MLS 038

• Phlebotomy


  An incision into a vein
• Phlebotomy is the oldest medical procedure, dating back to the early Egyptians
• Bloodletting


  Used to cure disease and maintain the body
• Hippocrates believed that disease was caused by an excess of body fluids, including blood, bile, and phlegm, and that removal of the excess would cause the body to return to or maintain a healthy state
• Techniques for bloodletting included suction cup devices with lancets that pulled blood from the incision; the application of blood-sucking worms, called "leeches," to an incision; and barber surgery, in which blood from an incision produced by the barber's razor was collected in a bleeding bowl
• The familiar red and white striped barber pole symbolizes this last technique and represents red blood and white bandages and the pole that the patients held on to during the procedure
• Therapeutic phlebotomy


  Bloodletting is now called "therapeutic phlebotomy" and is used as a treatment for only a small number of blood disorders
• Phlebotomist


  A person trained to obtain blood samples primarily by venipuncture and microtechniques
• Traditional duties of a phlebotomist

  • Correct identification and preparation of the patient before sample collection
  • Collection of the appropriate amount of blood by venipuncture or dermal puncture for the specified tests
  • Selection of the appropriate sample containers for the specified tests
  • Correct labeling of all samples with the required information
  • Appropriate transportation of samples back to the laboratory in a timely manner
  • Effective interaction with patients and hospital personnel
  • Processing of samples for delivery to the appropriate laboratory departments
  • Performance of computer operations and record-keeping pertaining to phlebotomy
  • Observation of all safety regulations, quality control checks, and preventive maintenance procedures
  • Attendance at continuing education programs
• Additional duties of a phlebotomist

  • Training other healthcare personnel to perform phlebotomy
  • Monitoring the quality of samples collected on the units
  • Evaluation of protocols associated with sample collection
  • Performing and monitoring point-of-care testing (POCT)
  • Performing electrocardiograms
  • Performing measurement of patient's vital signs
  • Collection of arterial blood samples
  • Collection of samples from central venous access devices (CVADs)
• Professional characteristics that are important for a phlebotomist

  • Dependable
  • Cooperative
  • Committed
  • Compassionate
  • Courteous
  • Respectful
  • Honest
  • Integrity
  • Competent
  • Organized
  • Responsible
  • Flexible
• General appearance guidelines for a phlebotomist

  • Clothing and lab coats must be clean and unwrinkled
  • Shoes must be clean, polished, closed-toed, and skid-proof
  • Jewelry must be conservative
  • Perfume and cologne are usually not recommended or must be kept to minimum
  • Hair including facial hair must be clean, neat, and trimmed
  • Personal hygiene is extremely important
  • Fingernails must be clean and short
• Nonverbal skills


  Body language, including facial expressions, posture, and eye contact
• Verbal skills


  Enable phlebotomists to introduce themselves, explain the procedure, reassure the patient, and help assure the patient that the procedure is being competently performed
• Listening skills


  A key component of communication, involving looking directly and attentively at the patient, encouraging the patient to express feelings and concerns, allowing the patient time to describe why they are concerned, providing feedback, and encouraging patient communication by asking questions
• Verbal communication barriers and methods to overcome them

  • Hearing impairment: speak loudly and clearly, look directly at patient to facilitate lip-reading, communicate in writing
  • Patient emotions: speak calmly and slowly, do not appear rushed or disinterested
  • Age & education levels: avoid medical jargon, use age-appropriate phrases
  • Non-English speaking: locate a hospital-based interpreter, use hand signals, show equipment, remain calm, smiling, and reassuring
• General cultural diversity guidelines for a phlebotomist


  • Approach all patients with a smile and use a friendly tone of voice
  • Be alert to patient reactions and accommodate them, do not force your style
  • Do not stereotype a particular culture, not all people of same ethnic culture react in the same manner
  • Remember the amount of personal space varies among cultures, certain cultures are not as welcoming to touching
  • Plan to spend additional time explaining procedures and patient instructions, be sure instructions are understood
  • Show respect for their diversity
• Six rules of proper telephone etiquette

  • Answer the phone promptly and politely, stating the name of the department and your name
  • Always check for an emergency before putting someone on hold, and return to calls that are on hold as soon as possible
  • Keep writing materials beside the phone to record information
  • Make every attempt to help callers, and if you cannot help them, transfer them to another person or department that can
  • Provide accurate and consistent information by keeping current with laboratory policies
  • Speak clearly and make sure you understand what the caller is asking and that they understand the information you are providing
• Preanalysis


  Involves all the complex steps that must take place before a sample can be analyzed, approximately 32-75% of testing errors happen in this phase, careful attention is necessary to ensure meaningful results
• Turn-around time


  The amount of time to complete a whole process (from preanalysis to postanalysis)
• Patient-related variables affecting pre-collection

  • Physiology: diurnal variation, exercise, diet
  • Common interferences: tobacco smoking, hemolysis, hemoconcentration, hemodilution, icterus, lipemia
• Specimen collection considerations


  • The test order
  • Time of collection
  • Specimen acceptability and identification issues
  • Blood collection devices
  • Tube additives
  • Blood storage and preservation
  • Collection of other body fluids: urine, cerebrospinal fluid, synovial fluid, pleural/pericardial/peritoneal fluid
• Definitions


  • Anticoagulant: tube additive that prevents blood clotting
  • Basal state: resting metabolic state of the body early in the morning after fasting for 12+ hours
  • Clot activator: tube additive that accelerates clotting
  • Diurnal variation: normal daily fluctuations in body chemistry
  • Hemolysis: rupture or destruction of red blood cells
  • Icteric: bright dark yellow serum/plasma due to excess bilirubin
  • Lipemia: turbidity of serum/plasma caused by increased lipids
  • Hemoconcentration: decrease in plasma/serum volume, increase in RBC and other constituents
  • Hemodilution: decreased concentration of cells and constituents due to gain of plasma/serum
• Patient-Related Variables


  • Physiology
  • Exercise
  • Diet
  • Stress
  • Posture
  • Age
  • Gender
• Diurnal Variation


  Transient changes encountered when testing for hormones, iron, acid phosphatase, urinary excretion of most electrolytes such as sodium, potassium, and phosphate
• Exercise


  1. Transient changes: initial decrease followed by an increase in free fatty acids, and lactate may increase by as much as 300%. Elevated creatine phosphokinase (CK), aspartate aminotransferase (AST), and lactate dehydrogenase (LD) and may activate coagulation, fibrinolysis, and platelets

  2. Long-term changes: increase CK, aldolase, AST, and LD values. Chronic aerobic exercise associated with lesser increases in plasma concentration of muscle enzymes such as CK, AST, alanine aminotransferase (ALT), and LD. Decreased levels of serum gonadotropin and sex steroid concentrations are seen in long-distance athletes, while prolactin levels are elevated
• Diet


  1. Glucose (blood sugar) levels increase dramatically with the ingestion of carbohydrates or sugar-laden substances but return to normal within 2 hours if the patient has normal glucose metabolism

  2. Ingestion of lipids (such as fats found in foods such as butter and cheese and in some IV feeding preparations) increases blood lipid content, a condition called lipemia. High levels of lipids cause the serum or plasma to appear milky (cloudy white) or turbid, and the specimen is described as being lipemic. Lipemia can be present for up to 12 hours, which is why accurate testing of triglycerides (a type of lipid) requires a 12-hour fast. In addition, some chemistry tests cannot be performed on lipemic specimens because the cloudiness interferes with the testing procedure

  3. Some test methods that detect occult (hidden) blood in stool specimens also detect similar substances in meat and certain vegetables. Consequently, a special diet that eliminates these foods must be followed for several days before the specimen is collected

  4. Fluid intake can also affect blood composition. Excessive fluid intake can decrease Hemoglobin levels, and alter electrolyte balance. Consumption of caffeine beverages can affect cortisol levels. Chronic consumption or recent ingestion of large amounts of alcohol can cause hypoglycemia, and increased triglycerides
• Stress


  Mental and physical stresses induce the production of adrenocorticotropic hormone (ACTH), cortisol, and catecholamines. Total cholesterol has been reported to increase with mild stress, and HDL cholesterol to decrease by as much as 15%. Hyperventilation affects acid-base balance and elevates leukocyte counts, serum lactate, or free fatty acids
• Posture


  1. Upright position increases hydrostatic pressure, causing a reduction of plasma volume and increased concentration of proteins

  2. Change from supine to upright increases Albumin and Calcium

  3. After bed rest in the hospital, a patient's hemoglobin (Hb) can decrease from the original admitting value
• Age-related changes


  • Newborn: much of the Hemoglobin is Hb F, not Hb A, as seen in the adult. Bilirubin concentration rises after birth and peaks at about 5 days. High Uric Acid but decreases for the first 10 years of life then increases, especially in boys, until the age of 16
  • Infants: lower glucose level than adults because of their low glycogen reserve. Increase in Alkaline Phosphatase in skeletal growth. Increase creatinine in muscle development
  • Most serum constituents remain constant during adult life
  • Menopausal women and middle-aged men: Increases of about 2 mg/dL (0.05 mmol/L) per year in total cholesterol and 2 mg/dL (0.02 mmol/L) per year in triglycerides. The increase in cholesterol seen in postmenopausal women has been attributed to a decrease in estrogen levels
  • The elderly secrete less triiodothyronine, parathyroid hormone, aldosterone, and cortisol
  • After age 50, men experience a decrease in secretion rate and concentration of testosterone, and women have an increase in pituitary gonadotropins, especially follicle-stimulating hormone (FSH)
• Gender-related differences


  • Women: lower Magnesium, Calcium, Albumin, serum iron, and ferritin
  • Men: higher Alkaline Phosphatase, Aminotransferases, Creatine kinase, and aldolase
• In Vitro Interferences


  • Tobacco Smoking
  • Hemolysis
  • Hemoconcentration
  • Hemodilution
  • Icterus
  • Lipemia
• Tobacco Smoking


  Increases carboxyhemoglobin, catecholamines esp. Epinephrine, cortisol, free fatty acids, hemoglobin, red blood cells, white blood cells esp neutrophils and monocytes, lactate, insulin, growth hormone, urinary secretion of 5-Hydroxyindole Acetic Acid, thiocyanate, immunoglobulin E (IgE), and sperm morphology abnormality

  Decreases eosinophils, vitamin B12, immunoglobulins (IgA, IgG, and IgM), and sperm count and motility
• Hemolysis


  Causes false increase in potassium, magnesium, iron, lactate dehydrogenase, phosphorus, ammonium, and total protein
• Hemoconcentration


  Caused by extended application of tourniquet resulting into increased concentrations of analytes and cellular components
• Hemodilution


  Usually caused by a short draw of blood during venipuncture
• Icterus


  A serum or plasma sample is described as icteric if it appears bright to dark yellow due to increased bilirubin. When serum bilirubin approaches 430 mmol/L (25mg/L), interference may be observed in assays for albumin, cholesterol, and total protein
• Lipemia


  Occurs when serum triglyceride levels are elevated causing a turbid sample. The increase may cause artifactual values in some laboratory determinations such as amylase, urate, urea, Creatine Kinase, Bilirubin, and total protein
• Reasons for Specimen Rejection

  • Hemolysis/Lipemia
  • Clot present in an anticoagulated specimen
  • Non-fasting specimen when test requires fasting
  • Improper Blood Collection Tube
  • Short draw, wrong volume
  • Improper transport conditions
  • Discrepancies between requisition
  • Unlabeled or mislabeled specimen
  • Contaminated specimen or leaking container
• Policy for Handling Mislabeled Specimen

  • Do not assume any information about the specimen
  • Do not relabel an incorrect labeled specimen
  • Do not discard the specimen until investigation is complete
  • Leave specimen exactly as you received it; put it in the proper storage area until errors are resolved
  • Notify floor, nursing station, doctor's office, etc, of problem and why it must be corrected for analysis to continue
  • Identify problem on specimen requisition with date, time, and your initials
  • Make person responsible for specimen collection participate in solution problem(s). Any action taken should be documented
  • Report all mislabeled specimens to the quality assurance board