PMLS L8 PT2

• Vascular access devices


  are tubing and other devices that are specifically designed to allow entry to veins or arteries. They are often used for patients who require frequent venous or arterial access, most commonly used for

  administration of medications, fluids, blood products, and sometimes blood collection.
• As a general rule, venipuncture should not be performed on

  an extremity with a VAD. Only nurses and other specially trained personnel are permitted to draw blood specimens from vascular access devices (VADs), phlebotomist typically assists by supplying the appropriate tubes, transferring the blood to the tubes.
• INTRAVENOUS LINE

  ✓ referred to simply as an IV, is a quick way to deliver fluids, medications, blood transfusion products, and other substances to patients.

  ✓ It is preferred that blood specimens not be drawn from an arm with an IV, as the specimens can be contaminated or diluted with the IV fluid, causing erroneous test results.

  ✓ When a patient has an IV in one arm, collect blood specimens from the other arm if possible. If a patient has IVs in both arms, blood specimens can be collected below one of the IV, through capillary, through the IV line by trained practitioner.
• performing venipuncture below an iv

  
• ✓ An IV catheter lock is a needleless connection device in the form of a stopcock or a cap that is connected to the hub of a catheter or cannula by a short length of IV tubing.

  ✓ A 5mL discard tube should be drawn first when blood specimens are collected from a heparin lock or from a saline lock that has been flushed with heparin.

  ✓ Drawing coagulation specimens from them is also not recommended because traces of heparin or dilution with saline can negatively affect test results.
• 
  

  ✓ Previously active IV sites present a potential source of error in testing.

  ✓ Never collect blood specimens from known previous IV sites within 24 to 48 hours of the time the IV was discontinued.
• ARTERIAL LINE/A-LINE/ART-LINE

  ✓ A catheter that is placed in an artery, commonly located in the radial artery of the wrist and is typically used to provide accurate and continuous measurement of a patient’s blood pressure.

  ✓ Never apply a tourniquet or perform venipuncture on an arm with an arterial line.
• Arteriovenous shunt, fistula, or graft


  Permanent surgical connection of an artery and vein that bypasses the capillaries and forces arterial blood directly into a vein
• AV fistula


  Dialysis shunt created by direct permanent fusion of the artery and vein, visible as a large bulging section of vein
• Shunt


  • Has a distinctive buzzing sensation called a "thrill" that is the result of the pressure of the arterial blood flow meeting the passive flow of the vein
• A shunt is a dialysis patient's lifeline
• Never perform venipuncture or apply a blood pressure cuff or tourniquet on an arm with any type of shunt
• A needleless closed blood sampling device is sometimes connectedd to an arterial or central venous catheter (CVC) for the specific purpose of collecting blood specimens.
• CENTRAL VASCULAR ACCESS DEVICES - also called an indwelling line, consists of tubing inserted into a main vein or artery.

  ✓ used primarily for administering fluids and medications, monitoring pressures, and drawing blood (trained individuals)

  ✓ To help ensure that the specimen is not contaminated with the flush solution, a small amount of blood must be drawn from the line and discarded (2x for anticoagulated tubes & 6x for non-coagulated tubes) before a blood specimen can be collected.
• PATIENT COMPLICATIONS AND CONDITIONS

  ALLERGIES TO SUPPLIES AND EQUIPMENTS, APPREHENSIVE PATIENT, EXCESSIVE BLEEDING, FAINTING SPELLS, NAUSEA AND VOMITTING, PAIN, PETECHIAE, SEIZURE/CONVULSION
• ALLERGIES TO SUPPLIES AND EQUIPMENTS

  ✓ Always confirm for allergies before doing the procedure!

  ✓ Ask the patient on any allergies for latex, antiseptics and glue in the bandage.

  ✓ Change materials immediately; use alternatives

  ✓ Patients with known allergies often wear special armbands or have allergy-specific warning signs posted in their hospital

  rooms.
• APPREHENSIVE PATIENT

  ✓ Ask assistance to the nurse-on-duty, relative or colleague to stabilize the patient.

  ✓ Mentally-capable adult patients has the right to refuse the collection procedure.
• EXCESSIVE BLEEDING

  ✓ Patients may have prolonged bleeding due to aspirin or anticoagulant therapy

  ✓ Continue to apply pressure to the area

  ✓ If the bleeding continues for more than 5 mins, notify appropriate personnel

  ✓ NEVER let a patient leave the collection room with a pressure bandage if signs of bleeding is noticed!
• FAINTING SPELLS (SYNCOPE)

  ✓ Loss of consciousness and postural tone resulting from insufficient blood flow to the brain.

  ➢ Vasovagal syncope: fainting caused by nervous system reacting to

  pain, trauma, or stress.

  ✓ Deriving factors: hemophobia, fear of needle, ill or fasting for an extended period of time, anemia, dehydration, fatigue, hypoglycemia,

  hyperventilation, medications and poor compromised breathing.
• fainting spells (syncope)

  
• warning signs for fainting spells:

  cold and clammy skin, pallor, perspiration, hyperventilation, dizziness, light-headedness, nausea, tunnel vision and fading sounds
• NAUSEA & VOMITTING

  ✓ Warning signs: nauseous, pale, beads of sweat n the forehead

  ✓ Reassure the patient and make them comfortable.

  ✓ Let them hold an emesis basin or waste basket as a precaution.

  ✓ If had vomited, provide with tissue or washcloth and water for mouth-rinsing or drinking.

  ✓ NEVER SHOW YOUR DISGUST!
• PAIN

  ✓ Small amount of pain is normal in venipuncture or other collection

  procedure.

  ✓ Marked or extreme pain, numbness of the arm and electroshock

  sensation or pain that radiates arm indicates nerve involvement and

  requires needle removal.

  ✓ Apply cold compress to alleviate the pain, if it persist seek medical

  advise.
• PETECHIAE

  ✓ Tiny, non-raised red, purple, or brownish colored spots that appear on

  patient’s skin when torniquet is applied.

  ✓ This is due to platelet abnormalities and vascular defects
• SEIZURE/CONVULSION

  ✓ It is known to occur in venipuncture but has no direct link to

  venipuncture.

  ✓ Discontinue the procedure immediately!

  ✓ Apply pressure while not restricting the movement of the patient but make sure to protect the head of the patient.

  ✓ Call for help to ease the patient to the floor and turn him/her to one side to keep airway clear

  ✓ Looses a tie, collar button, or anything else restrictive of breathing.

  ✓ Time the seizure, and notify appropriate first aid personnel.
• HEMATOMA FOMATION AND BRUISING

  ✓ Most common complication in collection procedure.

  ✓ Caused by blood leaking into tissues during or following a venipuncture.

  ✓ Characterized by reddish or purple swelling near the site. Typically painful for the patient and crates bruising.

  ✓ If noticed, DISCONTINUE IMMEADIATELY!

  ✓ Apply a forceful pressure to the site for several minutes if accidental arterial puncture is noticed!

  ✓ If the hematoma is large and causes swelling, elevate the arm and apply cold compress to relieve the swelling or if pain is intolerable, take pain killers.
• IATROGENIC ANEMIA

  ✓ Adverse condition brought on by the effects of treatment

  ✓ Blood loss from blood testing is common among infants.

  ✓ Exsanguination: blood loss to a point at which life cannot be sustained

  ✓ How to avoid this risk:

  1. Coordination of the physicians on the test orders

  2. Minimize redraws by following the quality assurance protocol

  3. Collecting minimum volume of blood

  4. Keeping a log of draws

  5. Save specimen/ save serum
• INADVERTENT ARTERIAL PUNCTURE

  ✓ “Accidental arterial puncture” occurs when doing deep or blind probing esp in the areas near the basilic vein.

  ✓ Look for early signs such as: hematoma, bright red blood, pressurized collection

  ✓ If seen, terminate the procedure immediately and apply forceful pressure to the patient.
• INFECTION (NOSOCOMIAL & IATROGENIC)

  ✓ A great risk to the patient since blood collection is an invasive procedure.

  ✓ It can be minimized by following appropriate aseptic techniques:

  1. Do not open, cut adhesive tape ahead of time.

  2. Do not open the needle and pre-attached to the holder.

  3. Allow alcohol to dry prior to needle insertion.

  4. Do not touch the site after disinfection.

  5. Minimize the time between removing needle and the cap.

  6. Remind the patient to keep the bandage for 15 mins.
• NERVE INJURY

  ✓ Permanent damage to the motor or sensory nerve function of the arm and hand is a serious complication in phlebotomy.

  ✓ Two types of nerve injury from venipuncture: (1) needle directly contacting the nerve in the form of nick or puncture; (2) compression injury to the nerve by swelling
• ✓ CAUSES OF NICK/PUNCTURE TO THE NERVE:

  1. Improper site selection

  2. Inserting needle too deeply and quickly

  3. Excessive or lateral redirection of the needle.

  4. Blind probing

  5. Patient startle reflex upon needle insertion.
• CAUSES OF COMPRESSION INJURY: Hematoma

  ✓ Knowledge of the arm anatomy, standards in site selection lessens this risk.

  ✓ Look for warning signs such as extreme pain and terminate the procedure immediately.

  ✓ Document the event and report to the healthcare provider, advise the patient on the facility protocol if the pain persist.
• REFLUX OF ADDITIVE

  ✓ In rare instances, it is possible for blood to reflux into the patient’s vein from the tube during collection procedure.

  ✓ Caused by normal variation in vein pressure or sudden drop in pressure after torniquet removal.

  ✓ EDTA reflux attributes to adverse effects.

  ✓ To prevent this from happening, the patient’s arm should be placed in a downward position and do not create a back-and-forth movement of the tube.
• VEIN DAMAGE

  ✓ Properly performed venipuncture will not impair the patient’s

  vein.

  ✓ Numerous venipuncture to one area will build up scar tissue.

  ✓ Blind probing and improper technique when redirecting the

  needle can also damage the vein.
• ✓ Venous stasis from prolonged torniquet application is the primary causes hemoconcentration.

  ✓ Other causes: heavy massaging of the site, vein probing, long-term IV, drawing blood from sclerosed vein, vigorous hand pumping

  ✓ Increases: RBC, albumin, ammonia, calcium, cholesterol, coagulation factors, enzymes, iron, potassium, total protein

  ✓ Prevention: release the fist upon blood flow, choose an appropriate patent vein, do not allow fist pump, do not excessively massage the site, do not probe or redirect needle multiple times, release the torniquet after 1 minute
• HEMOLYSIS

  ✓ This results when RBC are damaged and the hemoglobin escapes to the plasma making I appear as pink (slight hemolysis), dark pink to light red (moderate) to dark red (gross hemolysis).

  ✓ Causes: hemolytic anemia, liver disease, transfusion reaction, but commonly caused by procedural errors.

  ✓ Increases: K+ (23x), ammonia, cathecolamine, CK, LDH, iron, magnesium, phospahate; ↓ RBC ct

  ✓ REJECT HEMOLYZED SPECIMEN!
• Partially filled tube/overfilled tubes


  • Short draws - failing to fill the tube until the normal amount of vacuum is exhausted
  • SST and RTT generally acceptable but for anticoagulated tube the volume must be followed to avoid the effect of improper blood-anticoagulant ratio
• Excess EDTA


  Can shrink the RBC
• Excess heparin


  May interfere in chemistry analysis
• Excess Na F


  Can hemolyze the sample