1 MT-PRACTICE 2 REVIEWER

Capillary Puncture

Capillary Puncture Conditions Influencing the Choice of Heel or Finger-Prick

▪ Superficial puncture of skin w sharp point to draw small Condition Heel-Prick Finger-Prick
amount of blood Age birth to about > 6 months
▪ Collected in small, calibrated glass tubes, slides, or 6 months
reagent strips Weight 3-10 kg > 10 kg
▪ Can be done in the non-dominant finger (3rd/4th or Placement of medial or side of the ball of
ring/middle finger), heel of a toe, and in the earlobe (not Lancet lateral plantar the finger
used anymore) surface perpendicular to
▪ Preferred blood collection method for newborns/infants the lines of the
fingerprint
( less than 1 year of age)
Recommended n/a 3rd/4th
Finger finger(middle/ring);
2 Types of Capillary Tubes
avoid the thumb &
1. Plain – blue top capillary tubes are non-heparinized index finger bc of
2. Heparinized – red top capillary tubes are sodium- calluses; avoid the
heparinized to prevent blood clotting little finger because
the tissue is thin
Advantages: Capillary Puncture > Venous Blood Sampling
✓ Less invasive Recommended Recommended
✓ Requires small amount of blood Puncture Site Incision Depth
✓ Can be performed quickly and easily up to
✓ Can be done several times Premature
neonates heel 0.85 mm
Composition of Capillary Blood (up to 3 - 10 kg)
▪ Capillary blood acquired by skin puncture is different Infants under 6 heel 2.0 mm
from that of venous or arterial blood samples. The months of age
mixture is composed of blood from Child aged 6 finger 1.5 mm
✓ Arterioles moths to 8 years
✓ Venules > 8 years and finger 2.4 mm
✓ Capillaries Adults
✓ Intracellular & Interstitial Fluid – fluid that forms
within tissue layers and gaps General Criteria for Capillary Puncture
▪ Contains more arterial blood > venous blood, equating ✓ Skin is warm, pink, normal color
to stronger pressure ✓ No scars, cuts, bruises
✓ No rashes, cyanosis edema, or infection
REMEMBER: Analytes in the capillary blood differs in the level
when you find it in the venous blood. It is important to TAKE NOTE
convey the type of specimen so that the MT working on this o Cyanosis Edema – bluish skin color due to the decreased
analysis will give out the correct reference range for capillary amounts of oxygen
blood.
Capillary Puncture Sites
Tests Reference Values of Capillary Blood
• Lower levels: potassium, calcium, protein Infants
• Higher levels: glucose ▪ Medial or Lateral Surface of the Heel
o Osteomyelitis – infection of the bone which may be
TAKE NOTE
due to puncturing the middle of the heel where a
o 70% Alcohol – used in disinfecting the skin site for
bone is located
capillary puncture, strictly not povidone-iodine
o Osteochondritis – accidental puncture of an artery
o Povidone-iodine – using it can increase the results
in the middle of the heel
of chemical tests, specifically for bilirubin, uric acid,
▪ No more than 2 mm deep
phosphorus, potassium
Adults & Children
Capillary Prick Collection Sites
▪ Middle/Ring finger of non-dominant hand
A. For ADULT patients ▪ Palmar surface
▪ The finger (3rd/4th or ring/middle finger) in the non- ▪ Distal or end segment
dominant hand is usually the preferred site for capillary ▪ Central fleshy portion of the finger
testing. ▪ Don’t puncture perpendicular to the finger pricks, it
▪ Sides of the heel are only used for pediatric & neonatal should be across to the finger-prick
patients because adult patients have callouses on their
feet.
▪ Ear lobes are sometimes used in mass screening or
research studies.

B. For PEDIATRIC & NEONATAL (newborn) patients

▪ Selection of a site in a pediatric patient is usually based
on age and weight of the patient
▪ If the child is walking, the child’s feet may have calluses
that hinder adequate blood flow

BY: CZRN 1
2 MT-PRACTICE 2 REVIEWER
Capillary Puncture

Heel Puncture Site

Puncture 21 G x 1.8 Fingerstick

Needle mm Medium Flow

BD Microtainer
Contact-
Activated Lancet
(Pink)
Fingerstick
High Flow
Puncture 1.5 mm x 2 (500 °L from
Blade mm single
puncture)

BD Microtainer Heelstick Low

Contact- Flow
Activated Lancet (premature
When to Do A Capillary Puncture (Blue) infants)
✓ Patients w fragile, superficial, or difficult to access veins
✓ Patients where multiple unsuccessful venipunctures
have already been performed, especially if the test Incision 1.75 mm x Low birth-
request requires only a small volume of blood Blade 0.85 mm weight babies
✓ Patients w burns or scarring in venous blood collection or full-term
sites infants where
✓ Extremely obese patients lower blood
✓ Patients requiring only one blood test for which a volume is
BD Microtainer required
capillary specimen is appropriate Quikheel Lancet
✓ Patients whose veins are reserved for IV or (Pink)
chemotherapy
✓ Point-of-care testing where only a few drops of blood are
needed Incision 2.5 mm x 1 Heelstick High
o Capillary Blood Glucose (CBG) – capillary puncture Blade mm Flow (infants)
is required
✓ Patients at risk of serious complications in venipucture Full-term
such as thrombosis, thrombophlebitis infants where
higher blood
Inappropriate for BD Microtainer volume is
✓ Severely dehydrated patients Quikheel Lancet required
✓ Patient has a swollen finger (Teal)
✓ Patients w poor peripheral circulation
✓ Coagulation studies requiring plasma specimens Order of Draw for Capillary Puncture (Opposite in
✓ Tests that require large volumes of blood (ESR & blood Venipuncture)
cultures) ▪ Specimens must be collected quickly to minimize the
effect of platelet clumping and microclot formation.
2 Types of Devices to be Used for Skin Puncture 1. Blood Gases
1. Puncture Devices – puncture the site by inserting a 2. EDTA Tubes
needle; can be repeatedly used for monitoring testing 3. Other Additive Tubes (Green, Black)
2. Incision Devices 4. Serum Tubes
▪ Uses a blade, which are less painful
▪ Requires fewer repeat incisions & shorter collection Why EDTA tubes should be collected first:
time ▪ Capillary blood quickly form clots due to hemostasis
▪ Recommended for infants heel-sticks (platelet plug formation, thrombin formation)
▪ Microclots in EDTA tubes result to errors in results
Capillary Puncture Devices
Preparation for Finger Stick (Blood Collection in Microtainer)
Device Type Width x Intended Use 1. Place all collection materials on top of disposable pad.
Depth Open the lancet, alcohol swabs, gauze, bandage, and
(mm) other items.
2. Put your powder-free gloves. Turn patient’s hand
upward. Massage patient’s hand and lower part of the
Puncture 30 G x 1.5 Fingerstick low finger to increase blood flow.
Needle mm flow (single 3. Scrub the patient’s middle/ring finger w an alcohol swab.
drop)
Dry w gauze.
4. Hold the finger in an upward position and lance the finger
Demonstrates
(across the fingerprint) between the side and the pad w
significantly less
BD Microtainer pain for patients the proper size lancet (adult/child). Press firmly on the
Contact- than comparable finger when making the puncture. Doing so will help you
Activated Lancet products to obtain the amount of blood you need.
(Purple)

BY: CZRN 2
3 MT-PRACTICE 2 REVIEWER
Capillary Puncture

5. Apply slight pressure to start blood flow. Blot the 1st drop
of blood on a gauze pad and discard in an appropriate
biohazard container.
6. Keep the finger in a downward position and gently
massage it (but do not milk) to maintain blood flow. Hold
the microtainer at a 30° below the collection site and use
the scoop on the microtainer to guide the drop into the
vial. Do not scrape the skin. Fill the microtainer 250-500
μL level.
7. Crop the microtainer and gently invert it 8-10 times to
prevent clots from forming.
8. Apply a sterile adhesive bandage over the puncture site.

Heel Stick
1. Pre-warming the infant’s heel (42°C for 3-5 mins) is
important to obtain CBG samples and warming also
greatly increases the flow of blood for collection of other
specimens.
2. Clean the site to be punctured w an alcohol sponge. Dry
the cleaned area ww a dry cotton sponge. Hold the
baby’s foot firmly to avoid sudden movement.
3. Using a sterile blood lancet, puncture the area of the heel
that is off center from the very center of the heel.
4. Wipe away the 1st drop of blood w a piece of clean dry
cotton.
5. Fill the capillary tube(s) or micro collection devices as
needed.
6. When finished, elevate the heel, place a piece of clean
dry cotton on the puncture site and hold it in place until
the bleeding has stopped.
7. Be sure to dispose of the lancet in the appropriate sharps
container.
8. Dispose of contaminated materials in appropriate waste
receptacles.
9. Remove your gloves and wash your hands.

Capillary Blood Test Applications

• Point-of-Care testing (POCT) (i.e., blood glucose
monitoring)
• CBC, Hemoglobin & Hematocrit (H&H)
• Peripheral Blood Smear (manual slide for WBC
differential)
• Neonatal Blood Gases
• Neonatal Bilirubin
• Neonatal Screening (filter paper or blood spot testing)
• Electrolytes

Comfort & Reassurance

▪ Show the child that you care verbally/physically. A
simple gesture is all it takes to leave the child on a
positive note.
▪ A small amount of sucrose (0.012-0.12 g) is safe &
effective as an analgesic for newborns undergoing
venipuncture/capillary heel-pricks.

Unsuccessful Attempts in Pediatric Patients

▪ Adhere strictly to a limit on the no of times a pediatric
patient may be stuck
▪ If no satisfactory sample has been collected after 2
attempts, seek a second opinion to decide whether to
make a further attempt or cancel the tests

Complications
✓ Collapse of veins if the tibial artery is lacerated from
puncturing the medial aspect of the heel
✓ Osteomyelitis of the heel bone (calcaneus)
✓ Nerve damage if the fingers of neonates are punctured
✓ Hematoma and loss of access to the venous branch used

BY: CZRN 3