VAD & SPECIAL POPULATION

• Blood Culture Sample Collection

  1. Mix the blood culture bottles by gentle inversion eight times

  2. Clean the iodine off the arm with alcohol if necessary

  3. Label the samples appropriately and include the site of collection

  4. Verify identification with the patient

  5. Dispose of used equipment and supplies in a biohazard container

  6. Check the venipuncture site for bleeding and bandage the patient's arm

  7. Thank the patient, remove gloves, and wash hands

  8. Fill other collection tubes after the blood culture tubes
• Central Venous Catheters (CVCs)


  • Inserted by a physician or certified health-care professional
  • Can be used for administration of fluids, drugs, blood products, and nutritional solutions and to obtain blood
  • Sterile technique procedures must be strictly adhered to when entering IV lines
• Types of CVCs


  • Nontunneled, noncuffed CVC
  • Tunneled/cuffed
  • Implanted port
  • Peripherally inserted central catheters (PICCs)
• Nontunneled, noncuffed CVC


  Used for short-term dwell times, inserted through the skin into the jugular, subclavian, or femoral vein and threaded to the superior vena cava
• Tunneled/cuffed CVC


  Considered more permanent, used for long-term dwell times, surgeon performs a cut-down of the vein and tunnels the catheter in subcutaneous tissue under the skin
• Implanted port


  A small chamber attached to a catheter, implanted in subcutaneous tissue under the skin, used for long-term access to the central venous system
• Peripherally inserted central catheters (PICCs)

  Placed in the basilic or cephalic vein in the antecubital area of the arm, with the tip threaded to the superior vena cava
• Blood Sample Collection from Central Venous Catheters

  1. Stop IV fluids for 5 minutes before collecting the blood sample

  2. Use syringes larger than 20 mL should not be used

  3. Discard or conserve the first 5 mL of blood (or two times the dead space volume of the catheter)

  4. Use a new syringe to collect the sample

  5. Drawing coagulation tests is not recommended, but if necessary, discard 20 mL (or five to six times the dead space volume of the catheter)

  6. Order of tube fill: first syringe discard/conserve, second syringe blood cultures, third syringe anticoagulated tubes, clotted tubes
• Blood Alcohol Samples


  1. Cleanse the site with soap and water or a nonalcoholic antiseptic solution

  2. Tubes should be completely filled and not uncapped for longer than necessary
• Blood alcohol levels


  Frequently collected in gray stopper tubes with sodium fluoride
• Molecular Diagnostics


  Blood samples collected for HIV and hepatitis C virus (HCV) viral loads, diagnosis of hematological disorders, coagulation disorders, management of warfarin (Coumadin) therapy, and identification of genetic disorders
• Evacuated tubes for molecular diagnostics

  • Yellow stopper tubes containing acid-citrate-dextrose (ACD) commonly used for DNA paternity testing
  • EDTA or sodium citrate as the anticoagulant may be required
• The Joint Commission recommends that phlebotomists be proficient with all age groups and that age-specific competencies be demonstrated and evaluated
• DNA paternity testing


  Common use of ACD tubes
• Two concentrations of ACD tubes are available and the sample must be collected in the tube with the required concentration
• Other procedures may require ethylenediaminetetraacetic acid (EDTA) or sodium citrate as the anticoagulant
• A variety of specialized tubes is also available
• Phlebotomists


  • Must be proficient with all age groups and demonstrate age-specific competencies
  • Must develop knowledge and skills in working with all age groups of patients
• Geriatric population


  • Physical and emotional factors related to aging can cause difficulty with blood collection and affect sample integrity
  • Goal is to perform atraumatic venipuncture without bruising or excessive bleeding and provide a quality sample
• Physical factors affecting blood collection in geriatric patients

  • Hearing loss
  • Failing eyesight
  • Decreased senses of taste, smell, and feeling
  • Muscle weakness
  • Memory loss
  • Thinner epithelium and subcutaneous tissues
  • Smaller muscles
  • Delayed epidermal cell replacement
  • Decreased collagen and elasticity of veins
  • Decreased fatty tissue layer
  • Sclerotic arteries and veins
• Disease states in geriatric patients that contribute to challenges in venipuncture

  • Alzheimer's disease
  • Stroke
  • Coma
  • Arthritis
  • Parkinson's disease
• Emotional factors in geriatric patients

  • Embarrassment, anxiety, fear, depression, sadness, anger
  • Phlebotomist must be sensitive and treat patients with respect and dignity
• Blood collection in geriatric patients

  1. Patient identification

  2. Equipment selection

  3. Tourniquet application

  4. Site selection

  5. Performing the venipuncture

  6. Bandages
• Dermal puncture should be performed on older patients when possible to avoid complications
• Pediatric population


  • Ideally, children younger than 2 years should have blood collected by dermal puncture
  • Venipuncture required for special tests
  • Phlebotomist must develop interpersonal skills to gain trust and cooperation of young patients and parents
  • Emotional stress and crying can affect blood analytes and cause erroneous test results
• Erythrocyte sedimentation rates, special diagnostic studies, or blood cultures require more blood than can be collected from a finger or heel stick and must be collected by venipuncture
• Pediatric blood collection


  • Involves preparing both the child and parent, using certain restraining procedures, and special equipment
  • Presents emotional as well technical difficulties and should be performed by only experienced phlebotomists
  • A negative experience can lead to a child's life-long fear of needles
  • There is often only one chance to attempt a venipuncture on a child
• Phlebotomist


  • Must develop interpersonal skills to successfully gain both the young patients' and parents' trust and cooperation
  • Must be skilled with the special types of equipment used for pediatric venipuncture
• It is important to keep the patient as calm as possible during the procedure because emotional stress and crying can affect blood analytes and cause erroneous test results
• Techniques for dealing with children

  1. Vary depending on the child's age

  2. Establish guidelines and be honest with both the patient and parent
• Newborns and infants


  Totally dependent on their parents
• Dealing with newborns and infants

  1. Introduce yourself to the parents and explain the procedure

  2. Ask the parents about the child's previous experiences with blood collection

  3. Have the parent hold the child and encourage the parent to use distraction and comforting techniques

  4. Parents must identify the child if it is an outpatient setting
• Toddlers


  Have limited language skills and fear of strangers
• Dealing with toddlers


  1. Talk to the child calmly and maintain eye contact

  2. Demonstrate the procedure using toys

  3. Allow children to have their comfort toys or blanket and develop strategies to distract or entertain them

  4. Have the parents assist with holding and comforting the child

  5. Reward the child with praise and stickers

  6. Thank the child and parent for their cooperation
• Dealing with older children

  1. Explain the steps of the procedure and demonstrate the equipment

  2. Demonstrate and allow the child to touch the tourniquet or other clean equipment

  3. Answer their questions honestly

  4. Never tell a child it will not hurt

  5. Explain that "it will hurt a little bit, but if you hold very still, it will be over quickly"

  6. Enlist the child's help in holding the gauze

  7. Give the child permission to cry
• Teenagers


  More independent and often embarrassed to show their emotions
• Dealing with teenagers


  1. Use adult language with teenagers for identification and explanation of the procedure

  2. Ask them if they have fainted or had any reaction to a previous venipuncture procedure

  3. Encourage them to ask questions about the procedure

  4. They may or may not want their parents present
• Methods of restraint


  1. Older children can usually sit in a drawing chair by themselves

  2. An infant cradle pad facilitates blood collection for infants

  3. Never draw blood from a small child without some type of assistance

  4. Physical restraint may be required to immobilize the young child and steady the arm for the venipuncture procedure

  5. This can be accomplished by having someone hold the child or by using a papoose board

  6. Either a vertical or horizontal restraint will work
• Vertical restraint


  1. The parent holds the child in an upright position on the lap

  2. The parent places an arm around the toddler to hold the arm not being used

  3. The other arm holds the child's venipuncture arm firmly from behind, at the bend of the elbow, in a downward position
• Horizontal restraint


  1. The child lies down, with the parent on one side of the bed and the phlebotomist on the opposite side

  2. The parent leans over the child holding the near arm and body securely while reaching over the body to hold the opposite venipuncture arm for the phlebotomist