Principles of Medical Laboratory Science

LECTURE – BSMLS-1B
Kizza Claire A. Tattao

LESSON 6: PRE-ANALYTICAL CONSIDERATIONS IN

PHLEBOTOMY
• Cortisol- around 8:00 A.M.
 The preanalytical (before analysis) or pre- • Fe
examination phase of the testing process begins
for the laboratory when a test is ordered and ends • WBCs and platelets- chemotherapy
drugs
when testing begins. Drug Therapy
• Enzymes
 Reference ranges/Interval- results used for • Hormones
comparison which shows a range of values with
high and low limits. • Arterial pH and PCO2 (↓)
 Basal State - refers to the resting metabolic state • Glucose, creatinine, insulin, lactic
of the body early in the morning after fasting for Exercise/IM acid, and total protein (↑)
Injection • Potassium (K+) is released from the
approximately 12 hours.
cells during exercise, therefore, (↑) the
- for establishment of reference range plasma.
- can be influenced by a number of
physiologic patient variables such as Fever Hormones, cortisol
age,
RBC, Hgb, and Hct normal values-
gender, and conditions of the body Gender
higher for males than for females.
that
cannot be eliminated. (↑) Bilirubin - deposits of yellow bile
pigment in the skin, mucous
Jaundice membranes, and sclerae (whites of the
Outpatient specimens are not basal-state specimens
eyes), giving the patient a yellow
and may have slightly different reference ranges
appearance.
(normal values).
(↑) Creatine kinase (CK) and the
Intramuscular
skeletal
Injection
PHYSIOLOGICAL VARIABLES THAT INFLUENCE LABORATORY muscle fraction of LDH.
TEST RESULT
Position Protein, K

Variable Affected Pregnancy (↓) RBC

Age RBC, WBC, creatinine clearance (↑) Cholesterol, cortisol, glucose,

Smoking
growth hormone, triglyceride, WBC
RBC (Hgb and Hct have higher
reference ranges at higher elevations) (↑) WBC, ACTH, catecholamine, and
*C-reactive protein and uric acid. Stress cortisol
* Analytes that decrease in value at (↓) serum Fe
Altitude
increased altitude include urinary
creatinine (which in turn affects Temperature
Hemoconcentration
creatinine clearance tests) and plasma and Humidity
renin.
PROBLEM AREAS TO AVOID AND TROUBLESHOOTING IN THE
Hemoconcentration SITE SELECTION
Dehydration RBCs, enzymes, Fe, Ca, Na, and
coagulation factors.
Burns, Scars, and Tattoos
• Ammonia, urea, and uric acid levels  Healed burn sites and other areas with extensive
(↑)- high-protein diets. scarring may have impaired circulation.
• Cortisol and ACTH levels (↑)-
 Newly burned areas are painful and also
consumption of beverages containing
caffeine. susceptible to infection.
• Glucose (blood sugar) levels (↑)-  Tattooed areas can have impaired circulation, may
ingestion of carbohydrates/sugar-laden be more susceptible to infection, and contain dyes
Diet substances. that can interfere with testing.
• Hgb levels (↓) and electrolyte balance
altered- drinking excessive amounts of Damaged veins
water and other fluids.
• Lipid levels (↑)- ingestion of foods  May be sclerosed (hardened) or thrombosed
such as butter or margarine, cheese, (clotted)
cream, and some enteral (tube feeding)
preparations. Edema
Diurnal • Thyroid-stimulating hormone (TSH) -  Also known as oedema
Variation predawn hours  Abnormal swelling

Tattao, KC 1
Principles of Medical Laboratory Science
LECTURE – BSMLS-1B
Kizza Claire A. Tattao

 Yield inaccurate test results owing to  Also called an indwelling line

contamination with tissue fluid or altered blood  consists of tubing inserted into a main vein or
composition caused by the swelling artery.
 CVADs are used primarily for administering fluids
Hematoma and medications, monitoring pressures, and
 Mass of blood (often clotted) caused by blood drawing blood.
leaking from a blood vessel during or following Three main types of CVADs
venipuncture a. Central Venous Catheter (central line)-
inserted into a large vein (subclavian) and advanced
Mastectomy into the superior vena cava. There are a number of
different types of CVCs, including Broviac, Groshong,
 Impaired lymph flow makes the arm susceptible to
and Hickman.
swelling (lymphedema), and to infection.
b. Implanted Port- a small disk-shaped chamber
attached to an indwelling line.
Obesity
c. Peripherally Inserted Central Catheter
 Proper tourniquet selection and application is the (PICC)- a flexible tube inserted into the peripheral
first step to a successful venipuncture. venous system (veins of the extremities) and threaded
into the central venous system (main veins leading to
VASCULAR ACCESS SITES AND DEVICES the heart).

There are cases when VADs are needed for blood sampling, HANDLING PATIENT COMPLICATIONS ASSOCIATED
infusing medication, central venous pressure readings, and WITH BLOOD COLLECTION
blood transfusion of a patient.
Allergies to Equipment and Supplies
Arterial line
 Adhesive allergy- a gauze should be placed over
 catheter that is placed in an artery (radial artery). the site and should be removed after 15 minutes.
 to provide accurate and continuous measurement  Antiseptic allergy- use a different antiseptic.
of a patient’s blood pressure  Latex allergy- look for a sign to indicate the allergy
Arteriovenous shunt, fistula, or graft
and use a non-latex alternative for gloves,
tourniquet, and bandages.
 Permanent surgical connection of an artery and
vein by direct fusion (fistula), resulting in a bulging
Excessive Bleeding
vein, or with a piece of vein or tubing (graft) that
creates a loop under the skin.  Pressure must be maintained over the site until the
 Joins the radial artery and cephalic vein above the bleeding stops. If the bleeding continues after 5
wrist on the underside of the arm, and has a minutes, the appropriate personnel should be
distinctive buzzing sensation called a “thrill” when notified.
palpated.
 Used for dialysis Fainting
 Patients prone to fainting during venipuncture are
Blood-sampling device asked to lie down during the procedure.
 Needleless closed blood sampling device
sometimes connected to an arterial or central Nausea and Vomiting
venous catheter for the purpose of collecting blood  Discontinue the procedure until the patient feels
specimens. better or until the feeling subsides. An emesis
 Reduces the chance of infection, prevent basin or wastebasket should be provided and a
needlesticks, and minimize waste associated with cold, damp washcloth or other cold compress
line draws. should be applied to the patient’s forehead.

Heparin or Saline Lock Pain

 Commonly called “hep-lock”  Remove the needle if the patient complains of
 IV catheter or cannula connected to a stopcock or a extreme pain or numbness and apply ice on the
cap with a diaphragm (thin rubber-like cover) that site because this could indicate nerve involvement.
provides access for administering medication or
drawing blood. Petechiae
 To keep it from clotting, the device is flushed and
filled with heparin or saline.  Are tiny, non-raised red spots or purple spots
(rashes-like) that appear on the patient’s skin when
Intravenous (IV) Sites a tourniquet is applied.
 catheter inserted in a vein to administer fluids.
Seizures or Convulsions
Central Vascular Access Devices (CVADs)

Tattao, KC 2
Principles of Medical Laboratory Science
LECTURE – BSMLS-1B
Kizza Claire A. Tattao

 The blood draw should be discontinued quickly  Damaging the vein could be avoided by following
when seizures or convulsions occur. There must be the proper technique (even when redirecting the
pressure held over the site but it must be made needle) and blind probing.
certain that movement is not restricted; the mouth
is free from any obstruction and the patient is
protected from self-injury. Notify the appropriate SPECIMEN QUALITY
first-aid personnel.  The quality of a blood specimen can be
compromised by improper collection techniques.
AVOIDING AND HANDLING PROCEDURAL ERROR RISKS  poor-quality specimen will generally  poor-
AND FAILURE TO DRAW BLOOD quality results, affecting the patient’s care.

HEMATOMA FORMATION HEMOCONCENTRATION

 A cold compress or ice pack may be offered to  Venous stasis/venostasis- the trapping of blood
relieve pain and reduce swelling. Follow facility in an extremity by compression of veins.
protocol.  (↓) in the fluid content of the blood with a
Situations that can trigger hematoma formation: subsequent (↑) in nonfilterable large molecule or
• Excessive or blind probing protein-based blood components such as RBCs.
• Inadvertent arterial puncture.  Other analytes (↑)- albumin, ammonia, calcium,
• The vein is too small cholesterol, coagulation factors, enzymes, iron,
• The needle penetrates all the way through potassium, and total protein.
the vein.
• The needle is not completely inserted Cholesterol levels can increase up to 5% after 2
• The tourniquet is still on when the needle minutes of tourniquet application and up to 15% after 5
was removed. minutes.
• Pressure is not adequate

IATROGENIC ANEMIA
 Blood loss due to blood draw
HEMOLYSIS (HAEMOLYSIS)
INADVERTENT ARTERIAL PUNCTURE  Rupture of RBCs, releasing the
hemoglobin into the fluid portion of
 Rapidly forming hematoma and blood filling the
the specimen.
tube very quickly.
 Slight hemolysis- plasma appears
pink
INFECTION
 Moderate hemolysis- dark pink to
 The risk of infection can be avoided by making sure light red
that;  Gross hemolysis- dark red
- tapes or bandages are not opened ahead of *** The specimen is described as being “hemolyzed”
time
- needles are not preloaded into the tube PARTIALLY FILLED TUBES
holders
 Referred to as a short draw
- insertion site of the needle is not touched after
 Leads to incorrect blood-to-additive ratio.
sterilization
 Red tops and SSTs- short-draw serum tubes that are
- cap is removed just before the venipuncture
generally acceptable for testing as long as the
- the patient is reminded to keep the bandage
specimen is not hemolyzed and there is sufficient
on for at least 15 mins after collection.
specimen to perform the test.
NERVE INJURY
SPECIMEN CONTAMINATION
 Improper vein selection, rapid needle insertion,
 The specimen is compromised due to incorrect
excessive redirection of needle, and blind probing
handling which involves;
 If initial needle insertion results in unsuccessful
- Allowing, alcohol, fingerprints, powder or
vein entry and slight forward or backward
other materials into the sample
redirection of the needle
- Getting glove powder or perspiration into
blood films (slides) or in capillary specimens.
REFLUX OF ANTICOAGULANT
- Using the wrong antiseptic; or simply not
 To prevent reflux, the patient’s arm must be kept following the proper antiseptic procedure.
in a downward position so that the collection tube
remains below the venipuncture site and fills from WRONG OR EXPIRED COLLECTION TUBE
the bottom up.
 Drawing a specimen in the wrong tube can affect
test results and jeopardize patient safety if the
VEIN DAMAGE
error is not caught before testing.

Tattao, KC 3
Principles of Medical Laboratory Science
LECTURE – BSMLS-1B
Kizza Claire A. Tattao

TROUBLESHOOTING FAILED VENIPUNCTURE

Failure to initially draw blood during a venipuncture
attempt can be caused by a number of procedural
errors.

TUBE POSITION
 Check the tube to see that it is properly seated and
the needle in the tube holder has penetrated the
tube stopper.

NEEDLE POSITION
 Insertion of the venipuncture needle so that the
bevel is correctly positioned within the vein is
critical to the success of venipuncture.

The phlebotomist should ensure the following do

not happen.

1. Needle inserted
far enough.
2. Bevel partially
out of the skin
3. Bevel partially
into the vein
4. Bevel partially
through the vein
5. Bevel completely
through the vein
6. Bevel against
the vein wall
7. Needle beside
the vein
8. Undetermined
needle position

COLLAPSED VEIN
 When a vein collapses, the walls draw together
temporarily, shutting off blood flow.

This can happen if

a) the vacuum draw of a tube or the pressure
created by pulling on a syringe plunger is
too much for the vein;
b) the tourniquet is tied too tightly or too
close to the venipuncture site;
c) the tourniquet is removed during the draw.
 This is often the case in elderly patients, whose
veins are fragile and collapse more easily

TUBE VACUUM
 A tube can lose its vacuum during a venipuncture if
the needle bevel is not completely under the skin
(bevel partially out of the skin).

KEY POINT Tube vacuum problems at the start of

a draw may be a sign that the tube is cracked or
has
been dropped. Cracked tubes present a safety
hazard because they may leak or break with further
handling. Never use a tube that has been dropped.
Discard it instead.
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