05 Dermal Puncture

• DERMAL PUNCTURE

  • Also known as Capillary or Skin puncture
• DERMAL PUNCTURE

  • Blood collected comes from the capillaries, arterioles, and venule
• Dermal Puncture

  • The method of choice for collecting blood from infants and children younger than 2 years.
• DERMAL PUNCTURE

  • Involves taking a very small amount of blood from the patient, usually from the end of a finger.
• DERMAL PUNCTURE

  • It is over quickly and requires very little in the way of preparation; therefore, reducing concern and anxiety in patients, particularly in children and nervous adults.
• Capillary Blood Collection Sites:

  • Ring/ Great Finger
  • Infant's Heel
  • Earlobe
• Dermal puncture may be required in many adult patients,including:

  • Burned or scarred patients
  • Patients receiving chemotherapy who require frequent tests and whose veins must be reserved for therapy
  • Patients with thrombotic tendencies
  • Geriatric or other patients with very fragile veins
  • Patients with inaccessible veins
  • Obese patients
  • Patients requiring home glucose monitoring and point-of-care tests
• Different Types of Lancets:

  • Feather Lancet
  • Quickheel Lancet
  • Tenderlett Lancet
  • Unistick 2
  • Tenderfoot Lancet
  • BD Microtainer Contact-activated Lancet
• Lancets

  • Sterile, disposable, sharp-pointed or bladed instrument
  • Punctures or cuts skin to obtain capillary blood specimen
  • Designed for either finger or heel puncture
• Dermal Puncture Devices

  Primary danger in dermal puncture :

  • Accidental contact with the bone
  • followed by infection or inflammation (osteomyelitis or osteochondritis)
• Dermal Puncture Devices

  To prevent contact with bone, the depth of the puncture is critical. The Clinical and Laboratory Standards Institute (CLSI) recommends that the incision depth should not exceed 2.0 mm in a device used to perform heel sticks.
• Microsample Containers:

  • Capillary Tubes
  • Microtainer Tubes
• Capillary Tubes

  • Also known as microhematocrit tubes small tubes
  • used to collect approximately 50 to 75 μL of blood
  • for performing a microhematocrit test
  • One end of tube is sealed with plastic or clay sealants
• Microtainer Tubes

  • Small plastic tubes designed to hold approximately 600 μL of blood.
  • Color coded in the same way as evacuated tubes.
  • Some have stoppers & markings for min/max fill levels
• Warming equipment

  • increases blood flow as much as 7 times
• Commercial Heel warmer

  • A packet containing sodium thiosulfate and glycerin that produces heat when the chemicals are mixed together by gentle squeezing of the packet.
• WARMING EQUIPMENT:

  • Commercial Heel Warmer
  • Warm washcloths or towels
• CAPILLARY PUNCTURE STEPS:

  1. Review and Accession the Test Request
  2. Approach, Identify and Prepare the patient
  3. Verify the Patient’s Diet Restrictions and Latex Sensitivity
  4. Sanitize Hands and put on gloves
  5. Position the Patient
  6. Select the puncture or incision site
  7. Warm the site if necessary
  8. Clean and Air-Dry the Site
  9. Prepare the equipment
  10. Puncture the site and discard the lancet
• CAPILLARY PUNCTURE STEPS: (pt. 1)

  1. Review and Accession the Test Request
  2. Approach, Identify and Prepare the patient
  3. Verify the Patient’s Diet Restrictions and Latex Sensitivity
  4. Sanitize Hands and put on gloves
  5. Position the Patient
  6. Select the puncture or incision site
  7. Warm the site if necessary
  8. Clean and Air-Dry the Site
  9. Prepare the equipment
  10. Puncture the site and discard the lancet
• CAPILLARY PUNCTURE STEPS: (pt. 2)

  11. The first blood drop should be wiped away because it may be contaminated with excess tissue fluid

  12. Fill and mix tubes or containers in the order of draw

  13. Place gauze and apply pressure. (Keep the incision site elevated)

  14. Label the specimen and observe special handling instructions

  15. Check the site and apply bandage

  16. Dispose of used and contaminated materials

  17. Thank patient, remove gloves and sanitize hands

  18. Transport specimen to the lab
• Phlebotomist Preparation

  • Phlebotomists should carefully examine the information on the requisition form to ensure that they have the appropriate equipment to collect all required samples as well as the skin puncture device that corresponds to the age of the patient
• Patient Identification and Preparation

  Patients for dermal puncture must be identified using:

  • Requisition form
  • Verbal identification
  • ID band
• Patient Position

  • For fingerstick: Patient must be seated or lying down with the hand supported on a firm surface, palm up, and fingers pointed downward
• Patient Position

  • For heelstick: infants should be lying on the back with the heel in a downward position
• SITE SELECTION

  The primary dermal puncture sites:

  • Plantar surface of the heel (infants younger than 1 year old)
  • 3rd and 4th fingers on the palmar side of the nondominant hand (performed on adults and children over 1 year of age).
• Areas not to be punctured (Capillary Puncture):

  • Callused
  • scarred
  • bruised
  • edematous
  • cold or cyanotic
  • infected areas
• Warming the Site

  Primarily required for:

  • Patients with very cold or cyanotic fingers
  • For heelsticks to collect multiple samples
  • For the collection of capillary blood gases
• Warming the Site

  • Moistening a towel with warm water (42 °C) or activating a commercial heel warmer and covering the site for 3 to 5 minutes
• Cleansing the Site

  • Using 70% isopropyl alcohol in a circular motion.
• Performing the Puncture

  • While the puncture is performed, the heel or finger should be well supported and held firmly, without squeezing the puncture area. Massaging the area before the puncture may increase blood flow to the area.
• Puncture Device Disposal

  • Puncture device should be placed in an appropriate sharps container.
• Sample Collection

  • First drop of blood must be wiped away with a clean gauze
  • Alternately applying pressure to the area and releasing it will produce the most satisfactory blood flow.
• ORDER OF COLLECTION:

  1. Capillary blood gases
  2. Blood smear
  3. EDTA tubes
  4. Other anticoagulated tubes
  5. Serum tubes
• Bandaging the Patient

  • Pressure is applied to the puncture site with sterile gauze.
• Labeling the Sample

  • Microsamples must be labeled with the same information required for venipuncture samples.
• Completion of the Procedure

  • Proper waste disposal of all used materials
  • Proper Handwashing
  • Thanking the patient and/or the parents for their cooperation
• Order of draw

  1. capillary blood gas specimens (CBGs)
  2. EDTA specimens
  3. other additive specimens
  4. other serum specimens
• SPECIAL DERMAL PUNCTURE:

  • Collection of Newborn Bilirubin
  • Newborn Screening
  • Capillary Blood Gases
• Collection of Newborn Bilirubin

  • Samples must be collected quickly and protected from excess light during and after the collection.
  • Amber-colored Microtainer for the collection of neonatal bilirubin
• Collection of Newborn Bilirubin

  • Bilirubin is a very light-sensitive chemical and is rapidly destroyed when exposed to light.