposite arm, in any case not
proximal from the running infusion.

1- The preanalytical phase of the testing process begins when a

a. blood or body fluid specimen is collected. b. patient is admitted to a healthcare facility.

c. specimen is submitted for processing. d. test is ordered by a patient’s physician

2-The best specimens to use for establishing inpatient reference ranges for blood tests are
a. basal state specimens. b. fasting specimens.

c. postprandial specimens. d. steady-state specimens.

3- Which of the following tests is most affected by altitude?

a. Cholesterol b. Electrolytes

c. Magnesium d. RBC count

4- A 12-hour fast is normally required when testing for this analyte.

a. Bilirubin b. Calcium

c. Electrolytes d. Triglycerides
5- This blood component exhibits diurnal variation, with peak levels occurring in the morning.
a. Cortisol b. Creatinine

c. Glucose d. Phosphate

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4- VENIPUNCTURE
1- Equipments (Tourniquet, Needles, Collection Tubes)

2- Selection of a Vein for Routine Venipuncture

Equipments for Venipuncture

1- Tourniquet

❖ A tourniquet is used to provide a barrier

against venous blood flow to help locate a vein.

❖ A tourniquet can be a disposable elastic strap,

a heavier Velcro strap, or a blood pressure cuff.

❖ The tourniquet should be applied 3 to 4 inches above the venipuncture site and
left on for no longer than 1 minute before the venipuncture is performed.

❖ Latex-free tourniquets are available for individuals with a latex allergy.

2- Needles

1- Length
- Vary from 1 to 2 inches
- Many phlebotomists prefer the 1-inch needle,
because it gives them more of a feeling of “control”

2- Bore size or gauge

- Also varies

- The phlebotomist may use 19-gauge to 23-gauge needles

(the larger the number, the smaller the bore).

- A small vein requires a small-gauge needle, for instance a 23-gauge.

A normal-size vein would require a 20-gauge or 21-gauge needle.

Multiple-sample Needle
• The needle has two sharp ends:

- One end designed to perform the venipuncture.

- The other to penetrate the rubber stopper of the collection tube.

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Syringes
A syringe consists of a barrel, graduated in milliliters, and a plunger.
Syringe needles have a point at one end and an open hub
at the other end that attaches to the barrel of the syringe.

Syringes are available with different sizes.

- It is important to attach the needle securely to the syringe

to prevent air from entering the system.

Winged Blood Collection Set (Butterfly)

A winged blood collection set or butterfly consists of

1- a short needle with plastic wings connected to thin tubing.

2- The other end of the tubing can be connected to

a needle holder for an evacuated tube, a syringe, or a blood culture bottle.

- The phlebotomist may use this needle on fragile veins when

only a small volume of blood needs to be drawn (children)

3- Collection Tubes

The most common means of collecting blood specimens

is through the use of an evacuated tube system.

When the needle is inserted into a vein and a tube is inserted into the holder, the back
of the needle pierces the stopper, allowing the vacuum pressure in the tube
to automatically draw blood into the tube

Manufacturers of evacuated tubes in the United States follow a universal color code in
which the stopper color indicates the type of additive contained in the tube.

Serum vs Plasma

Tube additives
(Anticoagulant / Clot activator / Gel separator)

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Selection of a Vein for Routine Venipuncture
The superficial veins of the antecubital fossa (bend in the elbow)
are the most common sites for venipuncture.

There are two anatomical patterns of veins in the antecubital fossa

In the “H” pattern, the three veins that are used, in the order of preference, are
(1) the Median cubital vein, which connects the basilic and cephalic veins
in the antecubital Fossa

(2) the Cephalic vein, located on the outside (lateral) aspect of

the antecubital fossa on the thumb side of the hand

(3) the Basilic vein, located on the inside (medial) aspect of the antecubital fossa.

In the “M” pattern the order of preference is the

(1) Median vein

(2) Accessory cephalic vein

(3) the Basilic vein.

Feel, Roll, Trace, Palpate

Feel the vein with your index finger.
Roll your finger back and forth over the vein to determine its size.
Trace the vein to determine its path.
Palpate the vein to determine its resiliency.

Solutions for Skin Antisepsis

The most common skin antiseptic is 70% isopropyl alcohol in a commercially prepared
pad.

- The phlebotomist cleans the phlebotomy site in a circular motion,

beginning in the center and working outward.

- The area is allowed to air-dry before the venipuncture is performed so that the
patient does not experience a burning sensation after needle insertion and to
prevent contamination of the specimen with alcohol.

- The phlebotomist must use a non-alcohol-based antiseptic to collect blood

for a legal blood alcohol level.

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Venipuncture Procedure
The minimal amount of information that
must be on each tube is as follows:
a. Patient’s full name
b. Patient’s unique identification number
c. Date of collection
d. Time of collection (military time)
e. Collector’s initials or code number

Note: Compare the labeled tube with the patient’s identification bracelet or
have the patient verify that the information on the labeled tube is
correct whenever possible.

Venipuncture in Children
Pediatric phlebotomy requires experience, special skills, and a tender touch.

- Smaller gauge (22- to 23-gauge) needles are employed.

- Use of a winged blood collection set may be advantageous for accessing small
veins in young children.

- The child’s arm should be immobilized as much as possible so that the needle
can be inserted successfully into the vein and can be kept there if the child tries
to move.

Complications Encountered in Venipuncture

1- Ecchymosis (Bruise)

- The most common complication encountered in obtaining a blood specimen.

- Caused by leakage of a small amount of blood in the tissue around the puncture
site.

By applying direct pressure to the venipuncture site with a gauze pad.

** Bending the patient’s arm at the elbow to hold the gauze pad in place
is not effective in stopping the bleeding and may lead to bruising.

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2- Hematoma

Leakage of a large amount of blood around the puncture site causes the area
to rapidly swell. Most commonly occur when

1- the needle goes through the vein

2- when the bevel of the needle is only partially in the vein

3- when the phlebotomist fails to remove the tourniquet before removing
the needle or does not apply enough pressure to the site after venipuncture
4- after inadvertent puncture of an artery.

If swelling begins, the phlebotomist should remove the needle immediately

and apply pressure to the site with a gauze pad for at least 2 minutes.

3- Fainting (Syncope)

A common complication
Before drawing blood, the phlebotomist should always ask the patient whether he
or she has had any prior episodes of fainting during or after blood collection.

If the patient begins to faint, the phlebotomist should

- remove and discard the needle immediately

- apply pressure to the site with a gauze pad

- lower the patient’s head

- loosen any constrictive clothing.

- notify the designated first-aid providers at the facility.

The incident should be documented.

4- Hemoconcentration

- Hemoconcentration is an increased concentration of cells, larger molecules,

and analytes in the blood as a result of a shift in water balance.
- Hemoconcentration can be caused by leaving the tourniquet on the patient’s
arm for too long.
The tourniquet should not remain on the arm for longer than 1 minute.

- If it is left on for a longer time because of difficulty in finding a vein, it should be

removed for 2 minutes and reapplied before the venipuncture is performed.

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5- Hemolysis

The rupture of red blood cells with the consequent escape of hemoglobin causing
the plasma or serum to appear pink or red.

Hemolysis can occur if:

1- the phlebotomist used too small a needle during a difficult draw

2- drew the blood through an existing hematoma
3- pulled back too quickly on the plunger of a syringe
4- forced blood into a tube from a syringe by pushing the plunger
5- mixed a tube too vigorously
6- contaminated the specimen with alcohol or water at the venipuncture site
or in the tubes.
7- physiologically as a result of hemolytic anemias.

6- Nerve Damage

- The phlebotomist must select the appropriate veins for venipuncture and should not
blindly probe the arm with the needle or try to laterally relocate the needle.

- If a nerve has been affected, the patient may complain about shooting or sharp pain,
tingling, or numbness in the arm.

- The phlebotomist should immediately remove and discard the needle, apply pressure
with a gauze pad, and collect the blood from the other arm.

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