Blood Collection, Equipment,

Additives, and Order of Draw

Chapter 7
 Objectives
• Define the key terms and abbreviations listed at
the beginning of this chapter.
• List, describe, and explain the purpose of the
equipment and supplies needed to collect blood
by venipuncture.
• Compare and contrast antiseptics and
disinfectants and give examples of each.
• Identify appropriate phlebotomy needles by
length, gauge, and any associated color coding.
 Objectives
• List and describe evacuated tube system (ETS)
and syringe system components, explain how
each system works, and tell how to determine
which system and components to use.
• Identify the general categories of additives
used in blood collection, list the various
additives within each category, and describe
how each additive works.
 Objectives
• Describe the color coding used to identify the
presence or absence of additives in blood
collection tubes and name the additive,
laboratory departments, and individual tests
associated with the various, color-coded
tubes.
• List the “order of draw” when multiple tubes
are being collected and explain why it is
important.
 General Blood Collection Equipment
• Blood-Drawing Station
• Phlebotomy Chairs
• Equipment Carriers
– Hand-held
– Carts
• Gloves
– FDA regulates glove quality
 General Equipment cont.
• Antiseptics = prevent or inhibit growth of
microbes but does not necessarily kill them
• Disinfectants = used to remove or kill microbes on
surfaces and instruments
– Not typically safe for skin
• Hand Sanitizers
• Gauze
• Bandages/Tape
• Needles and Sharps Container
 Venipuncture Equipment
• Vein-Locating Devices
• Tourniquet
• Needles
– Bevel
– Shaft
– Hub
– Lumen
– Gauge = number that relates to the diameter of the lumen
• Larger the number, the smaller the actual diameter of the needle
• 21 Gauge needle is standard
– Length = 1 or 1.5 inch
– Safety Device – OSHA requires the needle or the equipment it is
being used with to have a safety feature
 Evacuated Tube System (ETS)
(Vacutainer)
• Most common and CLSI preferred system for
collecting blood

OSHA requires that

Called multisample needle
because it allows multiple
tubes of blood to be
collected during a single
venipuncture
the tube holder with
needle attached be
disposed of as a unit
Tube size is based on
age of patient,
amount of blood
needed, and size and
condition of patient’s
vein
 Evacuated Tube
• Vacuum = Evacuated tubes fill with blood
automatically due to negative pressure in
them
– Premeasured by the manufacturer so that the
tube will fill with exact amount of blood indicated
– Premature loss of vacuum can occur and the tube
will fail to fill with blood
• Can result in a “Short Draw” = underfilled tube
 Evacuated Tubes
• Additive = substance placed within tube
– Underfilled tube that contains additive will have
an incorrect additive-to-blood ratio which can
lead to inaccurate test results
• Expiration Dates
 Syringe System
• Used for patients with small or difficult veins

When drawing venous Syringe transfer device allows

blood, slowly pull back the safe transfer of blood into
the plunger to create a the tubes without using the
vacuum that causes the syringe needle
barrel to fill with blood
 Winged Infusion Set (Butterfly)
• Used for collecting blood from small or
difficult veins
• Hand veins
• Pediatric patients
• 23 gauge is most
commonly used
 Blood Collection Additives
• Never transfer blood from one additive tube
into another additive tube as it will interfere
with the test
– Even if the same additive, mixing together will
create an excess of additive
• Invert the tube 3-8 times immediately after
collection
– Never shake as it can cause hemolysis
 Anticoagulants
• Substances that prevent blood from clotting
– Chelating or precipitating calcium so it is
unavailable for the coagulation process
– Inhibiting thrombin needed to convert fibrinogen
to fibrin in the coagulation process
 Anticoagulants
• EDTA = prevents by chelating calcium
– Used in hematology since it preserves cell
morphology and inhibits platelet aggregation
– Mix immediately to prevent microclots or platelet
clumps otherwise will need to recollect
– Need to fill tubes completely otherwise it will
cause RBCs to shrink due to excess EDTA and
changes the CBC results
– Also used in blood bank
 Anticoagulants
• Citrates = prevent coagulation by chelating
calcium
– Sodium Citrate (light blue tubes) is used for
coagulation tests (PT or APTT) since it preserves
the coagulation factors well
• Coag tests are performed on plasma
• Critical 9:1 ratio of blood to anticoagulant so need to fill
them completely
– Underfilled tubes cause false prolonged clotting times and will
be rejected
• Needs immediate mixing
 Anticoagulants
• Heparin = prevents clotting by inhibiting
thrombin formation
– Heparinized plasma is used for stat chemistry
tests
– Mix immediately
– 3 heparin formulations: Ammonium, Lithium, and
Sodium
• Lithium causes the least interference in chemistry
testing and is most widely used anticoagulant for
plasma and whole-blood chemistry tests
 Anticoagulants
• Oxalates = prevent clotting by precipitating
calcium
– Potassium oxalate is most widely used (gray)
– Commonly added to tubes containing glucose
preservatives to provide plasma for glucose
testing
– Need immediate mixing
– Fill completely since excess oxalate can cause
hemolysis and release hemoglobin into plasma
 Special-Use Anticoagulants
• Acid Citrate Dextrose (ACD) = prevents clotting
formation by binding calcium
– Used in immunohematology tests such as DNA
testing and human leukocyte antigen (HLA)
phenotyping needed in paternity evaluation and
for transplant compatibility
– Yellow
– Needs immediate mixing
 Special-Use Anticoagulants
• Citrate-Phosphate Dextrose (CPD) = prevents
clotting by chelating calcium
– Used for collecting units of blood for transfusion
• Sodium Polyanethol Sulfonate (SPS) =
prevents clotting by binding calcium
– Used for blood culture collection, it reduces the
action of a protein called complement that
destroys bacteria, slows down phagocytosis, and
reduces activity of certain antibiotics
– Need immediate mixing
 Antiglycolytic Agents
• Substance that prevents glycolysis
(breakdown of glucose by blood cells)
• If not prevented, the glucose concentration in
a specimen decreases at a rate of 10 mg/dL
per hour
• Most common antiglycolytic agent is Sodium
Fluoride (Gray) – it preserves glucose for up to
3 days
 Clot Activators
• Substance that enhance coagulation
• Include substances that provide more surface for
platelet activation such as glass (silica) particles
and inert clays like celite, and clotting factors
such as thrombin
• Silica particles are the clot activator in Serum
Separator Tubes (SST) and plastic red-top tubes,
cause blood to clot within 15-30 min
• Thrombin causes clotting within 5 min
• Require mixing
 Thixotropic Gel Separator
• Inert (nonreacting) substance contained in or
near the bottom of certain blood collection tubes
• When a specimen in a gel tube is centrifuged, gel
undergoes a change in viscosity and moves to a
position between the cells and the serum
forming a physical barrier between
• Physical separation prevents cells from
continuing to metabolize substances, such as
glucose, in the serum
• Different color and name depending upon
company
 Trace-Element-Free Tubes
• Royal blue stoppers indicate trace element
free tubes
• Tubes are made of materials that are free of
trace element contamination and are used for
trace element tests, toxicology studies, and
nutrient determinations
• Contain EDTA, heparin, or no additive
• Tube labels are color-coded to indicate the
type of additive
 Order of Draw
• Filling tubes in wrong order can lead to
interference in testing from additive
carryover, tissue thromboplastin, or microbes
• Tissue thromboplastin is a substance present
in tissue fluid that activates a coagulation
pathway and can interfere with coag tests
– Discard tube should be drawn when using a
butterfly needle if a coagulation tube is the first or
only to be drawn due to the air in the tubing
 Order of Draw
• Microbe Contamination
– Blood Cultures detect microbes in the blood and
require special site cleaning measures prior to
collection to prevent contamination from bacteria
normally found on the skin
• Sterile bottles and are drawn first
 Order of Draw
1. Sterile tube (blood culture)
2. Blue top coagulation tube
3. Serum tube with or without gel or clot
activator
4. Heparin tube with or without gel plasma
separator
5. EDTA tube
6. Glycolytic inhibitor tube
Order of Draw
 Syringe Order of Draw
• Obsolete – do NOT need to know!
• Use the same Order of Draw