CHAPTER 11 SPECIAL BLOOD COLLECTION  Response time for the collection of this test sample is determined

by EACH HOSPITAL or CLINIC and MAY VARY by laboratory tests

Special Techniques:
STAT SAMPLES
 Patient preparation
 Timing of sample collection  Latin “STATUM or STATIN”
 Other blood collection techniques  Means immediately
 Sample handling  Sample is to be collected, analyzed, and results reported
Phlebotomist must know: IMMEDIATELY
 HIGHEST PRIORITY
 When these techniques are required  Usually ordered from the EMERGENCY DEPARTMENT or for a
 How to perform them CRITICALLY ILL patient whose treatment will be determined by
 How sample integrity is affected the lab result
COLLECTION PRIORITIES  Deliver samples promptly and notify lab personnel upon arrival.

Test order designations: FASTING SAMPLES

 Routine Fasting Basal State

 ASAP only refrained from Fasting + refraining
 Stat eating and drinking from EXERCISE
(EXCEPT WATER) for
 Timed
12 hours
 Collection lists and turnaround times for test results are based
 Drinking water is encouraged to avoid dehydration, which
on these designations
can affect lab results
 Phlebotomist must prioritize workload according to
 A patient who is NPO “nulla per os” – nothing through the
designations to accommodate test priorities
mouth- is not allowed to have food or water; Because of
possible complications with anesthesia during surgery or
ROUTINE SAMPLES
certain medical conditions
 Are tests ordered by the HC provider to DIAGNOSE AND
MONITOR patient’s condition. Test results most critically affected in a non-fasting patient
 Usually collected EARLY in the MORNING (morning extraction)
 Glucose
 Can be collected throughout the day during SCHEDULED  Cholesterol
SWEEPS (collection times) on the floors or from outpatients  Triglycerides / Lipid Profile
ASAP SAMPLES LIPID PROFILE
 “As soon as possible”  Triglycerides
 Cholesterol  Monitoring CHANGES in a patient’s CONDITION (e.g. such as
 Low Density Lipoprotein steady decrease in hemoglobin, platelet count, hematocrit)
 Measurement of cardiac markers following ACUTE
 High Density Lipoprotein myocardial
 Very Low Density Lipoprotein  Monitoring ANTICOAGULANT therapy
 Measuring substances that exhibit DIURNAL VARIATIONS (
*CHYLOMICRONS normal changes in blood levels at different times of the day)
 Determining blood levels of MEDICATION
Prolonged fasting INCREASES: Bilirubin and Triglycerides
GLUCOSE TOLERANCE TESTS
Prolonged fasting DECREASES: Glucose
Methods for diagnosis of diabetes mellitus/ gestational diabetes
 It is the responsibility of the phlebotomist to determine whether
 2-hour postprandial glucose test
the patient has been fasting for the required length of time
 Classic glucose tolerance test.
 If the patient has not fasted, REPORT to a SUPERVISOR or the
NURSE 2-hour postprandial glucose test
 If the decision is made to collect a nonfasting sample it is NOTED
ON THE REQUISITION FORM  Compares a patients FASTING GLUCOSE LEVEL with
GLUCOSE LEVEL 2 hours AFTER eating a meal with HIGH
# LIPEMIC SAMPLES (LIPEMIA) is an indication that the patient CARBOHYDRATE CONTENT.
was not fasting and may interfere with lab testing.
CLASSIC GTT
 Patients drink a standard glucose load and return for testing
TIMED SAMPLES on an HOURLY basis up to 6 HOURS in length.
 Blood is drawn at specific times AMERICAN DIABETES ASSOCIATION (ADA) and World HEALTH
 Phlebotomist should be available at the specified time an ORGANIZATION – standardized and shortened the methods used
should record actual time of collection on the REQUISTION for the diagnosis of HYPERGLYCEMIA. This include:
and SAMPLE TUBE
 2-hour OGTT
 If samples are collected too early or too late results may be
falsely elevated or decreased.  1-step and 2-step methods (gestational diabetes)
 Phlebotomist should be aware the variation in the procedures
 Misinterpretation of results can cause improper treatment
and follow institutional protocol for instructing patients,
Reasons for timed samples: administering the glucose loads and setting up sample
collection schedules
 Measurement of body’s ability to METABOLIZE a particular
substance (e.g. OGTT) GTT PREPARATION
BEFORE THE TEST: 4. Ask the patient to drink the appropriate glucose solution WITHIN
5 MINUTES. SMALL AUDLTS and CHILDREN may have adjusted
- Patients should be instructed to eat a BALANCED DIET ( 150
amounts based on 1g GLUCOSE/ KILOGRAM of WEIGHT. Oral
g/ day of CARBOHYDRATES for 3 DAYS)
glucose loads may vary when testing for gestational diabetes.
- Fasting includes abstaining from food and drinks including
coffee and unsweetened tea except water (FAST for 12 5. TIMING for the remaining collection times BEGINS when patient
HOURS; NOT MORE THAN 16 HOURS BEFORE AND DURING FINISHES DRINKING the glucose solutions. Outpatient are given a
THE TEST) copy of the schedule an instructed to CONTINUE FASTING, to
 phlebotomist should ask patient about medications because DRINK WATER and REMAIN in the drawing station area.
some medications can interfere with the tests this includes:
6. Collect remaining samples at schedules times. TIMING of sample
 Alcohol
collection is CRITICAL, because test results are related to the
 Anticonvulsants scheduled times; DISCREPANCIES should be noted on the
 Aspirin REQUISITION
 Birth Control pills
 Blood pressure medications 7. The TYPE OF EVACUATED TUBES used for blood collection must
 Corticosteroids be CONSISTENT. Collect in Gray stopper tubes if blood samples are
 Diuretics not tested until the end of the sequence. CONSISTENCY OF DERMAL
 Estrogen-replacement pills PUNCTURE OR BENIPUNCTURE must also be maintained (glucose
values differ per type of blood). “FASTING” VENOUS BLOOD are
 AVOIDED BEFORE and DURING the test because they
STIMULATE DIGESTION and may cause inaccurate test preferred.
results: 8. Corresponding labels containing ROUTINELY REQUIRED
 Smoking INFORMATION and SAMPLE ORDER (1-hour, 2-hour and 3-hour)
 chewing tobacco are placed on blood samples. Some HC provider request 1/2 –hour
 alcohol blood sample and urine samples to be collected and tested with
 sugarless gum, and each sample.
 vigorous exercise
9. During scheduled sample collections, phlebotomists should also
GTT PROCEDURE observe patients for any changes in their condition. (e.g. dizziness –
reaction to the glucose and should report any changes to a
1. Identify patient and explain procedures supervisor)
2. Confirm fasting ( 12 hrs not exceeding 16 hours) 10. Some patients may not be able to tolerate the glucose solution,
3. Draw FASTING GLUCOSE SAMPLE. The FBS is tested before if vomiting occurs, the TIME OF VOMITING must be reported to a
continuing to determine if patient can safely be give a large amount SUPERVISOR and the HC PROVIDER is contacted for a decision to
of glucose continue or not. Vomiting early in the procedure is most critical and
the tolerance test is discontinued in most situations.
11. Transport samples to lab immediately. Samples not collected in  (1) a 50-g glucose challenge load is administered to the
gray stopper tubes must be centrifuged or tested within 2 HOURS fasting patient and blood collected and tested at 1-hour
of collection for reliable results. postigestion.
 (2) administered on a different day, consist of either: ( based
* Timing of inpatient glucose tolerance test collections is the
on institution protocol and HC provider preference)
responsibility
 A 75-g OGTT (2 hour) NV: 155mg/dL
*Outpatients must understand the importance of adhering  100-g 3 hour OGTT NV:140 mg/dL
*when collecting glucose tolerance test samples, closely observe the LACTOSE TOLERANCE TEST
patient for symptoms of hyperglycemia or hypoglycemia.
 Evaluates a patient’s ability to digest lactose (milk sugar)
2-Hour Oral Glucose Tolerance Test  The enzyme MUCOSAL LACTASE converts LACTOSE into
 The OGTT is now the recommended method for the GLUCOSE AND GALACTOSE
diagnosis of DIABTES MELLITUS.  Patients without it are unable to break down lactose from
milk products this results in GASTROINTESTINAL
Procedure: collection of a fasting glucose sample, having the patient DISCOMFORT AND DIARRHEA
drink a 75-g glucose solution within 5 minutes and return for an  This test diagnose LACTOSE INTOLERANCE
additional glucose test in 2 hours.  Procedure: the patient drinks a standardized amount of
Indicative of diabetes mellitus: equal or greater than 200 mg/ dL LACTOSE based on BODY WEIGHT
 Blood collection schedule is similar to a 2hr GTT.
One- and Two- Step Method for Gestational Diabetes  Glucose levels will raise no more than 20mg / dL from
 Timing for these tests may vary with institutions and HC fasting sample result if lactose intolerant
providers. DIURNAL VARIATIONS
 It is important for phlebotomist to check with a supervisor
for any request she is not familiar with. Substances and cell counts affected by diurnal variations:
 Corticosteroids
 Hormones
ONE-STEP METHOD  Serum iron
 Same procedure as the diagnostic OGTT  Glucose
 Wbc “EOSINOPHILS:
 NV: 140mg/dL
 Test these samples at specific times, usually corresponding to
TWO-STEP METHOD the PEAK DIURNAL LEVEL.
 Plasma cortisol level drawn at 8 am and 10 am is twice as high
 Requires the patient to receive two test.
than levels drawn at 4 pm.
 If sample cannot be collected at specified time, HC provider is  Ideally, trough levels are tested before administering
notified and test is rescheduled the next day the next dose to ensure that the level is low enough
for the patient to receive more medication
THERAPEUTIC DRUG MONITORING
 shortly after medication is given (peak level)- ensures
 Is the science of analyzing tissues or body fluids to determine that the drug is not at toxic level
the concentration of a prescribed drug present at a particular  The time for collecting peak levels varies with
time and correlating the concentration of a drug in that medication and method of administration. ( e.g. 30
compartment with its effect on the patient. min after IV, 1 hr after Intramuscular or 1-2 hrs after
 To ensure that a given dosage of a drug produces maximal oral dosage)
therapeutic benefit and minimal toxic side effects.  Information from drug manufacturers provides: half-life,
 Medications affect patients differently this results in the need to toxicity level and the recommended times for collection of
change dosages or medications peak levels.
 To ensure patient safety and medication effectiveness, blood  To ensure correct documentation of the peak and trough
levels of many therapeutic drugs are monitored levels, REQUISITION and SAMPLE TUBE labels should
include TIME and METHOD of administration of LAST dosage
Frequently monitored therapeutic drugs: given and TIME of blood sample was drawn.
 Digoxin  TDM collections are coordinated with pharmacy laboratory
 Phenobarbital and nursing staff.
 Lithium
*collection of blood in gel serum separator tubes has caused
 Gentamicin
FALSELY LOW LEVELS for certain medications. RED stopper tubes
 Tobramycin
are RECOMMENDED for TDM and samples should be transported in
 Vancomycin
UPRIGHT position.
 Dilantin
 AMikacin *TDM depends half life of medication and timing of peak levels
 Valproic Acid
BLOOD CULTURES
 Theophlline
 Methotrexate  One of the most difficult phlebotomy procedures is the
 Various antibiotics collection of blood cultures
 Because of the ASEPTIC TECHNIQUE required and the need
 Random samples are occasionally requested to collect multiple samples in special containers
 Most beneficial levels are:  False positive could be from skin contamination and not
 drawn before the next dosage is given/ “trough levels” – from the actual infection.
are collected immediately before the drug is to be given  Are requested on patients when symptoms of fever and
and represent the lowest level in the blood and ensure chills indicate a possible infection of blood by pathogenic
that the drug is in the THERAPEUTIC (effective) range. microorganisms. (SEPTICEMIA)
  Patient’s initial diagnosis is often FEVER OF UNKOWN  WINGED BLOOD COLLECTION with LUER adapter and a
ORIGIN (FUO). specially designed holder (for transferring blood directly
 Blood culture test can determine the microorganism causing from patient to bottles with culture media)
the infection and the most effective antibiotic to treat the  SYRINGE can be used for blood collection and aseptically
infection. transferred to blood culture bottles at bedside using a safety
transfer device
TIMING OF SAMPLE COLLECTION
 OSHA does not allow direct inoculation from syringe to the
 Usually ordered as STAT or as TIMED bottle.
 Isolation is often difficult due to the small number of  A HC provider may order blood cultures on a patient who is
organisms needed to cause symptoms on ANTIBIOTIC therapy. This requires blood to be collected
 Collected in SETS OF TWO drawn 30 or 60 minutes apart or using special blood collection systems. This include:
just before the patient’s temperature reaches its HIGHEST  ARD (antimicrobial removal devices) – contains resin
POINT (SPIKE). that inactivates antibiotics
 May vary per institution  FAN (fastidious antimicrobial neutralization) blood
 Concentration of microorganisms is highest just before the collection system – uses bottles that contain an activated
patient’s temperature spikes charcoal that neutralizes the antibiotic.
 This explains why collections may be ordered at specific  Blood cultures may be collected from IV lines by specially
time intervals or ordered stat if a pattern has been observed trained personnel.
in the temperature chart.  The recommended procedure is to collect one blood culture
 If antibiotics are to be started immediately, sets are drawn from the IV line and a second culture by venipuncture. Both
at the same time from different sites. sources must be documented according the facility’s policy.
 Samples drawn from DIFFERENT SITES at SAME TIME serve BLOOD CULTURE ANTICOAGULATION
as a control for possible contamination and must be labeled
as to the collection site and number in the series.  Anticoagulant are present in blood culture bottles or tube to
prevent microorganisms from being trapped within a clot.
COLLECTION EQUIPMENT Where they might be left undetected.
 Can be drawn directly into bottles containing culture media  this is why blood cultures must be mixed after the blood is
 Can be drawn into sterile yellow stopper evacuated tubes added
with anticoagulant, sodiumpolyanethol sulfonate, and  SPS (sodiumpolyanthol sulfonate) is used for blood culture
transferred to culture media in lab. because
 Each set should be collected in the same manner as the first  They do not inhibit bacterial growth
set  Enhance bacterial growth by inhibiting the action of
phagocytes, complement and some antibiotics.
 Other anticoagulants are not used because bacterial growth
may be inhibited.
*Blood collection bottles should be transported to the lab for creating a friction on the skin, which is effective in skin
testing ASAP, particularly the ARD and FAN antisepsis.
 Chlorhexidine gluconate is NOT recommended for infants
CLEANSING THE SITE
younger than 2 months
 The venipuncture technique for collecting blood cultures
*follow the manufacturer’s instructions when using commercially
follows the routine procedures EXCEPT for the INCREASED
packaged venipuncture site blood culture prep kits
ASEPTIC PREPARATION of the puncture site.
 Contamination of blood culture bottles with skin bacteria *Phlebotomists should take every precaution not to retouch the
could interfere with the interpretation of the test results. puncture site after it has been cleaned. If the vein must be
 Antiseptics for disinfecting : repalpated, the gloved finger must be cleaned in the same manner
 2% Iodine tincture as the puncture site.
 Povidone-iodine
 The tops of the blood culture bottles also must be cleaned
 Multiple isopropyl alchohol preps
before inoculating with blood.
 Chlorhexidine gluconate
 Rubber stoppers can be cleaned using alcohol and allowed
- All are equally effective in killing bacteria on the skin
to dry before use or as recommended by manufacturer
 Following institutional policy and strict adherence to aseptic
 The alcohol pad remain on the bottle until inoculation
technique ensure that a positive blood culture is not caused
 Iodine should not be used on the stoppers because it can
by external contamination
enter the culture during sample inoculation and may cause
 Cleansing of site begins with VIGOROUS SCRUBBING of the
deterioration of some stoppers during incubation
site for 1 MIN using ISOPROPYL ALCHOL
 It is followed by scrubbing the site with 2% iodine tincture SAMPLE COLLECTION
or povidone-iodine for another MINUTE starting in the
 Two samples are routinely collected for each set
CENTER of the venipuncture site and progressing outward 3
to 4 INCHES in CONCENTRIC CIRCLES.  One to be incubated AEROBICALLY and the other
ANAEROBICALLY.
 Allow iodine to dry on the site for at least 30 SECONDS. To
prevent irritation of the patient’s arm and iodine’s possible  SYRINGE: ANAEROBIC bottle should be inoculated first
adverse effect on THYROID and LIVER  WINGED BLOOD COLLECTION SET: AEROBIC bottle is
 The iodine is removed with alcohol when the procedure is inoculated first so that the air in the tubing does not enter
complete the anaerobic bottle.
 Chlorhexidine gluconate/ isopropyl alcohol is becoming  Filling bottles directly through an ETS is not recommended
more routinely used in many HC facilities because of the because of the possibility of broth media refluxing back into
frequency of iodine sensitivity ; It is a one-step application the vein. It is also difficult to ensure that the correct volume
using a commercially prepared swab or sponge. The site is of blood has been collected.
scrubbed 30 to 60 seconds in a BACK-and-FORTH motion
 *failure in proper inoculation procedure is most crictical for the 8. Release tourniquet
anaerobic sample because the addition of air to the anaerobic
9. Sterilize the site using chlorhexidine gluconate. Creating a
bottle will kill any anaerobic organisms present.
friction, rub for 30-60 seconds and allow o air dry at least 30
 Pediatric blood culture volume requirements are based on seconds for better antisepsis
the child’s weight and pediatric bottles
10. Assemble the equipment while antiseptic is drying. Attach
 Draw 1mL of blood for every 5kg (approx. 10lbs) of patient
needle to syringe.
weight.
 The sample of a child heavier than 45kg is treated as an 11. Remove plastic cap on culture bottles ad confirm the volume of
ADULT. blood required from the label
 Draw 1mL of blood on babies weighing less than 5kg and
12. Clean the top of the bottle with a 70% isopropyl alcohol pad and
place all of the blood in one pediatric bottle.
allow to dry
 At Least a 1:10 ration of blood to media.
 Adult Blood culture bottles usually require 8 to 10 mL for 13. Reapply the tourniquet and perform venipuncture. Do NOT
each repalpate without cleansing the palpating finger in the same
 Pediatric bottles require 1 to 3 mL manner as the puncture site
 The label contains the volume of blood required. 14. Release the tourniquet. Place gauze over the puncture site and
Phlebotomists should follow instructions for the system apply pressure
being used.
 Overfilling of bottles should be avoided because they may 15. Activate the safety device or remove the syringe needle with a
cause false-positive results with automated systems. Point-Lok device
 Underfilled blood culture bottles may cause false-negative 16. Attach safety transfer device
results
17. Inoculate the anaerobic blood culture bottle when using syringe
BLOOD CULTURE SAMPLE COLLECTION or second when using Winged collection set
1. Obtain & examine requisition form 18. Dispense the correct amount of blood into bottles. Some
2. Greet patient and explain procedure institutions require documenting the amount of blood dispensed.

3. Correctly identify the patient ( 2 identifiers) 19. Mix the blood culture bottles by gentle inversion eight times

4. Prepare the patient and verify allergies 20. Fill other collection tubes after the blood culture tubes

5. Select equipment 21. Clean the iodine off the arm with alcohol if necessary

6. Wash hands and don gloves 22. Label the samples appropriately and include the site of
collection. Verify identification with the patient.
7. Apply the tourniquet and locate site
23. Dispose of used equipment and supplies in biohazardous  The lumen’s not being used should be clamped to avoid
container. contamination of the sample
 An occlusive waterproof dressing covers the insertion site.
24. Check the venipuncture site for bleeding and bandage the
patient’s arm  Flushes are necessary to maintain patency of the CVC

25. Thank the patient, remove gloves and wash hands.

2. Tunneled/ cuffed CVC
BLOOD COLLECTION FROM CENTRAL VENOUS CATHETERS
(CVCs)  Considered more permanent and is used for long-term dwell
times (e.g. chemotherapy)
 Blood samples may be obtained from indwelling lines called  Type of external catheters: Broviac, Hickman and Groshong
CVCs catheters ( single, double or triple lumen)
 Performed only by specially trained personnel and physician  A surgeon performs a cut-down of the vein with local or IV
authorization is required. sedation and tunnels the catheter tip in the Superior vena
 CVCs are special type of catheter that is inserted by a cava
Physician or a certified health care professional either  A sterile dressing is applied over the insertion site
internal or external into a large blood vessel.  Dressing changes and flushing with heparin or saline are
 CVCs can be used for administration of fluids, drugs, blood required for maintenance
products, and nutritional solutions and to obtain blood.
3. IMPLANTED PORT
 Catheters are flushed with saline/ heparin to prevent
thrombosis when blood collection is completed  This is a small chamber attached to a catheter that is more
 STERILE technique procedures must be strictly followed permanent
when entering IV lines, because they provide a direct a path  For long term access to the central venous system for a
for infectious organisms to enter the patient’s bloodstream patient requiring frequent IVs or receiving chemotherapy.
TYPES OF CVCs  A surgeon implants the port in subcutaneous tissue under
the skin, usually at the collar bone with the catheter tip
1. Nontunneled, noncuffed CVC placed in the superior vena cava using local or IV sedation
 Short-term dwell times  It consists of a self-sealing septum housed in a metal or
plastic case
 Inserted through the skin into the JUGULAR, SUBCLAVIAN or
FEMORAL vein and threaded to the SUPERIOR VENA CAVA  The self-sealing septum of the port withstands 1,000-2,000
by a physician during surgery or in a hospital room with needle punctures
local anesthetic.  Only specially designed noncoring needles can be used. This
 It can be single-, double-, triple-lumen catheter. needle has a deflected tip and is configured at a 90-degree
angle
 For multilumen catheters, PROXIMAL lumen is the preferred
from which to obtain a blood sample.  Single or double lumen
  Advantage: there is no visible catheter tubing and no site - Drawing coagulation tests from venous catheter is not
care is needed. It is flushed monthly with heparin or saline recommended. but if it is necessary they should be collected
after 20mL ( or 5-6 times the dead space volume of the
4. Peripherally Inserted central catheters
catheter of blood) has been discarded or used for other test
 Is placed in the basilica or cephalic vain of the antecubital - Reinfusion of blood (instead of discarding) from CVADs for
area of the arm lab draws is an ALTERNATIVE procedure for patients in
 The tip threaded into Superior Vena Cava hospital on the BLOOD CONSERVATION PROGRAM. This
 Can be placed by IV team nurses or physician. procedure uses a THREE-WAY STOPCOCK DEVICE with a
 Can be used for weeks to months sterile syringe attached to reinfuse the blood/ saline back to
 The catheter is threaded through an introducer needle 6-10 the patient
inches of catheter exposed and covered by an occlusive - The order of tube fill may vary slightly to accommodate the
dressing amount of blood that must be drawn before coagulation test.
 There is an antireflux valve connector device attached to the - Blood cultures are always collected FIRST. They are drawn
end of the catheter where the IV is connected or blood from CVCs primarily to detect infection of the catheter tip
samples are removed and should be compared with results from blood cultures
drawn from a peripheral vein.
 Advantage: few risks and causes minimal discomfort to the
- ORDER OF DRAW
patient
1. First syringe- 5mL, discard or conserve
 Disadvantage: catheter walls are easily collapsed
2. Second syringe- blood cultures
3.Third syringe-anticoagulated tubes (light blue, lavender,
BLOOD SAMPLE COLLECTION green and gray)
4. Clotted tubes (red and serum separator tube)
- Blood sample collection for lab testing can be routinely
drawn from CVADs - If blood cultures are not ordered, the coagulation tests (light blue)
- A HC provider’s order is required for the first time access of can be collected with a new syringe after the other samples have
a newly inserted CVAD. been collected using the order shown earlier.
- Blood sample collection may be drawn from peripheral
-Phlebotomist assist the nurse who is collecting blood from the CVC
venous access devices only at the time of insertion.
and should understand sample collection requirements.
- Blood samples are not collected from indwelling peripheral
or midline catheters The source of the sample is noted in the requisition form.
- The IV fluids administered should be stopped for 5 minutes
*When blood is collected from a CVAD blood should not be left in
before collecting blood sample
- Syringe larger than 20mL should not be used because of the the syringe while extensive flushing of the CVAD is performed
high negative pressure the catheter wall may collapse
- The first 5mL ( or two times the dead space volume of the
catheter) volume of blood must be discarded or conserved
*Flushing CVC is performed to ensure and maintain patency of the 12. Remove syringe and apply a NEW EMPTY SYRINGE to the SAME
catheter and to prevent mixing of medications and solutions that stopcock port. ( the inside of the 1st syringe is contaminated by the
are incompatible. plunger and must be changed to keep blood clean to reinfuse)
Blood Sample Collection from CVAD 13. Turn stopcock to off position to the unaccessed port. Unclamp
lumen. Aspirate 5mL blood into empty syringe. (leave attached)
1. Verify patient’s identity (2 identifiers)
14. Attach another empty syringe to the 2nd stopcock port
2. Explain procedure and position the patient (SUPINE)
15. Turn stopcock to off position to the blood filled syringe
3. Assemble supplies
16. Draw blood sample into empty syringe
4. Wash hands don STERILE gloves. Maintain ASEPTIC technique
17. Reinfuse blood from previously filled syringe
5. Discontinue administration of all infusates prior to collection. If
the lumen to be used for lab draws has an infusion cap, cap the 18. Remove stopcock and syringe. Cleanse injection cap with
tubing with a male/female cap when disconnecting alcohol pad
6. When drawing from multilumen catheters, PROXIMAL lumen is 19. Attach prefilled saline syringe and flush with 18 to 19 mL saline
preferred. Use clamp on lumen to control blood flow and help
20. If IV infusion has been disconnected, remove protective cap
eliminate confusion with the stopcock
from tubing and reconnect infusion tubing
7. Attach a 10mL prefilled saline syringe to a three-way stopcock.
21. Resume all infusions in all lumens
PRIME the stopcock with saline
22. Connect a blood transfer device to the collection syringe and
8. Disinfect injection cap with alcohol wipe. Using vigorous friction,
insert into evacuated tubes. Allow each tube to fill completely and
scrub on the top and in the grooves for 15 SECONDS. If lab draw is
according to order of fill
for blood cultures, scrub injection cap with alcohol wipe for 30
SECONDS 23. Label tube and confirm with patient
9. Attach stopcock with syringe to injection cap 24. Prepare sample and requisition for transport to the lab
10. Unclamp lumen and flush with remainder of saline. If the only 25. Dispose of used supplies in biohzarad container
lumen to draw blood has Total Parenteral Nutrition infusing, flush
26. Remove gloves, wash hands and thank the patient.
with 18 to 19 mL of Saline
*If there is uncertainty about the integrity of the blood to be
11. Clamp lumen and/or turn stopcock to off position to syringe
reinfused (contaminated or clotted), the blood is discarded
port
*Potential test error can occur when blood is obtained from CVAD
due to HEMOLYSIS caused by AIR LEAKS when using incompatible
blood collection components an INCOMPLETE FLUSHING of the blood into appropriate blood sample tubes using a blood transfer
collection site causing CONTAMINATION or DILUTION device if a syringe is used. Mix the blood by GENTLE INVERSION 3-
8 times
BLOOD COLLECTION FROM AN IMPLANTED PORT
11. Flush the needle and port with 10mL of saline
1. Verify patient’s identity (2 identifiers)
12. Change syringes and flush with 3mL HEPARINIZED saline
2. Assemble equipment
13. Remove the needle and apply a STERILE DRESSING over the site
3. Palpate shoulder area to locate and identify the septum of the
access port 14 Label samples and confirm with patient, remove gloves and
wash hands
4. Prepare the area with a VIGOROUS scrub using CHLORHEXIDINE
GLUCONATE applicator. If using ALCHOL and IODINE pads, prep in 15. Prepare sample and requisition form for transport. Dispose
a CIRCULAR motion from within to outward, approx. 4 to 6 inches. used supplies
Allow IODINE to dry COMPLETELY.
16. Thank patient
5. Connect the NONCORING needle tubing on the end of one 10mL
SPECIAL SAMPLE HANDLING PROCEDURES
saline flush syringe and prime the needle with saline until it is
expelled COLD AGGLUTININS
6. Locate the septum of the port with the NONDOMINANT hand;  are AUTOANTIBODIES produced by persons infected with
firmly anchor the port BETWEEN THUMB and FOREFINGER. MYCOPLASMA PNEUMONIAE (atypical pneumonia) or with
AUTOIMMUNE HEMOLYTIC ANEMIAS.
7. Holding the noncoring needle with the other hand, puncture the
 These autoantibodies react with RBC at temperature BELOW
skin and insert the needle at a 90 degree angle into the septum
BODY TEMPERATURE. They ATTACH to RBC when blood
using firm pressure. Advance the needle until RESISTANCE is met
cools below body temp
and the needle TOUCHES the BACK WALL of the port
 Samples must be kept warm until the serum can be separated
8. Inject 1 to 2 mL SALINE, observe area for SWELLING and EASE of from the cells.
FLOW; if swelling occurs, REPOSISTION the needle in the port  They are collected in tubes that have been warmed in an
without withdrawing it from the skin. If there is no swelling, incubator at 37oC for 30 mins. that contain NO ADDITIVES or
ASPIRATE for blood return. If blood return is observed continue to GELS
flush with saline  Tubes are carried in a warm container or TIGHTLY CLOSED
FIST.
9. Using the same syringe, aspirate 10 mL of blood and discard or
 Collect samples as quickly as possible and return sample to lab
conserve it. If samples is for coagulation studies discard 20mL.
and place it back in incubator
10. Attach the syringe or evacuated tube holder to the needle tubing  Small portable heat blocks that have been warmed to 37oC are
and collect the blood necessary for ordered lab tests. Dispense the available for transporting samples
  FAILURE to keep sample warm before serum separation will  CLSI recommends not chilling ABG unless in conjunction
produce FALSELY DECREASED TEST RESULTS with LACTIC ACID, when they have been collected in
 CRYOFIBRNOGEN and CRYOGLOBULIN are two proteins that PLASTIC syringes and analyzed within 30 minutes
PRECIPITATE when cold and must be collected and handled in  For adequate chilling, sample is placed in CRUSHED ICE or a
same manner as Cold agglutinins MIXTURE of ICE and WATER or in a UNIFORM ICE BLOCK at
bedside
CHILLED SAMPLES
 Placing in large ice cubes is NOT ACCEPTABLE because
 Chilling INHIBITS METABOLIC PROCESSES that continue UNIFORM CHILLING will NOT occur because part of the
after blood collection sample to freeze resulting in HEMOLYSIS
 Samples that require chilling:  Immediately transport to lab for processing
 Ammonia
SAMPLES SENSITIVE TO LIGHT
 Lactic Acid
 Aceton  Exposure to ARTIFICIAL LIGHT or SUNLIGHT (UV) for ANY
 Free Faty Acid LENGTH of time may DECREASE the concentration of
 Pyruvate various analytes
 Glucagons  SAMPLES SENSITIVE TO LIGHT:
 Gastrin  Bilirubin
 ACTH  Beta-carotene
 PTH  Vitamin A
 RENIN  Vitamin B6
 Angiotensin-converting enzyme  Vitamin B12
 Catecholamine  Folate
 Homocysteine  Poryphyrins
 Some coagulation studies  Wrap tubes in ALUMINUM FOIL or using AMBER sample
 Arterial Blood Gases (IF INDICATED) container
 Chilling is contraindicated for some analytes *BILIRUBIN is RAPIDLY destroyed in samples exposed to light
 POTASSIUM levels will FALSELY INCREASE if sample is and DECREASE up to 50% after 1 HOUR exposure
chilled; thus WHOLE BLOOD samples collected for
electrolytes must be collected in a SEPARATE tube when LEGAL (FORENSIC) SAMPLES
ordered with other tests that require chilling  Drawing samples for test results that may be used as
 Chilling blood samples for Prothrombin time, PT (INR) EVIDENCE in legal proceedings,
testing is unacceptable as it may cause ACTIVATION of  Documentation of sample handling “CHAIN OF CUSTODY” is
FACTOR VII essential
  Special forms are provided for this documentation and
special containers and seals may be required
 DOCUMENTATION:
 Date
 Time
 Identification of handler
 Patient identification and sample collection should be done
in the presence of a WITNESS (Law enforcement officer)
 IDENTIFICATION: (paternity cases)
 Fingerprinting
 Heel printing
 Most frequent test: ALCOHOL and DRUG levels and DNA MOLECULAR DIAGNOSTICS
ANALYSIS  Health-care systems, work places, universities, and colleges
BLOOD ALCHOL SAMPLES may require scheduled or random drug screening.
 the field is rapidly expanding from blood testing of DNA for
 Blood alcohol levels may be requested on a patient for paternity and body fluid DNA in criminal cases
medical reason legal reason or as a part of an employee drug  Samples collected by swabs for identification of
screening microorganism, blood samples are collected for HIV and
 Chain of custody protocol is strictly followed hepatitis C virus viral loads, diagnosis of hematological
 Cleansing of site disorders, coagulation disorders and management of
 soap and water warfarin (coumadin) therapy and identification of genetic
 nonalcoholic antiseptic solution (BENZALKONIUM disorders
CHLORIDE/ ZEPHIRAN CHLORIDE)  YELLOW stopper tubes containing ACID-CITRATE-
* Tincture of Iodine and Chlorhexidine gluconate contain alcohol DEXTROSE are commonly used for DNA PATERNITY
and should NOT be used to clean the site for blood alcohol levels TESTING
 EDTA or Sodium Citrate may be required in some
 tubes are completely filled and not uncapped for longer than procedures
necessary to prevent escape of the volatile alcohol
 are frequently collected in GRAY STOPPER tube with * Yellow stopper with SPS is not acceptable for molecular
SODIUM FLUORIDE diagnostic testing

DRUG SCREENING
  URINE is the sample of choice because of the EASE of
collection and because substance REMAINS in the urine for
a LONGER period of time
 Documenting chain of custody is essential
 Sample substitution, contamination or dilution must be
prevented
* Technical errors and failure to follow chain of custody protocol
are primary targets of defense in legal proceedings