CAPILLARY PUNCTURE

I. Introduction

Capillary puncture also called dermal puncture is one of the blood collection techniques wherein
the blood specimen is obtained by puncturing the capillary bed of the skin with a lancet or other sharp
device. It is useful in pediatrics where removal of larger quantities of blood can have serious
consequences. Performed in the laboratory due to the advancing techniques in specimen collection such
as POCT and microsampling.

Although venipuncture is the most frequently performed phlebotomy procedure, it is not

appropriate in all circumstances. Advances in laboratory instrumentation and the popularity of point-of-
care testing make it possible to perform a majority of laboratory tests on microsamples of blood obtained
by dermal puncture on both pediatric and adult patients. In most institutions, dermal (capillary or skin)
puncture is the method of choice for collecting blood from infants and children younger than 2 and in
adults with special cases.

Dermal Puncture Equipment

Lancets
-are sterile, disposable, sharp instruments that punctures the skin by means of inserting
either a needle of a blade vertically into the tissue. The length of the needle must be
1.75mm and the depth of incision should not be larger than 2.0 mm for infants & children
(to avoid contact with the bone) and not larger than 2.5 mm for adults.
Capillary tubes
-are small tubes used to collect approximately 50 to 75 μL of blood for the primary
purpose of performing a microhematocrit test. The tubes can be heparinized (for
collecting directly from capillary puncture) or nonheparinized/plain (used in filling with
blood from EDTA tube).
Microcollection tubes
-can be plastic collection tubes such as the microtainer which provide a larger collection
volume and present no danger from broken glass. Usually, they have a variety of
anticoagulants and additives, including separator gel, and have a color-coded stoppers
that corresponds to color-coding of ETS.

II. Specimen Collection

A. Sites for capillary puncture

o Use the medial and lateral areas of the plantar surface of the heel.
o Use the central fleshy area of the third or fourth finger.
o Do not use the back of the heel.
o Do not use the arch of the foot.
o Do not puncture through old sites.
o Do not use areas with visible damage.
o Do not use fingers on newborns or children younger than 1 year.
o Do not use swollen sites.
o Do not use earlobes.
o Do not use fingers on the side of a mastectomy.
 B. Capillary Puncture Procedure

1. Patient identification and preparation

2. Appropriate incision device selection and puncture site
3. Warming of puncture site
4. Proper disinfection of the puncture site
5. Wipe away the first drop of blood
6. Avoid milking, scooping, or scraping of the puncture site
7. Collect specimen quickly (less than 2 minutes)
8. Fill the correct volume of collection containers
9. Proper mixing
10. Properly label specimen

C. Order of Draw

SINGLE COLLECTION FOR CBC

1. Blood smears
2. EDTA microtainer

MULTIPLE COLLECTION
1. Capillary blood gas
2. Blood Smear
3. EDTA microtainer
4. Other anticoagulant microtainers
5. Serum microtainers

III. Contraindications of Capillary Puncture

Areas selected for dermal puncture should not be callused, scarred, bruised, edematous, cold or
cyanotic, or infected. Punctures should never be made through previous puncture sites because this
practice can easily introduce microorganisms into the puncture and allow them to reach the bone. Do not
collect blood from the fingers on the side of a mastectomy without a health-care provider’s order.

IV. Advantages and Disadvantage of Capillary Puncture

A.
Advantages of capillary puncture in children

- The collection of blood is easier and simpler.

- Will not have a hard time in finding a vein, compared to venipuncture.
- There are certain tests that requires capillary specimen (e.g. newborn screening)
- Small amount of blood is needed.

Disadvantages of capillary puncture in children

- Risk of bone injury and possible infection (osteomyelitis).
- Problems with bleeding and infection can occur.
- Capillary blood collection can sometimes rupture the blood cells, producing
results that are inaccurate.
 B.
Advantages of capillary puncture in adults

- The vein will not be hard to find

- Only a small amount of blood is needed
- Collection can be changed so that the risk of scarring and pain is lessened

Disadvantages of capillary puncture in adults

- Overuse of the same area for collection can cause scarring.

- Problems with bleeding and infection can occur.
- Not all tests are applicable in capillary samples.
- Capillary blood collection can sometimes rupture the blood cells, producing
results that are inaccurate.

V. Blood Smear Preparation

A. Procedures

• Place the second drop of blood in the center of glass slide near the frosted edge. The drop
should be 1-2 mm in diameter.
• Place the spreader slide with a clean smooth edge in front of the blood at 30-40 degree angle
inclined over the blood.
• Slide the back of the spreader to the edge of the drop of blood allowing the blood to spread
across the end.
• Lightly push the spreader maintaining the angle and not applying pressure on the spreader
• Terminate at around 0.5 mm inch before the edge of the slide.
• Label by writing the patient’s information on the
frosted area using a pencil.

B. Qualities of Good Smear

1. The film is two thirds to three fourths the length of the slide.
2. The film is finger shaped, very slightly rounded at the feather edge, not bullet shaped
3. The lateral edges of the film are visible
4. The film is smooth without irregularities, holes or streaks
5. The film progresses from being thick at the point of origin to thin with a uniform edge at the
termination point
6. Should have a lightly feathered edge without streaks.

C. Disadvantages of Errors on Blood Smear

Incorrect application of the angle, speed, amount of blood and pressure in the blood smear can
lead to these discrepancies; (1) Uneven distribution of blood (ridges); (2) Holes in the smear; (3) No
feathered edge; (4) Streaks in the feathered edge & (5) Smear too thick and short making the blood smear
undesirable.

Thus, taking a good blood smear must have a gradual shift from a thick film to a thin film, can
occupy 2/3 of the slide, it should not touch any of the edges of the slide and there should be no holes.
VI. Special Dermal Puncture

A. Newborn Screening

- Is the testing of newborn babies for genetic, metabolic, hormonal, and functional
disorders that can cause physical disabilities, mental retardation, or death. It is
usually tested within 7 days of age of the newborn baby and collected after 24
hours of life but not later than 3 days from delivery.

B. Newborn Bilirubin

- Is one of the most frequently performed tests on newborns that measures

bilirubin levels and samples for this determination are often collected at timed
intervals. This test is typical in newborn for monitoring of hemolytic disease of
the newborn (HDN).

C. Capillary Blood Gas

- Arterial blood is the preferred sample for blood gases (oxygen and carbon
dioxide content) and pH level on adults. However, since deep arterial punctures
in newborns and young children is usually not recommended blood gases are
performed on capillary blood.

D. Malarial Smear

- It is performed for malaria parasite quantification. The parasites (Plasmodium

species) that can cause malaria invade the RBCs, and their presence is detected
by microscopic examination of thick (for presence or absence of malarial
parasite) and thin (for identification of specific malarial parasite) blood smears.