PHLEBOTO

MY

What is
Phlebotomy?

Phlebotomy means to cut into a vein.

Phlebotomy is the practice of drawing
blood from patients and taking the blood
specimens to the laboratory for testing
This procedure of cutting or puncturing a
vein is performed by a phlebotomist.
The primary role of a phlebotomist is to
obtain blood specimens for testing.

History of
Phlebotomy
Removing blood from veins dates back to about
1400 B.C. when leeches were applied to the skin
of sick people.
In the early 1800s, medicinal leeches were used
for the procedure known as bloodletting.
Bloodletting was typically performed by barbers
or anyone claiming medical training.

History of
Phlebotomy
THEN
Performed by a cut into a
vein with a sharp instrument
to drain blood
The lancet was the most
popularly used instrument
Aseptic practices were not
known, so the lancet was
reused for several patients

NOW
Profession emerged as a
result of technology and
expansions in laboratory
function
Performed by trained
professionals
Standards of practice set by
the Clinical and Laboratory
Standards Institute (CLSI)

MATERIALS
AND
EQUIPMENTS

SYRINGE
-used to collect blood
from patients with
difficult, small or
fragile veins.
-The gauge number
indicates the bore size:
the larger the gauge
number, the smaller
the needle bore.

TWO-WAY
NEEDLE
It is designed to fill
-

with a predetermined
volume of blood by
vacuum.

LANCET
-is used for capillary
blood sampling and
come in a wide variety
of shapes and sizes.

BUTTERFLY
NEEDLES
-is used when
collecting blood taked
from the wrist, hand
and foot.

TORNIQUET
-is used to stop the flow of
venous blood and makes
the veins more prominent

TUBES
-are used when
drawing blood in
predetermined
volume.

MICROTAINER
- Is used to draw blood
from a skin puncture,
such as on the heel or
fingers.

ADAPTER
-is use with the
evacuated collection
system.

ALCOHOL & IODINE

SWAB
-is used for cleansing the
skin before an injection
or drawing of blood to
prevent contamination.

MICROPORE
-is used to protect the
venipuncture site after
collection.

CAPILLARY
TUBES
-are used to collect
small volumes of blood.
The tubes have a
ring/ tip color to
indicate any
additive
*red- sodium heparin
*green-ammonium
heparin
*blue- plain/ no additive
-

BLOOD CULTURE
BOTTLE
-is used to collect blood
from patients
suspected of having
septicemia or
bacteremia.

TEST TUBES
AND THEIR
USES

RED
TOP

GOLD
TOP

ADDITIVE

None

MODE OF ACTION

Blood clots, and the

serum is separated by
centrifugation

USES

Chemistries,
Immunology and
Serology, Blood Bank
(Crossmatch)

ADDITIVE

None

MODE OF ACTION

Serum separator tube

(SST) contains a gel at
the bottom to separate
blood from serum on
centrifugation

USES

Chemistries,
Immunology and
Serology

LIGHT GREEN
TOP Plasma Separating Tube
ADDITIVE

(PST) with Lithium

heparin

MODE OF ACTION

Anticoagulates with
lithium heparin; Plasma is
separated with PST gel at
the bottom of the tube

USES

Chemistries

ADDITIVE

Plasma Separating Tube

(PST) with Lithium
heparin

PURPLE TOP
ADDITIVE

EDTA

MODE OF ACTION

Forms calcium salts to

remove calcium

USES

Hematology (CBC) and

Blood Bank
(Crossmatch);
requires full draw invert 8 times to prevent
clotting and platelet
clumping

LIGHT BLUE TOP

GREEN
TOP

ADDITIVE

Sodium citrate

ADDITIVE

Sodium heparin or
lithium heparin

MODE OF ACTION

Forms calcium salts to

remove calcium

MODE OF ACTION

Inactivates thrombin and

thromboplastin

USES

Coagulation tests
(protime and
prothrombin time), full
draw required

USES

For lithium level, use

sodium heparin
For ammonia level, use
sodium or lithium heparin

DARK BLUE
TOP

ADDITIVE

EDTA-

MODE OF ACTION

Tube is designed to
contain no
contaminating metals

USES

Trace element testing

(zinc, copper, lead,
mercury) and
toxicology

ADDITIVE

LIGHT GRAY
TOP
Sodium fluoride and
potassium oxalate

MODE OF ACTION

Antiglycolytic agent
preserves glucose up to 5
days

USES

Glucoses, requires full

draw (may cause
hemolysis if short draw)

YELLOW TOP

YELLOW-BLACK
TOP

ADDITIVE

ACD (acid-citratedextrose)

ADDITIVE

Broth mixture

MODE OF ACTION

Complement
inactivation

MODE OF ACTION

Preserves viability of
microorganisms

USES

HLA tissue typing,

paternity testing, DNA
studies

USES

Microbiology - aerobes,
anaerobes, fungi

BLACK TOP

ORANGE TOP

ADDITIVE

Sodium citrate
(buffered)

ADDITIVE

Thrombin

MODE OF ACTION

Forms calcium salts to

remove calcium

MODE OF ACTION

Quickly clots blood

USES

STAT serum chemistries

USES

Westergren
Sedimentation Rate;
requires full draw

LIGHT BROWN
TOP
ADDITIVE

Sodium heparin

MODE OF ACTION

Inactivates thrombin
and thromboplastin;
contains virtually no
lead

USES

Serum lead
determination

PINK TOP
ADDITIVE

Potassium EDTA

MODE OF ACTION

Forms calcium salts

USES

Immunohematology

WHITE TOP
ADDITIVE

Potassium EDTA

MODE OF ACTION

Forms calcium salts

USES

Molecular/PCR and
bDNA testing

ORDER OF
DRAW
The purpose of the order of draw recommended by CLSI
is to:

Avoid possible test result error due to

cross contamination from tube additives

ORDER OF
DRAW

VACUTAINER
METHOD

SYRINGE METHOD

PLASTIC TUBE

INDWELLING
CATHETER

Sterile tube

Sterile tube

Sterile tube

Syringe (discard)

plain

citrate

citrate

Sterile

Citrate

EDTA

plain

EDTA

Heparin

heparin

heparin

heparin

EDTA

Fluoride/oxalate

EDTA

citrate

Fluoride/
oxalate

plain

Fluoride/
oxalate

plain

ORDER OF
DRAW
COAGULATION TESTING

SKIN PUNCTURE USING

MICROTAINER

RED/PLAIN
( PRIME TUBE discard)

EDTA

CITRATE

heparin
plain

ORDER OF
DRAW
Incorrect order of draw may result in:
Falsely elevated potassium levels
Spurious CBC results
Contaminated blood cultures
Erroneous coagulation results

VENIPUNCTURE SITE SELECTION

Basic Steps for Capillary

Puncture
1.

Patient identification, isolation and dietary

restrictions

2.

Reassure the patient

3.

Position the patient

4.

Assemble the supplies needed

5.

Verify the tests requested

6.

Choose the puncture site

7.

If necessary, warm the site

8.

Cleanse the area

9.

Perform the skin puncture

Basic Steps for Capillary

Puncture
9. Perform the skin puncture
10.Wipe the first drop
11.Collect the blood sample into the appropriate
collection devices
12.Cap or seal the collection device
13.Apply pressure to site
14.Discard the lancet
15.Label the specimens and check for proper sample
handling
16.Date, sign, and record time on sample and paperwork
17.Document on requisition that the sample was
collected by a skin puncture

Basic Steps for Venipuncture

1. Patient identification, isolation and dietary restrictions
2. Reassure the patient
3. Position the patient
4. Assemble the supplies needed
5. \Apply the tourniquet and choose the phlebotomy site
6. Cleanse the area
7. Perform the venipuncture
8. Release the tourniquet

Basic Steps for Venipuncture

9. Remove the needle and position the gauze
10.Apply pressure
11.Fill tubes if syringe is used
12.Dispose of needle unit
13.Label specimen and check for proper sample handling
14.Date, sign, and record time on sample and paperwork
15.Transport tubes properly to laboratory

Dos and Don'ts

The phlebotomist's role requires a professional, courteous,
and understanding manner in all contacts with the patient.
Greet the patient and identify yourself and indicate the
procedure that will take place. Effective communication both verbal and nonverbal - is essential.
Proper patient identification MANDATORY. If an inpatient is
able to respond, ask for a full name and always check the
armband or bracelet for confirmation.DO NOT DRAW
BLOOD IF THE ARMBAND OR BRACELET IS
MISSING.For an inpatient the nursing staff can be
contacted to aid in identification prior to proceeding.

Dos and Don'ts

An outpatient must provide identification other than the
verbal statement of a name. Using the requisition for
reference, ask a patient to provide additional information
such as a surname or birthdate. A government issued photo
identification card such as a driver's license can aid in
resolving identification issues.
If possible, speak with the patient during the process. The
patient who is at ease will be less focused on the
procedure. Always thank the patient and excuse yourself
courteously when finished.

Dos and Don'ts

Avoid a venipuncture at the site of extensive scarring or
hematoma
If a woman has had a mastectomy, the arm veins on that
side of the body should not be used as the surgery may
have caused lymphostasis, which could affect blood counts.
An arm containing a cannula or an arteriovenous fistula
should not be used without a doctor's consent.
When drawing from an intravenous line, the fluid should be
turned off for 3-5 minutes before collecting the sample.
This should be documented on the requisition slip and the
chart.

Dos and Don'ts

Pumping the fist before a venipuncture should be avoided.
Ask the patient to just make a fist, not to pump the fist.
Pumping the fist causes:
1. increase in potassium, phosphate, and lactate

concentrations
2. lowering of the blood pH from the lactate accumulation will
cause
the plasma ionized calcium concentration to increase

When performing a venipuncture on children, stress or

trauma may cause an increase in the WBC, cortisol and
growth hormone levels.
The tourniquet should not be left on for more than 1-2
minutes at a time.
The alcohol should be allowed to dry, otherwise damage

Certain areas are to be

avoided when choosing a site

Extensive scars from burns and

surgery - it is difficult to puncture the
scar tissue and obtain a specimen.
The upper extremity on the side of a
previous mastectomy - test results may
be affected because of lymphedema.
Hematoma - may cause erroneous test
results. If another site is not available,
collect the specimen distal to the
hematoma.

Certain areas are to be

avoided when choosing a site

Intravenous therapy (IV) / blood

transfusions- fluid may dilute the
specimen, so collect from the opposite arm
if possible. Otherwise, satisfactory samples
may be drawn below the IV by following
these procedures:

1. Turn off the IV for at least 2 minutes before venipuncture.

2. Apply the tourniquet below the IV site. Select a vein other
than the one with the IV.
3. Perform the venipuncture. Draw 5 ml of blood and discard
before drawing the specimen tubes for testing.

Certain areas are to be

avoided when choosing a site

Lines - Drawing from an intravenous line may

avoid a difficult venipuncture, but introduces
problems. The line must be flushed first. When
using a syringe inserted into the line, blood
must be withdrawn slowly to avoid hemolysis.

Cannula/fistula/heparin lock - hospitals

have special policies regarding these devices.
In general, blood should not be drawn from an
arm with a fistula or cannula without consulting
the attending physician.

Edematous extremities - tissue fluid

accumulation alters test results.

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