SUBJECT: Principles of Medical Laboratory Science DOCUMENT NO.

: PMLS2-M003
TOPIC: Pre-Analytical Considerations CONSOLIDATED BY: Sam Jeffrey Tiongco

I. PRE-ANALYTICAL CONSIDERATIONS

SITE SELECTION LIMITATION WHEN COLLECTING VENOUS BLOOD SPECIMEN

SITES THAT MUST NOT BE USED

1. Fistula, Arm with Fistula or Vascular Graft

a. Vascular Graft – People that undergo dialysis.
b. Threatens integrity of fistulas or vascular graft.
c. Serious patient complication
2. Arteries/Arterial Puncture
a. Hematoma Formation
b. Risk of Misinterpretation of Results
c. Patient Management
d. Difference of arterial and venous blood analyte concentration
e. High risk of injury and complication
Note: Venous blood is darker than arterial blood.
3. Veins on Lateral and Palmar Surface of the Wrist
a. Palmar Surface – Underside of Wrist
b. Risk Involving
i. Nerves
ii. Tendon
iii. Arteries
4. Infected Sites
a. Potential alteration of results
b. Exacerbation of infection
c. Patient discomfort

SITES THAT REQUIRE PHYSICIAN’S PERMISSION

1. Limbs on the Side of a Mastectomy

a. Lymphedema – commonly caused by the removal or damage to lymph nodes.
b. Potential for Altered Test Results
c. Risk of Introducing Infection
2. Any Part of the Lower Extremities
a. Risk tissue necrosis in diabetic patients
b. Thrombophlebitis in patients with
coagulopathies – formation of clots in
vein resulting in blockage of blood flow.
i. Coagulopathies – bleeding
disorder

SITES THAT SHOULD BE AVOIDED

1. Extensive Scarring and Healed Burns

a. Palpation and needle insertion complication
b. Inability to detect adverse reaction
c. Sclerosed Veins (damaged veins) – hardening of the vein.

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SUBJECT: Principles of Medical Laboratory Science DOCUMENT NO.: PMLS2-M003
TOPIC: Pre-Analytical Considerations CONSOLIDATED BY: Sam Jeffrey Tiongco

2. Hematoma
a. Escape of blood from the vein.
b. Cause: If the bore is partially inserted or no application of pressure during patient
care
c. May cause discomfort to the patient
d. Potential altered test results – possibility of contamination due to the presence of
blood.
3. Above and Below Infusing Fluids or from a Vascular Access Device
a. Possible contamination of specimen with IV fluids.
b. Heparin/Saline Lock
c. IV Therapy
i. Below an IV Site
1. Ideal
2. Shut off IV for 2 mins. With assistance.
3. Perform venipuncture; use discard tube.
ii. Drawing above an IV Site
1. Result: Diluted Specimen
2. Consider alternative site
3. Vascular Access Device
d. Various Type
i. Central Venous Catheters
ii. Arterial Lines
iii. Peripherally inserted central catheters
e. Risk Involved
i. Blood culture contamination
ii. IV fluid contamination
iii. High rate of hemolysis
iv. Potential to introduce air embolism into bloodstream
v. Introducing bacteria to bloodstream
vi. Risk of line of occlusion
4. Inflamed Sites
a. Including inflamed tattoos
b. Infection Complication – high number of WBC
c. Patient Discomfort
d. Potential Altered Result
5. Edematous Sites
a. Accumulation of fluid or secretion of fluid.
b. Patient Discomfort
c. Potential Altered Result
6. Extremity Affected by Store or Injury
a. Cannot hyperextend numb site.
b. Results in:
i. Nerve Injury
ii. Pain
iii. Infection

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SUBJECT: Principles of Medical Laboratory Science DOCUMENT NO.: PMLS2-M003
TOPIC: Pre-Analytical Considerations CONSOLIDATED BY: Sam Jeffrey Tiongco

PHLEBOTOMY-ASSOCIATED PATIENT REACTIONS AND COMPLICATIONS

1. Fainting/Syncope
a. Description/Cause
i. At the sight of the blood.
ii. Some patients may present with nausea or vomiting.
b. Management
i. Phlebotomist’s awareness of patient’s condition
ii. Terminate procedure
iii. “Head Down” position
iv. Do not drive any vehicle for at least 30 mins.
Note: The spirit of ammonia can aggravate patients with asthma.
2. Hematoma
a. Description/Cause
i. Escape of blood to surrounding tissue
ii. If patients have bleeding disorders or under medication (such as aspirin,
warfarin, cortisone – can affect clotting mechanism)
iii. Strenuous arm use following venipuncture.
iv. Syringe application is too far or partially inserted.
b. Management
i. Terminate procedure; apply pressure for 5 mins.
ii. Assure patient and give instruction.
iii. Application of cold compress to stop the bleeding. Apply hot compress to
dilate the vein.
Note: Application of ice pack can cause increase in blood flow due to vasodilation.
3. Thrombosis
a. Description/Cause
i. Formation of clots within the
blood vessel
ii. Thrombi – solid mass clots that
reside in blood vessels.
iii. Rigid/bumpy and lack elasticity
b. Management
i. Do not collect.
4. Petechiae
a. Description/Cause
i. Small, red spots appearing on patient’s
skin (indicates fragile vein)
ii. Indicates minute amount of blood escaping
into the skin epithelium
iii. May be the result of coagulation defects
(platelet abnormalities)
b. Management
i. Expect patient to bleed excessively

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SUBJECT: Principles of Medical Laboratory Science DOCUMENT NO.: PMLS2-M003
TOPIC: Pre-Analytical Considerations CONSOLIDATED BY: Sam Jeffrey Tiongco

ii. Make sure bleeding has stopped after venipuncture.

5. Excessive Bleeding
a. Description/Cause
i. Patient on anticoagulant therapy or other medication
b. Management
i. Apply pressure until bleeding stops
6. Seizures (One-Time Occurrence)
a. Description/Cause
i. Happen because of sudden, abnormal electrical activity in the brain.
b. Management
i. Terminate immediately
ii. Attempt to maintain pressure over puncture site
iii. Seek assistance
iv. Do not attempt to place anything on the patient’s mouth
7. Mastectomy
a. Description/Cause
i. Lymph Stasis – obstruction of lymph flow.
1. Increases risk of thrombophlebitis
b. Management
i. Not suitable for blood sample collection.
8. Collapsed Vein
a. Description/Cause
i. Plunger withdrawn quickly
ii. Vacuum too great for the vein.
iii. Smaller and geriatric veins are susceptible.
b. Management
i. Pull plunger slowly
ii. Use smaller draw volume or ‘partial draw’
iii. Terminate procedure.
iv. Release tourniquet, remove tube from holder, re-apply tourniquet and
replace tube.
v. Do not probe a collapsed vein.
9. Burned or Scarred Areas
a. Description/Cause
i. Burned or scarred
b. Management
i. Sensitive and prone to infection
ii. Difficult to palpate
iii. Avoid this area
10. Edema
a. Description/Cause
i. Accumulation of fluid in the intercellular spaces of the body.
b. Management
i. Difficult to palpate and puncture
ii. Contamination with tissue fluid.
11. Obesity
a. Management

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SUBJECT: Principles of Medical Laboratory Science DOCUMENT NO.: PMLS2-M003
TOPIC: Pre-Analytical Considerations CONSOLIDATED BY: Sam Jeffrey Tiongco

i. Difficult to visualize or palpate

ii. Take extra time to locate suitable veins
12. Intravenous Therapy
a. Description/Cause
i. Damaged, sclerosed or occluded veins.
ii. Patients on long term IV therapy.
iii. Palpable and visible but partially occluded or sclerosed.
b. Management
i. Avoid using arm with IV line.
13. Hemoconcentration
a. Description/Cause
i. Affects K+ levels.
ii. Caused by prolonged
tourniquet application.
iii. It is also due to excessive
massaging of the arms,
squeezing, and sometimes
probing.
iv. Sclerosed or occluded vein
– blocking the normal blood
flow
1. Accumulation of
RBCs
b. Management
i. Avoid prolonged tourniquet application.
14. Hemolysis
a. Description/Cause
i. Results in dilution of blood and destruction of RBCs thereby causing
decreased RBC count.
ii. Hemolysis:
1. ↑ = K+, P, LDH (Lactate Dehydrogenase), AST (Aspartate
Aminotransferase) and ALT (Alanine Aminotransferase)
2. ↓ = RBC, Hematocrit
iii. Excessive pulling of plunger
iv. Vacuum may cause the veins to collapse.
v. Very small gauge causes hemolysis.
vi. Transfer from syringe to tube via needle.
vii. Shaking and mixing tubes vigorously.
viii. Not following proper number of inversions.
ix. If the phlebotomist is too excited, the needle is inserted before the alcohol
dries sufficiently.
x. Hemolytic diseases
b. Management
i. Pull plunger slowly.
ii. Remove needle before dispensing.
iii. Shake gently and follow proper number of inversions.
iv. Allow alcohol to dry.

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SUBJECT: Principles of Medical Laboratory Science DOCUMENT NO.: PMLS2-M003
TOPIC: Pre-Analytical Considerations CONSOLIDATED BY: Sam Jeffrey Tiongco

15. Allergies
a. Description/Cause
i. Skin is sensitized to certain allergens.
ii. Allergies to anti-septic.
b. Management
i. Make use of hypoallergenic gloves and proper hand hygiene
ii. Make use of iodine and chlorhexidine
16. Accidental Arterial Puncture
a. Description/Cause
i. Light-red in color
ii. Faster flow of blood
iii. Rapid formation of hematoma
b. Management
i. Terminate the procedure and apply pressure at the area.
ii. Make an incident report.
17. Nerve Injury
a. Description/Cause
i. Shooting electrical or severe unusual pain.
ii. Tingling or numbness
iii. May cause paralysis
b. Management
i. Terminate the procedure immediately.
ii. Make an incident report.

TROUBLESHOOTING

1. There is no blood seen or too little blood flow into the tube.

Cause Description Management

Needle may not be placed at
the center of the rubber
stopper.
The needle bevel may be
positioned against the wall of
the vein.
Tourniquet was tied too tight
or too long causing stoppage
of blood flow.
Tube may have been
previously punctured or open.
Needle has transfixed the
vein.
The needle is not completely
in the vein or has not reached
the vein.
The vein has collapsed.
May have hit the rubber
Reposition the needle and
sheath at the sides of the top
make sure it passes that part.
of the tube.
Turn syringe ¼ clockwise to
make sure the bore of the
needle will be facing the
lumen.
Terminate the procedure and
Collapse of vein
repeat the procedure.
Replace the tube.
Going through the backwall Retract until there is blood
of the vein. flow into the tube.
Advance the needle forward
until you feel the vein.
Terminate and repeat the
procedure

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SUBJECT: Principles of Medical Laboratory Science DOCUMENT NO.: PMLS2-M003
TOPIC: Pre-Analytical Considerations CONSOLIDATED BY: Sam Jeffrey Tiongco

Tubes may be removed from

the holder during the
repositioning process.

2. Underfilling of tubes.

Cause Management
Ensure that the vacuum is exhausted to fulfill
Premature removal of tubes.
the volume requirement of the tube.
Dead space in the tubing of the winged
Make use of discard tube.
collection set

3. Blood stops flowing during blood collection.

Cause Management
Vein may have collapsed. Terminate and repeat.
Needle may have been repositioned outside
Reposition needle or repeat venipuncture.
the vein.

4. Occurrence of hematoma.

Cause Management
Needle may not be completely in the vein.
Needle transfix the vein.
Release the tourniquet, remove needle, and
Excessive probing.
apply pressure over the swollen area.
The tourniquet is placed too near the
insertion site.

5. Volume draw is too large.

a. Solution: use of partial draw or make use of microtainer.
6. Possible causes of hemolyzed specimens

Causes
Vigorous mixing of tubes.
Alcohol contamination.
Transferring from syringe to
needle.
Underfilling of tubes
Prolonged tourniquet
application.
Management
Mix tubes gently and follow proper number of inversions.
Allow disinfected site to dry before venipuncture procedure.
Remove needle from syringe and remove stopper top of
tube before dispensing.
Anti-coagulant to blood ratio – causes rupture and
hemolysis due to osmosis.
Hemoconcentration can
Release tourniquet and apply
lead to a hemolyzed
proper palpation.
sample.

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