Best Practices in phlebotomy And How to perform a Venipuncture

Introduction

Phlebotomy is procedure in which a needle is used to take blood from a vein, normally for laboratory investigations. Also, phlebotomy can be done to remove extra red blood cells from the blood, to treat certain haematological conditions. The procedure is called blood draw or venipuncture.

The term phlebotomy refers to the drawing of blood for laboratory examination.

Phlebotomy Origins: The word “phlebotomy” (and most medical terminology) is derived from the Greek language.

Pleb: A prefix meaning veins or blood vessels
tomy: A suffix meaning to cut or make an incision

The most common methods of today for blood collecting are:

Venipuncture: withdrawing venous blood sample using a needle.
Skin puncture: puncturing the skin (usually on a finger or heel) for a small amount of capillary blood (*Skin punctures are also referred to as dermal sticks, capillary draws,finger sticks, and heel sticks.)

Considerations In Phlebotomy

1. Identify the client:

All patients must be positively identified before the specimen collection is performed. checking the hospital medical card, appointment slip or Saudi ID and the laboratory request form, ask the patient to state his/ her full name or if not possible, the relative of the patient.

2. Hand with cannula

Do not draw blood from arm with a running IV fluid , use different vein (if possible) because it effects on ↑Glucose ,electrolytes (depending on IV)3. Sclerosed Veins, Edema, Scars, Burns, Haematoma.

Do not draw blood from areas that have scarring, a healed burn and bruised, because it’s difficult to detect the vein. You have to Select another site.

4. Consent

Try to persuade. If unsuccessful, notify nurse. Never draw without consent may lead to charges of assault.

Special Test Requirements

1 Fasting

Find out from the patient before undergoing a specific laboratory test such as fasting, Nothing to eat or drink (except water) for at least 8 hrs. there are some test affected by fasting such as Fasting blood sugar, triglycerides, lipid panel, gastrin, insulin

2. Chilling

Place in slurry of crushed ice & water. Don’t use ice cubes alone because RBCs may lyse. chilling is important for these test :ACTH, acetone, ammonia, gastrin, glucagon, lactic acid, pyruvate, PTH, renin.

3. Warming

Use 37C heat block, heel warmer, or hold in hand. the Cold agglutinins and Cryoglobulins are needed to warming before the tests

4. Protection from light

You should wrap the tube by aluminum foil and protected from light , because that’s effects on : Bilirubin, carotene, erythrocyte protoporphyrin, vitamin A, vitamin B12 Tests.

5. Lock Box

Any test used as evidence in legal proceedings; e.g. blood alcohol, drug screens, DNA analysis, Lock box may be required also highly infectious samples , Histopathology samples and Body Fluids .

Phlebotomy Sources of Errors

1. Drawing at incorrect time

Treatment errors happen if samples for certain tests aren’t drawn at appropriate time, e.g., therapeutic drug monitoring, analytes that exhibit diurnal variation, analytes. In AM: ACTH, Cortisol, Iron In PM: Growth Hormone, PTH, TSH

2. Improper skin disinfection

Infection at site of puncture. Contamination of blood cultures & blood components. Isopropyl alcohol wipes can contaminate samples for blood alcohol.

3. Fist pumping during venipuncture

Avoid drawing blood while fist pumping because that’s effects on ↑ K+, lactic acid, Ca2+, phosphorus; ↓ pH

4- Tourniquet for more than 1 min

Never leave the tourniquet longer than 1 minute because this effects ↑ K+, total protein, lactic acid

5. Expired collection tubes

Avoid collection sample in an expired tubes because that effects ↓ vacuum, failure to obtain specimen

6. Incorrect anticoagulant or contamination from incorrect order of draw

K2EDTA before serum or heparin tube , that’s effects on ↓ Ca2+, Mg2+, ↑ K+ Contamination of citrate tube with clot activator: erroneous coagulation results.

7. Short draws

Incorrect blood volume: anticoagulant ratio affects some results, e.g., coag tests.

8. Inadequate mixing of anticoagulant tube

Micro-clots, fibrin, platelet clumping can lead to erroneous results.

Step-by-step procedure for Venipuncture

(a) Preparation: locate and organize the puncture site

Inspect the area to identify a suitable site for puncture: use a tourniquet, and instruct the patient to make a fist, and palpate using the index finger to identify a large-diameter vein that is non rolling and has the best turgor.
In order to distend and locate veins, feel a a good site with the fingertips. It can help allow the arm to hang down, increasing venous pressure. Utilize a vein-viewer device if a suitable vein is not seen properly
After locating a suitable site, remove the tourniquet.
Apply anesthetic if it is being used and allow adequate time for it to take effect (e.g. 1 to 2 minutes for gas injector, 30 minutes for topical).
Disinfect the puncture site with a disinfectant, starting at the needle-insertion site and performing several outwardly expanding circles.
Allow for the antiseptic solution to dry completely.

NB: If the blood sample is being collected for blood cultures, vigorously cleanse the site with alcohol for at least 30 seconds, wait for the alcohol to dry, and then swab in outwardly expanding, overlapping circles using chlorhexidine or povidone-iodine. allow for the antiseptic effect to occur (atleast 1 minute for chlorhexidine or 1.5 to 2 minutes for iodine). remove off povidone-iodine using alcohol and allow the alcohol to dry.

(b)Collect the sample:

Get the vein properly and collect the blood sample with atmost 30 seconds after tourniquet placement. Do not leave the tourniquet on for more 60 seconds.

Put the tourniquet proximal to the located insertion site. Do not let patients make a fist or let their arm hang down in the process of drawing blood because these maneuvers can lead to various erroneous laboratory values (like, increased potassium, lactate, phosphate).
Examine with gloved finger to identify the middle of the target vein.
Put a gentle traction to the vein distally with the thumb of the nondominant hand to avoid the vein from rolling. Traction might not be necessary for larger veins of the forearm or antecubital fossa.
Ask the client that the needlestick is about to take place.
Get enter the needle proximally (i.e. in the direction of venous blood flow), with the bevel facing up, along the midline of the vein at a shallow angle (10 to 30 degrees) to the skin.
Blood will show up in the needle hub (blood flash ) when the needle tip enters the lumen of the vein. At this point, stop pushing the needle further, lower the needle to better align it with the vein, and advance it into the vein an additional 1 to 4 mm, to ensure that it remains in position during blood collection.
Incase there is no flash in the hub after 1 to 2 cm of insertion, removal the needle slowly. If the needle had initially gone completely through the vein, a flash may now show up, withdraw the needle tip back into the lumen. If a flash still does not appear, withdraw the needle almost to the skin surface, change direction, and try again to advance the needle into the vein.
Incase a local swelling comes up, blood is extravasating. stop the procedure, remove the tourniquet and the needle and apply pressure to the puncture site with a gauze pad (a minute or 2 is usually enough unless the patient has a coagulation problem).
Do not move the needle while in the vein.
Start to withdraw the blood sample and, when blood begins to flow, remove the tourniquet.
If you’re using vacuum tubes, push each tube fully into the tube holder, be careful not to dislodge the needle from the vein.
Fill multiple collection tubes in the proper sequence.
When you have finished removing a tube from the holder, gently invert the tube 6 to 8 times to mix the contents;
Do not shake the tubes

If using a syringe,

Pull back on the plunger gently to avoid damaging the blood cells or collapsing the vein.
If blood collection is now complete, gently apply and hold a folded gauze square or cotton at the venipuncture site with the nondominant hand, and in one motion remove the needle and immediately apply pressure to the site with the gauze.
Remove the tourniquet if you did not do so earlier.
Tell the patient or an assistant to continue to applying the pressure to the site.
If you used a syringe for sample collection, transfer samples to collection tubes and bottles; it is done either by inserting the needle directly into the tops of the vacuum tubes, or remove the needle and attach a vacuum tube holder to the syringe.
Caution, Do not inject blood into vacuum collection tubes as this will cause haemolysis;
Let the vacuum to draw the blood into the tube.
When blood has been added to a tube, gently invert the tube 6 to 8 times to mix the contents;
Do not shake the tubes.
Use s safety cover over the exposed needle.
Discard used blood-collection devices (with needles) into a sharps container.
Never recap non-safety needles prior to disposal unless a sharps container is not immediately available.
Apply gauze and tape or a bandage to the site
When multiple blood tests are to be done, blood should be allocated to the collection tubes in a proper sequence; first cultures, then tubes with anticoagulant, and then others.

NB:

The rubber tops of blood-culture bottles should be properly disinfected before introducing the blood sample (e.g., by scrubbing each top with separate 70% alcohol wipes for 30 seconds and leaving it to dry)

Safe work practices

Observe universal (standard) safety precautions. Observe all applicable isolation procedures. PPE’s will be worn at all time.
Wash hands in warm, running water with the chlorhexidine gluconate hand washing product (approved by the Infection Control Committee), or if not visibly contaminated with a commercial foaming hand wash product before and after each patient collection.
Gloves are to be worn during all phlebotomies, and changed between patient collections.
Palpation of phlebotomy site may be performed without gloves providing the skin is not broken.
A lab coat or gown must be worn during blood collection procedures.
Needles and hubs are single use and are disposed of in an appropriate ‘sharps’ container as one unit. Needles are never recapped, removed, broken, or bent after phlebotomy procedure.
Gloves are to be discarded in the appropriate container immediately after the phlebotomy procedure. All other items used for the procedure must be disposed of according to proper bio-hazardous waste disposal policy.
Contaminated surfaces must be cleaned with freshly prepared 10% bleach solution. All surfaces are cleaned daily with bleach.
In the case of an accidental needle stick, immediately wash the area with an antibacterial soap, express blood from the wound, and contact your supervisor.

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