Blood Collection Equipment, Additives and Order of Draw​

• Venipuncture


  A process of collecting or "drawing" blood from a vein of the patient for laboratory testing purposes

  
• Phlebotomist


  • Should acquire the knowledge and skill to perform venipuncture since he will perform this procedure frequently as part of his duties and responsibilities in the healthcare institution
• General Blood Collection Equipment and Supplies


  • Blood - Drawing Station
  • Phlebotomy Chair
  • Equipment carrier
  • A new pair of gloves and glove liners
  • Antiseptics
  • Disinfectants
  • Hand sanitizer & wall-mounted hand sanitizer dispenser
  • Gauze Pads
  • Bandages
  • 1x3 inches glass microscope slides
  • Pen with non-smear ink
  • Watch with timer
  • Needle and sharps disposal containers
  • Biohazard bags

  
• Venipuncture equipment


  • Vein-Locating Devices
  • Tourniquet
  • Needles
  • Needle gauge
  • Evacuated Tube System (ETS)
• Disinfectants used in venipuncture

  • EPA -registered sodium hypochlorite
  • 1:100 dilution and 1-10 dilution for spills prior to clean-up procedures
  • Contact time required is 10 minutes
• Antiseptics used in venipuncture

  • 70% ethyl alcohol
  • 70% isopropyl alcohol
  • Benzalkonium chloride
  • chlorhexidine gluconate
  • hydrogen peroxide
  • povidone-iodine and tincture iodine
• Types of phlebotomy needles

  • multi-sample needles
  • hypodermic needles
  • winged infusion
• Syringe System


  Used for patients as an alternative method when drawing blood from patients with small or difficult veins. It is the traditional collection procedure that uses a syringe to draw blood from the patient and the collected specimen is transferred into tubes.

  
• Syringe System Components


  • Syringe needle that has a resheating feature
  • A syringe which is divided into graduated barrel and plunger
• Evacuated Tube System (ETS)


  A closed collection system that is considered the most efficient system for collecting blood samples. It allows numerous tubes to be collected in a single venipuncture. It is composed of multi-sample needles, tube holders and evacuated tubes which prevent the exposure of the specimen from contaminants. Evacuated tubes are color coded tubes filled with predetermined volume of blood by vacuum.

  
• Categories of Additives used in Blood Collection


  • anticoagulants
  • special-use anticoagulants
  • antiglycolytic agents
  • clot aviators
  • thixotropic gel separator
  • trace element-free tubes
• Color Coding in Identifying Additives in Blood Collection Tubes


  • Red - No additive
  • Orange - Coagulant
  • Yellow - Coagulant and Separation Gel
  • Green - Sodium Heparin
  • Light Green - Lithium Heparin
  • Purple - EDTA Coagulant
  • Light Blue - Sodium Citrate 1:9
  • Black - Sodium Citrate 1:4
  • Grey - Potassium Oxalate Monohydrate and Sodium Fluoride
• Order of Draw


  The specific order that must be followed by a phlebotomist when collecting blood samples to prevent any cross-contamination especially when dealing with multiple collection tubes. Not following the prescribed sequence affects the test results due to cross contamination.

  
• Order of Draw


  • Blood Culture (sterile collections)
  • Coagulation tube
  • Glass non-additive tube
  • Plastic clot activator tube
  • Serum separator tube (PSTs)
  • Heparin tube
  • EDTA tube
  • Plasma-preparation tube (PPTs)
  • Oxalate/fluoride tubes

  
• Test Request


  The first step of the pre-examination phase where a physician orders a test. The request form includes information on the type of test ordered and any special instructions or conditions that should be considered during the pre-examination and examination phase. The request can be manual, computerized or bar-coded.
• Required Requisition information


  • Name of the physician who ordered the test
  • Patient's full name including the middle initial
  • The medical record number for inpatients
  • Birthday and age of the patient
  • Room number and bed number if inpatient
  • Type of test ordered
  • Date when the test is to be performed
  • Billing information with ICD-9 codes for outpatient
  • Test status
  • Special precaution
• Accessioning


  Assigning a special number to the specimen to be collected that will serve as the reference number for all associated processes and paperwork. This helps improve the documentation, handling and reporting of test results.
• Common Test Status Designations


  • Routine
  • Stat
  • Timed
  • Fasting
  • Repeat
• Bedside Manner


  The behavior of a healthcare worker as perceived by the patient which is applicable to both in- and out-patient settings. This includes knocking on the door gently before entering, greeting the patient warmly, staying organized, and approaching the patient in a professional manner.
• Importance of proper patient identification

  • Obtaining a specimen from the wrong person can have serious consequences and can even be fatal in cases that involve blood transfusion. Misidentifying patients can be a ground for dismissal or lawsuit on the grounds of malpractice. When identifying patients, confirm the name and date of birth of the patient. If the patient is fast asleep, the phlebotomist should wake him up gently for proper identification.
• Patient Complications


  • Apprehensive patient
  • Fainting (Syncope)
  • Seizures
  • Petechiae
  • Allergies
  • Vomiting
  • Patient Refusal
• Technical Complications


  • Failure to Obtain Blood
  • Collection Attempts
  • Nerve Injury
  • Iatrogenic Anemia
  • Hemolyzed Samples
  • Hematoma Formation

  
• Major reasons for sample rejection


  • Unlabeled or mislabeled samples
  • Inadequate volume
  • Collection in the wrong tube
  • Hemolysis
  • Lipemia
  • Clotted blood in an anticoagulant tube
  • Improper handling during transport (such as not chilling the sample)
  • Samples without a requisition form
  • Contamination
• Hemolyzed samples


  Detected by the presence of pink or red plasma or serum
• Errors causing hemolysis


  • Using a small needle with large evacuated tube
  • Probing
  • Errors in processing or handling of the sample (e.g. rimming clots; prolonged contact of serum/plasma with cells, etc.)
• Major reasons for sample rejection

  • Unlabeled or mislabeled samples
  • Inadequate volume
  • Collection in the wrong tube
  • Hemolysis
  • Lipemia
  • Clotted blood in an anticoagulant tube
  • Improper handling during transport (such as not chilling the sample)
  • Samples without a requisition form
  • Contaminated sample containers
  • Delays in processing the sample
  • Use of outdated collection tubes
• Equipment for capillary collection


  • Lancet/Incision Devices
  • Laser Lancet
  • Microcollection Containers
  • Microhematocrit Tubes and Sealants
  • Microscope Slides
  • Warming devices
  • Capillary Blood Gas Equipment (CBG)

  
• Types of blood specimens

  • Capillary blood
  • Arterial blood
  • Venous blood
• Indications for performing capillary puncture


  • Veins are fragile and not accessible
  • Veins are reserved for another procedure
  • Clotting tendencies
  • Extreme fear of needles
  • Veins will be used for POCT such as glucose monitoring
• Indications for capillary puncture in infants and young children


  • Health risks such as anemia, and cardiac arrest
  • Requires only a small volume of blood
  • Venipuncture could damage veins and tissues surrounding the site
  • Puncturing could result to hemorrhage, thrombosis, gangrene, and infection
  • Risk of injury because of the restraint needed in venipuncture
  • Capillary blood is the preferred specimen
• Order of draw for collecting capillary specimen

  1. Blood gas specimens (CBGs)

  2. EDTA specimens

  3. Other additive specimens

  4. Serum specimens

  
• Positioning the patient's arm during finger puncture

  Arm placed in a firm surface, extended with palms facing up
• Positioning the patient during infant heel puncture

  Infant in supine position, foot not lower than torso
• Criteria for incision site


  • Skin should be pink, normal in color, and warm
  • Free from scars, cuts, bruises, rashes, cyanosis, edema, or infection
• Incision site for adults and older children

  • Palmar surface of the distal, end segment of the middle finger or ring finger of the non-dominant hand
• Incision site for infants


  • Plantar surface of the heel, or on the median or lateral edge
  • Incision less than 2.0 mm deep to avoid bone damage
• Warming the incision site

  Using a warm washcloth or towel, warm the site for 3 to 5 minutes
• Cleaning the incision site

  Using antiseptic or 70% isopropyl alcohol
• Wiping away the first blood drop


  They may be contaminated with excess tissue fluid
• Filling and mixing tubes/containers in order of draw


  1. Prioritize collection of slides, platelet counts, and other hematology specimens

  2. Anticoagulant containers next

  3. Serum specimens last