LESSON 5

PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY

PROBLEM AREAS TO AVOID AND TROUBLESHOOTING IN THE SITE SELECTION

Phlebotomists should be aware of the following problem areas when selecting the venipuncture site. They could
choose an alternative site, or perform the procedure under special conditions.
1. Burns, Scars, and Tattoos – veins in the area may be difficult to examine and blood circulation may be
impaired. Burns may be too painful to touch. Tattoos may also be susceptible to infection due to the dyes used.
2. Damaged Veins – difficult to perform and puncturing damaged veins may produce inaccurate results. Veins
could be sclerosed or hardened or thrombosed or clotted.
3. Edema – also known as oedema, an abnormal swelling caused by the accumulation of fluid in the tissues. The
tissues become fragile, making the vein harder to locate. Edema can be due to reactions from medication, pregnancy,
infections, and other medical problems.
4. Hematoma – is a solid swelling or mass of blood in the tissues caused by the leakage of blood from the
vessels during venipuncture. It will also be painful for the patient because hematoma obstructs the blood flow. It can
also lead to contamination of the blood sample.
5. Mastectomy – refers to the removal of breast through surgery due to breast cancer. Drawing from patients
with mastectomy is hard because the lymph flow is obstructed, and there may be swelling and infection after the
surgery. Torniquet can’t also be applied because it can cause an injury. It could also change blood composition.
6. Obesity – a condition where an individual is grossly overweight. Patients who are obese have veins that are
deep and difficult to locate. So, a longer tourniquet or locating the cephalic or cubital vein can be done instead.

VASCULAR ACCESS SITES AND DEVICES

Vascular Access Devices (VADs) are needed for blood sampling, infusing medication, central nervous pressure
readings and blood transfusion for patients. In choosing VA sites, the patient’s needs, the purpose, and the length of
time the device is to remain is taken into consideration.
1. Arterial Line – a thin catheter is inserted to a critically ill patient’s arm to obtain samples for arterial blood gas
and laboratory studies. It is also used for monitoring blood pressure continuously.
2. Arteriovenous Shunt or Fistula – it is a passageway created through surgery and is usually in the arms with
the intention of connecting the artery and a vein directly. This may be created for hemodialysis treatment or
pathological process such as erosion of arterial aneurysm.
3. Blood-sampling Device – device collects blood from the arterial or central venous catheter where it is
connected. Used to avoid needle sticks, prevent infections and reduce wastage from line draws.
4. Heparin or Saline lock – commonly called a hep-lock. It is an intravenous (IV) catheter attached to a stopcock
or cap with diagram.
5. Intravenous (IV) Sites – is a thin plastic tube or catheter inserted into a vein in the forearm to inject a volume
of fluids into the bloodstream. Avoid collecting blood from the arm with IV because the blood collected could be
contaminated with IV fluid.
6. Central Vascular Access Devices (CVADs) – also known as indwelling lines, are any of the tubings inserted to
the main vein or artery used for blood collection, monitoring the patient’s pressures, and administering medications and
fluids.
Three types of CVADs:
a. Central venous catheter – known as a central line inserted into the large vein (subclavian) and
advanced into the superior vena cava.
 b. Implanted port – surgically implanted disk-shaped chamber attached to the indwelling line. This is
usually placed on the upper chest just below the collarbone.
c. Peripherally inserted central catheter (PICC) is a flexible tube inserted into the veins of extremities
and the central veins.
HANDLING PATIENT COMPLICATIONS ASSOCIATED WITH BLOOD COLLECTION

1. Allergies to Equipment and Supplies

- Adhesive allergy? a gauze should be placed over the site and should be removed after 15 mins.
- Antiseptic allergy? Simply use a different antiseptic
- Latex allergy? Use non-latex alternative for gloves, torniquet, and the bandages.
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 the stops.
3. Fainting
- is a temporary loss of consciousness which is caused by the insufficient flow of blood to the brain. Ask a
patient to lie down during procedure if they are prone to fainting.
4. Nausea and Vomiting
- if the patient feels nauseous, the phlebotomist should stop . An emesis basin should be provided as well as a
cold damp washcloth applied to the forehead.
5. Pain
- Patients should be warned when the needle is being inserted and the phlebotomist should avoid redirecting
the needle. If pain complains about extreme pain or numbness, remove the needle and apply ice on the site.
6. Petechiae
- a condition that involves the appearance of small red or purple spot that look like rashes, which appear on the
arm when tourniquet is applied.
7. Seizures or Convulsions
- Stop blood draw immediately if seizures or convulsions occur. Pressure should be applied to the site without
restricting the movement and mouth should be free of any obstruction.

AVOIDING AND HANDLING PROCEDURAL ERROR RISKS AND FAILURE TO DRAW BLOOD
1. Hematoma Formation
 Excessive/blind probing
 Inadvertent arterial puncture
 Size of vein is too small
 Needle penetration gone through the vein
 Needle not completely inserted
 Tourniquet is still on when the needle was removed
2. Iatrogenic Anemia
- results from blood loss due to blood draw. Ensure that only the required specimen volume is collected.
3. Infection
4. Nerve Injury – avoid improper site selection, rapid needle insertion, excessive redirection of the needle, and blind
probing.
TROUBLESHOOTING FAILED VENIPUNCTURE
The needle position is critical to the success of the venipuncture. The phlebotomist should ensure that the
following do 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 the vein wall
7. Needle beside vein
8. Undetermined position