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Best practices in phlebotomy for blood culture
- 1. Best Practices in Phlebotomy - In-service Training Program for Blood Culture Sample Collection. Date: 30/01/2020 Location: Bansal Lab (Conference Room) Dr. Ruchi Gupta (Consultant MD Pathologist) Bansal Endocrinology & Clinical Lab, Ludhiana.
- 2. Venous Access Sites 1. Antecubital area of arm (highlighted area) – most commonly used 2. Dorsal Hand Veins – used when veins in antecubital area are inaccessible
- 3. Site selection in Arm • The highlighted area shows the antecubital fossa region. • The major veins commonly used for venipuncture are located in this area. • The veins of choice, in order of their preference for venipuncture are: 1. Median Cubital Vein 2. Cephalic Vein 3. Basilic Vein
- 4. Site selection in Arm 1. Median cubital vein This is the first choice because – It is large – Well-anchored – Generally least painful – Least likely to bruise 2. Cephalic vein This is the second choice – It is large – Not as well-anchored – May be more painful than the median cubital vein 3. Basilic vein This is the third choice – It is generally large – It is easy to palpate (elastic / feel) – Often not well anchored (slippery) – It lies near brachial artery and median nerve – either of which could be accidentally punctured
- 5. Site selection in Hand • May be used1 if antecubital fossa veins are unsuitable or unavailable. • Extra care must be used to anchor these veins. • Because wrist veins have a narrow diameter, it may be necessary to use a small gauge needle and small volume2 evacuated tubes. • Use of a winged (‘butterfly’) blood collection set with Luer® adapter may enhance success and make the procedure less painful. • institutional policies may determine which healthcare workers are authorised to access vein in the dorsal area of the hand • partial draw tubes will help to prevent vein collapse
- 6. Site selection in Foot The last resort for blood collection is from the foot veins after the arm veins have been determined unsuitable. As for dorsal veins on the hand, institutional policies may determine which healthcare workers are authorised to access veins in this area.
- 7. Applying latex / vinyl strip Tourniquet A. The tourniquet is positioned under the arm approximately 10 cm (4 inches) above the intended venipuncture site, with each hand grasping one side of the tourniquet. B. Tension is applied and maintained. Without rolling or twisting the tourniquet, the two sides of the tourniquet are brought together. C. One side is crossed over the other and a portion of the upper side is securely tucked under the lower side. D. Care should be taken to ensure that the loop is below the tourniquet band and the free ends (flaps) of the tourniquet are pointing away from the venipuncture site. This prevents it from interfering with the site of needle entry. E. The flaps are positioned so they can easily be grasped with one hand. Gently pulling on the flaps releases the tourniquet
- 8. More on the Tourniquet……. • Tourniquet is used to make the veins easier to locate and feel. • When correctly placed on the patient's arm, it should be tight enough to slow venous flow without affecting arterial flow. • It should feel slightly tight to the patient, allowing more blood to flow into than out of the area. The tourniquet will cause the veins to enlarge, making them easier to palpate and penetrate with a needle. Aim for a maximum application time of one minute. Application beyond this time may affect some test results (alteration in relative concentrations of small and large molecules in the specimen). If a significant amount of time is required to select the site (with tourniquet applied), remove the tourniquet to allow the arm to ‘recover’ for at least 2 minutes and re-apply immediately prior to venipuncture. If you can take sample for serum Calcium without applying tourniquet will be give you best result of serum calcium. . Do not apply a tourniquet over an open wound. Too Tight Too Close to the site X X
- 9. Select the Site for Venepuncture • The patient is asked to make a fist • Venipuncture is most commonly performed in the anticubital fossa area of the arm where the median cubital, cephalic, and basilic veins lie fairly close to the surface. • The tip of the index finger is used to palpate (examine by feel) the vein. This helps determine the size, depth, and direction of the vein. • A vein is selected that is easily palpated, large enough to support good blood flow, and well- anchored by surrounding tissue. • Veins that feel hard or cord-like or lack resilience should not be selected since these may be sclerosed or thrombosed. • If the tourniquet is applied for vein selection, it should be released while the site is cleaned.
- 10. Cleanse the Site • The venipuncture site is cleaned with alcohol prep pad (or alternative) to help prevent patient infection and microbial contamination of the specimen. • The cleaning is started at the center of the site and moved outwards in ever widening, concentric circles. Failure to follow this procedure may re-introduce dirt and bacteria. A sufficient pressure is used to remove surface dirt and debris. • The process is repeated with a fresh alcohol prep pad if the site remains dirty. • The site is allowed to air dry (30 - 60 seconds) prior to beginning the venipuncture. • The site should not be wiped, blown on, or fanned, as these actions may re-introduce contaminant micro- organisms • For blood culture draws, the laboratory's standard operating procedure must be followed. • The site should not be touched after it is cleaned.
- 11. Needle Insertion Angle • Insertion at an angle of incidence of 15 – 30 degrees is recommended. • Top Picture: Bevel of the needle is fully inserted in the lumen of the vein within 15- 30 degree angle. • Middle Picture: Needle angle is too steep. Increased potential for needle to completely penetrate the vein, possibly resulting in formation of hematoma. X • Lower Picture: Needle angle is too shallow, causing bevel to rest on the wall of the vein (leading to occlusion of the bevel). Increased potential also for needle placement partially in the vein lumen and partially in tissue, again possibly resulting in formation of hematoma. X
- 12. Special Collection Procedures: BD BACTEC™ Blood Culture • Use of the BD Vacutainer® Push Button Blood Collection Set or BD Vacutainer® Safety-Lok™ winged collection set is recommended for all blood culture collection procedures. • Thorough skin preparation is essential* • The site should first be cleansed with 70% alcohol • The site should then be swabbed with 1-10% povidine-iodine solution or chlorhexidine gluconate (the latter is recommended for infants and patients with iodine sensitivity) by circular motion, starting in the middle. • The site must then be allowed to dry. The iodine / chlorhexidine can then be removed with an alcohol swab. * institutional policies and procedures must be followed • The culture bottle stopper should be disinfected following manufacturer’s instructions.
- 13. Special Collection Procedures: BD BACTEC™ Blood Culture • Adult Vials – The aerobic vial(s) is filled first – Optimum specimen volume is 8 - 10 ml (minimum 3 mL) – Note that vials do not have a ‘calibrated draw’ – If fungaemia / candida sepsis suspected, collection of two aerobic bottles may be considered* – 3 sets of bottles over the initial 12 hours is recommended (first two sets from different sites)* – Drawing from in-dwelling lines is not recommended (if testing status of line/access site, endeavor to provide second set of bottles from alternate site) * Institutional policies and procedures must be followed • Pediatric Vials – Optimum specimen volume in case of pediatric vials is 1.0 - 3.0 mL (minimum 0.5mL) • Transportation – The specimens should be forwarded to the laboratory as soon as possible. – Maximum time before entry to BD BACTEC™ instrument is 20 hrs at 37C or 48 hrs at RT
Editor's Notes
- Explain that because of easy accessibility of this site, the veins present on the arm are the most preferred site for venipuncture.
- While examining the area, some veins are easily visible while others need to be located by feel. Most prominent veins are often found in the dominant arm. While examining the site, the patient is asked to position the arm in downward position (without bending at the elbow). This will help ‘fix’ (anchor) the veins and also enlarge them due to gravity and hence help with their location. The tip of the index finger is used to palpate or feel the veins to determine their suitability or to locate the veins that can’t be seen. Palpating also helps in determining their size, depth, and direction or the path that they follow. In order to adequately palpate the vein, it is pressed and released several times. A good vein will exhibit a ‘bounce’ or resilience.
- Reasons for antecubital fossa veins not being available could be: Intravenous lines in both arms Burned or scarred areas Cast(s) on arm(s) Thrombosed veins Edematous arms Partial or radical mastectomy on one or both sides. In case the veins are not visible, one could consider wrapping a warm, wet towel around the hand for a few minutes. Warming the site increases the blood flow and helps make the veins easier to feel. Where there is uncertainty about a vein, tapping the site sharply a few times may assist. This helps dilate the vein and makes it more prominent. The wrist veins tend to move or roll aside as the needle is inserted, therefore it is critical to hold the hand such that veins are well anchored. It is preferable to use a blood collection set to perform venepuncture on wrist veins.
- The use of veins in the feet for blood specimen collection should be a last resort. Institution policies must be followed. Blood flow in extremities (such as foot) may not be representative of general circulation (particularly in patients with vascular disease – e.g diabetes) and may yield erroneous results. Further, venipuncture of veins in the lower extremities can have dangerous consequences such as thrombus formation, especially in patients with coagulopathy.
- The alteration in relative concentrations of small and large molecules (and hemoconcentration) is covered in the Pre-analytical Science Module, 6.1. This topic is also covered in ‘Samples: From the Patient to the Laboratory’ Guder, WG et al. 3rd Edition, Wiley-VCH Verlag GmBH & Co, 2003. (refer to page 19)
- The patient must not be allowed to vigorously pump (open and close) the fist since this can lead to erroneous test results (may exacerbate hemoconcentration effect and may cause release of potassium from muscle cells). Patients generally have most prominent vein in the dominant arm. A vein that feels hard and cord-like or lacks resilience should not be selected as it is likely to be thrombosed or sclerosed. These veins roll easily, are hard to penetrate and may not have adequate blood flow. If a suitable vein cannot be found in one arm, the other arm may be examined. In case a suitable vein cannot be found in either arm, the veins in the back of the hand could be examined.
- While cleaning with alcohol swab, it is recommended not to rub so hard that it abrades the skin especially in the case of infants and elderly patients. The evaporation and drying process of alcohol helps in destroying microbes. If the needle is inserted before the alcohol has completely dried, the patient may experience excessive pain since alcohol causes a burning sensation. It may also lead to specimen hemolysis.
- Most micro-organisms causing septicaemia are aerobic and for this reason the aerobic vial represents the best chance of finding a positive culture. This is why it is recommended for the aerobic vial to be drawn first (if there are any problems with drawing the required volume of blood, it is best to have the correct volume of specimen in the vial that is most likely to support the growth of the organism). Note that policies and procedures vary between healthcare facilities. Before discussing this topic with phlebotomists, BD Associates should consult with the Microbiology Department to ensure the message being delivered is consistent with local policies.
- Conduct draws using MSN, Safety Lok BCS, PBBCS (if available), FBN and Eclipse on training arm. Involve the group in a critical appraisal of the procedures (correctness of patient preparation, site selection, skin preparation, use of holder and needle, order of draw, safety shield activation, mixing, labelling)