PRE-ANALYTICAL CONSIDERATIONS

IN PHLEBOTOMY
 LEARNING OUTCOMES
At the end of this lesson, the students must be able to:
1. Enumerate the physiological variables that influence laboratory test results
and identify the tests most affected by each one;
2. Identify problem areas to avoid in site collection, give causes for concern, and
describe the procedure to follow when a difficult situation occurs;
3. Specify the various vascular access sites and devices and illustrate what to do
when they are encountered;
4. Explain how to handle patient complications associated with blood collection;
5. Spell out how to avoid or handle procedural error risks, and reasons for
failure to draw blood; and
6. Discuss appropriate specimen quality
 OVERVIEW OF THE PRE-ANALYTICAL PHASE OF TESTING

• The pre-analytical testing phase includes procedures such as

laboratory handling and identification which takes place prior to
any laboratory testing.
• It is in this phase where proper control measures are placed to
avoid subsequent issues. This starts when the doctor's order is
given and ends when the laboratory testing has officially
commenced
 OVERVIEW OF THE PRE-ANALYTICAL PHASE OF TESTING
• The phlebotomist should also possess the skill of being able to identify
factors that affect the process and address the same as needed.
• The laboratory test is used by physicians to diagnose and monitor the
presence of a disease.
• In phlebotomy, the basal state is ideal for establishing a reference range
since it represents the condition of the metabolism of the body early in the
morning or after approximately 12 hours of fasting.
PROBLEM AREAS AND TROUBLESHOOTING IN THE SITE
SELECTION
1. Burns, Scars, & Tattoos - a site that has burns, scars, or tattoos is
not recommended 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.
PROBLEM AREAS AND TROUBLESHOOTING IN THE SITE
SELECTION
2. Damaged Veins -aside from encountering difficulty in puncturing the
site when veins are damaged another problem is the possibility of
getting inaccurate results.
Damaged Veins could be Sclerosed or Hardened or Thrombosed or
Clotted.
PROBLEM AREAS AND TROUBLESHOOTING IN THE SITE
SELECTION
3. Edema - which is also known as Oedema, is an abnormal swelling
caused by 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.
PROBLEM AREAS AND
TROUBLESHOOTING IN THE SITE
SELECTION
4. Hematoma - a solid swelling or mass of blood in the tissues which is
caused by the leakage of blood from the vessels during venipuncture.
This is not only painful because it obstructs the blood flow it could also
lead to the contamination of the blood sample.
PROBLEM AREAS AND TROUBLESHOOTING IN THE SITE
SELECTION
5. Mastectomy - a treatment for breast cancer that requires removal of
the breast through surgery. Blood drawing becomes a challenge since the
lymph flow is obstructed, and there may be swelling and infection after
the surgery. In addition, a tourniquet cannot be applied because it can
cause injury. It should also be noted that it could also change the blood
composition.
PROBLEM AREAS AND TROUBLESHOOTING IN THE SITE
SELECTION
6. Obesity - the individual is grossly overweight. Patients that are obese
have veins that are deep and they are harder to locate. A solution is to
use a longer tourniquet or try locating the cephalic or cubital vein.
 VASCULAR ACCESS SITES AND
DEVICES
• There are cases when a patient requires the use of Vascular
Access Devices (VADs) for blood sampling, infusing
medication, central venous pressure readings, and blood
transfusion. The choice of vascular access sites is based on
the needs of the patient, the purpose, and the length of time
it needs to remain in the body. Listed are vascular access
sites and devices used in phlebotomy:
 VASCULAR ACCESS SITES AND
DEVICES
• Arterial Line
To obtain samples for arterial blood gas and laboratory
studies, critically ill patients require arterial lines where a thin
catheter is inserted into an artery. This is also used to monitor
blood pressure continuously. Neither a tourniquet nor
venipuncture is allowed in the arm with an arterial line.
VASCULAR ACCESS SITES AND
DEVICES
• Arteriovenous Shunt or Fistula
- An arteriovenous shunt or fistula is a passageway
created thru surgery which is usually in the arms to
connect the artery and a vein directly. This may be
created for hemodialysis treatment or pathological
processes such as erosion of arterial aneurysm.
• Blood Sampling Device
A blood sampling device is used to avoid the use of needle sticks,
reduce infections, and reduce wastage from line draws. The device
collects blood from the arterial or central venous catheter where it is
connected.
VASCULAR ACCESS SITES AND
DEVICES
• The heparin or saline lock,
- which is commonly called a "hep-lock," is an intravenous (IV)
catheter attached to a stopcock or cap with diaphragm. The basic
function is to provide access for administering medicine or drawing
blood from the patient. This is threaded in the peripheral vein which is
in the lower arm above the wrist for up to 48 hours. It is usually flushed
with heparin or saline (to prevent clogging) and capped for future use.
VASCULAR ACCESS SITES AND
DEVICES
•  Intravenous (IV) Sites
- An IV line is a thin plastic tube or catheter inserted into a vein in
the forearm to inject a volume of fluids into the bloodstream.
- The phlebotomist should avoid collecting blood from the arm
with an IV because the blood collected could be contaminated with IV
fluid.
- If blood collection is necessary, the collection site should be
below the IV. Take note that collection of blood from known previously
IV sites should be avoided for 24 to 48 hours
 Central Vascular Access Devices (CVADs)
• ✓ also known as indwelling lines which is a tubing
inserted into the main vein or artery used for blood
collection, monitoring the patient's pressures, and
administering medications and fluids.

• ✓ There are three (3) types of CVADs which include the

Central Venous catheter lines, implanted port, and
peripherally inserted central catheter.
A. CENTRAL VENOUS CATHETER is also known as a
central line inserted into the large vein (subclavian) and advanced into
superior vena cava.
B. IMPLANTED PORT is a surgically implanted disk-shaped
chamber attached into the indwelling line. This is usually placed on the
upper chest just below the collarbone.
C. PERIPHERALLY INSERTED CENTRAL CATHETER
(PICC) is a flexible tube inserted into the veins of extremities and the
central veins
 HANDLING PATIENT
COMPLICATIONS ASSOCIATED WITH
BLOOD COLLECTION
• 1. Allergies to Equipment and Supplies
- When the patient has an adhesive allergy, a gauze
should be placed over the site and should be removed after
fifteen minutes. The alternative is to ask the patient to apply
pressure for five minutes. For Antiseptic allergy, simply use a
different antiseptic.
- For 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. If the patient is
prone to fainting during venipuncture, they 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 better or until the feeling subsides. An emesis basin or
wastebasket should be provided, and a cold damp washcloth should be
applied in 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 a tourniquet is applied.
• 7. Seizures/Convulsion
- When seizures or convulsions occur, the blood draw should be
discontinued immediately.
- Hold pressure over the site but make sure that movement is not
restricted, the mouth is free from any obstruction and the patient is
protected from self-injury.
- Call the attention of the first-aid personnel.
 AVOIDING AND HANDLING PROCEDURAL
ERROR RISKS AND FAILURE TO DRAW BLOOD
• Hematoma Formation
- The phlebotomist should hold pressure on the site
immediately after discontinuing the draw.
- A cold compress or ice pack may be offered to help
address the swelling.
 Factors that trigger Hematoma are:
1. Excessive or blind probing
2. Inadvertent arterial puncture
3. Size of the vein - too small
4. The needle penetration - all through the vein
5. Needle is not completely inserted
6. Tourniquet was still on when the needle was removed
7. Pressure - not adequate
• Iatrogenic Anemia
- This results from blood loss due to blood draw. It is
important to ensure to collection of only the required
specimen volume because if 10% of the blood volume is
removed at once from the body, the patients could face a
threat.
Inadvertent Arterial Puncture
- This happens when blood is filling up the tube rapidly
and there is a rapid formation of hematoma on the site.

Infection
- can be avoided by making sure that tapes or bandages
are not opened ahead of time, needles are not preloaded into
the tube holders, the insertion site of the needle is not
touched after sterilization, a cap is removed just before
venipuncture, and patients are advised to keep the bandage
on the site for at least 15 minutes
• 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 not successful, 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.
• Reflux of Anticoagulant
- To avoid blood that has already been drawn flowing back into
the vein from the collection tube, which may cause adverse reactions
because of the presence of tube additives, make sure to keep the arm
of the patient in a downward position and the tube just below the
venipuncture site.

• Vein Damage
- Damaging the vein could be avoided by following the proper
technique and avoiding blind probing
 Troubleshooting failed venipuncture
• The phlebotomist should ensure that the following does not happen:

1. Needle not inserted far enough

2. Bevel partially out of skin
3. Bevel partially into the vein
4. Bevel partially through the vein
5. Bevel completely through the vein
6. Bevel against the vein wall
7. Needle beside vein 8. Undetermined position
• 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 was removed during the draw.
Tube Vacuum
- To avoid failure due to loss of vacuum, the phlebotomist should
make sure that the bevel is not partially out of the skin and the tube
itself is not damaged
 SPECIMEN QUALITY
• 1. Hemoconcentration
- is a decrease in the fluid content or plasma volume which is
usually caused by a tourniquet that stagnates the normal flow of blood,
leading to the increase in concentration of red blood cells and other
nonfilterable large molecules. Hemoconcentration can cause falsely
elevated results for glucose, potassium, and protein-based analytes
such as cholesterol.
• 2. Hemolysis
- which is also called hemolysis, refers to the rupture of the red
blood cells. The hemoglobin is then released to the surrounding fluid.
• 3. Partially Filled Tubes, or short draws, happen when the
phlebotomist pulls a tube before reaching the required
volume which may lead to the incorrect blood-to-additive
ratio.
• 4. Specimen Contamination means that the specimen is
compromised due to incorrect handling, which includes
allowing alcohol, powder, or other materials into the sample.
• 5. Wrong or Expired Collection Tube should not be used
because the manufacturer could not warrant the quality of
the seal and pressure after the expiration date declared in
the tube.