Complications

of Phlebotomy Medical/Physiological complications: Common complications: a.) Syncope (fainting) results from insufficient blood flow to the brain. Causes: fatigue, a sudden decrease in blood volume, cardiac arrhythmia, hypoglycaemia, hyperventilation For individuals who are having their blood collected, fainting is primarily due to psychological causes. If a patient is sitting in a phlebotomy chair and faints before venipuncture, guide the patients head between his/her knees. A cold compress placed on the back of the neck is also helpful. It is also a good idea to have ammonium salts available, but these can be very strong and must be used with care. Once the patient recovers, have him lie down. A cool drink may also help. b.) Hematoma Most common complication from phlebotomy. Occurs when the needle is improperly placed in the vein, allowing blood to escape from the vein and collect under the skin. Primary indication is swelling around the venipuncture site while the needle is being inserted. c.) Short Draw or No Blood Collected When insufficient blood is collected in a given tube or for a given test. When needle is in the vein but blood flow is reduced but blood flow is reduced, the needle Bevel may be against the vessel wall. Slight manipulation of the needle will remedy this problem. Suction of the tube vacuum may be too great, causing the vessel to collapse. In these cases, smaller tubes or syringes may be used. Collapsed veins may also occur if the syringe plunger is withdrawn too quickly. Needle is not inserted far enough. Needle may be below the skin but above the vein.

Needle may have been inserted through the vein.

Anticoagulated tube must be filled to the proper level. Short draw will alter the anticoagulant-to-blood ratio, producing spurious results. Other complications: 1. Petechiae - small red dots that appear on the skin as a result of capillary hemorrhage. Capillaries bleed excessively because of a coagulation problem, generally related to platelets. Petechiae can also be the result of tying the tourniquet too tight and leaving it too long. So tourniquet should not be on longer than 1 min. 2. Edema - results when excessive fluid collects in the tissues of a patient, causing swelling. These areas should be avoided because: a.) It is often difficult to locate a vein. b.) Specimen may be diluted with tissue fluid, which could adversely affect testing results. 3. Excessive bleeding - phlebotomist must not leave a patient until bleeding has stopped following venipuncture. 4. Intravenous veins 5. Obesity - veins are generally deeper and cannot be seen. 6. Allergies 7. Damaged or scarred veins - look for alternative site and if none can be located microcapillary procedure should be considered. 8. Burned areas - should be avoided as they are very susceptible to infection 9. Convulsions rare, simple hysteria causes most convulsions in phlebotomy patients 10. Mastectomy - venipuncture should be avoided in the arm on the same side on which a mastectomy was performed. This is because the patient may be susceptible to infection on that 1

side of the body because of the removal of lymph nodes with the breast. In double mastectomy, the physician or nurse should be consulted. 11. Nerve Injury - occasionally, even when proper technique and equipment are used, a patient may sustain nerve injury. Signified by a shooting pain in the forearm. Nerves may overlie the vein identified for phlebotomy. Phlebotomy should be discontinued immediately. The following may increase the chance of nerve injury: 1. Excessive probing 2. Going significantly through the vein 3. Sudden movement by the patient during phlebotomy Specimen Collection and Processing For Hemostasis Testing A nontraumatic venipuncture is the goal any time blood is drawn, but probably in no other area of laboratory testing is the quality of the sample as important to the accuracy of test results as in studies related to hemostasis. Premature activation of the clotting process can occur before the sample can be evaluated in the test procedures. Causes: 1.) Contamination with tissue thromboplastin - It is a potent clot-activating substance found in fluids that escape from injured cells and tissue spaces. This explains why capillary blood clots faster. It activates the extrinsic pathway of clotting and causes erroneous test results. 2.) Contact with the surface of an inappropriate specimen container - the contact factors (prekallikrein or Fletcher factor, XII and XI) will be activated prematurely by contact with glass causing a shortening of both intrinsic and extrinsic pathways. Recommended materials are plastic, polystyrene or silicone-coated glass. 3.) Improper temperature - labile factors (V and VIII) will deteriorate if left at room temp for an

extended period. Cold tends to activate factors VII and XI prematurely. 4.) Hemolysis - hemolyzed red cells act like tissue thromboplastin in activating plasma clotting factors. If it occurs in the blood-drawing process, technical problems are usually the cause. The Effect of Hemolysis on Common Tests Test Effect Potassium Increased value Magnesium Increased value Chemistry Aldolase Increased value Lactate Increased value dehydrogenase May invalidate Blood Bank Antibody screening test; specimen rejected Prothrombin time Increased value if (PT) severe Hematology Activated partial Increased value if thromboplastin time severe Causes of hemolysis: 1. Technical Vigorously shaking the tube of blood Using a needle that is too small (gauge 23) Drawing too hard on the syringe plunger (this collapses the vein, creating a vacuum and causes hemolysis on the rbc) Expelling blood too quickly through the syringe into the collection tubes (let the blood flow to the sides of the tube) Allowing the specimen to overheat (the heat causes hemolysis 2. Physiological Transfusion reaction Autoimmune haemolytic anemia Paroxysmal nocturnal hemoglobinuria Disseminated intravascular coagulation Activated Partial Thromboplastin Time (APTT) - used in monitoring patients with anti-coagulant therapy. Equipment: 1. Tourniquet Venous stasis occurs if it is applied too tightly (>1 min)

2. Needle Should be of the disposable type and coated with polymeric silicone. (These will make skin penetration and vein entry smooth and easy with minimal pain, trauma and activation of coagulation factors. 20 gauge - most commonly used 19 gauge - when more than 20 ml is to be drawn. 21 gauge - pediatric patients or those with narrow or small veins. 3. Sample containers Plastic syringes or silicone-coated evacuated tubes. Whenever citrated plasma is required = use silicone-coated evacuated tube with trisodium citrate (the anticoagulant of choice) ; ratio is 4:1 in the black top tube Samples drawn into these tubes are satisfactory for both coagulation and platelet function studies Anticoagulant of choice It preserves the labile clotting factors V and VIII better The most satisfactory for platelet aggregation studies Citrated plasma samples also are more sensitive to the effects of heparin; therefore they are preferred for tests to monitor heparin therapy. Ratio of Anticoagulant to Blood Standard ratio for Citrate: Nine parts blood to one part anticoagulant (9:1) This ratio is satisfactory for specimens with normal Hct. If Hct exceeds 0.50 L/L (polycythemia; normal is 0.45) or there is incomplete filling, the amount of

When arterial flow or venous return is interrupted, there is activation of the fibrinolytic system and clotting factors. To minimize such stasis and the hemoconcentration that also develops. The tourniquet should be released as soon as the vein is entered and blood appears in the syringe or evacuated tube. Seraket tourniquet is recommended.

unbound citrate causes a false prolongation of clotting time, especially in PT and APTT. This is because the standard amount of calcium is used to recalcify the plasma must inactivate excess unbound citrate in addition to initiating clotting of the specimen. The same can be said for underfilled blood. The small volume of plasma also contributes to excess unbound citrate.

3 remedies: 1.) Solve for the correct ratio - Involves repeat extraction and recomputation after extraction. 2.) Increase the calcium used to recalcify. 3.) Decrease the concentration of the anticoagulant. Most practical means of correction: DECREASE the concentration of the anticoagulant. Under normal conditions, the citrate in the evacuated tube is enough to anticoagulate half of the normal blood volume. If you have high Hct, it is preferable to use lesser concentrations of citrate. Coagulation tests are more sensitive to an excess of citrate in the plasma (as with high Hct.)and an underfilled tube than to an excess of calcium which occurs with low Hct or an overfilled tube. Although 3.8% (.29 molar) Na citrate is still used, 3.2% (.109 molar) buffered Na citrate has been adopted as the standard anticoagulant for coagulation studies by the NCCLS (National Committee for Clinical Laboratory Standards). The buffered sodium citrate also minimizes the effect of pH. Buffering of the citrate solution has the added effect of stabilizing the pH of blood samples and increases the stability of the labile clotting factors. EDTA o Not satisfactory for coagulation testing because it inhibits the fibrinogen-thrombin reaction. o Also, factor V is not stable in its presence. o Used in cell counting and cell morphology. 3

Heparin o An organic acid (mucoitin polysulfuric acid) that acts with anti-thrombin III and inhibits the reactions of all stages of coagulation. o Not used for collecting blood for coagulation studies because of its many anticoagulant actions o But it may be the anticoagulant of choice for platelet retention test.

Testing should be done immediately on centrifuged samples because the buffering effect of red cells is lost after centrifugation. Plasma should be stored at 4C for not longer than 2 hours.

Processing and Holding Samples before Testing Effects of pH: 1. Changes in pH can affect values by causing prolongation of clotting times. 2. The buffered citrate contained in evacuated tubes protects samples against such loss also red 3. Cells have a buffering effect that helps to stabilize the pH. 4. To maintain this effect, samples should remain in unopened tubes if testing is not done immediately. 5. Normal samples collected in evacuated tubes and stored at room temperature (unopened) for as long as 6 hours show no significant changes in PT or APTT. 6. If you separate the blood sample once it has been centrifuged, you have to use it within 2 hours. Effect of Temperature: 1. If samples are left at room temperature for an extended time, factors V and VIII are likely to deteriorate. 2. Factors VII and XI tend to be prematurely activated at refrigerated temperatures (4C). Centrifugation: For most coagulation testing, platelet-free plasma is required. Platelet-poor plasma (PPP) is prepared by centrifuging anticoagulated blood 2000 x g for 10 min. Plasma should be removed immediately with a plastic or siliconized pipet (glass pipets allow premature activation of contact factors). Only the upper should be aspirated (do not disturb plasma portion). For some tests, centrifugation of sample at 2 to 4C is advisable. Refrigerated centrifuge or small centrifuge placed in a ref is required.

Frozen Samples: Samples should not be frozen if testing can be done within 2 hours after collection. If freezing is necessary, it should be done rapidly at -20C or lower (rapid freezing). Slow freezing can cause ice particles to form and denature the clotting proteins. If frozen properly, fibrinogen is stable for at least 4 hours after thawing and survives refreezing and thawing.

Source: Mrs. Cinco November 12, 2010 Encoded by: Manzano and Miro Edited by: Yongco