Specimen collection cc

GENERAL CONSIDERATIONS“No Laboratory test can be better than its manner of specimen collection”PATIENT IDENTIFICATIONPATIENT PREPARATIONSPECIMEN IDENTIFICATIONCOLLECTION TECHNIQUESPECIMEN CONTAINERADDITIVES

BloodSpecimen Collection PHLEBOTOMISTWith good interpersonal skillsProfessional attitudeEnsure Patient confidentiality

MACROSAMPLEMACROSAMPLE (Venipuncture)Syringe MethodVacutainer MethodArterial PunctureRadialBrachialFemoral

MACROSAMPLEEquipment NeededTourniquetAntiseptic solutionSyringe and needleVacutainer setButterfly Infusion Set

Blood CollectionMacrosample Collection

ADVANTAGES OF VENIPUNCTUREallows repetition of tests/follow up avoids tissue juicescan be mailedFastest method from a large number of patientsDISADVANTAGES OF VENIPUNCTUREMore complications may arise

Hard to do on some patientsBlood CollectionMacrosample CollectionSITES OF COLLECTIONNB up to 18 monthsSuperior Longitudinal sinus veinExternal jugular veinTemporal vein

Blood CollectionMacrosample CollectionSITES OF COLLECTIONOlder than 18 months – 3 y/oFemoral veinLong Saphenous veinAnkle veinPopliteal veinExternal Jugular veinTemporal vein

Blood CollectionMacrosample CollectionSITES OF COLLECTIONOlder than 3 y/oVeins on the antecubitalfossaWrist veinVeins of the dorsal handVeins of the Foot

Specimen Collection by VenipucturePatient IdentificationNote Isolation RestrictionsNote Dietary RestrictionsReassure patientPosition the patientSelect venipuncturelocationAssemble Supplies

Apply the tourniquetCleanse the siteInspect needlePerform venipunctureRelease tourniquetWithdraw needle & apply pressurePost Phlebotomy ProceduresProper disposal Label specimenCheck patient

Complications of Venipucture1. Immediate Local complicationHematomaHemoconcentrationCirculatory failureSyncopeFailure of blood to enter the syringe

Complications of Venipucture2. Late Local ComplicationsThrombosisThrombophlebitis3. Delayed General ComplicationsHIVHepatitis

Reasons for Specimen RejectionHemolysis/LipemiaClots in an anticoagulated specimenNonfasting specimen when test requires fastingWrong volumeImproper transport conditionsDiscrepancies bet requisition & specimen labelUnlabeled or mislabeled specimenContaminated specimen/Leaking container

AnticoagulantsAnticoagulants inhibit clot formation. As soon as blood is removed from a vessel, activation of coagulation begins. Although blood drawn directly into an evacuated tube contacts the anticoagulant, it is necessary to immediately and gently invert the tube, mixing the content to prevent micro-formation. DEFIBRINATION

Serum PreparationTube Stoppers:

EDTA: (Na or K)K3EDTA or K2EDTATube stoppers:Commonly Used Anticoagulants

Sodium Citrate: Tube Stoppers:Commonly Used Anticoagulants

Commonly Used AnticoagulantsHeparinTube Stoppers:

Commonly Used AnticoagulantsOther Tube Stoppers:

44Specimen ProcessingSerum or plasma should be separated from cells within 2 hours of collection (unless collected in a gel separator tube).

Allow red top tubes to clot sufficiently (20-30 minutes) before centrifugation to avoid fibrin strands.45Specimen ProcessingCentrifuge 10 ± 5 minutes at 1000-1200 × g.

Keep tubes capped during centrifugation to avoid loss of CO2, change of pH, evaporation, or aerosol formation.

Lipemicspecimens can be ultracentrifugedto remove chylomicrons.46Specimen ProcessingIf analysis will be delayed more than 5 hours, serum or plasma for most tests can be capped and stored at 4°C. Some analytes should be frozen. Avoid repeated freezing and thawing.

Specimens for lactate dehydrogenase (LD) should be kept at room temperature.47Specimen ProcessingFor acid phosphate, add citrate (10 mg/mL) and freeze.

Glucose is stable in serum separator tubes for 24 hours and in sodium fluoride tubes for 24 hours at room temperature or 28 hrs at 4°C.Tests Requiring a Fasting SpecimenFasting blood sugarGlucose tolerance testTriglyceridesLipid panelGastrinInsulin

Specimens Requiring Special Handling

Open SystemComponents needed :Blood taken transfer into ...Containers of different sizesSyringes of different sizes

Closed SystemLabOPN13 Basic Components :Blood flows straight into tubes ...BD Vacutainer® Standard HolderBD Vacutainer® Multi Sampling Needle21G (Green), 22G (Black)BD Vacutainer® Evacuated Tubes

Collection System - Implication to CollectorsLabOPN1N&SVacutainer® SystemOpen SystemManual manipulation of plungerManualtransfer of specimenClosed SystemQuick & easy fill, no manipulation neededAuto & direct transfer of specimen

Material Used - CollectionN&SVacutainer® SystemDisposable needleEvacuated specimen tubeReusable holderDisposable needleNon-evacuated specimen tubeDisposable syringe

Collection System - Implication to CollectorsLabOPN1N&SVacutainer® SystemPossible spillageExposure to blood, contaminationInaccurate fill causing inaccurate blood:additive ratioSafety to patient and collector for good infection controlReduce redraw from patient - Precise vacuum preserves precise ratio

Manual StepsLabOPN1N&SVacutainer® SystemRemove needle from veinRemove cap from containerRemove needle from syringeTransfer blood into container(s)Recap container(s)Remove tube from needle holderRemove needle from veinAdditional time saving during collection is approximately 20%Risk of incomplete closure seal

Collection System- Implication to LaboratoryLabOPN1N&SVacutainer® System Hemolysis redrawMicroclots (delay in contact with additive & this is a variable factor)QNS redrawNo specific color codeLess hemolysis with full system usageSpecimen integrity is preserved - no microclotsSufficient quantity Int’l color code - easy ID

LabOPN1Evacuated System AssemblyScrew on NeedleTwistthe seal of the needle and remove the clear shield (cap) that covers the center-threaded section and back end of the needle. Insert the back end of the needle into the holder, and twist the needle tightly into the holder.CAUTION: If the seal on a needle has already been broken, the needles no longer sterile. Discard the needle in a sharps container.

Insert TubePlace the first tube into the holder and partially advance it onto the needle. Do not fully push tube onto needle at this point, because this will break the tube's vacuum. Needle sheath on the front end is removed just prior to needle insertion.Once needle is in the vein, advance tube to the end of the holder. When needle fully punctures stopper, blood should begin to flow freely into tube. Lack of blood flow at this point suggest lack of tube vacuum or error in venipuncture technique.Pay particular attention to enlarged graphic demonstrating both partial and fully inserted needle positions.

ButterflyThe illustration shows a winged infusion set (butterfly) with an attached adapter for evacuated tubes.Inserting the needle into the vein is facilitated by pressing and holding the wings together between the thumb and forefinger.A Butterfly needle is useful when drawing from small, fragile, and hard-to-locate veins.The phlebotomist should exercise caution when using the apparatus. Because the needle is separated from the holder by the tubing, needle-stick injuries occur more easily to both patient and phlebotomist during disposal of the apparatus.

TourniquetA variety of tourniquet types are available and illustrated here. Each has advantages and disadvantages.Latex is commonly used because it is stretchable, does not support bacterial growth, and can be cleaned with disinfectant.CAUTION: Alternatives to latex must be used when patient has developed an allergy to latex. Anaphylactic shock occurs if a latex tourniquet is used.

GlovesThe Occupational Safety and Health Administration mandates that gloves must be worn as protection whenever blood, body fluids, or other possibly contaminated items are handled.The gloves should be cleaned but need not be sterile. Gloves protect the phlebotomist and the patient. Fresh gloves should be worn for each patient.

Cart and TrayCarts and trays are examples of devices used to store / carry equipment. They should contain all the equipment required to properly perform phlebotomy. CartTray

AntisepticsThe venipuncture site must be thoroughly cleansed prior to puncture. Isopropylalcohol (70%) is commonly used.Alcohol wipes usually come in individually wrapped prep pads.When opened, the pad should be fully saturated with alcohol; if it is not, discard the pad and open another.Isopropylalcohol is not a disinfectant, e.g., iodine. If tubes are being drawn for blood culture, cleansing of the site must be done using a disinfectant. Follow the laboratory's standard operating procedure for blood culture draws.

GauzeClean 2" x 2" gauze pads are used to place pressure over the venipuncture site once the needle is removed.Do not use cotton. It tends to stick to the wound site.Do not remove gauze too soon. The clot that is forming may be disturbed and bleeding may restart.

BandagesUse an adhesive bandage to cover the site once bleeding has ceased.Use paper, cloth, or knitted tape over a folded gauze square for patients who are sensitive to adhesive bandages. To prepare a gauze pad, fold the gauze in half, and then in half again to form a square. Place this over the puncture site and secure in place with tape.

DisposalsDiscard contaminated needles in a designated container referred to as a "sharp container“A variety of containers are manufactured. They provide for safe removal of the needle from the holder whether an evacuated tube system or syringe is used.They must be rigid, puncture-resistant, leak-proof, disposable, and easily sealed when full.They should have a locking lid which does not permit entry into the container. They are usually red, bright orange, or yellow, and must be labeled "BIOHAZARD".

Site selection in ArmThe highlighted area shows the antecubitalfossa where the major veins used for venipuncture are located. Choose one that is bouncy or resilient, large enough to support good blood flow, and well-anchored by tissue.

Median cubital vein is the first choice because it is large, well-anchored, least painful, and least likely to bruise.Site selection in ArmCephalic vein is the second choice. It is large, but not as well anchored and is more painful when punctured than the median cubital.Basilic vein is the third choice. It is generally easy to palpate, but not well anchored. It lies near the brachial artery and the median nerve, either of which could accidentally be punctured.

Avoiding the Median NerveAvoid major nerves. Hitting a patient's nerve with a needle can cause sharp and immediate pain. The patient may also experience an involuntary reflex action, pulling the arm away from the needle. Arteries, which can be detected by a pulse, should not be used for routine blood collection. To avoid inadvertently puncturing an artery, do not select a vein that overlies or is close to an artery. As seen in the diagram, both the median nerve and the brachial artery lie close to the basilic vein. Excessive or blind probing while performing a venipuncture can lead to permanent injury of the nerve or artery that may result in legal action.

Site selection in HandHand or wrist veins may be used when antecubitalfossa veins are unsuitable or unavailable.Phlebotomist must use extra care to anchor them. These veins have a narrow diameter, it may be necessary to use a small gauge needle and small volume evacuated tubes.Use of a butterfly apparatus may enhance success and make the procedure less painful.

Site selection in FootThe last resort for blood collection is from the foot veins after the arm veins have been determine unsuitable. Always check with the hospital policy before this type of sampling is carried out.

Inappropriate Sites for VenipunctureArms on side of MastectomyEdematous areasHematomasArm in which blood is being transfusedScarred areasArms with cannulas, fistulas or vascular graftsArm above IV lines

Assemble EquipmentPrior to initiating venipuncture, gather all equipment needed. Place the necessary evacuated tubes in the proper sequence for specimen collection. A sharps container should be easily accessible for immediate needle disposal following completion of the venipuncture.

Wash Hands The most important means of preventing and controlling the spread of infection is proper hand washing:Remove watch and ringsWithout touching the sink, wet hands under warm, running water. Apply soap and work up a lather, rubbing hands together to create friction for at least 15 seconds.Rinse hands in a downward motion from wrists to fingertips.Repeat steps 2 and 3.Dry hands with a clean paper towelTurn the faucet off with another clean paper towel.

Apply GlovesOSHA regulations require the wearing of gloves during phlebotomy procedures. A new pair of gloves must be worn for each patient. When donning gloves, pull them over the cuff of protective clothing.

Position PatientA patient should be either seated or lying down while having blood drawn.The patient's arm should be firmly supported and extended downward in a straight line from the shoulder to the wrist. Ensure patient's hand is closed, which makes the veins more prominent. Do not ask the patient to pump his / her hand.

Correct arm positioning:Allows gravity to help veins enlarge.Helps assure the specimen collection tubes fill from the bottom up to prevent reflux and additive carryover between sample tubes.

Tie TourniquetPosition tourniquet under the arm 3-4 inches above the intended venipuncture site, with each hand grasping one side of the tourniquet.Apply and maintain tension. Without rolling or twisting the tourniquet, bring the two sides together.Cross one side over the other and securely tuck a portion of the upper side under the lower side.Note 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 the interfering with the site of needle entry.The flaps should be positioned so they can easily be grasped with one hand. Gently pulling on the flaps releases the tourniquet.

Apply TourniquetApply tourniquet to increase pressure in the veins and aid in vein selection. 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 veins enlarge, making them easier to palpate and penetrate with a needle.Ideally, never leave a tourniquet on the patient longer than one minute. Tourniquets left on longer may alter test results.Do not apply a tourniquet over an open sore.Do not apply a tourniquet to the arm on the side of a recent mastectomy.

Select SiteVenipuncture is most commonly performed in the anticubitalfossa area of the arm where the median cubital, cephalic, and basilic veins lie fairly close to the surface.Use the tip of the index finger to palpate (examine by feel) the vein. This helps determine the size, depth, and direction of the vein. Select vein that is easily palpated, large enough to support good blood flow, and well-anchored or fixed by surrounding tissue.

Cleanse siteClean venipuncture site with antiseptic to help prevent microbial contamination to the specimen and patient. Start at the center of the site and move outward in ever widening, concentric circles. Failure to follow this procedure may re-introduce dirt and bacteria.Use sufficient pressure to remove surface dirt and debris. Repeat the process with a fresh alcohol prep pad if the site's is still dirty.Let the site air dry (30 - 60 seconds) prior to beginning the venipuncture. Do not wipe, blow on, or fan the site, as these actions may re-introduce contaminations. For blood culture draws, refer to the laboratory's standard operating procedure for instructions.

Insertion AngleInsert the needle at a 15-30 degree angle when penetrating the skin and the vein.

Insertion AngleAbove picture: Bevel of the needle is fully inserted within the lumen of the vein within 15-30 degree angle.Middle picture: Needle angle is too steep. If needle advances further into the vein, it may penetrate completely through the vein to tissue.Lower picture: Needle angle is too shallow, causing bevel to rest on the wall of the vein. Needle may be partially in the lumen and partially in tissue, resulting in hematoma formation. Insert needle at a 15-30 degree angle when penetrating the skin and the vein.

Insert NeedleGrasp patient's arm with thumb on top and fingers wrapped to the back. Pull skin taut below the intended venipuncture site with thumb, anchoring vein to keep it from moving or rolling.Using a smooth motion, quickly insert the needle, bevel up. Stop needle advancement when a slight decrease in resistance is felt, signaling entry into the vein. Advance tube onto needle to the end of holder Use thumb to push tube while index and middle fingers grasp flanges of tube holder. Blood should begin to flow into tube.Release tourniquet as soon as possible, depending upon blood flow. Ideally, do not leave tourniquet on for more than one minute.

Fill TubeMaintaintube in a downward position so that blood and any tube additive it contains does not touch the needle.Fill tube until vacuum is exhausted and blood flow stops. Remove tubes from holder by applying pressure against flanges of tube holder with thumb and index finger while using a slight twist to remove the tube. Hold needle steady as tubes are removed and inserted.If tube contains an additive, invert it gently several times after removal to mix the blood and additive. Additional mixing can be performed while other tubes are filling.

Remove NeedleRelease tourniquet prior to removing needle. Ensure patient's hand is openAfter the last tube is removed from holder, hold a clean gauze pad in position over the entry site. Gently and quickly remove needle from the arm.It is necessary to apply pressure to the site to prevent leakage of blood and possible hematoma formation.As soon as needle is fully withdrawn, but not before, apply pressure firmly to the puncture site using a gauze pad. If the patient is alert, ask him / her to continue to apply pressure until bleeding has stopped.Keep arm extended and preferably raised; arm should not be bent as this increases the risk of hematoma formation.

Dispose NeedleDiscard contaminated needles in a container referred to as a "sharp container"Never cut, bend, break, or recap needles.A variety of containers are manufactured. They provide safe removal of the needle from holder when using an evacuated tube system. Place needle in the proper slot in the lid, and turn it clockwise until it unscrews from the holder.Do not attempt to remove needle with your fingers. If needle doe not separate from the holder, throw the entire unit away in a sharps container.Proper Needle DisposalImproper Needle Disposal

Label TubeAlways verify information on tube labels. All identifiers on the labels must be accurate.Label tubes after they are drawn, while the patient is still present, to reduce the risk of specimen misidentification. If additional information must be added to the label (e.g., fasting, time to draw), write with ink, never pencil.Never:Label tubes prior to venipunctureLeave an inpatient room before labeling the tubesDismiss an outpatient before labeling is completed.

Transport TubeWhen transporting tubes through public hallways, place them in a secondary container to minimize the risk of leakage and spillage.The secondary container must be clearly labeled "BIOHAZARD.“Once the tubes are in the container, seal it before transport.Securely attach paper requisition(s) to the secondary transport container.

Blood taken and transferred toSyringes of different sizesContainers of different sizesBlood collection: Open System

HolderEvacuated tubeNeedleBlood collection: Closed System

Blood collection: Closed SystemHow it works

Transparent Needle HubBD Vacutainer FLASHBACK NEEDLE

Black- G22x1”Green- G21x1”BD Vacutainer FLASHBACK NEEDLE

BD Vacutainer FLASHBACK NEEDLE

Do not eat or drink in the area of blood collection,transportation or specimen processing and analysisDo not apply cosmetics anytime during blood collection,transportation or processing and analysisWash hands before and after eating, drinking and before and after using the restrooms

No long necklaces, large and or dangling earrings or loose bracelets during any type of blood collection, transportation or processing and analysis Remove laboratory coat or smock used during blood collection or other patient care activities before going to an area where coffee breaks or meals are taken

Wear gloves for all blood collection and every skin punctureWash hands before and after putting on glovesUse a new, clean pair of gloves for each procedure – use non-latex glovesWear a laboratory coat, a gown or a smock during blood collection. Remove garment and leave it at the facility for appropriate cleaning and disinfecting

Wear eye and face protectors if blood and body fluid splashing is anticipatedFollow procedure for disposing of blood collection itemsDecontamination of tourniquets and trays after use is highly recommended

Never recap a needle by handUse safety lancets with self –retracting bladeDisposed of sharps, needles, blades and others in a puncture resistant container

for safer blood collection and reliable test results.

Blood CollectionMacrosample CollectionPROCEDURAL STEPS

Introduction to PatientGreet PatientIntroducing yourself by nameDescribe the procedure to be performed, providing reassurance to the patient.

Patient IdentificationAsk an outpatient to state his/her full name, spell the last name, and state his/her date of birth. Verify the requisition (order) and samples labels, if applicable, have the same identifiers.

Patient IdentificationCheck inpatient's identification band to verify the name and hospital identification number match the order. If the patient is not wearing an identification band, DO NOT perform the venipuncture.Correct identification of patient is critical. Blood test results collected from a mis-identified patient will be linked to the wrong patient, and may put the health of two patients at risk.

Position PatientSeated or lying The patient's arm should be firmly supported and extended downward in a straight line from the shoulder to the wrist. Ensure patient's hand is closed, which makes the veins more prominent.

Tie Tourniquet3-4 inches above the intended venipuncture site, Apply and maintain tension. Without rolling or twisting the tourniquet, bring the two sides together.Cross one side over the other and securely tuck a portion of the upper side under the lower side.The loop should be below the tourniquet band and the free ends (flaps) of the tourniquet are pointing away from the venipuncture site. The flaps should be positioned so they can easily be grasped with one hand.

Site Selection Cubital veinCephalic veinBasilic veinAvoid major nerves (can cause sharp and immediate pain; involuntary reflex action) Avoid arteries which can be detected by a pulse.Do not select a vein that overlies or is close to an artery. Avoid excessive or blind probing while performing a venipuncture

Cleanse siteClean venipuncture site with antiseptic Let the site air dry (30 - 60 seconds) prior to beginning the venipuncture. Do not wipe, blow on, or fan

Dispose NeedleProper Needle DisposalImproper Needle Disposal

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