SPECIAL COLLECTION

&
POINT- OF-CARE TESTING

PMLS

ALKUINO, REAH JAYZEL G.

BMLS 1B
I. SPECIAL BLOOD COLLECTION
Special Blood collection is not part of the routine of venipuncture procedure. It contains special
techniques like patient preparation, timing of sample collection, other blood collection techniques, and
sampling.

II. COLLECTION PRIORITIES

The phlebotomist must prioritize his or her workload accordingly to accommodate the various test priorities
In order for Phlebotomist to accommodate the various test priorities he or she must arrange his/her work
loads accordingly. The three different types of sample collection priorities, namely Routine sample, ASAP
samples and STAT samples.

 Routine samples, is a test given to monitor and diagnose the patient’s condition. It is usually
collected during scheduled “sweeps” (collection times).
 As soon as Possible or ASAP, which the time collection is determined by clinic and hospitals.
 STAT samples, is the highest prioritized sample and the result must be released and reported
immediately. It is usually ordered from the emergency department and patient with critical
condition.

III. FASTING SAMPLES

It is type of sample that collected from a patient who has had nothing to eat or drink except. The
fasting sample is usually collected from the patient who is refrained from consuming food and drinks for
12 hours, while the basal state is collected from the fasting patient and who is also refrained from exercise.
In addition, the analytes that requires the fasting samples are Glucose, Triglyceride, and lipid profiles.

IV. TIMED SAMPLES

Timed samples are samples that is needed to test the following:

 Measurement of the body’s ability to metabolize a

 particular substance
 Monitoring changes in a patient’s condition (such as a
 steady decrease in hemoglobin)
 Determining blood levels of medications
 Measuring substances that exhibit diurnal variation
 (normal changes in blood levels at different times of
 the day)
 Measurement of cardiac markers following acute
 myocardial infarction
 Monitoring anticoagulant therapy

A. Glucose Tolerance test

GTT is usually used for the diagnosis of diabetes mellitus and gestational diabetes. It contained 2 hours
postprandial glucose test where the glucose level of the fasting patient is compared with the glucose level
2 hours after consuming a meal with high content of carbohydrate. The classic GTT requires the patient to
drink a standard glucose load and return for testing on an hourly basis.

Before performing the test, the Patients should be been Fasting for 12 hrs, not more than 16 hrs, should be
AMBULATORY, consume unrestricted diet of 150g Carbohydrate/day for 3 days prior to testing, Patient
should NOT exercise, smoke & drink alcohol prior to testing, and as required, the Glucose load for Adults
is should be 75g while Children receive 1.75g/kg of body weight.

Procedure of Glucose Tolerance Test

Step 1. Identify the patient and explain the procedure.

Step 2. Confirm that the patient has fasted for 12 hours and not more than 16 hours.
Step 3. Draw a fasting glucose sample (baseline).

Step 4. Ask the patient to drink the appropriate flavored glucose solution within 5 minutes.
Step 5. Timing for the remaining collection times begins when the patient finishes drinking the glucose
solution.
Step 6. Collect remaining samples at the scheduled times.

The Following are the Glucose Tolerance test scheduled for 3-hour test:

Medications that can possibly interfere:

 Alcohol
 Anticonvulsants
 Aspirin
 Birth Control Pills
 Blood Pressure Medications
 Corticosteroids
 Diuretics
 Estrogen-Replacement Pills

B. Lactose Tolerance test

The test used to diagnose lactose intolerance and evaluates patient’s ability to digest lactose. The principle:
Lactose degraded by lactase into glucose and galactose, where the patient consume a standard lactose
solution; performing the same procedure with GTT.
C. Diurnal Variation

Diurnal variation refers to a daily cycle or during the day.

The Primarily affected by diurnal variation are the following:

 Eosinophils
 Serum Iron
 Glucose
 Corticosteroids

D. Therapeutic Drug Monitoring

The test is performed to ensure patient safety and medication effective ness, the blood levels of
many therapeutic drugs are monitored. The trough levels are instantly collected before the drug is to be
given and it represent the lowest level in the blood, ensuring drug is within therapeutic range. In addition,
the gathering for peak levels varies with the medication and method of administration.

Frequently Monitored Drugs:

 Methotrexate
 Theophylline
 Various Antibiotics
 Phenobarbital
 Digoxin
 Lithium

V. BLOOD CULTURE

Blood Culture are usually requested on patients with symptoms indicating a possible septicemia
and requires strict aseptic technique. Also, it can be used to diagnose and identify the causative pathogen
and determine most effective treatment.

A. Timing of Collection

It is usually ordered stat or as timed collections. The samples are collected in sets of two drawn 30
or 60 minutes apart, or just before the patient’s temperature reaches its highest point. Hence, the sets are
drawn at the same time from different sites if antibiotics are to be started immediately.

B. Collection Equipment

Blood can be drawn directly into blood culture tubes containing anticoagulant, sodium polyanethol
sulfonate. Antimicrobial removal devices (ARDs) is also present in some blood culture collection system,
which has resin that inactivates antibiotics. Similarly, fastidious antimicrobial neutralization (FAN) blood
collection system uses bottles that contain an activated charcoal that neutralizes the antibiotic.

Cleansing the Site

Cleansing typically begins with vigorous scrubbing of the site for 1 minute using isopropyl alcohol. It
should be from the center of the puncture site progressing outward 3 to 4 inches in concentric circles.
Antiseptics for disinfecting:

 2% iodine tincture
 povidone-iodine
 multiple isopropyl alcohol preps
 chlorhexidine gluconate

Sample Collection

In sample collection there are Two samples are routinely collected: one incubated aerobically and
the another anaerobically. In Syringe method, anaerobic bottle inoculated first while in winged blood
collection set, aerobic bottle inoculated first. Overfilling and Underfilling of the bottles cause false result.

There should be at least a 1:10 ratio of blood to media. Adult blood culture bottles usually require
8 to 10 mL for each and pediatric bottles require 1 to 3 mL for each.

Pediatric blood volume requirement:

 Less than 45 kg: 1mL of blood for every 5 kg of patient weight

 Above 45 kg: treated as that of an adult
 Babies less than 5 kg: 1 mL

C. Procedure

Step 1. Obtain and examine the requisition form.

Step 2. Greet the patient and explain the procedure to be performed.
Step 3. Use two identifiers to correctly identify the patient.
Step 4. Prepare the patient and verify allergies.
Step 5. Select equipment.
Step 6. Wash hands and don gloves.
Step 7. Apply the tourniquet and locate the venipuncture site.
Step 8. Release tourniquet.
Step 9. Sterilize the site using chlorhexidine gluconate Creating a friction, rub for 30 to 60 seconds and
allow to air dry for at least 30 seconds for antisepsis.
Step 10. Assemble equipment while the antiseptic is drying. Attach the needle to the syringe.
Step 11. Remove the plastic cap on the collection bottle. Confirm required blood volume.
Step 12. Clean the top of the bottles with a 70 percent isopropyl alcohol pad and allow to dry.
Step 13. Reapply tourniquet and perform the venipuncture. Do not repalpate the site without cleansing
the palpating finger in the same manner as the puncture site
Step 14. Release the tourniquet. Place gauze over the puncture site, remove needle, & apply pressure.
Step 15. Activate the safety device or remove the syringe needle with a Point-Lok device.
Step 16. Attach safety transfer device.
Step 17. Inoculate the anaerobic blood culture bottle first when using a syringe or second when using
a winged blood collection set.
Step 18. Dispense the correct amount of blood into bottles. Some institutions require documenting the
amount of blood dispensed.
VI. ARTERIAL BLOOD COLLECTION

Performing Arterial blood collection is more difficult, uncomfortable and dangerous to patient. The
Arterial blood Collection is not a routine duty of the phlebotomist. Also, it is usually requested for
evaluation of blood gasses, ammonia, and lactic acid.

Blood Gases
The test measures the ability of the lungs to provide oxygen (O2) to the blood and to remove
carbon dioxide (CO2) from the blood and exhale it. It is usually tested using specialized instrumentation
designed to measure the pH, PO2 and PCO2, and to determine HCO3, ctO2 and
O2Sat levels.

A. Equipment

It is collected and transported in specially prepared syringes like plastic and glass syringe. Plastic
syringe with freely moving plunger, it must contain 25 gauge and are 5/8 to 11/2 inches long, while the
Glass syringes must be available for use when samples cannot be tested within 30 minutes.

B. Site Selection

The Arterial punctures are considered as a hazardous procedure. Hence, site selection should be performed
and followed properly.

Acceptable artery puncture site must be:

 Large enough to accept at least a 25-gauge needle.

 Located near the skin surface so that deep Puncture is not required.
 In an area where injury to surrounding tissues Will not be critical.
 Located in an area where other arteries are Present to supply blood (collateral circulation) in Case
the punctured artery is damaged.

Arteries for Arterial Blood Collection

 Radial Artery
 Brachial Artery
 Femoral Artery
 Umbilical Artery
 Scalp Artery
 Foot Artery

Modified Allen test

Performed if the puncture site is the radial artery and to determine if the ulnar artery id capable of
providing collateral circulation to the hand. It is advisable to choose another site if it lacks of available
circulation to prevent loss of the hand or its function.
C. Procedure

The Arterial Blood Collection Procedure:

Step 1. Obtain and examine the requisition form.

Step 2. Greet the patient and explain the procedure to be performed.
Step 3. Disinfect the site.
Step 4. Insert needle at a 30- to 45-degree angle.
Step 5. Allow syringe to fill.
Step 6. Remove the needle and apply pressure on the puncture site.

D. Technical Errors

E. Complications

VII. BLOOD BANK PHLEBOTOMY

It is used to accumulate units of blood to provide the blood bank a supply of blood and blood
components for transfusions. 1 unit of blood is composed of 405 to 495 mL of blood mixed with 63 mL of
anticoagulant and preservative. The preservatives of the blood are Citrate -Phosphate-Dextrose and Citrate
-Phosphate-Dextrose with Adenine.
 The process for accumulating blood from donors is alike to that used for blood sampling; yet,
limited additional measures are required for collection of donated blood. Blood donor collections are
performed following guidelines established by the American Association of Blood Banks (AABB) and the
Food and Drug Administration (FDA) for donor selection and unit collection and processing.

In order to minimize contamination of blood products from the skin flora of the donor’s arm, it is
advisable to measure primarily to ensure patient safety. Safe blood collection ensures that the blood
products are safe for therapeutic use throughout their shelf life.

A. Responsibilities of a Phlebotomist

The Responsibilities of a Phlebotomist are the following:

 Donor interview and screening

 Donor identification
 Donor informed consent
 Venipuncture
 Product collection
 Post donation care
 Complication management

B. Equipment Requirements

The following are the equipment requirements for Blood Bank:

 Sterile, closed systems consisting of one or more plastic bags connected to tubing and a
sterile needle
 Large-gauge needles
 15 to 16 regular gauge, or
 17 gauge thin-walled
 Tourniquet or blood pressure cuff
C. Procedure
The Blood Bank Procedure:

Step 1. Obtain and examine the requisition form.

Step 2. Greet the patient and explain the procedure to be performed.
Step 3. Select puncture site and disinfect accordingly.
Step 4. Perform the venipuncture using aseptic technique.
Step 5. Monitor the donor and the donated unit.
Step 6. Remove the needle and apply pressure on the puncture site.

D. Post-Donation Care

Donor Care

 ask the donor to remain and relax for a few minutes

 inspect the venipuncture site for bleeding or hematoma
 ask the donor to sit up slowly and ask how the person is feeling – offer the donor some refreshments.
Blood Unit and Sample

 Transfer the blood unit to a proper storage container according to the product and the blood bank
requirements.
 Ensure that collected blood samples are stored and delivered to the laboratory with completed
documentation and in a leak-proof, closed container.

E. Adverse Reaction

 Hematoma
 Dizziness
 Fainting
 Arterial puncture
 Nerve damage
 Infection

VIII. SPECIAL HANDLING PROCEDURE

A. Cold Agglutinins

It is autoantibodies produced by persons infected with Mycoplasma pneumoniae or with

autoimmune hemolytic anemias. The autoantibodies react with red blood cells at temperatures below body
temperature. The gathered samples must be kept warm in an incubator at 37˚C for 30 minutes.
Cryofibrinogen and cryoglobulin are two proteins that precipitate when cold and must be collected and
handled in the same manner as cold agglutinins.

B. Chilled Samples
Chilling the gathered samples inhibits metabolic processes that continue after blood collection and
can adversely affect laboratory results. For adequate chilling, the sample must be placed in either crushed
ice or a mixture of ice and water, or in a uniform ice block at the bedside. Potassium levels will be falsely
increased if the sample is chilled. Also, prothrombin time (PT) (international normalized ratio [INR])
testing is unacceptable as it may cause activation of Factor VII and alter the results.
C. Light Sensitive Samples

Artificial light or sunlight (ultraviolet) exposure for any length of time may decline the
concentration of various analytes.

The following are Samples Sensitive to Light:

 Bilirubin
 β-carotene
 Vitamin A
 Vitamin B6
 Vitamin B12
 Folate
 Porphyrins

D. Blood Alcohol Samples

The test usually requested for medical reasons, legal reasons, or as part of employee drug screening.
It must strictly follow the chain of custody (COC) protocol. Benzalkonium chloride is the disinfectant to
the puncture site for this test. The sample collected is put in gray stopper tubes.

IX. POINT-OF-CARE TESTING (POCT)

Samples can be collected by dermal puncture and tested by phlebotomists or other health-care
personnel in the patient area. Test results are available quickly and transportation of samples to the
laboratory is avoided. Phlebotomists performing point-of-care testing (POCT) should follow all
manufacturer recommendations.

A. Location

Environments POCT Might Be Employed:

Primary Care Secondary and Tertiary Care

• Home • Emergency room

• Health centers • Admissions unit
• Workplace clinic • Operating room
• Diagnostic and • Intensive care unit
treatment center • Ward
• Paramedical support • OP clinic
vehicle
B. Advantages

 Decreased turnaround time

 Decreased time to treatment
 Decreased length of stay
 Fewer follow-up visits or calls
 Less traumatic sample collection
 Convenience for both physician/nurse and patient
 Decreased manpower needs

C. Disadvantage

 Significantly more expensive.

 Increased regulatory burden.
 Increased work for clinical staff.
 Maintenance of quality control and quality assurance is difficult.
 Greater potential for pre analytic, analytic, and post analytic errors.
 Results may not correlate with central laboratory.

E. Regulatory Requirements
Clinical Laboratory Improvement Act of 1988 (CLIA 88) established standards for all laboratory
testing to ensure accuracy, reliability, and timeliness of patient test results regardless of where the test was
performed.
LEVELS OF COMPLEXITY
 Certificate of Waiver  Waived Testing
 Certificate of Registration  Provider-Performed
 Certificate for PPMPs  Microscopy Procedures
 Certificate of Compliance  Moderate-Complexity
 Certificate of  Testing
 Accreditation  High-Complexity Testing

Waived Testing
• Requires minimal training and education to perform. The erroneous results are likely negligible. It poses
no harm when done incorrectly. Most POC tests are waived.
Provider-Performed Microscopy Procedures

Must only Performed by licensed physicians, dentists, and midlevel practitioners. It is subcategory
of moderate complexity testing. Involves the use of a microscope. Usually There are no QC materials
available

• Wet mounts
• KOH preparations
• Pinworm examinations
• Postcoital direct examinations
• Fern test
• Semen analysis
• Nasal smears for eosinophils

Moderate- and High-Complexity Testing

It is also “non-waived testing”. The test is usually performed in larger and more advanced
laboratory settings and majority of POCT is moderate complexity.

E. Types of Analyzer

Single-use cartridge/strip tests

 Qualitative or semi-quantitative
 Quantitative
Multiple use
 Handheld devices
 Bench top devices
 Wearable devices
Characteristics of a POCT Analyzer

 Release results in a minute or less

 Portable instruments with
 consumable reagent cartridges
 One- or two-step protocol
 Capable of performing direct
 specimen analysis
 Built-in/integrated calibration and
 quality control
 Low instrument cost

REFERENCES
• The phlebotomy textbook by Strasinger, 3rd ed.
• Clinical Chemistry: Principles, Techniques, and Correlations by Bishop, 7th ed.
• Tietz Fundamentals of Clinical Chemistry, 6th ed.