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Lesson 4: Venipuncture and Additives; POCT

Reminders:  A new pair of gloves and glove liners

• Supplemental handouts for Principles in  Antiseptics
Medical Laboratory Science 2  Disinfectants
• Refer to your discussion and references  Hand sanitizer & wall-mounted hand
for the full context of the information sanitizer dispenser
here.  Gauze Pads
• You are not allowed to distribute, share,  Bandages
or reveal to anyone, the contents of the  1x3 inches glass microscope slides
handouts.  Pen with non-smear ink
• Remember to act ethically and uphold  Watch with timer
the core values of National University -  Needle and sharps disposal containers
MOA.  Biohazard bags

Lesson 4 Venipuncture equipment

VENIPUNCTURE 1. Vein-Locating Devices
o a process of collecting or "drawing" blood 2. Tourniquet
from a vein of the patient for laboratory 3. Needles
testing purposes. 4. Needle gauge
o a phlebotomist should acquire the 5. Evacuated Tube System (ETS)
knowledge and skill to perform
venipuncture since he will perform this
procedure frequently as part of his duties
and responsibilities in the healthcare
institution.

EQUIPMENT AND SUPPLIES USED IN

VENIPUNCTURE
Selecting the correct tools and using them
properly during the testing procedure ensures
not only safe collection, but also guarantees an
accurate result.
1. General Blood Collection
2. Venipuncture Equipment

General Blood Collection Equipment and

Supplies
 Blood - Drawing Station
 Phlebotomy Chair
 Equipment carrier
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ANTISEPTICS AND DISINFECTANTS USED

IN VENIPUNCTURE
Disinfectants
✓ EPA -registered sodium hypochlorite
✓ 1:100 dilution and 1-10 dilution for spills
prior to clean-up procedures
✓ contact time required is 10 minutes.

Antiseptics
✓ 70% ethyl alcohol,
✓ 70% isopropyl alcohol,
✓ Benzalkonium chloride,
✓ chlorhexidine gluconate,
✓ hydrogen peroxide,
✓ povidone-iodine and tincture iodine.

PHLEBOTOMY NEEDLES
Types of phlebotomy needles that are used in
evacuated tube systems or syringe systems:
1. multi-sample needles
2. hypodermic needles
3. winged infusion Evacuated Tube System
• closed collection system that is
considered the most efficient system for
collecting blood samples.
• allows numerous tubes to be collected in
a single venipuncture.
• composed of multi-sample needles, tube
holders and evacuated tubes which
EVACUATED TUBE SYSTEM (ETS) AND prevent the exposure of the specimen
SYRINGE SYSTEM COMPONENTS from contaminants.
Syringe System • evacuated tubes are color coded tubes
• used for patients as an alternative filled with predetermined volume of
method when drawing blood from blood by vacuum.
patients with small or difficult veins.
• traditional collection procedure that uses
a syringe to draw blood from the patient
and the collected specimen is transferred
into tubes.
• The components of this system include:
(1) syringe needle that has a resheating
feature, and
(2) a syringe which is divided into
graduated barrel and plunger.

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Light
Sodium Citrate 1:9
Blue
Black Sodium Citrate 1:4
Potassium Oxalate Monohydrate
Grey
and Sodium Fluoride

ORDER OF DRAW refers to the specific order

that must be followed by a phlebotomist when
collecting blood samples to prevent any cross-
contamination especially when dealing with
multiple collection tubes. Not following the
prescribed sequence affects the test results due
to cross contamination.

CATEGORIES OF ADDITIVES USED IN

BLOOD COLLECTION
 anticoagulants
 special-use anticoagulants
 antiglycolytic agents
 clot aviators
 thixotropic gel separator
 trace element-free tubes

COLOR CODING IN IDENTIFYING

ADDITIVES IN BLOOD COLLECTION
TUBES Order of Draw Tube stopper color
An anticoagulant/additive is any
Blood Culture
substance that is placed within the tube, and Yellow SPS
(sterile collections)
they can be used in ETS tubes to prevent
clotting and preserving the components. Coagulation tube Light Blue

Cap Glass non-additive

Specification Red
Color tube
Red No additive Plastic clot
Red
Orange Coagulant activator tube
Yellow Coagulant and Separation Gel Serum separator Red and grey
Green Sodium Heparin tube (PSTs) rubber, Gold plastic
Light Green and grey
Lithium Heparin
Green Heparin tube rubber, Light green
Purple EDTA Coagulant plastic
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Lavender, pink or  Room number and bed number if

EDTA tube inpatient
purple
 Type of test ordered
Plasma-preparation
Pearl top  Date when the test is to be performed
tube (PPTs)
 Billing information with ICD-9 codes for
Oxalate/fluoride outpatient
Gray
tubes  Test status
 Special precaution

Accessioning the test request helps improve

the documentation, handling and reporting of
test results. This means that the specimen to be
collected is assigned a special number that will
serve as the reference number for all associated
processes and paperwork.

Table 5.1 Common Test Status Designations

THE REQUEST PROCESS

The Bedside Manner is the behavior of a
o the first step of the pre-examination
healthcare worker as perceived by the patient
phase is the test request that came from
which is applicable to both in- and out-patient
a physician.
settings. The following should be followed when
o a request form includes information on
doing collection:
the type of test ordered and any special
 Knock on the door gently before entering
instructions or conditions that should be
the room.
considered during the pre-examination
 Make a good impression by greeting the
and examination phase.
patient warmly.
o test requisition could be manual,
 Stay organized and have all supplies
computerized or bar-coded.
available and approach the patient in a
professional manner that goes well with
Required Requisition information are as follows:
having a neat appearance.
 Name of the physician who ordered the
test
Importance of proper patient
 Patient's full name including the middle
identification
initial
- Obtaining a specimen from the wrong
 The medical record number for inpatients
person can have serious consequences
 Birthday and age of the patient

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and can even be fatal in cases that
involve blood transfusion.
- Misidentifying patients can be a ground
for dismissal or lawsuit on the grounds of
malpractice.
- When identifying patients, confirm the
name and date of birth of the patient.
- If the patient is fast asleep, the
phlebotomist should wake him up gently
for proper identification.
PATIENTS COMPLICATIONS
1. Apprehensive patient
2. Fainting (Syncope)
3. Seizures
4. Petechiae
5. Allergies
6. Vomiting
7. Patient Refusal
TECHNICAL COMPLICATIONS
1. Failure to Obtain Blood
2. Collection Attempts
• When blood is not obtained from
the initial venipuncture, select
another site, either in the other
arm or below the previous site
• If the 2nd puncture is not
successful, notify the nursing
station and request for another
phlebotomist.
3. Nerve Injury
• Most critical permanent injury
in the venipuncture procedure
• The patient may experience a
shooting pain, electric-like
tingling or numbness running
up or down the arm used for
venipuncture.
• Blind probing
• Selecting high-risk
venipuncture sites (underside
of the wrist, basilic vein)
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• Employing an excessive angle
of needle insertion
(greater than 30 degrees)
4. Iatrogenic Anemia
• A condition of blood loss (anemia)
caused by treatment.
• Occurs when large amounts of
blood are removed for one time
testing or over a period of time.
• Removal of over 10% of a
patient’s blood can be life-
threatening to infants and the
elderly
• To reduce excessive blood
collections.
• Collect minimum amount of
blood
• Monitor collection orders
for duplicate requests
• Avoid redraws
5. Hemolyzed Samples
• Detected by the presence of pink
or red plasma or serum
• Rupture of the RBC
membrane releases cellular
contents into the serum or plasma
• Sample may need to be redrawn.
• Errors in performance of the
venipuncture (e.g. using a small
needle with large evacuated tube,
probing, etc.)
• Errors in processing or
handling of the sample (e.g.
rimming clots; prolonged contact
of serum/plasma with cells, etc.)
6. Hematoma Formation
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SAMPLE REJECTION
Major reasons for sample rejection
1. Unlabeled or mislabeled samples
2. Inadequate volume
3. Collection in the wrong tube
4. Hemolysis
5. Lipemia
6. Clotted blood in an anticoagulant tube
7. Improper handling during transport
(such as not chilling the sample)
8. Samples without a requisition form
9. Contaminated sample containers
10. Delays in processing the sample
11. Use of outdated collection tubes
TYPE OF EQUIPMENT FOR CAPILLARY
COLLECTION
The following are the equipment used for
capillary collection:
• Lancet/Incision Devices
• Laser Lancet
• Microcollection Containers
• Microhematocrit Tubes and Sealants
• Microscope Slides
• Warming devices
• Capillary Blood Gas Equipment (CBG)
COMPOSITION OF CAPILLARY BLOOD
SPECIMEN, THE TEST AND REFERENCE
VALUE
1. The Capillary blood specimen
2. Arterial Blood
3. Venous Blood
4. Capillary Blood
INDICATION SOF PERFORMING
CAPILLARY PUNCTURE ON ADULTS,
CHILDREN, AND INFANTS
(1) veins are fragile and not accessible
because of scars, burns, etc.
(2) veins are reserved for another procedure
such as chemotherapy.
(3) clotting tendencies,
(4) extreme fear of needles and
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(5) veins will be used for POCT such as
glucose monitoring.
This is also the preferred method for infants
and young children because of the following
reasons:
(1) health risks such as anemia, and cardiac
arrest.
(2) requires only a small volume of blood.
(3) venipuncture could damage veins and
tissues surrounding the site.
(4) puncturing could result to hemorrhage,
thrombosis, gangrene, and infection;
(5) risk of injury because of the restraint
needed in venipuncture; and
(6) capillary blood is the preferred specimen.
ORDER OF DRAW FOR COLLECTING
CAPILLARY SPECIMEN
Order of Draw refers to the specific
sequence with which blood must be drawn and
collected in tubes to avoid cross contamination
of additives between the tubes. The Order of
Draw should be Blood gas specimens (CBGs),
EDTA specimens, other additive specimen and
serum specimen.
During finger puncture, the patient's arm
should be placed in a firm surface. His arms
should be extended, and his palms are facing
up.
When the patient is a young child, he
should be placed in the lap of his guardian.
While infants, the infant heel puncture should
be performed with the baby in a supine position
and his foot not lower than his torso.
✓ As a general criterion, the skin of the
incision site should be pink, normal in
color, and warm. The selected area
should be free from scars, cuts, bruises,
rashes, cyanosis, edema, or infection.
✓ When the patient is an adult or an older
child the palmar surface of the distal, end
segment of the middle finger or ring
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finger of the non-dominant hand should
be used.
✓ For infants, the incision site should be
less than 2.0 mm deep and to avoid bone
damage the incision the recommended
site should be in the plantar surface of
the heel, or on the median or lateral
edge.
✓ Warming the incision site increases the
blood circulation in the area for up to
seven times. Using a warm washcloth or
towel, warm the site for 3 to 5 minutes.
Warming is usually done when the
specimen is for pH or blood gas specimen
collection and also recommended for heel
sticks.
✓ The incision site should be clean and
sanitized using antiseptic or 70%
isopropyl alcohol.
✓ Wipe Away the first blood drop because
they may be contaminated with excess
tissue fluid.
✓ Fill and Mix Tubes/Containers in Order of
Draw
✓ The phlebotomist should prioritize the
collection of slides, platelet counts, and
other hematology specimens to avoid
clumping and clotting. The anticoagulant
containers should be next followed by
serum specimens. Do not forget to touch
collection device to drop of blood.
ROUTINE AND THICK BLOOD SMEARS
✓ Routine blood film/smear preparation is a
blood test that is used to check
abnormalities in the blood cells.
✓ A small drop of blood is placed near the
frosted end of the glass side. Another
slide is used to spread the blood in a thin
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film over the slide. It is then air-dried and
stained.
✓ Thick blood smear preparation is used to
determine if the patient has malaria
which is diagnosed by its presence in the
peripheral blood smear.
COLLECTION OF SPECIMENS FOR
CAPILLARY GAS, NEONATAL
BILIRUBIN, AND NEWBORN
SCREENING TESTS AND ITS CLINICAL
SIGNIFICANCE
✓ Capillary blood gas specimen by heel
puncture which is recommended for
infants and small children. The blood
samples are collected on the same site as
routine capillary puncture specimens.
✓ Neonatal bilirubin collection is used to
help determine any liver disorder in
infants. This is collected with a heel stick.
✓ Newborn/neonatal screening is done as
part of the routine check for infants to
determine inborn disorders.
✓ Newborn screening blood spot collection
is done 24 to 48 hours after the baby is
born, where a few drops of blood are
collected through heel stick to determine
disorders that are not apparent at birth
that could lead to disability or even
death.
Point of Care Testing (POCT)
● Point-of-care testing (POCT),
previously referred to as alternate site
testing, near-patient testing,
decentralized testing, bedside testing, or
ancillary testing, is the performance of
laboratory tests at the patient’s bedside
or nearby rather than in a central
laboratory.
● POCT is particularly beneficial to patient
care in the critical care or intensive care
units, operating suites, emergency
department, or neonatal intensive care
units.
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● Other POCT locations include satellite and require documentation of training in

laboratories, physician offices, testing principles, instrument calibration,
ambulatory clinics, ambulances or and QC.
helicopters, long-term care facilities, ● Moderate complexity testing requires
workplace screenings, health fairs, that testing personnel have a minimum
dialysis centers, and home settings. of a high school diploma or equivalent.
● Many laboratory tests in chemistry and
Common POCT in Clinical Analysis Areas hematology have been assigned to this
category.
● Facilities performing moderate
complexity tests are subject to
proficiency testing and on-site
inspections.
● Ex: APTT, AST, ALT

3. High complexity
● High complexity tests require
sophisticated instrumentation and a high
degree of interpretation by the testing
personnel.
● Personnel performing high complexity
test must have formal education with a
degree in laboratory science.
● Most tests performed in microbiology,
immunology, immunohematology, and
cytology are in this category
● Ex: ABO/Rh Typing, DAT, HIV testing,
TYPES OF POCT Drug testing
1. Waived tests
- defined as simple procedures that are
cleared by the FDA for home use.
- employ methodologies that are easy to
perform and the likelihood of erroneous
results is negligible; or pose no
reasonable risk of harm to the patient if
the test is performed incorrectly.
- Waived tests are considered simple to
perform and interpret, require no special
training or educational background, and
require only minimum QC.
- Ex: Blood glucose, urine pregnancy test,

2. Moderate complexity
● Moderate complexity tests are more
difficult to perform than are waived tests
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