MODULE 6.

PRE-ANALYTICAL CONSIDERATION Variable Blood Composition Affected

Age Red blood cells, white blood cells,
IN PHLEBOTOMY creatinine clearance
Attitude Red blood cells
-Introduction- Dehydration Hemoconcentration, red blood cells.
enzymes, iron, calcium, sodium
The pre-analytical testing phase includes procedures such Diet Glucose, lipids, electrolytes
as laboratory handling, and identification, which take place Diurnal Thyroid-stimulating hormone, cortisol,
prior to any laboratory testing. In this phase proper control variation iron
measures are placed to avoid subsequent issues. It starts Drug Therapy Enzymes, hormones
when the doctor’s order is given and ends when the Exercise/ Potential of hydrogen (pH), carbon
laboratory testing has officially commenced. lM injection dioxide partial pressure (PCO2), creatine
kinase (CK), lactic acid dehydrogenase
During this phase, the phlebotomist must not only be able (LDH), glucose
to draw blood from the patient but must also be able to
Fever Hormones, cortisol
identify factors that affect the process and address them .as
Gender Red blood cells, hemoglobin, hematocrit
needed.
Jaundice Yellow color interfaces due to increased
bilirubin
-objectives- Intramuscular Creatine kinase and the skeletal muscle
injection fraction of LDH
Upon completion of this module, you should be able to: Position Protein, potassium
1. enumerate the physiological variables that Pregnancy Red blood cells
influence laboratory test results and identify the Smoking Cholesterol, cortisol, glucose, growth
tests most affected by each one; hormones, triglyceride, white blood cells
2. identify problem areas to avoid in site selection, Stress White blood cells, iron,
give causes for concern, and describe the adrenocorticotropic hormone,
procedure to follow when a difficult situation occurs; catecholamine, cortisol
3. explain how to handle patient complications Temperature Hemoconcentration
associated with blood collection; and humidity
4. spell out how to avoid or handle procedural error
risks, and reasons for failure to draw blood; and PART 2. PROBLEM AREAS TO AVOID AND
5. discuss appropriate specimen quality. TROUBLESHOOTING IN THE SITE SELECTION

Definition of terms Phlebotomists should be aware of the following problem

Term Definition (Meriam Webster Dictionary)
Pre-analytical - is the testing phase that occurs first in
the laboratory process.
-discussion-
The laboratory test is used by physicians to diagnose and
monitor the presence of a disease. The physicians compare
the results to a reference range or reference interval. This
range shows the high and low limits of result values as
compared to healthy individuals. Several factors are
considered as part of the reference interval study or the
interpretation of the data obtained.
In phlebotomy, the basal state is ideal in establishing
reference range since it represents the condition of the
metabolism of the body early in the morning or after
approximately 12 hours of fasting. This can be influenced
by age, gender, and conditions of the body.
PART 1. PHYSIOLOGICAL VARIABLES THAT
INFLUENCE LABORATORY TEST RESULTS
Listed below are some of the factors that affect blood
collection.
areas when selecting the venipuncture site. They could
choose an alternative site or perform the procedure under
special conditions.
1. Burns, Scars, and Tattoos – It is not advisable to
choose a site that has burns, scars, or tattoos
because veins in the area may be difficult to examine
and blood circulation may be impaired. Burns may be
too painful to touch, and tattoos may also be
susceptible to infection due to the dyes used that
may interfere with the process.
2. Damaged Veins - Aside from being difficult to
perform, puncturing damaged veins may also
produce inaccurate results. Veins could be sclerosed
or hardened or thrombosed or clotted.
3. Edema - Edema, also known as oedema, is an
abnormal swelling caused by the accumulation of
fluid in the tissues. The tissues become fragile,
making the task of locating the veins harder. This
condition may be due to reactions from medications,
pregnancy, infections, and other medical problems.
4. Hematoma - Hematoma is a solid swelling or mass
of blood in the tissues caused by the leakage of blood
from the vessels during venipuncture. Selecting a
venipuncture site with hematoma will be painful for
the patient because it will obstruct the blood flow. It
could also lead to the contamination of blood sample.

Figure 6.1 Hematoma
5. Mastectomy - This procedure, often done to breast
cancer patients, refers to the removJ of the breast
through surgery. Blood drawing from patients who
had undergone this procedure becomes a
challenge since the lymph flow is obstructed, and
there may be swelling and infection after the
surgery. In addition, tourniquet cannot be applied
because it can cause injury. It could also change
the blood composition.
6. Obesity- This is the condition in which the
individual is grossly overweight. Patients who are
obese have veins that are deep and difficult to
locate. A solution is using a longer tourniquet or
locating the cephalic of cubital vein.
PART 3. HANDLING PATIENT COMPLICATIONS
ASSOCIATED WITH BLOOD COLLECTION
1. Allergies to Equipment and Supplies
 When the patient has adhesive allergy, a gauze
should be placed over the site and should be
removed after 15 minutes. The alternative is to ask
the patient to apply pressure for five minutes. When
the patient has antiseptic allergy, simply use a
different antiseptic. When the patient has latex
allergy, look for a sign to indicate the allergy and
use a non-latex alternative for gloves, tourniquet,
and bandages.
2. Excessive Bleeding
 When a patient is on aspirin or anticoagulant, the
bleeding may take a longer time. The pressure
should be applied to the site until the bleeding
stops. The attention of the authorized personnel
should be called when the bleeding continues after
five minutes.
3. Fainting
 Fainting is a temporary loss of consciousness
which is caused by the insufficient flow of blood to
the. brain. Patients prone to fajnting during
venipuncture are asked to lie down during the
procedure.
4. Nausea and Vomiting
 When the patient feels nauseous and has the
tendency to vomit, the phlebotomist has to
discontinue the procedure until the patient feels
MODULE 6 –PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY
better or until the feeling subsides. An emesis basin
or wastebasket should be provided, and a cold
damp washcloth should be applied to the forehead.
5. Pain
 The patient should be warned before the needle
insertion, and the phlebotomist should avoid
redirection of the needle. If the patient complains of
extreme pain or numbness, remove the needle and
apply ice to the site because this could indicate
nerve involvement. The phlebotomist needs to
document the incident if the condition persists.
6. Petechiae
 This condition involves the appearance of small red
or purple spots that look like rashes, which appear
on the arm when tourniquet is applied.
Figure 6.2 Petechiae
7. Seizures or convulsions
 When seizures or convulsions occur, the blood
draw should be discontinued quickly. There must
be pressure held over the site but it must be made
certain that movement is not restricted; the mouth
is free from any obstruction and the patient 1s
protected from self-injury. The first-aid personnel
must be notified immediately.
PART 4. AVOIDING AND HANDLING PROCEDURAL
ERROR RISKS AND FAILURE TO DRAW BLOOD
1. Hematoma Formation
The phlebotomist should hold pressure over the
site immediately after discontinuing the draw. A
cold compress or ice pack may be offered to help
address the swelling. The following are conditions
that trigger hematoma:
• There is excessive or blind probing.
• There is inadvertent arterial puncture.
• The size of the vein is too small.
• The needle penetration has gone all
through the vein.
• Needle is not completely ·inserted.
• Tourniquet is still on when the needle was
removed.
• The pressure is not adequate.
2. Iatrogenic Anemia
This results from blood loss due to blood draw to
blood draw. It is important to ensure that only the
required specimen volume is collected because if
10% of the blood volume is removed at once from
the body, the patient could face a threat.
2

3. Inadvertent Arterial Puncture
This happens when blood is filling up the tube
rapidly and there is a rapid formation of hematoma
on the site.
4. Infection
Infection can be avoided by making sure that tapes
or bandages are not opened ahead of time;
needles are not preloaded into the rube holders,
insertion site of the needle is not touched after
sterilization; cap is removed just before
venipuncture; and the patients are advised to keep
the bandage on the site for at least 15 minutes.
5. Nerve Injury
Nerve injuries happen when there is improper site
selection, rapid needle insertion, excessive
redirection of the needle, and blind probing.
If the initial attempt is unsuccessful, the
phlebotomist should try to redirect the needle by
using a slightly forward or backward movement.
The next step is to remove the needle and look for
an alternative site.
6. Reflux of Anticoagulant
Blood that has already been drawn flowing back
into the vein from the collection tube may cause
adverse reaction because of the presence of tube
additives. To avoid this, make sure that the arm of
the patient is in a downward position and the tube
is just below the venipuncture site.
7. Vein Damage
Damaging the vein could be avoided by following
the proper technique and avoiding blind probing.
PART 5. SPECIMEN QUALITY
1) Hemoconcentration is a decrease in the fluid content
or plasma volume which is usually caused by
tourniquet that stagnates the normal flow of blood
leading to the increase in concentration of red blood
cells and other non-filterable large molecules.
2) Hemolysis, which is also called haemolysis, refers to
the rupture of the red blood cells. The hemoglobin is
then released into the surrounding fluid.
3) Partially filled tube or short draw, happens when the
phlebotomist pulls a tube before reaching the
required volume. This may lead to the incorrect
blood-to-additive ratio.
4) Specimen contamination means that the specimen is
due to incorrect handling, which involves allowing
alcohol, powder or other materials into the sample.
Getting glove powder or perspiration into films and
specimens; using the wrong antiseptic; or simply not
following the proper antiseptic procedure could
interfere with the results.
MODULE 6 –PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY
5) Wrong or expired collection tube should not be used
because the manufacturer could not warrant the
quality of the seal and the pressure after the
expiration date indicated in the tube.
PART 6. TROUBLESHOOTING FAILED
VENIPUNCTURE
Venipuncture attempts could fail due to improper setting of
the tube and failure of the needle to go through the stopper.
The phlebotomist must be aware and must take measures
to ensure that the proper procedures are followed.
The needle position is critical to the success of the
venipuncture. The phlebotomist should ensure that the
following do not happen.
1. Needle not inserted far enough
2. Bevel partially out of skin
3. Bevel partially into vein
4. Bevel partially through vein
5. Bevel completely through vein
6. Bevel against vein wall
7. Needle beside vein
8. Undetermined position
A. Collapsed Vein
The collapsed veins usually occur when conditions are less
than ideal, which leads to the veins being blocked, resulting
in insufficient blood flow. This happens when there is a
strong pressure in the vacuum of the tube or plunger; the
tourniquet is too close to the site or it is too tight; or when
the tourniquet has been removed during the draw.
B. Tube Vacuum
To avoid failure due to loss of vacuum, the phlebotomist
should make sure that the bevel is not partially out of skin
and the tube itself is not damaged.
Figure 6.3 Correct
Angle of the Bevel
(15-30o)
Figure 6.4 Failed
Venipuncture
3
 Student assessment question 1:
A patient blood sample looked normal without any
hemolysis, but the following critical values were obtained
and flagged:
Initial test Repeated Test
Ca2+ 0.6 mmol/L 0.7mmol/L
K+ 15.5mmol/L 15.5mmol/L
ALK 5 U/L 4 U/L

These abnormal data were not consistent with the

patient’s medical history. As a result, the medical
laboratory scientist communicated this to the
phlebotomist and learned this patient serum sample was
contaminated by EDTA-K2 because the tested sample
was a combination of his blood from a purple top tube
(with EDTA-K2 as coagulant) and a red top tube.

Case Study Questions:

1. Do you think this is considered as a Pre-analytical
error? Explain your answer. (10 pts)
2. What was the effect of combining blood from a purple
top tube and a red top tube. Make sure to support your
answer. (20 pts)
3. What would be your next step after knowing what
happened? (10 pts)

-SUMMARY-
A professional Medical Laboratory Scientist knows that the
pre-analytical phase – when a specimen is collected,
transported, and processed – is a crucial part of the lab
testing process. Over 40% of lab errors happen during the
pre-analytical stage, while a mere 7% occur during the
actual testing. These errors result in added medical costs
when tests have to be re-issued and can sometimes lead to
patient misdiagnosis and in extreme cases they can be the
cause of serious patient illness. Pre-analytical errors can
occur at any point during the specimen collection process.

-reference-
• Learning Guide for Principles of Medical
Laboratory Sciences 2
Copyright 2020 by C&E Publishing Inc.,
Bernard U. Ebuen, Nini F. Lim, Edliberto P.
Manahan, Jose Jurel M. Nuevo, Maria Luisa R.
Olano, and Aileen C. Patron

Prepared by:

Ruth Abigail S. Contante, RMT, LPT

Instructor

MODULE 6 –PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY 4