Blood sample collection in children

Do’s and Don'ts

Dr Swati Bhave
 Preparation of Pediatric
Patients
• Find out –
Is it the first time for the child?
Find out about past experience.
How did the child react ? How did
the parents react ?
• Explain –
To parent and child about
procedure (if possible with dolls or
puppets)
Explain need of second attempt if
required
 Parental co-operation

• Assess - Parental ability to

participate or assist you
• Decide - Whether parent
should be present or not
• If present - Decide how will
they assist : physical
restrain, distraction,
emotional support ,
explanation
 How to relieve Anxiety & Fear

• Collect blood away from other patients in a special

room. Never in the hospital bed. This is a comfort
zone
• Area should be child friendly. Uniforms should be
colourful
• Keep equipment out of site
• Ask child’s preference of hand
• Allow child to select comfort object
• Stop procedure if child combative
• Try later or another person
 Minimizing PAIN

• Topical anesthetic like AMETOP, EMLA

• Cost, time ( 10-60min)
• More than one site tried, allergy
• Sucrose or pacifier
 Selection of Site

• Very important to get adequate volume

• Will be decided by
– Age of the child: heel or finger stick, IV
– Whether arterial or venous blood
required
– Equipment available eg neonate
capillary tubes, vacutainers, routine
needle & syringe etc
 Infants and Neonates
HEEL stick puncture
• Lateral plantar bottom surface
• 3 - 5 min Pre-Warming > blood flow (arterializes)
• Pediatric lancet New born 2.5mm L /1mm D,
Preterm o.75 mm L / 0 .85 mm D
• Depth of major BV is 0.03 mm to 1.6 mm from skin
to calcaneous
• > 2.4 mm depth injury: Osteomyelitis
 Infants and Neonates
HEEL stick puncture

• Do not use anteromedial area or posterior curve of

C
• Do not use alcohol swabs to stop bleeding :
stinging; Use sterile gauze for pressure
• Do not use adhesive tapes :maceration and
bruising of skin
• Do not squeeze or milk excessively : hemolysis or
dilutes blood with tissue and interstitial fluid :
erroneous results
• Discard first drop
• Complications cellulitis, abscess, scarring, tissue
loss, calcified nodules
Older child : > one yr age finger
prick
• Damaged veins, arm in cast or
bandaged
• Do not use if edema, infection, <
circulation
• Skin to BV depth 1.5 -2.4 mm
• Should not go >2.4 mm deep
• Pediatric lancet sizes 1.75/1.25/0.85
 Intravenous blood collection
• Site selection
• Tourniquet not excessively tight

• Special precautions when

– Heparin lock or
– IV line collection
 What is required from the sample

• Does the test require : whole blood ,

serum or plasma.

• How much is the volume required : 2, 4, 5,

ml etc. Pre-term 10 ml may be 5 % of total
volume

• What are the special bulbs or ready made

tubes required : e.g. fluoride bulb for
sugar, chemistry bulb for urea , EDTA for
hematology etc
 In What to collect blood ?

BULB FUNCTI ON USED FOR

CBC,Reticulocytes,
Chelates Ca preserves
EDTA ESR,G6PD, Hb
cellular elements
electrophoresis
Trisodium Converts Ca into PT, APTT, TT
citrate non-ionized form Fibrinogen etc
Enzyme poison.
I nhibits Glycolysis
Flouride Glucose
I n RBC (Glucose
destroyed at 5% / hr)
 ORDER of drawing

• This is important - so that additives in

one tube will not contaminate specimen
in subsequent tubes
• Blood culture
• Non Additive tube
• Coagulation tube
• Non Additive tube

• If using syringes minimize clotting by

filling additive tubes before non
additive
 When & How to get Serum &
Plasma
• Serum sample • Plasma sample
– blood collected – blood collected & mixed
without any anti- with anticoagulant and
coagulant and centrifuged
centrifuged – clear supernatant fluid
– clear supernatant with thrombosis
fluid devoid of any inhibited. Most
fibrin products satisfactory sample. No
changes occur in blood
• Plain bulb
– Most enzymes, • Heparinized bulb
– Biochemical LFT,KFT, – PH, NH4, RBC levels,
– S Electro. Plasma cortisol,
testosterone,
– Serological :Widal,
globin,cholinesterase
 For Special Testing

• PCR, Genetic, ammonia, blood gases, drug,

antibiotic & hormone levels etc.
• Before collection of sample ascertain that you
know everything about the sample collection
• Confirm from lab how much volume, what bulb,
procedure, timing etc
• Recollection of blood is distressing for
everyone: Child-parent- doctor & adds to
cost
 HEMOLYSIS OF SAMPLES

• Contact with water

• Excessive heat or cold
• Rigorous mechanical injury to RBS
( thin gauge )
• Prolonged storage
• Hemolyzed samples will give
erroneous results
 PREVENTION OF HEMOLYSIS

• Equipment used to collect :

absolutely dry
• Minimum constriction of limb
• Use correct gauge
• Collect slowly and steadily
• Remove needle and put
immediately into the bulb
• Easier if collection in Vacutainer
 Important steps before
collection

• Identification of the patient

• Labeling correctly: very very important
• Re-checking which test is required
• Keeping ready all the necessary equipment :
drawing of blood and bulbs for collection
• Clean up the area before and after
collection
 Following safety precautions

• Do no harm to your patient

– Ensure use of safe and sterile equipment
• Do no harm to yourself
– Follow universal precautions
– Avoid needle stick injuries and splashing of
blood into your eyes, skin or mucous
membrane
• Do no harm to the community
– Ensure that you have safely and correctly
disposed all equipment so that no other
person can get exposure
Transport & Storage of samples
• Ideally the sample should be collected
in the laboratory and immediately into
the processing

• If it cannot be sent immediately one

should follow instructions carefully for
Storage
• where should it be kept ? : room temp,
cold storage-what temp
Transport
• What are the precautions during
transport
 Summary
• Blood collection in children is a
traumatic and invasive procedure
• All efforts should be made to
reduce the discomfort
• Care should be taken to avoid
need for repeat puncture