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7/3/13

Objective and Scope


of Unit 4
Use standard protocol in handling and collecting specimen
Promote ethical and social responsibilities in dealing with patients.
Collaborate with other health care professionals for methods and protocols of specimen
handling and patient preparations needed for each determination.
Communicate properly the laboratory procedures and requirements to patients and physicians.

Maria Ruth B. Pineda, RMT, Ph.D.


Department of Medical Technology
University of Santo Tomas

1. Types of Specimen
1.1. Collection and Labeling
1.2. Handling, Transport processing, Storage, and Preservation
2. Specimen variables
2.1. Pre-collection
2.1.1. Patient identification and preparation
2.1.2. Anticoagulants and preservatives
2.2. Collection
2.3. Post-collection
2

Types of Specimen
Body fluids: blood, CSF, urine, sweat, gastric juices, etc.
Tissues
Organs
Others: hair, nail, skin scrapings, etc.

TYPES OF BLOOD SPeCIMEN


1. Serum

liquid portion of clotted blood

clearer than plasma


with albumin and globulin but no fibrinogen

not lipemic nor icteric

2. Plasma

Liquid portion of unclotted blood


with fibrinogen

3. Whole Blood

plasma and red cells

with anticoagulant

3 ways of obtaining
blood specimen
1. Venipuncture

Collapse easily

2. Arterial Puncture
bright red arterial blood

used for ABG test

VEINS
Thinner walls than arteries

purplish venous blood

Less pressure inside

3. Skin Puncture

usually contaminated with tissues juices

method of choice for pediatric and geriatric patients,


extremely obese adults, severe burn patients, and those
with thrombotic tendencies (bleeding disorders)
5

7/3/13

CHAPTER 2 PHLEBOTOMY AND SPECIMEN CONSIDERATIONS

39

ARTERIES

and processing. New gloves must be worn for each


throughout the body, is important to anyone who perpatient. Masks or respirators may be required when
forms phlebotomy.
drawing blood from patients with certain transmissible
Arteries (Fig. 2-1) have thick walls to withstand the
diseases.
pressure of ventricular contraction, which creates a
Hand hygiene: Proper hand hygiene is the most impulse that can be felt, distinguishing them from veins.
portant means of
preventing
the spread of infection.
Thick walls
When arterial blood is collected by syringe, the presHands must be decontaminated frequently, includsure normally causes blood to pump or pulse into
ing after glove removal, as gloves can contain de Higher pressure: pulse
the syringe under its own power. Normal systemic arfects. CDC and Healthcare Infection Control
terial blood is bright red because it is oxygen rich.
Practices Advisory Committee (HICPAC) guidelines
Veins (Fig. 2-1) have thinner walls than the same-size
*no
need
to
pull
the
plunger
allow use of alcohol-based antiseptic hand cleaners
arteries because blood in them is under less pressure.
instead of hand washing if hands are not visibly
Consequently, they collapse more easily. Blood is kept
soiled. To achieve antisepsis, cover all hand surfaces
moving through veins by skeletal muscle movement
with ample cleaner and let it evaporate. If no hand
and the opening and closing of valves that line their
washing facilities are available, clean visibly soiled
inner walls. Normal systemic venous blood is dark
hands with detergent wipes followed by alcoholbluish red because it is oxygen poor.
based cleaner.
Capillaries (Fig. 2-1) are only one cell thick to allow
Isolation: Isolation procedures separate certain pathe exchange of gases and other substances between
tients from others and limit their contact with hospithe tissues and the blood. The capillary bed in the skin
tal personnel and visitors. A description of required
can easily be punctured with a lancet to provide blood
precautions is normally posted on the patients door
specimens for testing.
and must be followed by all who enter the room. A 7
cart containing supplies needed to enter the room
or care for the patient is typically located outside
PHLEBOTOMY-RELATED VASCULAR
ANATOMY
the door.

CAPILLARIES
One cell thick to allow exchange of gases
For micromethod collection only

The major veins for venipuncture are in the antecubital


fossa, the area of the arm in front of the elbow. Here, several large veins lie near the surface, making them easier
to locate and draw blood from. Although exact locations

THE VASCULAR SYSTEM


Basic knowledge of the vascular system, the network of
arteries, veins, and capillaries that circulate blood

Artery

Vein

Venipuncture sites

Elastic tissue
Tunica intima
(endothelium)
Tunica media
(smooth muscle)

Valve

1. Antecubital fossa

Tunica adventitia
(connective tissue)
Blood flow

Median cubital
Cephalic
basilic

2. Other veins
Arteriole

Venule

Capillary
FIGURE 2-1. Artery, vein, and capillary structure. (Reprinted with permission from McCall R, Tankersley C.
Phlebotomy essentials. 4th ed. Baltimore, Md.: Lippincott
9 Williams & Wilkins, 2008.)

40

Brachial
Femoral
Radial
Ankle veins
Veins of the dorsal
hand
Etc.
10

PART 1 BASIC PRINCIPLES AND PRACTICE OF CLINICAL CHEMISTRY


Medial
cubital
nerve
Subclavian
vein

Medial cubital
nerve
Subclavian
vein
Cephalic
vein

Brachial
artery

Accessory
cephalic
vein
Cephalic
vein

Basilic vein

Ant. median
cutaneous nerve
Post. median
cutaneous nerve

Median cubital
vein
Basilic vein

Brachial artery
Cephalic vein
Accessory
cephalic vein
Median
cephalic vein

Cephalic vein

Median vein

Basilic vein
Ant. median
cutaneous
nerve

Post. median
cutaneous
nerve
Median basilic
vein
Basilic vein

Median vein

Inappropriate
venipuncture sites
Arm on side of mastectomy
Edematous areas
Hematomas
Arm in which blood is being transfused
Scarred area

Basilic vein

Cephalic
vein
Dorsal
metacarpal
veins

Arms with fistulas or vascular grafts


Sites above an IV cannula

C
11

12

FIGURE 2-2. Principal veins of the arm including major antecubital veins. (A) H-shaped
pattern of antecubital veins of the right arm in anatomic position. (B) M-shaped pattern
of antecubital veins of the right arm in anatomic position. (C) Right forearm, wrist, and
hand veins in prone position. (Reprinted with permission from McCall R, Tankersley C.
Phlebotomy essentials. 4th ed. Baltimore, Md.: Lippincott Williams & Wilkins, 2008.)

vary slightly from person to person, two basic patterns in


which the veins form the shape of either an H or an
M are seen most often (Fig. 2-2).

H Pattern Veins
The H pattern (Fig. 2-2A) is displayed by approximately
70% of the population and includes the following veins:

Median cubital vein: located near the center of the antecubital fossa. It is the preferred vein for venipuncture in the H pattern because it is typically large,
closer to the surface, and the most stationary, making
it the easiest and least painful to puncture and the
least likely to bruise.

Basilic vein: located on the medial side of the antecubital fossa. It is the last choice in either pattern.
Although normally large and easy to feel, it is not
well anchored and rolls easily, increasing risk of puncturing a median cutaneous nerve branch or the
brachial artery that is nearby. CLSI recommends
against using it unless no other vein in either arm is
more prominent.

M Pattern Veins
Although the cephalic and basilic veins help form the M
pattern (Fig. 2-2B), the veins commonly used for
venipuncture in this pattern are the following:

7/3/13

METHODS OF BLOOD
Collection based on amount

Skin puncture sites


lateral or at the medial surface of the heel

1. Macromethod 1.0 mL and above

ring finger

2. Micromethod 0.1 to 0.9 mL

ear lobes

3. Ultramicromethod 0.01 to 0.09 mL


4. Nanoliter method 0.001 to 0.009 mL

How to puncture?
Clean the area
One quick deep stab
Perpendicular to the finger prints

PREANALYSIS

PREANALYSIS

13

14

TABLE 3-5

Tube Color and Anticoagulant/Additive


TABLE 3-7

Stopper color

Anticoagulant/additive

Specimen type/use

Anticoagulant/Additive
on Blood Tests
Mechanism Effect
of action
Additive

Red (glass)
Red (plastic/Hemogard)
Lavender (glass)
TABLE 3-5
Tube
Color and Anticoagulant/Additive
Lavender
(plastic)
Stopper color
Anticoagulant/additive
Pink
Red (glass)
None

None
Clot activator
K3EDTA in liquid form
K2EDTA/spray-dried
Specimen type/use
Spray-dried
K2EDTA
Serum/chemistry and serology

EFFECT OF
INCORRECT

Evacuated tubes

Red (plastic/Hemogard)
Lavender (glass)
Lavender (plastic)
Pink

Clot activator
K3EDTA in liquid form
K2EDTA/spray-dried
Spray-dried K2EDTA

Black
Light green/black
Green
Royal blue

EDTA and gel


Sodium citrate
Thrombin and soybean trypsin
inhibitor
Sodium citrate
Lithium heparin and gel
Sodium heparin, lithium heparin
Sodium heparin, K2EDTA

White
Light blue
White
Light blue
blue
LightLight
blue

Serum/chemistry and serology


Whole blood/hematology
Whole blood/hematology
Whole blood/blood bank and
molecular diagnostics
Plasma/molecular diagnostics
Plasma/coagulation
Plasma/coagulation

Tan (glass)
Tan (plastic)
Yellow/gray and orange
Red/gray and gold

Mechanism of action
N/A
Silica clot activator
Chelates (binds) calcium
Chelates (binds) calcium
Chelates (binds) calcium

EDTA and gel


Sodium citrate
Chelates (binds) calcium
Chelates (binds) calcium
Thrombin and soybeanFibrin
trypsin
degradation products
inhibitor
Plasma/sed
rateshematology
Chelates (binds) calcium
Plasma/chemistry
Inhibits thrombin formation
Sodium
citrate
Plasma/chemistry
Inhibits thrombin formation
Plasma/chemistry/toxicology
Heparin inhibits thrombin formation
Na EDTA binds calcium
Lithium heparin and gel
Plasma/glucose testing
Inhibits glycolysis
Serum/microbiology
culture
Aids in
bacterial recovery by inhibiting
Sodium
heparin,
lithium
heparin
complement, phagocytes, and
certain antibiotics
Sodium
heparin,
K
EDTA
2
Plasma/blood bank, HLA phenotyping,
WBC preservative

Black
Light green/black
Gray
Sodium fluoride/potassium oxalate
Yellow
Sterile containing sodium
Green
polyanetholesulfonate
Royal
blue
Yellow
Acid citrate dextrose

and paternity testing


Plasma/lead testing
Plasma/lead testing

Sodium heparin
K2EDTA

Serum/chemistry and serology


Serum/chemistry and serology
Whole blood/hematology
Whole blood/hematology
ANTICOAGULANT
Whole blood/blood bank and
molecular diagnostics
Plasma/molecular diagnostics
Plasma/coagulation
Plasma/coagulation
Plasma/sed rateshematology
Plasma/chemistry
Plasma/chemistry
Plasma/chemistry/toxicology

Inhibits thrombin formation


Chelates (binds) calcium

Thrombin
Serum/chemistry
Clot activator
Gray
Sodium
fluoride/potassium
oxalate
Plasma/glucose testing
Clot activator separation gel
Serum/chemistry
Silica clot activator
15 containing sodium
Sterile
EDTA, Yellow
Ethylenediaminetetraacetic acid; HLA, human leukocyte antigen; K EDTA,
dipotassium form
of EDTA; K EDTA, tripotassium form of EDTA; N/A, not applicable; Na EDTA, Serum/microbiology culture
disodium EDTA; WBC, white blood cell.
polyanetholesulfonate
2

TABLE 3-6

Order of Draw: Evacuated Tube and Syringe

Yellow

1.
2.
3.
4.
5.
6.

Blood-culture tubes (yellow)


Coagulation sodium citrate tube (blue stopper)
Serum tubes with or without clot activator or gel separator
Heparin tubes with or without gel (green stopper)
Ethylenediaminetetraacetic acid tubes (lavender stopper)
Glycolytic inhibitor tubes (gray stopper)

citrate and are generally used for Westergren sedimentation rates, as are
lavender-top tubes. They differ from light bluetop tubes in that the ratio
of blood to anticoagulant is 4:1 in the black-top tubes and 9:1 in the light

tubes.dextrose
Acid bluetop
citrate

Heparin, a mucoitin polysulfuric acid, is an effective anticoagulant in


small quantities without significant effect on many determinations.
Heparin was originally isolated from liver cells by scientists looking for an
anticoagulant that could work safely in humans. Heparin is available as
lithium heparin (LiHep) and sodium heparin (NaHep) in green-top tubes.
Heparin accelerates the action of antithrombin III, neutralizing thrombin
and preventing the formation of fibrin. Heparin has an advantage over
EDTA as an anticoagulant, as it does not affect levels of ions such as
calcium. However, heparin can interfere with some immunoassays.
Heparin should not be used for coagulation or hematology testing. Heparinized plasma is preferred for potassium measurements to avoid an elevation due to the release of potassium from platelets as the blood clots
(Garza, 2002). Lithium heparin may be used for most chemistry tests
except for lithium and folate levels; for lithium, a serum specimen can be
used instead. Sodium heparin cannot be used for assays measuring sodium
levels, but it is recommended for trace elements, leads, and2 toxicology.
Sodium heparin is the injectable form used for anticoagulant therapy.
Gray-top tubes are generally used for glucose measurements because
they contain a preservative or antiglycolytic agent, such as sodium fluoride,
which prevents glycolysis for 3 days (Strasinger, 2003). In bacterial septicemia, fluoride inhibition of glycolysis is neither adequate nor effective in
preserving glucose concentration. Red-top tubes have no additive, so blood
collected in these tubes clots.
Red-top tubes are used for most chemistry, blood bank, and immunology assays. Integrated serum separator tubes are available for isolating
serum from whole blood. During centrifugation, blood is forced into a
thixotropic gel material located at the base of the tube. The gel undergoes
a temporary change in viscosity during centrifugation and lodges between
the packed cells and the top serum layer (Strasinger, 2003). Pediatric-sized
tubes are also available. Advantages of serum separator tubes include (1)
ease of use, (2) shorter processing time through clot activation, (3) higher
serum yield, (4) minimal liberation of potentially hazardous aerosols, (5)
only one centrifugation step, (6) use of single tube (same one as patient
specimen), and (7) ease of a single label. A unique advantage is that centrifuged specimens can be transported without disturbing the separation.

Tan (glass)
Sodium heparin
Tan (plastic)
K2EDTA
mandating substitution. This change from glass to plastic has required a
Yellow/gray and orange
Thrombin
modification in the order of draw. Glass or plastic tubes with additives,
including gel tubes, are drawn after the citrate tube (blue top) to avoid
Red/gray
andmeasurements
gold (Table 3-6). Glass or plastic
Clot activator separation gel
interference
with coagulation

PROPER ORDER OF DRAW

serum tubes, without a clot activator or gel separator, may be drawn before
the coagulation tubes are drawn, consistent with National Committee
on Clinical Laboratory Standards (NCCLS) guidelines (H3-A6)
(Ernst, 2004).

Plasma/blood bank, HLA phenotyping,


and paternity testing
Plasma/lead testing
Plasma/lead testing
Serum/chemistry
Serum/chemistry

EDTA, Ethylenediaminetetraacetic acid; HLA, human leukocyte antigen; K EDTA, dipotassium


disodium EDTA; WBC, white blood cell.

ANTICOAGULANTS AND ADDITIVES

Ethylenediaminetetraacetic acid (EDTA) is the anticoagulant of choice for


hematology cell counts and cell morphology. It is available in lavender-top
tubes as a liquid or is spray-dried in the dipotassium or tripotassium salt
form (K2EDTA in plastic, spray-dried, and K3EDTA in liquid form in glass
tubes). K3EDTA is a liquid and will dilute the sample 1%2%. K2EDTA
is spray-dried on the walls of the tube and will not dilute the sample. Pinktop tubes also contain EDTA. The EDTA is spray-dried K2EDTA. Pink
tubes are used in immunohematology for ABO grouping, Rh typing, and
antibody screening. These tubes have a special cross-match label for information required by the American Association of Blood Banks (AABB) and
approved by the U.S. Food and Drug Administration (FDA) for blood
bank collections. White-top tubes also contain EDTA and gel. They are
used most often for molecular diagnostic testing of plasma. For coagulation testing, a light bluetop tube containing 0.105 M or 0.129 M (3.2%
and 3.8%) sodium citrate is commonly used because it preserves the
labile coagulation factors. Black-top tubes also contain buffered sodium

TABLE 3-6

Order of Draw: Evacuated Tube and Syringe

28

1.
2.
3.
4.
5.
6.

16

Blood-culture tubes (yellow)


Coagulation sodium citrate tube (blue stopper)
Serum tubes with or without clot activator or gel separator
Heparin tubes with or without gel (green stopper)
Ethylenediaminetetraacetic acid tubes (lavender stopper)
Glycolytic inhibitor tubes (gray stopper)

mandating substitution. This change from glass to plastic has required a


17 Glass or plastic tubes with additives,
modification in the order of draw.
including gel tubes, are drawn after the citrate tube (blue top) to avoid
interference with coagulation measurements (Table 3-6). Glass or plastic
serum tubes, without a clot activator or gel separator, may be drawn before
the coagulation tubes are drawn, consistent with National Committee
on Clinical Laboratory Standards (NCCLS) guidelines (H3-A6)
(Ernst, 2004).

ANTICOAGULANTS AND ADDITIVES


Ethylenediaminetetraacetic acid (EDTA) is the anticoagulant of choice for
hematology cell counts and cell morphology. It is available in lavender-top
tubes as a liquid or is spray-dried in the dipotassium or tripotassium salt
form (K2EDTA in plastic, spray-dried, and K3EDTA in liquid form in glass
tubes). K3EDTA is a liquid and will dilute the sample 1%2%. K2EDTA

Test

N/A Alkaline phosphatase


Creatine kinase
Silica clot
Leucineactivator
aminopeptidase
Calcium and iron
PT and
PTT
Chelates
(binds)
calcium
Sodium and potassium
Platelet
aggregation
Chelates
(binds)
calcium
Oxalate
Acid phosphatase
Chelates
(binds)
calcium
Alkaline
phosphatase

EDTA

Amylase
LD
Calcium

Effect
Inhibits
Inhibits
Inhibits
Decrease
Increase
Increase
Prevents
Inhibits
Inhibits
Inhibits
Inhibits
Decreases
Increase
Distorts
Inhibit
Inhibits
Stimulates
Decreases
Decreases
Increase
Preserve
Increases
Increases
Increase
Causes blue background
Increases
Increases
Decreases
Decreases
Decreases
Decreases
Decrease
Distorts

Chelates
(binds)
calcium
Sodium
and potassium
Cell morphology
(binds)
calcium
CitrateChelates
ALT and
AST
Alkaline phosphatase
Fibrin Acid
degradation
products
phosphatase
Amylase
Calcium

Sodium and potassium


Chelates
(binds) calcium
Labile coagulation factors
Heparin
Triiodothyronine
Inhibits
thrombin formation
Thyroxine
PT and PTT
Inhibits
thrombin formation
Wrights stain
Lithium (LiHep tubes only)
Heparin
inhibits
thrombin
formation
Sodium
(NaHep tubes
only)
Fluorides
Acid phosphatase
Na2EDTA
binds calcium
Alkaline phosphatase
Amylase
Inhibits
glycolysis
Creatine kinase
and AST
Aids inALT
bacterial
Cell
morphology recovery by inhibiting
complement, phagocytes, and
ALT, Alanine aminotransferase; AST, aspartate aminotransferase; EDTA, ethylenediaminetetraacetic acid; LD, lactate dehydrogenase; LiHep, lithium heparin; NaHep,
certain antibiotics
sodium heparin; PT, prothrombin time; PTT, partial thromboplastin time.
WBC preservative

Some silica gel serum separation tubes may give rise to minute particles
that can cause flow problems during analysis. Filtering the serum solves
the problem.
Inhibits
formation
A few
specializedthrombin
tubes exist. Red/grayand gold-top tubes contain a
clot activator and a separation gel. These tubes are referred to as serum
Chelates
separator
tubes (SSTs)(binds)
and are usedcalcium
most often for chemistry tests. Therapeutic drug monitoring specimens should not be collected in tubes that
activator
containClot
gel separators,
as some gels absorb certain drugs, causing a falsely
lowered result. Significant decreases in phenytoin, phenobarbital, lidoactivator have been reported when stored in
caine, Silica
quinidine,clot
and carbamazepine
Vacutainer SST tubes (Becton, Dickinson, and Company [BD], Franklin
Lakes, N.J.),
while no changes
were notedCONSIDERATIONS
in theophylline and salicylate
CHAPTER
2 PHLEBOTOMY
AND SPECIMEN
47
form of EDTA; K3EDTA, tripotassium
form
of
EDTA;
N/A,
notVacutainer
applicable;
Natubes
2EDTA,
levels. Storage in standard
red-top
collection
without
barrier gels did not affect measured levels of the above therapeutic drugs
(Dasgupta,AND
1994).RATIONALE
Studies indicate
thatCOLLECTION
this absorptionORDER
is time dependent,
TABLE 2-3 ORDER OF DRAW, STOPPER COLORS,
FOR
and therefore speed in processing minimizes absorption. Acrylic-based gels
ORDER OF DRAW
TUBE STOPPER COLOR
RATIONALE
FOR COLLECTION
do not exhibit
the absorption
problemsORDER
associated with silicone and polyBlood cultures (sterile
Yellow SPS
chance of microbial contamination
ester gelsMinimizes
(Garza, 2002).
collections)
Sterile media bottle Tubes containing gels are not used in the blood bank or for immunologic testing,
as the
gel may
with because
the immunologic
Coagulation tubes
Light blue
The first
additive
tubeinterfere
in the order
all other reactions
(Strasinger,
2003). affect
Clotting
time for tubes
additives
coagulation
testsusing gel separators is approximately 30 minutes, and tubes that have clot activators, such as thrombin,
Glass nonadditive tubes
Red
contamination
by additives
in other
will clot Prevents
in 5 minutes.
Plain red-stoppered
tubes
with tubes
no additives take
about 60Filled
minutes
to coagulation
clot completely
(Strasinger,
2003).
Plastic clot activator tubes
Red
after
tests
because silica
particles
may affect
the transport
of water
cell and
Serum separator tubes
Red and gray rubber Anticoagulants
activate clotting
and affect
coagulation
tests between
(carry-over
plasma, thereby
cell size and
constituent
plasma concentration.
(SSTs)
Gold plastic
of silica altering
into subsequent
tubes
can be overridden
by
Oxalate anticoagulant
anticoagulants in
may
shrink red cells; thus blood anticoagulated
them)
with oxalate cannot be used to measure hematocrit. Combined ammonium/
Plasma separator tubes
Green and gray rubber
Heparin affects coagulation tests and interferes in
potassium oxalate does not have the same effect of shrinking cells.
(PSTs)
Light-green plastic
collection of serum specimens; causes the least
EDTA, citrate, and oxalate chelate calcium, thereby lowering calcium
Heparin tubes
Green
interference in tests other than coagulation tests
levels. Fluoride, used for glucose determinations, prevents glycolysis
EDTA tubes
Lavender
Responsible
more carry-over
than any other
thereby inhibiting
the Mg++by forming
an ionic for
complex
with Mg++,problems
!
and 2001).
K! levels,
chelates
decreases
Pink
additive:
dependent
enzyme,elevates
enolaseNa
(Young,
Table
3-7 listsand
anticoagulants/
Plasma preparation
Pearl top
and
iron on
levels,
elevates
and PTT results
additivescalcium
and their
effects
various
bloodPT
tests.

Rationale of the
order of draw

citrate and are generally used for Westergren sedimentation rates, as are
lavender-top tubes. They differ from light bluetop tubes in that the ratio
of blood to anticoagulant is 4:1 in the black-top tubes and 9:1 in the light
bluetop tubes.
Heparin, a mucoitin polysulfuric acid, is an effective anticoagulant in
small quantities without significant effect on many determinations.
Heparin was originally isolated from liver cells by scientists looking for an
anticoagulant that could work safely in humans. Heparin is available as
lithium heparin (LiHep) and sodium heparin (NaHep) in green-top tubes.
Heparin accelerates the action of antithrombin III, neutralizing thrombin
(PPTs)
SodiumHeparin
fluoride and potassium
affect
andtubes
preventing
the formation of fibrin.
has anoxalate
advantage
over
Oxalate/fluoride tubes
Gray
sodium and potassium levels, respectively, after hematolEDTA as an anticoagulant, as it does
notbecause
affect
levels
ofcellions
suchandas
ogy tubes
oxalate
damages
membranes
causes abnormal RBC morphology. Oxalate interferes in
calcium. However, heparin can interfere
with some immunoassays.
enzyme reactions.
18
Heparin
should not be used for coagulation
or hematology testing. HepaReprinted with permission from McCall R, Tankersley C. Phlebotomy essentials. 4th ed. Baltimore, Md.: Lippincott Williams & Wilkins, 2008.
rinized plasma is preferred for potassium measurements to avoid an eleva(lavender), of
and G
(gray). The
VENIPUNCTURE
PROCEDURES
tionor PST),
due Gto(green),
the L release
potassium
from
platelets
as the blood clots
phrase places the red top before the SST and the PST beThe following
ETS (Procedure
2-1), butterfly (Procedure
(Garza,
2002).
used for
most chemistry
tests
fore the green
top for Lithium
convenience inheparin
memorization.may
The be
2-2),
and
syringe
(Procedure
2-3) venipuncture proceorder of
draw,
with stopper
colors
and rationale
for colexcept
for
lithium
and
folate
levels;
for dures
lithium,
a serum
specimen
be
include the
steps necessary
to obtain ancan
approprilection order, is summarized in Table 2-3.
identified
quality blood
specimen from
a patients
used instead. Sodium heparin cannot be ately
used
for assays
measuring
sodium
arm or hand vein.
levels, but it is recommended for trace elements, leads, and toxicology.
CASE STUDY 2-2
Troubleshooting
Failed Venipuncture
Sodium heparin is the injectable form used
for anticoagulant
therapy.
A phlebotomist is sent to the cardiac care unit
Failure
to draw blood
can be caused by because
a misaligned
Gray-top
tubes are generally used for
glucose
measurements
(CCU) to collect a complete blood count (CBC) on a
tube in the holder, loss of tube vacuum, or improper
The patient
has tiny veins, so or
he selects
a
theypatient.
contain
a preservative
antiglycolytic
agent,
suchin the
as vein.
sodium
fluoride,
position
of the needle
A properly
positioned
small lavender-top tube and proceeds to collect the
needle is correctly
seated In
in the
lumen (Fig. 2-10A).
which
prevents
glycolysis
for tube,
3 days
(Strasinger,
2003).
bacterial
septi-If
specimen.
While blood
is filling the CBC
the
initially blood is not flowing into the tube, check the
patients
nurse tellsinhibition
him that the physician
has added
cemia,
fluoride
of glycolysis
isfollowing:
neither adequate nor effective in
a stat potassium to the request. He finishes collecting
Tube
preserving
glucose
Red-top
tubes
have
additive,
blood
position:
Verifyno
the tube
is properlyso
seated
in the
the CBC specimen,
grabsconcentration.
a small-volume green top,
holder and the needle has penetrated the tube stopper.
and proceeds
collect tubes
the potassium
specimen.
collected
in to
these
clots.
Reseat the tube if necessary.
Vacuum: Tubes
may bank,
have lost vacuum
before the draw
Red-top
blood
and immunolQuestions tubes are used for most chemistry,

BLOOD COLLECTION DEVIC

The most common blood collection syst


into a container; it consists of a color-co
double-headed needle, and an adapter/ho
pediatric and geriatric collections. The
modates various sizes (gauge) of blood
from large (16 gauge) to small (23 gaug
been designed to eject the needle after us
that the adapters be discarded with the u
Safety Prevention Act, 2002). Pediatric
and accommodate the smaller-diameter
Also available are a variety of safety needl
or retract the needle before it is discarde
Winged infusion sets (butterfly need
to be collected from a very small vein. B
and 25 gauge. These needles have plastic
needle that aid in insertion of the needl
attached to the back end of the needle, w
for attachment to a syringe or evacuated
must be made to protect the phlebotom
needle when a butterfly infusion set is us
Blood collected in a syringe can be t
Special syringe safety shield devices are
contact with the blood sample. If blood
becomes an important factor, and the b
clot formation begins. Once the blood has
lated tube must be thoroughly mixed to
Several additional pieces of phleboto
tourniquet, usually a flat latex strip or pie
the arm to occlude the vein before blood
each phlebotomy. OSHA guidelines state
performing phlebotomy and should be ch
are available in various sizes and are ma
latex sensitivity as experienced by some in
gauze pads, alcohol or iodine wipes for d
and a Band-Aid (Johnson & Johnson, N
bleeding after completion of the phlebot

BLOOD STORAGE AND PRE

During storage, the concentration of a b


may change as a result of various process
or plastic tubes, protein denaturation, ev
water movement into cells resulting in h
plasma, and continuing metabolic activitie
These changes occur, although to varying
and during refrigeration or freezing. St
by analyte.
Stability studies have shown that clin
occur if serum or plasma remains in pro
After separation from blood cells, analytes
and serum when stored under the same co
in unseparated serum and plasma decrea
and more slowly thereafter. This decreas
Two approaches have been used to minim
or plasma may be rapidly separated from
may be collected in a fluoride tube to in
cells, thereby stabilizing the glucose lev
Fluoride has little effect on reducing gl
storage and may not reach complete inh
One study has demonstrated a reducti
0.39 mmol/L in specimens collected in fl
separated. These authors suggest that spe
a negative bias in blood glucose levels (Sh
and a greater rise is seen in plasma tha
carbon dioxide (CO2) show a steady de
degree of change more pronounced in pl
for up to 24 hours, after which a rapid in
change is slightly more pronounced in
plasma yield clinically significant increase
nitrogen, albumin, calcium, magnesium,
are attributed to movement of water into
hemoconcentration (Boyanton, 2002). O
phosphorus, and glucose to be the analyt

7/3/13

Blood collection
procedure: open system

Blood collection
procedure: open system

1. Check request slip

10. Tie the tourniquet

2. Identify the patient

11. Perform venipuncture

3. Verify diet restrictions/fasting

12. Remove tourniquet before pulling out the needle.

4. Put on gloves and assemble the equipment

13. Apply cotton/bandage

5. Reassure and position the patient

14. Transfer blood collected to appropriate tubes (mix if


nicessary)

6. Apply tourniquet

15. Label tubes

7. Select the venipuncture site

16. Dispose contaminated materials

8. Cleanse the area

17. Transport specimen immediately

9. Inspect the needle and syringe


19

20

Blood collection
procedure

Blood collection
procedure

1. Check request slip

10. Tie the tourniquet

2. Identify the patient

11. Perform venipuncture

3. Verify diet restrictions/fasting

12. Fill the tubes and mix if necessary

4. Put on gloves and assemble the equipment


5. Reassure and position the patient

13. Release the tourniquet before withdrawing the


needle

6. Apply tourniquet

14. Apply bandage

7. Select the venipuncture site

15. Label tubes

8. Cleanse the area

16. Dispose contaminated materials

9. Inspect the needle and syringe

17. Transport specimen immediately


22

21

Specimen Variables
Prepare materials
& collect blood

Inside the lab

Technologist places
Technologist
Technologistplaces
specimens in the places
specimens
in the
specimen
hematology racks in
hematology
CC racks racks
Racks carried to the
Racks carried to the
analyzers and
analyzers and
processed
processed

no
Politely explain why &
give correct instructions

Repeat

NO

Smear

YES
Repeat

NO

Tubes placed in Tubes placed in


pending analysis pending analysis
racks
racks

Encode results
&Smear
sign
Smear
YES

NO
Results verified
and released

YES
YES

NO

YES

NO
Results verified
and released

Specimens
reanalyzed

Specimens
reanalyzed

Original and
Original and
repeated results repeated results
filed together
filed together

Reports pulled andReports pulled and


data collated
data collated

Specimens returned
Specimens returned
Tube placed in
to storageRelease
area to storage
area Tube placed in
results
the slide
the slide
preparation rack preparation rack

Results reviewed Results reviewed

Racks returned to Racks returned to


Tube carried
Tube carried
intake area
intake area
to slide
to slide
23
preparation area preparation area

end
A

Tube placed on
a rocker

Tube placed on
a rocker

Slide prepared
and labeled

Slide prepared
and labeled

Smear made
manually

Smear made
manually

Smear labeled

Smear labeled

Smear stained

Smear stained

Smear results
reported

Smear results
reported

Tube stored

Tube stored

PART 11
PART

Technologist picksTechnologist picks


up tubes
up tubes
Tubes sorted by Tubes sorted by
requirements/degree
requirements/degree
of urgency
of urgency

yes

Meet patient prep

Patients request
PART 1

Check request &


patient preparation

Patient preparation

Forward blood
inside the lab

Patient ID
Patient confirmation

Pre-analytical
Analytical
Post-analytical

Label specimen

Receipt of
lab. request

Pre-COLLECTION

Blood collection
Specimen Labeling
Entry to logbook
Specimen preparation

end

24

Technologist picksTechnologist picks


up tubes
up tubes
Technologist places
Technologist places
specimens into specimens into
hematology racks hematology racks
Racks placed
directly onto
analyzer

Racks placed
directly onto
analyzer

All the ordered


All the ordered
tests performed tests performed
and repeated as and repeated as
needed by the
needed by the
automated systemautomated system

Results verified
and released

NO
Tubes stored

Results verified
and released
Peripheral smears
YES Smear
YES Peripheral smears
Report
smear
made and stained made and
stained
criteria
results
on automated
on automated
met? stainer
stainer
NO

Smear
criteria
met?

Tubes stored

Tubes stored

Report smear
results

Tubes stored
Figure 2-3 A, Task
mapping:
hematology
cell for
counting.
Figure
2-3 Original
A, Task workflow
mapping:for
Original
workflow
hematology cell counting.
B, Task mapping: Improved
workflow for
hematology
cell for
counting
subsequent
to
B, Task mapping:
Improved
workflow
hematology
cell counting
subsequent to
workcell implementation.
Note
the reduction inNote
stepsthe
as reduction
comparedinwith
part
workcell
implementation.
steps
as A.
compared with part A.

7/3/13

PATIENT PREPARATION
1. Exercise
2. Fasting
3. Diet
4. Tourniquet Application
5. Drugs
6. Tobacco smoking
7. Alcohol intake
8. Posture
9. Stress
10.Diurnal Rhythms

EXERCISE
involves any form of physical activity
with short term or transient effect
within one hour after exercise
increases lactate (glycolysis: breakdown of glucose to
pyruvate and lactate)
increases fatty acids and alanine

long term effect


increase enzymatic activity of enzymes

CK
AST
LDH
ALD

25

26

FASTING

DIET (FOOD INTAKE)

depends on the laboratory test

Caffeine

Glucose Test (FBS) 6 to 8 hours

increases release of NEFA (non-esterified fatty acid)

PPBS 2 hours after eating full meal


OGTT 6 to 8 hours

increases plasma catecholamines from adrenal


medulla and the brain tissue

OGCT 6 to 8 hours or none

Protein diet
increases BUN and ammonia levels

27

TOURNIQUET
APPLICATION

28

< one minute only (max of 2 minutes)

affect the liver

long torniquet application:

induce hepatic
microsomal enzyme
release

hemostasis stop blood


hemoconcentration increases formed elements of he
blood
anaerobiosis affects pH, O2 tension, CO2 tension of
blood (ABG test)

Tobacco
Smoking

Drugs/
Alcohol

Alcohol
increases acetate and
acetaldehyde level in
the blood
increases GGT

29

Acute effects
increases plasma
catecholamines and
cortisol due to
nicotine
Chronic effects
increase WBC count
esp. Monocyte
increase
carboxyhemoglobin
(COHb)
increase MCV

30

7/3/13

POSTURE

STRESS

Diurnal rhythms

Tensecretions
Common Errors
affect
of in Specimen Collection
adrenal
hormones of patient
1. Misidentification
leads2.toMislabeling of specimen
hyperventilation
3. Short draws/wrong anticoagulant/blood ratio
4. Mixing problems/clots
disturbance
of acid5. Wrong
tubes/wrong
anticoagulant
base
balance

6. Hemolysis/lipemia
affecting
ABG test

leads to efflux or
transfer of filterable
substances from the
intravascular space to
the interstitial

increases TP, Bilirubin,


Lipids, and enzymes

7.
8.
9.
10.

31

Cortisol
Adrenocorticotropic
hormone
Plasma renin activity
Aldosterone
Insulin
Growth hormone
Acid phosphatase
Thyroxine
Prolactin

Hemoconcentration from prolonged tourniquet time


Exposure to light/extreme temperatures
Improperly timed specimens/delayed delivery to laboratory
Processing errors: Incomplete centrifugation, incorrect log-in, improper
storage

followed by an increase in free fatty acids, and lactate may increase by


as much as 300%. Exercise may elevate creatine phosphokinase (CK),
aspartate aminotransferase (AST), and lactate dehydrogenase (LD), and
may activate coagulation, fibrinolysis, and platelets (Garza, 1989). These
changes are related to increased metabolic activities for energy purposes
and usually return to preexercise levels soon after exercise cessation. Longterm effects of exercise may increase CK, aldolase, AST, and LD values.
Chronic aerobic exercise is associated with lesser increases in plasma concentration of muscle enzymes such as CK, AST, alanine aminotransferase
(ALT), and LD. Decreased levels of serum gonadotropin and sex steroid
concentrations are seen in long-distance athletes while prolactin levels are
elevated (Dufour, 2003).

Iron
Calcium

Peaks 46 AM; lowest 8 PM12 AM; 50% lower at


8 PM than at 8 AM; increased with stress
Lower at night; increased with stress

PART 1

body fluids and analytes fluctuations during the


TABLE 3-2
day Tests Affected by Diurnal Variation, Posture, and Stress

TABLE 3-1

Lower at night; higher standing than supine


Lower at night
Lower at night
Higher in afternoon and evening
Higher in afternoon and evening
Increases with exercise
Higher with stress; higher levels at 4 and 8 AM
and at 8 and 10 PM
Peaks early to late morning; decreases up to
30% during the day
4%32
decrease supine

to decrease by as much as 15% (Dufour, 2003). Hyperventilation affects


acid-base balance and elevates leukocyte counts, serum lactate, or free fatty
acids.

Posture. Posture of the patient during phlebotomy can have an effect on


various laboratory results. An upright position increases hydrostatic pressure, causing a reduction of plasma volume and increased concentration
of proteins. Albumin and calcium levels may become elevated as one
changes position from supine to upright. Elements that are affected by
Diet. An individuals diet can greatly affect laboratory test results. The
postural changes are albumin, total protein, enzymes, calcium, bilirubin,
effect is transient and is easily controlled. Glucose and triglycerides,
cholesterol, triglycerides, and drugs bound to proteins. Incorrect applicaabsorbed from food, increase after eating (Dufour, 2003). After 48 hours
tion of the tourniquet and fist exercise can result in erroneous test results.
of fasting, serum bilirubin concentrations may increase. Fasting for 72
Using a tourniquet to collect blood to determine lactate concentration may
hours decreases plasma glucose levels in healthy women to 45 mg/dL
result in falsely increased values. Prolonged tourniquet application may
3-4 also increase serum enzymes, proteins, and protein-bound substances,
(2.5 mmol/L), while men show an increase TABLE
in plasma
triglycerides,
TABLE 3-1
3-2TABLE
glycerol, and free fatty acids, with no significant change in plasma
including cholesterol, calcium, and triglycerides, as the result of hemoconTen Common Errors in Specimen Collection
Tests such
Affected
by Diurnal
Posture,
and
cholesterol. When determining blood constituents
as glucose,
centrationVariation,
when plasma water
leaves the
veinStress
because of back pressure.
triglycerides, cholesterol, and electrolytes, collection should be done in
After bed rest in the hospital, a patients hemoglobin (Hb) can decrease
the basal state (Garza, 1989). Eating a meal, depending
fromPeaks
the original
admitting
value
falsely
leadlower
a physician
Cortisol on fat content,
46 AM
; lowest
8 enough
PM12toAM
; 50%
at to
1. Misidentification of patient
Hemolysis/lipemia
may elevate plasma potassium, triglycerides, alkaline phosphatase,
and
suspect internal hemorrhage or hemolysis (Dufour, 2003). This effect can
8 PM than at 8 AM; increased with stress
2. Mislabeling of specimen
5-hydroxyindoleacetic acid (5-HIAA). Stool occult blood tests, which
be amplified by intravenous fluid administration. Patients should be
Clots
present
in
an
anticoagulated
specimen
detect heme, are affected by the intake of meat, fish,
iron, and horseradish,
advised
to avoid
changes in
their diet, consumption
Adrenocorticotropic
Lower
at night;
increased
with stressof alcohol, and strenu3. Short draws/wrong anticoagulant/blood ratio
a source of peroxidase, causing a false-positive occult blood reaction
ous exercise 24 hours before having their blood drawn for laboratory
hormone
Nonfasting testing.
specimen when test requires fasting
(Dufour, 2003). Physiologic changes may include hyperchylomicronemia,
4. Mixing problems/clots
thus increasing turbidity of the serum or plasma Plasma
and potentially
renininterfering
activity
Lower at night; higher standing than supine
5. Wrong tubes/wrong anticoagulant
Improper blood
collection
tube
with instrument readings.
Age. Age
of the patient has
an effect on serum constituents. Young defines
Aldosterone
at night
Certain foods or diet regimens may affect serum
or urine constituents.
fourLower
age groups:
newborn, childhood to puberty, adult, and elderly adult
6. Hemolysis/lipemia
Short draws,
wrong
Long-time vegetarian diets are reported to causeInsulin
decreased concentrations
(Young,
2001).
In
the newborn, much of the Hb is Hb F, not Hb A, as
Lower
atvolume
night
7. Hemoconcentration from prolonged tourniquet
time lipoproteins (LDLs), very-low-density lipoproteins
of low-density
seen in the adult. Bilirubin concentration rises after birth and peaks at
Growth
Higher
and
Improper
conditions
(iceevening
for blood
gases)
(VLDLs), total lipids, phospholipids, cholesterol,
andhormone
triglycerides. transport
about
5 days.in
Inafternoon
cases of hemolytic
disease
of the fetus
and newborn
8. Exposure to light/extreme temperatures Vitamin B deficiency can also occur, unless supplements are taken (Young,
CHAPTER
2 PHLEBOTOMY
AND SPECIMEN
CONSIDERATIONS
(HDFN),
bilirubin
levels
continue
rise. This
often causes
difficulty in 59
12
Acid
phosphatase
Higher
in afternoon
andtoevening
between
requisition
and specimen
label
2001).
high meat or other protein-rich diet may increaseDiscrepancies
serum urea,
distinguishing
between
physiologic jaundice
and HDFN. Infants
have a
9. Improperly timed specimens/delayed delivery
toAlaboratory
ammonia, and urate levels. High protein, low carbohydrate
diets,
such
as
lower
glucose level
thanexercise
adults because of their low glycogen reserve. With
Thyroxine
Increases
with
PROCEDURE
2-3.
NEEDLE
AND
SYRINGE
VENIPUNCTURE
(continued)
10. Processing errors: Incomplete centrifugation,
log-in,
improper
Unlabeled
or
mislabeled
specimen
the incorrect
Atkins diet, greatly
increase
ketones in the urine and increase
the serum
skeletal
growth and muscle
development, serum alkaline phosphatase and
Higher
with
stress; higher
levels
athigh
4 and
8 AM
blood urea nitrogen (BUN). Foods with a highProlactin
unsaturated-to-saturated
creatinine
levels,
respectively,
also increase.
The
uric acid
level seen
storage
Rationale/Explanation:
will pull blood
Order
specimen/leaking
container
fatty acid ratio may show decreased serum cholesterol, whileContaminated
a dietRationale/Explanation:
rich in
and ofatDraw
8 minimizes
and for
10adPMfirst
in a newborn
decreases
the
10 years of life, The
thenvacuum
increases,
espeinto the tube automatically. Forcing blood into a
ditive carry-over problems. The tube must be pushed
33
34 tube by pushing
purines will show an increased urate value. Foods such as bananas,
cially
in boys,
until
age
2001).the
Most
serum
constituents
plunger
can hemolyze
the specall pinethe way onto
the internal
needle
forthe
blood
to of 16 (Young,
Iron
Peaks early to late morning;
decreases
up to inoff,
apples, tomatoes, and avocados are rich in serotonin.
When ingested,
imen or
cause
the tube
stopper to pop
splashing
flow into the tube.
remain constant during adult life until
the
onset
of menopause
women
followed by an increase in free fatty acids, and
lactate
may
increase
by
tube
contents.
30%
during
the
day
elevated urine excretion of 5-HIAA may be observed. Beverages rich in
and middle age in men. Increases of about 2 mg/dL (0.05 mmol/L) per
caffeine elevate
plasma free fatty
acids and cause catecholamine release
quickly
until the per
vacuum
is gone.
To unyear in total cholesterol and 2 mg/dL
(0.02 fill
mmol/L)
year
in triglyas much as 300%. Exercise may elevate creatine
phosphokinase
(CK),
Calcium
4% decrease supine Tubes
derfill a tube,
back the
to stopseen
blood
the adrenal medulla and brain tissue. Ethanol ingestion increases
cerides until midlife have been reported.
Thehold
increase
in plunger
cholesterol
aspartate aminotransferase (AST), and lactatefrom
dehydrogenase
(LD), and
flow before removing it. Several tubes can be filled
plasma lactate, urate, and triglyceride concentrations. Elevated highin postmenopausal women has been
attributed
a decrease
as long
as there isto
enough
blood inin
theestrogen
syringe.
may activate coagulation, fibrinolysis, and platelets
(Garza, 1989).
These -glutamyl transferase (GGT),
density lipoprotein
(HDL) cholesterol,
levels. Uric acid levels peak in men in their 20s but do not peak in women
Step 20:
Discard
the Empty Syringeparathyroid
and Transfer
19: Mix Additive
Tubes
Upon
Removal
urate, and for
meanenergy
corpuscular
volume (MCV) to
have
been associated
until
middle
age.
The From
elderly
secrete
less
triiodothyronine,
changes are related to increased metabolic activities
purposes
decrease
byStep
aswith
much
as 15%
(Dufour,
2003).
Hyperventilation
Device
Unit in a Sharps Container affects
the
Transfer
Device
chronic alcohol abuse.
hormone, aldosterone, and cortisol. After age 50, men experience a
and usually return to preexercise levels soon afterSerum
exercise
cessation.
Long- triglycerides,
acid-base
balance
and elevates
leukocyte
counts,
serum
lactate,
or freethe
fatty
Rationale/Explanation:
Removing
transfer
device
Rationale/Explanation:
Additive
tubes mustrate
be and concentration
concentrations
of cholesterol,
and apoB
lipoprodecrease
in secretion
of testosterone
and
women
from the syringe would expose the user to blood in
mixed immediately for proper function, including
teins are AST,
correlated
withLD
obesity.
Serum LD activity,
have an increase in pituitary gonadotropins,
especially follicle-stimulating
term effects of exercise may increase CK, aldolase,
and
values.
acids.cortisol production,
the hubs of both units. The transfer device must go
preventing clot formation in anticoagulant tubes.
and glucose increase in obesity. Plasma insulin concentration is also
hormone (FSH) (Young, 2001). in the sharps because of the internal needle.
Chronic aerobic exercise is associated with lesser
increases
in
plasma
conincreased, but glucose tolerance is impaired. In obese men, testosterone
Adapted of
with permission
from Procedures
8-4 and 8-5, McCall
R, Tankersley C. Phlebotomy
essentials.
4th
ed. Baltimore,
Md.:
Lippincott
centration of muscle enzymes such as CK, AST,
alanine isaminotransferase
concentration
reduced (Young, 2001).
Posture. Posture
theGender.
patient
during
canhigher
havealkaline
an
effect
on
After
puberty,phlebotomy
men
generally have
phosphatase,
Williams & Wilkins, 2008.
aminotransferase,
kinase,increases
and aldolasehydrostatic
levels than women;
this is
(ALT), and LD. Decreased levels of serum gonadotropin and sex steroid
various laboratory results.
An uprightcreatine
position
presStress. Mental and physical stresses induce the production of adrenocordue to the larger muscle mass of men. Women have lower levels of
concentrations are seen in long-distance athletes
whilehormone
prolactin
levels
are and catecholamines.
sure, causing
reduction
of plasma
volume
concentration
ticotropic
(ACTH),
cortisol,
Totalacholesmagnesium,
calcium,
albumin,and
Hb, increased
serum iron, and
ferritin. Menstrual
TABLE 3-3
terol has been reported to increase with mild
and HDL cholesterol
blood calcium
loss contributes
to themay
lowerbecome
iron values elevated
(Young, 2001).
elevated (Dufour, 2003).
13 stress,
of proteins.
Albumin and
levels
as one

Specimen collection

Specimen collection

Needle insertion
Correct insertion technique; blood
flows freely into needle

Potassium (mEq/L)

PREANALYSIS

Effect of hemolysis

Bevel on vein upper wall does not


allow blood to flow

Bevel on vein lower wall does not


allow blood to flow

Needle inserted too far

Needle partially inserted and


causes blood leakage into tissue

Collapsed

When a vein rolls, the needle may


slip to the side of the vein without
penetrating it

FIGURE 2-10. (A) Correct needle insertion technique. (Reprinted with permission from McCall R, Tankersley C.
Phlebotomy essentials. 4th ed. Baltimore, Md.: Lippincott Williams & Wilkins, 2008.) (B) Bevel on upper vein
wall. (C) Bevel on lower vein wall. (D) Needle inserted too far. (E) Needle partially inserted. (F) Needle slipped
beside the vein. (G) Collapsed vein prevents blood flow.

PART 1

PART 1

(e.g., computer) or in writing (e.g., paper requisition). This information is


conveyed through written or computer order entry. Online computer
Reasons for Specimen Rejection
input is the most error-free means of requesting laboratory tests. The clinician initiates the request for a laboratory measurement or examination by
completing a written order for desired laboratory measurements or examinations in the patients medical record or chart. Verbal requests are made
in emergency situations and should be documented on a standard form;
after the blood is drawn, an official laboratory request or computerized
order should be placed (Garza, 2002). Physician direct order entry and
result acquisition through user-friendly networked computers are realistic
approaches to providing prompt and accurate patient care. Patient demographics include the patients name, sex, age, date of birth (DOB), date of
admission, date on which measurement or examination was ordered, hospital number, room number, physician, and physicians pharmacy code
number. Computerized laboratory information systems (LISs), common
in todays laboratories, are used to generate requisitions and specimen
labels. Some systems also generate requisitions with the number of tubes
SPECIMEN REJECTION
and the types of tubes required for collection.
All specimens must be collected, labeled, transported, and processed
Most laboratories facilitate test ordering by providing a written or
according to established procedures that include sample volume, special
computerized medical information system, which lists available tests, types
handling needs, and container type. Failure to follow specific procedures
of specimens required, collection methods, color of blood collection tubes
can result in specimen rejection. Inappropriate specimen type, wrong preused, amounts of blood/body fluid required, turnaround time, reference
servative, hemolysis, lipemia, clots, etc., are reasons for rejection. Not only
intervals, test codes, costs, diagnostic information, etc. All specimens must
is specimen rejection costly and time-consuming, it may cause harm to the
be clearly labeled.
Preprinted
bar code labels
applied
after proper patient
Changes
in Serum Concentration
(or Activities)
of Selected
12 changes position from supine to upright. Elements that are affected by
Constituents
Duespecimen
to Lysis of Erythrocytes
(RBCs)avoid preanalytic transidentification,
and
after
the
is
collected,
patient, especially when the blood sample in the tube is mislabeled. The
Diet. An individuals diet can greatly affect laboratory test results. The 11 postural changes are albumin, total protein, enzymes, calcium, bilirubin, 25
Percent
change
of
criptioneffect
errors.
Frequently,
theeasily
laboratory
receives
requests
for add-ons.
first goal Aof The Joint Commission 2008
National
is transient
and is
controlled.
Glucose
and
triglycerides,
Incorrect
applica- Patient Safety Goals
10 cholesterol, triglycerides, and drugs bound to proteins.
B
Ratio of
concentration (or
These are
additional
tests
requested
to (Dufour,
be performed
on48ahours
specimen
fortourniquet
Laboratories
is to improve
the
accuracy
of patient identification
absorbed
from food,
increase
after
eating
2003).in After
9 tion of the
and fist exercise
can result in
erroneous
test results.
concentration
(or
activity)
serum
activity)
in RBC may
to are
afterencountered
lysis of
1%
fasting, serum
bilirubin
concentrations
increase.
Fasting
forwhen
72 8 the
Using a tourniquet
to collect blood to determine lactate concentration may
that hasofpreviously
been
collected.
Problems
(www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals).
concentration (or
RBC, assuming a
C
hours
decreases
plasmatype
glucose
levels
in healthy
women to0.50
45 mg/dL
falsely increased
values.
Prolongedduring
tourniquet
application
may for transfusion or at
7 result in Misidentification
Constituent
activity)
serum
hematocrit oftest,
specimen
is not
the proper
for
theinadd-on
requested
the residual
of patients
sample
collection
(2.5 mmol/L), while men show an increase in plasma triglycerides, 6 also increase serum enzymes, proteins, and protein-bound substances,
volume glycerol,
is not sufficient
to
perform
the
test,
or
storage
conditions
result
in
the
time
of
transfusion
can
be
a
life-threatening
medical error. The inciLactate
dehydrogenase
1 significant change
+272.0
D result of hemoconand free
fatty acids, with16 :no
in plasma 5 including cholesterol, calcium, and triglycerides, as the
4:1
+220.0
deterioration
ofAspartate
the
analyte
(e.g.,
bicarbonate).
This
is
usually
due
to
the
dence
of
patient
misidentification
at
the
time
of
specimen collection is
cholesterol.
When
determining
blood
constituents
such
as
glucose,
centration
when
plasma
water
leaves
the
vein
because
of
back
pressure.
4
aminotransferase
cholesterol,
and electrolytes,
collectionorshould
be done
rest in the hospital,
patientsand
hemoglobin
(Hb) patients
can decrease
presencetriglycerides,
or absence
of a particular
anticoagulant
additive.
Allinadd-on
1 ina 1000,
1 in 12,000
receives a unit of blood
3 After bedapproximately
23 : 1
Potassium
+24.4
E
basalbe
state
(Garza, 1989). Eating
on fat content, 2 from thethat
G lead a physician to
original
value enough
to individual
falsely
Alanine
6.7a: 1meal, depending
+55.0
requeststhe
must
documented.
wasadmitting
not intended
for that
(Dzik, 2003; Linden, 2000). As a
may elevateaminotransferase
plasma potassium, triglycerides, alkaline phosphatase, and
suspect internal hemorrhage or hemolysis (Dufour, 2003). This effect can
Medicolegal
concerns
include
proper
identification
of
the
patient,
result,
the
College
of
American
Pathologists
requires laboratories to have
0.82
:
1
Glucose
5.0
5-hydroxyindoleacetic acid (5-HIAA). Stool occult blood tests, which
be 0amplified 1by intravenous
fluid
administration.
Patients should be
2
3
4
Inorganic
phosphate
0.78of
: 1 meat,
+9.1
proper detect
labeling
ofare
the
specimen,
patient
consent
issues,
patient privacy
planchanges
to
reduce
thediet,
riskconsumption
of mistransfusion
suggests as options collectheme,
affected
by the intake
fish, iron,
and horseradish,
advised toa avoid
inlevel
their
of alcohol,and
and strenuHemolysis
F
Sodium
:1
1.0
a source
of peroxidase,
causing
a0.11
false-positive
occult
blood
reaction
exercise
24
hours
before
their
blood drawn for
laboratory
issues, and
chain
of custody.
Laboratories
should
have
clearly
written
ing
two
samples
athaving
separate
phlebotomy
events,
or utilizing an electronic
Figure
3-1 ous
Relationship
between
hemolysis
and
potassium
in 60,989
serum
36 and
Calcium
0.10 : 1
+2.9
plasma specimens
grouped according to level of hemolysis. The mean values of
2003).
Physiologic
changes may
include
hyperchylomicronemia,
testing.
policies (Dufour,
for these
issues.
In addition,
policies
should
describe
what
to were
do
identification
verification
system
potassium
4.12, 4.23,
4.80, 5.36, and 6.93 mEq/L
for levels of hemolysis
from such as an electronic bar code reader for
Modified turbidity
from Caraway
CW.plasma
Chemicaland
interference
by druginterfering
and
thus increasing
ofWT,
theKammeyer
serum or
potentially
0 through 4, respectively.
other substances
with clinical
laboratory
test procedures.
when a with
patient
refuses
to have
blood
drawn,
whatClintoChem
doActa
if 1972;
the patient was
patient identification wrist bands (CAP TRM.30575). It is therefore esseninstrument
readings.
Age. Age of the patient has an effect on serum constituents. Young defines
41:395; and
Laessig RH, Hassermer DJ, Paskay TA, et al. The effects of 0.1 and
unable to be
drawn,
what
toregimens
doandif hemolysis
a patient
isserum
unavailable,
and
to deal
topseudohyperkalemia
thoroughly
train
medical
staffand
in elderly
all aspects
1.0
percent
serum
chemistry
J Clin how Another
Certain
foods
orerythrocytes
diet
may on
affect
orvalues.
urineAmconstituents.
special
casetial
where
can occurall
patients adult,
four
age
groups:
newborn, childhood
tois in
puberty,
adult of patient identificaPathol 1976; 66:639644, with permission.
with extremely
high blast
counts
inthe
acute
or accelerated
phaseofleukemias.
Long-time vegetarian
are reported
to cause decreased
concentrations
with a combative
patient, diets
as well
as emergency
measures
for patients
who
tion,
specimen
collection,
transportation,
and
Table 3-4 lists
(Young,
2001).
In
newborn,
much
the Hb is Hb F, not
Hbprocessing.
A, as
Those blasts can be fragile and may lyse during standard phlebotomy,
lipoproteins
(LDLs),The
very-low-density
lipoproteins
seen in In
the
adult.specimens
Bilirubin
concentration
after birth and peaks at
becomeofill low-density
or faint during
phlebotomy.
Health Insurance
Portability
various
reasons
for
rejection.
releasing potassium.
contrast,
with
veryspecimen
high WBC rises
counts
(VLDLs), total lipids, phospholipids, cholesterol, and triglycerides.
aboutgently
5 days.
In cases
of hemolytic
are collected
can show
pseudohypokalemia
whendisease
potassiumof
is the fetus and newborn
and Accountability
Act (HIPAA) ensures the security and privacy that
of health
taken up by(HDFN),
highly metabolically
active
leukemic
cells along
with glucose;
Vitamin B12 deficiency can also occur, unless supplements are taken (Young,
bilirubin
levels
continue
to rise.
This often causes difficulty in
such specimens can be transported on ice to slow this enzymatically
data and
protects
of all
record
information,
2001).
A COMMON
high the
meatconfidentiality
orINTERFERENCES
other protein-rich
dietpatient
may increase
serum
urea,
distinguishing
between
physiologic
jaundice
and
HDFN.
Infants have a
LOOD
OLLECTION
VERVIEW
uptake.
6
ammonia,
and urate levels.
protein, lowmust
carbohydrate
diets, such
as
including
all laboratory
data.High
Employees
be trained
tomediated
comply
lower
glucose
than during
adultsclotting,
becausesoof
theirhaslow
Normally
platelets
releaselevel
potassium
serum
a glycogen reserve. With
In Vivo
the Atkins diet, greatly increase ketones in the urine and increase the serum
skeletal
andthan
muscle
serum
alkaline
phosphatase and assembly attached to
slightly higher
value growth
ofVenipuncture
potassium
plasma
from
the same individual;
isdevelopment,
accomplished
using
a needle/adapter
with HIPAA.
Tobacco
Smoking
this difference
is accentuated
when
the platelet
is extremely
blood urea nitrogen (BUN). Foods with a high unsaturated-to-saturated
creatinine
respectively,
alsocount
increase.
Thetube
high with
uric acid
level seen
anlevels,
evacuated
glass/plastic
test
a rubber/plastic
stopper. Blood
smokers have high blood carboxyhemoglobin levels, plasma catfatty acidTobacco
ratio may
show decreased serum cholesterol, while a diet richelevated.
inTo avoid
in problems
a newborn
decreases for theand
firsthemodilution,
10 years ofthelife, then increases, espeecholamines, and serum cortisol. Changes in these hormones often result
with hemoconcentration
may
also
be
collected
in
a
syringe
and
transferred
to the appropriate speciwill
show an
increased
urate value.
Foods such
as bananas,
cially
in boys,
age for
of 15
16to(Young,
2001).
in decreased
numbers
of eosinophils,
while neutrophils,
monocytes,
and pinepatient should
be seated
in a until
supine the
position
20 minutes
beforeMost serum constituents
TIMEpurines
OF
COLLECTION
men2001).
container
(evacuated
tube
A syringe
plasma fattyand
free avocados
acids increase.
of smoking
lead to
the blood isremain
drawn (Young,
Extended
application
of the
tourniquet
apples, tomatoes,
areChronic
rich ineffects
serotonin.
When
ingested,
constant
during
adult
life until
the
onset system).
of menopause
in womenmay be helpful when

Central venous catheter (CVC) or central


venous line

Line inserted into a large vein such as the subclavian, and


advanced into the superior vena cava. Several inches of tubing are surgically placed under the skin to an exit site in the
chest where one or more lengths protrude from the skin.

Implanted port

Small chamber attached to an indwelling line that is


surgically implanted under the skin in the upper chest or arm.

Peripherally inserted central catheter (PICC)

Line inserted into a vein in an extremity and threaded into a


main vein leading to the heart. It is typically placed in either
the basilic or cephalic vein with the exit just above the antecubital area.

(See Box 2-5 for situations that can trigger hematoma


formation.) Venipuncture must be discontinued and
pressure applied.
Iatrogenic anemia: anemia as a result of treatment (e.g.,
frequent blood draws or removing large quantities at a
time). Only minimum amounts of blood should be
drawn from infants.
Inadvertent arterial puncture: accidentally sticking an
artery; often the result of deep or blind probing or attempting to draw from the basilic vein. Venipuncture
must be discontinued and pressure applied for 5 minutes. Identify specimen as arterial blood if submitted
for testing.
Infection of the site: adverse effects of bacterial multiplication. Infection risk can be minimized by using
aseptic technique, including cleaning the site properly
and not touching it again before needle insertion.
Nerve injury: results from poor site selection, inserting
the needle too deeply or quickly, patient movement on
needle insertion, excessive or lateral needle redirection,

Procedural ERRors

Hematoma: rapid swelling at or near the venipuncture


site due to blood leaking into the tissues
Iatrogenic anemia: anemia as a result of treatment
Inadvertent arterial puncture
Infection

Reflux
Vein damage

37
Reprinted with permission from McCall R, Tankersley C.
Phlebotomy essentials. 4th ed. Baltimore, Md.: Lippincott
Williams & Wilkins, 2008.

POST-COLLECTION

or blind probing. Extreme pain, a burning or electric


shock sensation, arm numbness, or pain radiating up or
down the arm are all signs of nerve involvement that require immediate removal of the needle.
Reflux: backflow of blood from the tube into the patients vein that can occur if blood in the tube is in contact with the needle during a blood draw. To prevent
reflux, the patients arm must be in a downward position so that the collection tube fills from the bottom up.
Vein damage: scar buildup that can result from many
venipunctures in the same area for an extended period, improper redirection of the needle, or probing.
Vein damage can impair vein patency and make it difficult to perform subsequent venipunctures.

Patient
complications

Patient Conditions and Complications

Allergy

Blood collection personnel must recognize and respond


appropriately to patient conditions and complications
that include the following:

Excessive bleeding

Allergies to supplies or equipment: Patients can be allergic to antiseptics (e.g., iodine), adhesive glue in bandages, and latex (which can cause a life-threatening reaction in those who are severely allergic) in items such
as gloves and tourniquets. Use an alternate antiseptic if
required. Paper tape placed over folded gauze or selfadhesive bandage material can be used in place of
adhesive bandages. Never use latex items on latexsensitive patients or even bring them into the room.
Excessive bleeding: Some patients (e.g., patients on anticoagulant therapy) take longer than normal to stop
bleeding. Apply pressure to the site until bleeding
stops. If it continues beyond 5 minutes, notify appropriate personnel.
Fainting (syncope): Warning signs that a person may
faint include perspiration beads on the forehead, hyperventilation, and loss of color. Vasovagal syncope
(fainting due to abrupt pain or trauma) comes on suddenly without warning.

Fainting/syncope

BOX 2-5. SITUATIONS THAT CAN


TRIGGER HEMATOMA FORMATION
The vein is fragile or too small for the needle
size.
The needle penetrates all the way through the
vein.
The needle is only partly inserted into the vein.
Excessive or blind probing is used to locate the
vein.
The needle is removed while the tourniquet is
still on.
Pressure is not adequately applied following
venipuncture.

Nerve injury

7/3/13

Nausea or vomiting
Pain

Petechiae

Seizures/convulsion

38

Changes that occur if there


is delay in separation

Mixing

1. Glycolysis

Labeling

2. Enzymatic degradation: self destruction of enzymes (ACP)

Transport into the laboratory: protection

3. Hemolysis

Specimen handling and processing

4. Extravascular interchange/Electrolyte shift


extracellular: Na+, Cl-

Centrifugation
Rimming/ringing
Transfer of serum/plasma: aliquot

intravascular: K+, Mg2+


enzymes: ACP, AST, LDH (red cells)

39

40

Changes that occur if there


is delay in separation
5. Changes in Lipid Concentration (Lipolysis)
6. Increase Plasma Protein
7. Blood gas changes
Open system: pO2, pCO2, pH
Closed system: pO2, pCO2, pH

8. Changes in PO43- due to hydrolysis of organic phosphate


esters
9. Bacterial changes

glycolysis
decreased Urea concentration
increased NH3
41

THE END ...


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