Chapter 014

Special Collections
and Procedures
Chapter 14
Copyright © 2020 by Elsevier Inc. All Rights Reserved. 1

Learning Objectives
Lesson 14.1: Specimen Types, Therapeutic
Drug Monitoring, and Blood Cultures
(Slide 1 of 2)
1. Define and explain the uses of:

a. Fasting specimens
b. Timed specimens
2. Describe diurnal variation and list the blood
constituents that may be affected by it.
3. Define therapeutic drug monitoring (TDM),
describe the differences among a random level
and peak and trough levels and explain how TDM
samples are collected.

Learning Objectives
Lesson 14.1: Specimen Types, Therapeutic
Drug Monitoring, and Blood Cultures
(Slide 2 of 2)
4. Define the procedure for performing various

tolerance tests.
5. Describe the reasons and procedures for
collecting blood for culture.

Factors That Influence
Blood Composition
 Age  Medication
 Alcohol consumption  Medical treatment
 Altitude  Obesity
 Dehydration  Posture
 Diet
 Diurnal variation  Pregnancy
 Exercise  Smoking
 Gender  Stress

Fasting Specimens
 When patient has not had anything to eat or drink

(except water) for 8 hours
 If fasting specimen is requested, phlebotomist
must ask patient if he or she has had anything to

eat or drink other than water, or has had any
caffeine or nicotine, within the past 8 hours

Timed Specimens
 Timed specimens are most often used to monitor:

 Medication levels
 Changes in the patient’s condition
 Normal diurnal variation of various substances
throughout the day
 Cardiac enzymes, used to diagnose or rule out
myocardial infarction (heart attack); these are tested at
admission and then twice more at 8-hour intervals

Diurnal Variation
 Refers to the normal daily fluctuations in body

chemistry related to hormonal cycles, sleep-wake
cycles, and other regular patterns of change
 Many substances in the blood (especially
hormones) show diurnal variation, or regular

changes throughout the day
 Cortisol, for instance, is usually twice as high in
the morning as in the late afternoon

Representative Blood Constituents that
Show Marked Diurnal Variation
 Cortisol
 Estradiol
 Progesterone
 Testosterone
 Other hormones
 Serum iron
 Glucose
 White blood cells (eosinophils show especially
pronounced variation)

Therapeutic Drug Monitoring
(Slide 1 of 2)
 Patients differ greatly in the rate at which they

metabolize or excrete medications
 To maintain constant therapeutic plasma drug
levels and ensure that drug does not reach toxic

levels, a patient may require timed specimens to
measure medication levels
 The rate of metabolism is often given in terms of
drug’s half-life

Therapeutic Drug Monitoring
(Slide 2 of 2)
 Collection is usually timed to coincide with either

the trough or the peak serum level
 The trough level is the lowest serum level and
occurs immediately before the next dose of

medicine is given
 The peak level, or highest serum level, occurs
sometime after the dose is given; exactly when

depends on the characteristics of the drug, the
patient’s own metabolism, and the method of
administration

Diabetes Testing
 Four types of diabetes:

 Type 1
 Type 2
 Gestational
 Diabetes caused by other causes
 Diagnoses of diabetes or prediabetes relies on
results of four tests:
 Glycated hemoglobin (A1C)
 Fasting glucose
 Random glucose
 Oral glucose tolerance test (OGTT)

Oral Glucose Tolerance Test
(Slide 1 of 2)
 Tests for both diabetes and other disorders of

carbohydrate metabolism
 Measures change in blood glucose after drinking
very sweet solution

 Fallen out of use for the diagnosis of diabetes;
been replaced by either hemoglobin A1C or

fasting glucose sample

Oral Glucose Tolerance Test
(Slide 2 of 2)
 Glucose testing is still widely

used in pregnant woman to
diagnose gestational diabetes
 2-hr glucose tolerance test
(GTT)
 Fasting, 1 hr, and 2 hr
 3-hr GTT
 Fasting, 1 hr, 2 hr, and 3 hr
 5-hr GTT
 Fasting, 1 hr, 2 hr, 3 hr, 4 hr,
and 5 hr

Other Tolerance Tests
 The lactose tolerance test (LTT) determines

whether the lactose-digesting enzyme lactase is
present in the gut
 Stool acidity test may be ordered for patients and
children who are unable to undergo other tests

 Lactic acid and other acids from undigested
lactose can be detected in a stool, or fecal, sample

Blood Cultures
 A blood culture (BC) is ordered to detect the

presence of microorganisms in the blood, a
potentially life-threatening situation
 Such microorganisms include bacteria, fungi, and
protozoa
 Bacteremia refers specifically to the presence of
bacteria in the blood

 Septicemia is a life-threatening infection caused
by rapid multiplication of pathogens in the

bloodstream

Types of Collection Containers
 There are three basic types of containers for

collecting BCs
 A long-necked bottle, which accepts a BD Vacutainer
needle and tube holder
 A shorter bottle, which accepts a winged infusion
device, such as a BD Bactec, using a special adapter
 A standard evacuated tube with sodium polyanethole
sulfonate (SPS) anticoagulant

Site Preparation with Antiseptics
 Proper antiseptic preparation of skin reduces

presence of normal skin flora contaminants in the
BC sample
 Reducing risk of false positive
 Alcoholic preparations of iodine, povidone-iodine,
or chlorohexide gluconate (CHG): preferred
antiseptics

Timing
 The number of organisms in the bloodstream is

often highest just before a spike in the patient’s
temperature
 By frequently recording the temperature, these
spikes can often be predicted and collection

scheduled accordingly

Multiple Sites
 Contamination of the sample by skin bacteria is a

frequent complication of BC collection
 However, distinguishing contaminants from true
pathogens can be difficult because some

contaminants can grow on indwelling devices,
causing infection in the patient
 To reduce errors caused by this contamination, a
known skin contaminant must be cultured from at

least two different sites to be considered a blood
pathogen

Blood Culture Collection
(Slide 1 of 2)
 Prepare the site

 After identifying the site, scrub it vigorously with
alcohol to clean 1½ to 2 inches beyond the intended
puncture site
 Scrub vigorously with 2% iodine or a povidone–iodine
swab stick
 Avoid touching the site once it has been cleaned
 Prepare your collection equipment

Blood Culture Collection
(Slide 2 of 2)
 Collect the sample

 Reapply the tourniquet, and perform the venipuncture
 Attend to the patient
 After collection, remove the iodine from the patient’s
arm with alcohol
 Check the puncture site to be sure bleeding has stopped
 Apply a bandage, using a fresh adhesive bandage or
placing adhesive tape over the gauze square

Learning Objectives
Lesson 14.2: Blood Donor
Collection and Blood Smears
(Slide 1 of 2)
6. Explain the steps in collecting blood from donors for

transfusion.
7. Define and explain the uses of autologous donation
and therapeutic phlebotomy.
8. Explain how samples to be tested for or suspected of
containing cold agglutinins, cryofibrinogen, or
cryoglobulin should be handled.
9. List samples that should be chilled until tested.

Learning Objectives
Lesson 14.2: Blood Donor
Collection and Blood Smears
(Slide 2 of 2)
10. List samples that are light sensitive, and explain how
they should be handled.
11. Describe the precautions to be taken when collecting
legal or forensic specimens.
12. List samples that are time sensitive, and explain how
they should be handled.
13. Explain how to prepare blood smears, describe features
of unacceptable smears, and list the possible causes.
14. Explain how to prepare smears to be examined for
malaria.

Blood Donor Collection
(Slide 1 of 2)
 Blood donation is a vital link in the healthcare

system, and the phlebotomist plays a central role
in the collection of donated blood
 Blood banks collect and store donated blood for
use in both emergency and scheduled transfusions

Blood Donor Collection
(Slide 2 of 2)
 Potential donors must be screened to ensure that

the donation is not harmful to the donor or the
recipient
 Screening involves the following:
 Registration
 Interview and medical history
 Physical examination

Collection Procedure
 Blood is collected by the unit, whose volume is 400

to 500 mL, or approximately 0.5 L
 It is collected directly into a sterile plastic bag,
which hangs below the collection site and fills by

gravity
 The weight of the filled bag triggers a clamp that
stops the collection

 A 16- to 18-gauge needle is used for collection

Autologous Donation
 An autologous donation is blood donated by a

patient for his or her own use later
 Patients planning surgery often make autologous
donations before the procedure

 Because multiple units might be needed during
surgery, patients may need to donate several times

 A patient can donate as often as every 72 hours,
assuming that his or her health is good

Therapeutic Phlebotomy
 Therapeutic phlebotomy is the removal of blood

from a patient’s system as part of the treatment for
a disorder
 The principal disorders treated by therapeutic
phlebotomy are polycythemia, a disease

characterized by excessive production of red
blood cells (RBCs), and hemochromatosis, an
excess of iron in the blood
 In both cases, periodic removal of a unit of blood
may be part of the treatment program

Cold Agglutinins
 Cold agglutinins are antibodies often formed in

response to infection with Mycoplasma
pneumoniae, a cause of atypical pneumonia
 The antibodies created by the immune system
during the infection may also react with RBCs at

temperatures below body temperature, causing
them to stick together, hence cold agglutinins
(agglutination is the process of sticking together)

Cryofibrinogen and Cryoglobulin
 Warm collection and storage are required for two

other types of samples: cryofibrinogen (an
abnormal type of fibrinogen) and cryoglobulin (an
abnormal serum protein)
 These samples should be collected and handled in
the same manner as a cold agglutinin sample

Chilled Specimens
 A number of tests require that the specimen be

chilled immediately after collection
 Chilling is used to prevent chemical changes that
would alter test results

 The sample should be placed in crushed ice or in
an ice and water mixture and immediately

delivered to the laboratory

Light-Sensitive Specimens
 Exposure to light can break down or alter certain

blood constituents
 Specimens to be tested for these constituents must
be protected from light after collection

 This is done by wrapping the tube in aluminum
foil immediately after collection

Legal and Forensic Specimens
(Slide 1 of 2)
 Blood specimens may be collected for use as

evidence in legal proceedings, including alcohol
and drug testing, deoxyribonucleic acid (DNA)
analysis, or paternity or parentage testing
 The most important concept in handling forensic
specimens is the chain of custody (COC), a

protocol that ensures that the sample is always in
the custody of a person legally entrusted to be in
control of it

Legal and Forensic Specimens
(Slide 2 of 2)
 The purpose and procedure of the test must be

explained to the patient
 The patient must sign a consent form
 The patient must present picture identification
 The specimen must be labeled appropriately to
establish a COC
 The specimen must be sealed in such a way that any
tampering can be identified
 The specimen must be placed in a locked container
before transport to the testing site
 The recipient must sign for delivery of specimen
Legal Alcohol Collection
 Important features of alcohol testing include the

following:
 The site must not be cleaned with alcohol, as this would
falsely elevate the result
 Tubes must be filled as full as the vacuum allows to
minimize the escape of alcohol from the specimen into
the space above
 Note on the requisition form that the site was cleansed
with soap and water or another a nonalcoholic solution

Time-Sensitive Blood Constituents
 Adrenocorticotropic hormone (ACTH)

 Ammonia
 Brain natriuretic peptide
 Lactate
 Platelet aggregation
 Prostatic acid phosphatase

Blood Smears
 Blood smears are made to allow microscopic
examination of the blood cells
 The blood smear is used for determining the
proportion of the various blood cell types, called a

differential count; counting reticulocytes; and
performing special staining procedures

Blood Smear Preparation
(Slide 1 of 2)
 Prepare the smears

 Place one drop of blood on a clean slide, ½ to 1 inch
from the end, centered between the two sides
 Place the edge of a second slide, the “spreader,” onto
the first slide in front of the blood at a 25- to 30-degree
angle, and draw it back to just contact the drop
 Move the spreader slide forward, away from the drop,
in one continuous movement to the end of the slide

Blood Smear Preparation
(Slide 2 of 2)
 Examine the smears

 An acceptable smear
must have a feathered
edge, meaning that the
cells appear to thin out
farther from the
original drop
 At the far end, you
should see a very thin
transparent layer

Unacceptable Smears
and Their Causes
(Slide 1 of 2)
 Holes in the smear

 Dirty slide
 Smear that is too thick and long
 Drop that is too large
 Drop that is not placed close enough to far edge of slide
 Spreader slide that is lifted before it reaches end of
sample slide
 Smear that is too thick and long
 Drop of blood that is too big
 Angle of spreader slide > 30 degrees

Unacceptable Smears
and Their Causes
(Slide 2 of 2)
 Smear that is too thin and short

 Drop of blood that is too small
 Angle of spreader slide <25 degrees
 Streaks in the feathered edge
 Chipped or dirty spreader slide
 Spreader slide that is not placed flush against smear
slide
 Drop of blood that is in front of spreader slide
 Uneven distribution of blood
 Uneven pressure on spreader slide
 Uneven movement of the spreader slide

Malaria Smears
(Slide 1 of 2)
 Malaria is caused by blood-borne protozoa of the

genus Plasmodium
 A patient with malaria has cycles of fever and
chills that coincide with the life cycle of the

parasite in the bloodstream
 Malaria is diagnosed with a blood smear, drawn as
a stat or timed collection just before the onset of

fever or chills

Malaria Smears
(Slide 2 of 2)
 To make the thick smear, use a larger drop of blood, and

spread it out to only about the size of a dime
 Sample must be allowed to dry for at least 2 hours; then
stained to reveal parasites

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Special Collections

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 1

1. Define and explain the uses of:

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 2

4. Define the procedure for performing various

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 3

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 4

 When patient has not had anything to eat or drink

must ask patient if he or she has had anything to

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 5

 Timed specimens are most often used to monitor:

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 6

 Refers to the normal daily fluctuations in body

hormones) show diurnal variation, or regular

the morning as in the late afternoon

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 7

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 8

 Patients differ greatly in the rate at which they

levels and ensure that drug does not reach toxic

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 9

 Collection is usually timed to coincide with either

occurs immediately before the next dose of

sometime after the dose is given; exactly when

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 10

 Four types of diabetes:

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 12

 Tests for both diabetes and other disorders of

very sweet solution

been replaced by either hemoglobin A1C or

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 13

 Glucose testing is still widely

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 14

 The lactose tolerance test (LTT) determines

children who are unable to undergo other tests

lactose can be detected in a stool, or fecal, sample

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 15

 A blood culture (BC) is ordered to detect the

bacteria in the blood

by rapid multiplication of pathogens in the

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 16

 There are three basic types of containers for

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 17

 Proper antiseptic preparation of skin reduces

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 19

 The number of organisms in the bloodstream is

spikes can often be predicted and collection

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 20

 Contamination of the sample by skin bacteria is a

pathogens can be difficult because some

known skin contaminant must be cultured from at

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 21

 Prepare the site

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 22

 Collect the sample

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 23

6. Explain the steps in collecting blood from donors for

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 24

Copyright © 2020 by Elsevier Inc. All Rights Reserved. 25

 Blood donation is a vital link in the healthcare