PRINCIPLES OF MEDICAL LABORATORY SCIENCES PRACTICE 2: PHLEBOTOMY; Capillary Puncture & Arterial Puncture WHAT ARE CAPILLARIES? + Capilaries are the bridges between arteries and veins, blood collected by capillary puncture is a mixture of venous blood and arterial blood, PRE LAB DISCUSSION Although venipuncture is the most frequently performed phlebotomy procedure, it is not appropriate in all circumstances. ® In most institutions, dermal (capillary or skin) puncture is the method of choice for collecting blood from infants and children younger than 2 years for the following reasons: * Locating superficial veins that are large enough to accept ‘even a small-gauge needle is difcul in these patients, and available veins may need to be reserved for intravenous therapy. ‘© Use of deep veins, such as the femoral vein, can be dangerous and may cause complications including cardiac farrest, venous thrombosis, hemorrhage, damage to surrounding tissue and organs, infection, reflex atteriospasm (that can possibly result in gangrene), and injury caused by restraining the child ‘Drawing excessive amounts of blood from premature and ‘small infants can rapidly cause anemia, because a 2-pound infant may have a total blood volume of only 180 mL. ‘© Certain tests require capilary blood, such as newbom ‘screening tests and capillary blood gases Dermal puncture may be required in many adult patients, including: + Bumed or scarred patients + Patients receiving chemotherapy who require frequent tests and whose veins must be reserved for therapy + Patients with thrombotic tendencies + Geriatric or other patients with very fragile veins + Paliants with inaccessible veins + Obese pationts + Apprehensive patients + Patients requiring home glucose monitoring and point-of- care tests NOT ALL LABORATORY TEST SAMPLE CAN BE ‘OBTAINED THRU CAPILLARY PUNCTURE Reference Values in Capillary and Venous Blood Higher in Capillary Blood Higher in Venous Blood * Glucose * Calcium + Hemoglobin + Total protein + Potassium (serum sample) + Potassium (plasma sample) IMPORTANCE OF CORRECT COLLECTION > Hemolysis is more frequently seen in samples collected by dermal puncture than afer collection itis in those collected by venipuncture, Hemolysis may ‘occur in dermal puncture forthe following reasons Excessive squeezing of the puncture site(‘miking”) Newborns have increased numbers of red blood cells (RBCs) and increased RBC tragity Residual alcohol atthe sito Vigorous mixing of the microcollection tubes KK856 DERMAL PUNCTURE EQUIPMENTS. LANCETS + Sterile, sharp instruments that are intended for one-time use only, + Designed for use in making cuts in the skin for finger or heel puncture. Puncture Depth Use Dopth Finger stick 3.0mm Heel stick 20mm Heel stick(premature 0.55-0.85mm infants or neonates) Bleeding time 1.0mm Puncture width should not exceed 2.4 mm. CAPILLARY TUBES + Capillary tubes- these are narrow bore tubes that are made of either plastic or glass. + Typically used for hematocrit determinations, + They can hold 50 to 75ul + One end is sealed with sealants made of cay. Microcollection Tubes + Small plastic tube used to hold blood specimen collected in capillary puncture, + Volume ranges to 0.SmL to tml depending on the ‘manufacturer + Microcollection tubes are slanted down during the collection, and blood is allowed to run through the capillary colection scoop ‘and down the side ofthe tube. ‘tis important to work quickly, because blood that take smore than 2 minutes to collect may form microciotsin an anti- ‘coagulated microcollection container. GLASS SLIDES + Used for blood films for hematology determinations ‘ORDER OF DRAW FOR CAPILLARY PUNCTURE The order of draw for collecting muitiple samples from a dermal puncture is important because of the tendency of platelets to accumulate atthe site of the wound: Capillary blood gases Blood smear EDTA tubes Other anticoagulated tubes ‘Serum tubes A845 SITES OF COLLECTION: ADULTICHILOREN >t YR.OLD ‘A primary danger in dermal puncture is accidental contact with the bone, followed by infection or inflammation (osteomyelitis of osteochondritis) > Finger punctures are performed on adults and children over 4 year of age. SITE: + Fleshy areas located near the 3rd or 4° fingers on the palmar side of the non dominant handReason: + Increased nerve endings in the index finger + Possible calluses on the thumb + Decreased tissue in fith finger tae) 1 SITE COLLECTION: INFANT ‘The heel is used for dermal punctures on infants younger than 1 year because it contains more tissue than the fingers and has not yel become callused from walking. SITE: Medial and lateral areas of the plantar (bottom) surface of the heel. Reason: + Itis in these areas that the distance between the skin and the calcaneus (heel bone) is greatest = There is a short distance between the back of the heel and the calcaneus, Punctures should not be performed jn other areas of the foot, perticuary notin the arch, where ° ‘they may cause damage to nerves, tendons, and cartilage. + Use the medial and lateral areas ofthe plantar surface of the heel + Use the central fleshy area ofthe third or fourth finger. = Donotuse the back of the heel. Dont use the arch ofthe foot. = Dont puncture through od sites. = Donnot use areas with visible damage. = Donat use fingers on newboms or children younger than 1 year Donat use swollen sites. Dont use earlobes, + Donot use fingers on the side of a mastectomy, CAPILLARY PUNCTURE PROCEDURE 1. Perform proper patient identification 2. Select equipment according to age of patient, type of test ‘oFdered and amount of blood to be collected 3. Puton gloves 4. Position the patient’s arm on a firm surface with hand palm up. The child may have to be held in either the vertical or horizontal restraint, 5. Select puncture site Finger- 3° or 4” finger Heel- plantar surface 6, Warm puncture ifnecessary 7. Cleanse the area in concentric circles. Allow to air dry. 8. Prepare the lancet by removing lancet locking device or ‘open the cap by twisting, Open microtainer caps, 9. Hold the finger between the non-dominant thumb and index finger, with the palmar surface facing up and the finger pointing downwars. 10, Place the lancet firm the fleshy area of the finger perpendicular to the fingerprint and depress the lancet trigger. 11, Discard lancet 12. Gently squoeze the finger and wipe away the first drop “of blood that may contain alcohol residue and tissue fluid. ‘order of draw without scraping the skin. Do not milk the site Collect the sample within 2 minutes to prevent clatting. 14. Cap the microcollection container when the correct amount of blood has been collected, Mix tubes by gentle inversion, 18. Place cotton in the site, ask patient to apply pressure until bleeding stops. 16. Label tubes and send it tothe laboratory. HEEL PRICK: INFANT ‘Same procedure as finger prick method, but diferent site and with caution ‘Additional Steps: > Position the baby lying on his or her back with the foot lower than the body. > Warm the heel for 3 to 5 minutes by wrapping the heel with ‘a warm wash cloth or using a commercial heel warming device. > Hold the heel firmly by wrapping the heel with the non- dominant hand, > Place the lancet perpendicular to the heel print and depress the lancet trigger ARTERIAL PUNCTURE + Arterial Blood is collected to determine the level of oxygen and carbon dioxide in the blood and measure the pH. ARTERIAL BLOOD GAS + ABG testing determines the concentrations of oxygen and carbon dioxide dissolved in the blood and measures the pH. The absolute amount of oxygen is expressed as the partial pressure ‘of oxygen (P02). + Similarly, the carbon dioxide level is expressed as the partial pressure of carbon dioxide (Pco2) EQUIPMENTS: + Heparinized Syringe and Needle Arterial blood is collected in a syringe that hasbeen pretreated with heparin to prevent coagulation * Antiseptic Alcohol and Povidone-iodine is Used to clean the site * Lidocaine Anesthetic UNE 1 A tee nd Sr O.5mI of Lidocaine injected jon uovantcri cin ponies er mesty sas subcutaneously Other Equipment Other equipment needed for arterial pun cludes the following: S "Crushed ice Gauze pads Pressure bandages Thermometer (o take the patients temperature) Transport container No tourniquet is needed because arterial blood is under pressure SITE SELECTION Radial artery, supplying the hand, is the artery of choice sy © The brachial artery is large; therefore, itis easy to palpate and puncture, _ © The femoral artery is the = largest artery used, It is located in the groin area above the thigh, lateral to Stove th hg cue 2h ye ‘The modified Allen test is the most common method used to‘Modified Allen test 1. Extend the patient's wrist over a towel, and have the Patient make a fist. 2. Locate the pulses of both the ulnar and the radial , and compress both 3. Have the patient open and close the fist repeatedly, This squeezes blood out of the hand. The patient's palm ‘should blanch (become lighter 4.Roleaso the pressure {from the ulnar artery, Ooserve the color of the patient's palm within 5 to 10 ‘seconds. 5. Interpret the results. ‘Negative result: if no color appears during the 5 to 10 ‘seconds, there is inadequate collateral circulation and the artery should not be used. Positive result: If no color appears during the § to 10 seconds, there is adequate collateral circulation and you may proceed with the radial puncture. ARTERIAL PUNCTURE COMPLICATIONS + Arteriospasm, the spontaneous constriction of an artery in response to pain. Arteriospasmmay close the arlery,preventingoxygen from reaching tissue. + Embolism, oF blood vessel obstruction, due to an air bubble of dislodged clot in the artery. This can cause arterial occlusion (blockage), leading to loss of low. + Homatoma, resulting from inadequate pressure on the site. This is more likely in elderly patients, whose artery walls are not as elastic and thus not as Tkely to close ‘spontaneously = Hemorrhage. This is more kely in patients who have ‘coagulation disorders or are receiving anticoagulant therapy (heparin or warfarin). Infection, ‘rom skin contaminants, Contaminants are easily carried to the rest of the body without encountering the immune system. + Light headedness, nausea, or fainting + Nerve damage, caused by inadvertent contact with nerve. This is more likely during arterial puncture than venipuncture because the needle passes more deeply into tissue, + Severe pain, + Thrombosis, oF lot formation, within the artery PRINCIPLES OF MEDICAL LABORATORY SCIENCES PRACTICE 2: PHLEBOTOMY; Venipuncture PART 1: VENIPUNCTURE BLOOD COLLECTION MATERIALS VENIPUNCTURE SITE OF COLLECTION PATIENT IDENTIFICATION PATIENT PREPARATIONS. COMPLICATIONS IN VENIPUCTURE WHAT IS PHLEBOTOMY? + Defined as “an incision into a vein’ Traditional Duties Major traditional duties and responsibilities of the phlebotomist include: 1, Correct identification and preparation of the patient before sample collection 2. Collection of the appropriate amount of blood by venipuncture or dermal puncture for the specified tests Selection of the appropriate sample containers for the specified tests 4. Correct labeling of all samples with the required information 5. Appropriate transportation of simples back to the laboratory in a timely manner 6. Effective interaction with patients and hospital personnel Processing of samples for delivery to the appropriate laboratory departm 8. Performance of computer operations a record-keeping pertaining to phlebotom 9. Observation of all safety regulations, quality control checks, and preventive maintenance procedures 10. Auendance at continuing education programs Personal Protective Equipment OSHA regulations mandate that gloves must beworn when performing a venipuncture procedure. PHLEBOTOMY COLLECTION TRAY + trays designed to organize and transport collection equipment. Extraction area/ Phlebotomy area TOURNIQUET. + Functions: Impedes venous but not arterial blood flow, the tourniquet causes blood to accumulate in the veins making them more easily located + Soft, pliable, flat strip approximately! inch wide by 15-18 inches long. + According to CLSI tourniquet should be single-use only to avoid health-care acquired infections (HAs) for patients. + Tourniquet should be placed on the arm 3-4 inches above the venipuncture site. + Maximum application time of tourniquet is 1 minute. + Toumiquet is applied twice during the procedure, first during vein selection and second before the puncture is performed. = CLSI recommends that it should be release for 2 minutes before reapplying. TOURNIQUET APPLICATION 4. Positionthe vinyl or latex strip 3 to 4 inches above the venipuncturesite, 2, Grasp both sides of the tourniquet and, while maintaining tension, cross the tourniquet overthe patients 3, Hold both ends between the thumb and forefinger of one hand close to the arm, 4, Tuck a portion of the lel side under the right side to make a partial loop facing the antecubital area, 5. A properly applied tourniquet will have the ends pointing up ‘way from the venipuncture site WHEN RELEASING THE TOURNIQUET: 6. Pull the end of the loop to release the tourniquet with one hand