CHEM123 | LAB – FINALS Jazmin Madriaga OUR LADY OF FATIMA UNIVERSITY

AN INTRODUCTION TO PHLEBOTOMY PRE-ANALYTICAL CONSIDERATIONS

 Introduction 1. Reference Range/ Reference Interval
 Pre-Analytical Considerations o Range of values with high and low limits
 Physiological Variables o Used for comparison of patient results
 Blood Collection Equipment and Supplies (compared from using samples from healthy
 Veins used in Phlebotomy individuals)
 Blood Collection Additives 2. Basal State
 Venipuncture Techniques o Refers to the resting metabolic state of the body
 Steps in Venipuncture EARLY IN THE MORING after fasting hours
o Ideal for establishing reference ranges on
INTRODUCTION inpatients because the effects of diet, exercise,
 Phlebotomy and others are controllable
- The process of collecting blood through the vein by
using incision or puncture methods to draw blood for PHYSIOLOGICAL VARIABLES
analysis or as part of therapeutic or diagnostic  AGE
measures under the physician’s request. o RBC and WBC values higher in newborns then
- The word is derived from two Greek words: phlebos adults
and temnein. o Decreased kidney function in creatinine
 Main Goals of the Phlebotomy Practice are: clearance, urea clearance
- For diagnosis and treatment using blood samples
- For transfusion, to remove blood from the donor.  ALTITUDE
o RBC counts: Decreased oxygen levels at higher
- For removal of blood for polycythemia or therapeutic
altitudes cause the body to produce more RBCs
purposes.
to meet the body’s oxygen requirements
ROLE OF PHLEBOTOMISTS
Tradition Duties  DEHYDRATION
- Correct identification and preparation of the patient o Vomiting and diarrhea: decreases plasma
before sample collection volume (hypovolemia; causes
- Collection of the appropriate amount of blood by hemoconcentration)
venipuncture or by dermal puncture for their specific tests
- Correct labelling of all sample requirements  DIET
- Appropriate transportation of the specimen o High protein diets: increased ammonia, urea,
- Effective interaction with patient and hospital personnel uric acid
- Observation of safety regulations o Caffeine: increased cortisol and ACTH
(adrenocorticotropic hormone)
Professional and Personal Characteristics
- Dependable, cooperative, committed  DIURNAL/ CIRCADIAN RHYTHYMS
- Compassionate, courteous, respectful o Increased in the morning: ACTH, Cortisol,
- Honestly, integrity. Competence Aldosterone, Iron
- Organize, responsible, flexible o Increased in the afternoon: PTH, TSH, ACP,
Growth Hormone
Traits that Form the Professional Image
- Credentials  DRUG THERAPY
o Certification o Opiates (morphine): increased liver and
o License pancreatic enzymes
o Continuing education o Oral contraceptives: increased ESR, decreased
- Patient-Client Professionalism B12 (cyanocobalamin)
- Qualities of Professionalism
o Professional appearance should be maintained  EXERCISE
o Phlebotomists must have self-confidence o Decreased: arterial pH, pCO2
o They must be persons of integrity, exhibiting o Increased: Glucose, creatinine, insulin, lactic acid,
honesty and consistency in their actions, values, and total protein, potassium
and beliefs
o Healthcare professionals must show compassion,  FEVER
sensitivity, and calm o Hormones: fever induced hypoglycemia-
increased insulin, glucagon, cortisol
Basic Concepts of communication in the Healthcare Setting
- Verbal Communication  GENDER
- Non-Verbal Communication o RBC, Hgb, Hct: higher in males than females
- Active Listening
CHEM123 | LAB – FINALS Jazmin Madriaga OUR LADY OF FATIMA UNIVERSITY
 IM INJECTION
o Increased muscle enzymes: CK, LDH  Antiseptics
o Blood must be collected prior to injection or 1 o Are substances used to prevent sepsis or inhibit
hour after the growth and development of microorganisms
but do not necessarily kill them
 JAUNDICE o 70% isopropyl alcohol/ isopropanol (most
o Can interfere with chemistry tests based on color common antiseptic)
reactions, including reagent-strip analyses on
urine  Gauze Pad
o A loosely woven cotton fabric that is applied
 POSITION with pressure to the arm immediately upon
o From supine (lying down on the back) withdrawal of the needle following venipuncture
sitting/standing position:
o Decrease plasma volume in an adult up to 10%  Adhesive Bandage
o Placed over the puncture site to stop the
 SMOKING bleeding and patients should be advised to hold
o Patients who smoke prior to specimen collection: the arm straight, apply pressure for 3 to 5
o Increased: cholesterol, cortisol, glucose, GH, TAG, minutes, and remove the bandage in 15 to 20
WBC counts minutes

 STRESS  Needles
o Increased: transient (short-lived) elevations in o Must be sterile, disposable, and designed for
WBC, ACTH, catecholamines, cortisol single use only
o Needles vary in length and diameter/ gauge
 TEMPERATURE
o Interstitial fluid to moves into the blood vessels,
increasing plasma volume and influencing its
composition

 HUMIDITY
o High humidity can cause hemodilution when the
body sweats in an attempt to cool down

GENERAL BLOOD COLLECTION EQUIPMENTS AND SUPPLIES

 Blood Drawing Station
o Dedicated are of a medical laboratory or clinic
equipped for performing phlebotomy
procedures on patients, primarily outpatients
sent by their physicians for laboratory testing

 Phlebotomy Chair
o Should be comfortable for the patient and have
adjustable armrests to achieve proper
positioning of either arm have adjustable
armrests that lock in place to prevent the patient
from falling should fainting occur

 Gloves
o Are available in a variety of materials and in
many sizes and styles
o Types: Latex (powdered or non-powdered),
nitrile, neoprene, polyethylene  Tube Holders/ Barrel/ Adapter
o Used in ETS (Evacuated Tube System); together
 Tourniquet with a multi-sample needle
o A device that is applied or tied around a patient’s o Clear, plastic, disposable cylinder with a small
arm prior to venipuncture to restrict blood flow; threaded opening at one end where the needle
causes venous filling and stretches vein walls is screwed into it and a large opening at the
making the vein more prominent other end
o Types: latex, nitrile, vinyl (strap tourniquet)
CHEM123 | LAB – FINALS Jazmin Madriaga OUR LADY OF FATIMA UNIVERSITY
 Cephalic Vein
- Located in the lateral aspect (outer side) of the
antecubital area; second choice
- Often harder to palpate than medical cubital vein
- Fairly well anchored
- Often the only vein felt in obese patients

 Evacuated Tubes
o Are used with both ETS and the syringe method
of obtaining blood specimens
 Basilic Vein
o Either glass or plastic
- Located on the medial aspect of the antecubital area;
o Comes in varieties of sizes and colors depending
last choice
on the additive present and type of test
- Not well anchored and rolls easily
VEINS USED IN PHLEBOTOMY - Increased risk of puncturing a median cutaneous
 Antecubital Fossa nerve branch or the brachial artery
- Antecubital (means front of the elbow), fossa –
means a shallow depression
- The shallow depression in the arm that is anterior to
(in front of) and below the bend of the elbow

 Great Saphenous Vein

 Median Cubital Vein
- Located near the center of the antecubital fossa
- Preferred vein because it is typically, close to the
surface, and the most stationary
- Easiest and least painful to puncture and least likely
to bruise
- A large and superficial vein that is easy to access and
visualize
- Located near the femoral artery and nerve, so there is
a risk of damaging these structures during
venipuncture
CHEM123 | LAB – FINALS Jazmin Madriaga
 Femoral Vein
- Large and deep artery, there is a high risk of serious
complications if it is punctured improperly
- Located near to numbness and weakness in the leg
 Jugular Vein
- Not a recommended site for blood collection and can
lead to severe bleeding, which can be difficult to
control
- Near the carotid artery and nerve, damage may lead
to stroke and other serious complications
OUR LADY OF FATIMA UNIVERSITY
 Citrate
- Inhibits clotting by chelating or binding calcium
Sodium Citrate:
 3.2% Buffered sodium citrate (light blue top)
coagulation studies (PT and APTT)
 3.8% Buffered sodium citrate (black top tube)
original ESR (original Westergren)
- Concentration: 3.2-3.8 g/dL blood
Important Note:
- Underfilled tubes: prolonged PT and APTT
(inadequate blood sample)
- Require immediate mixing after collection to prevent
activation of the coagulation process

PARAMETERS Light Blue top Black top

tube tube
Concentration 3.2% 3.8%
Molarity 0.109 M 0.129 M
INAPROPPRIATE SITES FOR VENIPUNCTRUE Blood to AC Ratio 9:1 4:1
 Arms on side of mastectomy
 Edematous areas  Heparin
 Hematomas - Both an in vivo (naturally occurring) and in vitro
 Scarred areas anticoagulant
 Burns - Acts as a co-factor of: anti-thrombin III, Released by
 Tattoos basophils and mast cells (in-vivo)
 Damaged veins (e.g. thrombosed, non-elastic veins) - Inhibits clotting by preventing activation of thrombin
 Sites ‘downstream’ (proximal) from an IV line - Concentration: 0.2 mg/mL of blood or 15-20 U/mL of
blood
BLOOD COLLECTION ADDITIVES
 EDTA (Ethylenediaminetetraacetic acid) Important Note:
- Inhibits clotting by chelating or binding calcium - Cannot be used in preparation of blood smears (WBC
and platelet clumping)
(calcium salts)

TYPES:
 Di Potassium EDTA (K2): CLSI recommended
EDTA; less cell-shrinkage and dilution of sample
(Spray-dried)
 Di Sodium EDTA (Na2): spray-dried
 Tri Potassium EDTA (K3): liquid form
- Concentration: 1.5 mg/mL of whole blood

Important Note:
- MOST commonly used AC in the hematology section;
preserve cellular morphology and prevents platelet
aggregation (for complete blood count)
- Excess EDTA: causes shrinkage; causes platelet
satellitosis
 Oxalates
- Inhibit clotting by precipitating calcium (formation of
calcium oxalates)
- Most common is potassium oxalate – added to tube
with sodium fluoride (gray top tube)
Important Note:
- Oxalates distorts cellular morphology, RBC’s become
crenated
 Sodium Fluoride
- Substance that prevents glycolysis
- Most common is sodium fluoride - may use in
combination with potassium oxalate (gray top tube)
- If glycolysis is not prevented:
 Room Temp: 7 mg/dL per hr
CHEM123 | LAB – FINALS Jazmin Madriaga OUR LADY OF FATIMA UNIVERSITY
 4C: 2 mg/dL per hr

 Clot Activators
- A substance that enhances coagulation in tubes used
to collect serum specimens
- Enhances platelet activation
Examples:
 Silica particles
 Serum separator tubes (SST); blood clots
within 15-30 mins
 Thrombin: 5 mins
 Cellite, ellagic acid, diatomite, kaolin

 Thixotropic Gel (Gold top)

- An inert (non-reacting) nonsynthetic substance
initially contained in or near the bottom pf certain
blood collection tubes
- Moves between the cells and the serum or plasma
after centrifugation
- Found in serum separator tube (SST)

- Used for chemistry and serology

 SPS Tube (Sodium Polyanethol Sulfonate)

- Used for blood culture
- Inhibits phagocytosis
- Neutralize bactericidal effect of serum
- SPS in non-toxic to humans and does not interfere
with the growth of most clinically important
microorganisms
- Yellow top tube
CHEM123 | LAB – FINALS Jazmin Madriaga OUR LADY OF FATIMA UNIVERSITY

STEPS IN VENIPUNCTURE
1. Review and Accession the Test Request
2. Approach, Identify, and Prepare the Patient
3. Verify the Patient’s Diet Restrictions and Latex Sensitivity
4. Sanitize hand, position the Patient, Apply the Tourniquet,
and make a fist
5. Select vein, Release Tourniquet, and Ask patient to open
fist
6. Clean and Air-Dry the site
VENIPUNCTURE TECHNIQUES 7. Prepare the Equipment and Put on Gloves
 Syringe System 8. Reapply the tourniquet, Uncap, and Inspect the needle
- The components of this system include: 9. Ask the patient to remake a fist, Anchor the vein, and
 A syringe needle that has a resheating insert the needle
feature 10. Establish the blood flow, Release the tourniquet, and ask
 A syringe that is divided into a graduated the patient to open fist
barrel and plunger 11. Fill, Remove, and Mix the tubes in order of draw or Fill the
- Hypodermic needle: used in syringe system and syringe
comes with different gauges and lengths for different 12. Place gauze, Remove the needle, Activate the Safety
types of usage feature, and Apply pressure
13. Discard the collection unit, syringe needle, or transfer
device
14. Label the tubes and observe special handling instructions
15. Check patient’s arm and apply bandage
16. Disposal of contaminated materials
17. Thank the patient, remove gloves, and sanitize hands
18. Transport the specimens to the lab
(Specimens should be transported within 30 mins. to 1 hr)

SERUM: Non-Additives (Red and Gold)

- It has no clotting factors
 Butterfly System
- Also called winged infusion set
PLASMA: With Anticoagulant
- Used for difficult veins such as those of pediatric or
- Has clotting factors present
elderly because it is more flexible than the needle or
syringe
Mnemonics for Order of Draw: (BCNHES)
- Are easy to insert and less likely to cause pain or
Blood culture Yellow
discomfort to the patient
Coagulation/Citrate Blue
Non-Additive Red
Heparin Green
EDTA Purple
Sodium Fluoride Gray
Other Additives Black

 Evacuated Tubes System (ETS)

- A closed collection system that is considered the most
efficient system for collecting blood samples
- Multi-sample needles (two-way needle): used in the
evacuated tube system (ETS) and are equipped with
safety features