Venipuncture Materials

Materials:
1. Tourniquet
To draw blood you have to first locate or palpate the vein and using the tourniquet
is the most common way of doing this. Tourniquets do this by impeding venous blood
flow but not arterial blood flow in the area just below where the tourniquet is applied
thus making the veins palpable. Most commonly used are flat latex or vinyl strips. They
are inexpensive and maybe disposed of between patients or reused if disinfected. Other
tourniquets with Velcro and buckle closures are easier to apply but are more difficult to
decontaminate. The advantage of buckle closure is it stays on the patient’s arm after
release and retightened if necessary. Blood pressure cuffs may also be used. They are
used primarily for veins difficult to locate. The cuff should be inflated to approximately
40 mmHg.

2. Disinfecting agent
Antiseptic (refers to agent used to clean living tissue) and disinfectant (refers to
an agent used to clean a surface other than living tissue) are used to reduce the risk of
infection. The most commonly used antiseptic is 70% isopropyl alcohol (isopropanolol)
which is also bacteriostatic. For maximal effectivity is should be left for about 30 sec.
to 60 sec. For blood culture, blood donation, blood alcohol levels and even arterial
puncture other antiseptics are used such as povidone-iodine. Chlorhexidine gluconate
or benzalkium chloride is also used for blood culture if the patient is sensitive to iodine.
Since these chemicals are harsher, they might cause skin irritation, thus they should
be washed off with alcohol.

3. Needles
Parts of the needle are the following (Fig. 3):
a. Point- the sharp tip portion provides smooth entry into the skin
b. Bevel- or angle eases the shaft into the skin and prevents the needle from
coring out a plug of tissue
c. Shaft- refers to the length which range from ¾ inches for butterfly needles to
1 to 1½ inches for standard needles. The gauge refers to the diameter
of the needle’s lumen: the higher the gauge number, the smaller the
lumen; the smaller the gauge number, the bigger the lumen. The
smallest needle used for venipuncture is 23g for small, fragile veins. A
typical gauge for routine adult collection is 21g. Blood bank uses 16g
needles for collection. Large needles deliver blood more quickly but are
more damaging to the tissue and may collapse the vein. Small needles
are less damaging but the collection is slower and the blood cells maybe
hemolyzed as they pass through the narrower opening.
d. Hub- provides the attachment of the needle to the collecting tube or syringe

A. Multisample needles- for evacuated tube system (ETS) or vacutainer method.

The needle is double-ended. While one tip penetrates the patient’s skin, the
second tip pierces the rubber cap of an evacuated test tube (Fig. 4 & 5). The
 retractable sleeve covers the second needle when it is not inserted into a tube. It
also keeps blood from leaking into the adapter or tube. To prevent accidental
needle injuries, some needles have attached needle-safety devices or retractable
devices.

B. Syringe needles- used for syringe method

3. Adapters or needle holders- for the ETS method. It is a translucent plastic cylinder
with one small end opening for the needle and the other for the collection tube.

4. Syringe- it is sometimes useful for patients with fragile or small veins when the
vacuum of the evacuated tube is likely to collapse the vein (for parts of the syringe, see
fig. 3.)

5. Butterfly or winged infusion set- is used for small veins such as those in the hand,
elderly or pediatric patients (fig. 6).

Figure 3. Parts of the syringe and needle. Figure 4. Parts of a multisample

needle

Image sources: www.pinterest.com

Figure 5. Evacuated tube system (ETS)

 Figure 6. Butterfly needle attached to an adapter

Image sources: www.google.com

6. Evacuated collection tubes

 These are the color-coded tubes used in the different sections of the laboratory.
Each type of tube may contain additives which are chemicals designed to promote or
prevent changes in the blood sample. Which tube to use depends on the tests and it is
crucial for the phlebotomist to memorize which is which.

The tubes are either made of plastic or glass. But most tubes nowadays are
plastic for transportation safety reasons. Tubes are evacuated so that a measured
amount of blood may flow in easily. Tube size ranges from 2 mL to 10 mL. Choosing
and filling the best tube size depends on the test. However, 5 mL tubes are more than
enough for most routine tests. Tubes also contain expiration date and unused tubes
must be discarded when they expire because they have decreased vacuum, preventing
proper fill, or the additives might have been degraded.

Tube additives
All evacuated tubes have additives except for the red-stopper glass tube.
Additives include anticoagulants, chemicals that prevent coagulation, clot activators to
promote clotting, thixotropic gel to separate components and preservatives or inhibitors
of various cellular reactions to maintain the integrity of the specimen. Tubes with
additives should be inverted gently and repeatedly right after collection (Fig 7). Table 9
lists the various, most commonly used tube additives with their mechanism of action,
color codes and uses.

Table 9. Tube color and anticoagulants

Stopper color Anticoagulant/Additive Mechanism of action Specimen type/uses
and test examples
Red (glass) None None Serum/ Chemistry
and serology- most
tests
Red (plastic) Clot activator Silica clot activator Serum/Chemistry
and serology-most
tests
Lavender (glass) K3EDTA (liquid form) Chelates calcium Whole
(plastic) K2EDTA(spray coated) blood/Hematology-
ex. CBC
Light blue 3.2% or 3.8% Sodium Chelates calcium Plasma/Hematology-
citrate (tube must be ex. Coagulation tests
filled accordingly to
maintain 9:1 ratio of
blood to anticoagulant)
Green Heparin combined Inhibits thrombin Plasma or whole
with either sodium, formation blood/Chemistry
lithium or ammonium ex. ABG
Gray Potassium Oxalate Chelates calcium Plasma/Chemistry
(anticoagulant) plus ex. Glucose tests
sodium fluoride Antiglycolytic
(additive-preservative) (preserves glucose
for 3 days)

Gold or Red-Gray Clot activator and Promotes clot Serum/Chemistry

serum separator gel and Serology- most
tests
 Yellow/Sterile Sodium Polyethanol Chelates calcium and Whole
*color depends on Sulfate (SPS) aids in bacterial blood/Microbiology
the manufacturer recovery by inhibiting ex. Blood culture and
but blood c/s complement, sensitivity
containers come in phagocytes and
bottles not tubes certain antibiotics
Yellow Acid citrate dextrose Chelates calcium; Whole blood/Cellular
the dextrose or cytogenetics
preserves the red studies
cells ex. HLA typing
Pink K2EDTA Chelates calcium Whole blood or
plasma/Blood
banking
ex. Compatibility
testing
Black Sodium citrate (4:1) Chelates calcium Whole
blood/Hematology
ex. Erythrocyte
Sedimentation Rate

Order of draw
Multiple tests require different test tubes. Proper sequence is important to
prevent the transfer or contamination of the additive from the previous tube. For this
reason, the order of draw was implemented. Syringe method and the ETS follow the
same order (table 10).

Table 10. Order of draw

Tube additive/color Rationale
1. Sterile/yellow this prevents the transfer of unsterilized material from other tubes
into the sterile tube
2. Citrate/light blue always drawn before any other anticoagulants or clot activators
because other additives might interfere with the coagulation
testing
3. Plain/SST/red must not be contaminated with anticoagulants for clotting
4. Heparin/green heparin is less likely to interfere with EDTA than vice versa
5. EDTA/lavender binds many metals aside from calcium thus might give falsely low
or high results in some tests so it is drawn near the end
6. Fluoride/gray since this contains potassium oxalate it will cause increased
potassium levels, the oxalate damages the red cell membrane and
the antiglycolytic fluoride elevates sodium and inhibits many
enzymes

Ideally the number of tube inversions depends on the tube. For Citrate= 4 inversions
(gently), for EDTA, Heparin, Fluoride, SPS= 8-10 inversions; for tubes with clot
activators plastic red or SST= 5 inversions and no inversion for plain glass red tube. As
a guide for proper inversion, refer to figure 7a.
 Fig. 7a. Proper Inversion Technique

Image source: www.google.com

7. Needle disposal containers

Puncture-proof needle disposal containers must be available in the phlebotomy
tray or extraction area for proper disposal of used needles. Aside from being puncture-
proof, the containers must be sealable, leakproof and labeled with the biohazard symbol.

8. Other materials include gloves, cotton, gauze pads and bandages/micropore.

9. Vein locating device

The device emits infrared light and is absorbed by hemoglobin in the veins and
surrounding tissues which allows the phlebotomist to distinguish the veins and tissues.
This device assists the phlebotomist in locating the veins especially in certain patients.

Procedure for routine venipuncture

Venous Puncture Technique
1. Verify that computer-printed labels match requisitions. Check patient
identification band against labels and requisition forms. Ask the patient for his or
her full name, address, identification number, and/or date of birth.
2. If a fasting specimen or a dietary restriction is required, confirm patient has fasted or
eliminated foods from diet as ordered by physician.
3. Position the patient properly. Assemble equipment and supplies.
4. Apply a tourniquet and ask the patient to make a fist without vigorous hand pumping.
Select a suitable vein for puncture.
5. Put on gloves with consideration of latex allergy for the patient.
6. Cleanse the venipuncture site with 70% isopropyl alcohol. Allow the area to dry.
7. Anchor the vein firmly.
8. Enter the skin with the needle at approximately a 30-degree angle or less to the arm,
with the bevel of the needle up:
a. Follow the geography of the vein with the needle.
b. Insert the needle smoothly and fairly rapidly to minimize patient discomfort.
c. If using a syringe, pull back on the barrel with a slow, even tension as blood
flows into the syringe. Do not pull back too quickly to avoid hemolysis or
collapsing the vein.
d. If using an evacuated system, as soon as the needle is in the vein, ease the
tube forward in the holder as far as it will go, firmly securing the needle holder
in place. When the tube has filled, remove it by grasping the end of the tube
and pulling gently to withdraw, and gently invert tubes containing additives.
9. Release the tourniquet when blood begins to flow. Never withdraw the needle without
removing the tourniquet.
10. Withdraw the needle, and then apply pressure to the site. Apply adhesive bandage
strip over a cotton ball or gauze to adequately stop bleeding and to avoid a hematoma.
11. Mix and invert tubes with anticoagulant; do not shake the tubes. Check condition
of the patient. Dispose of contaminated material in designated containers (sharps
container) using Universal Precautions.
12. Label the tubes before leaving patient’s side with:
a. patient’s first and last name
b. identification number
c. date of collection
d. time of collection
e. identification of person collecting specimen
13. Deliver tubes of blood for testing to appropriate laboratory section or central
receiving and processing area.

Important notes to keep in mind:

• Greet and identify your patient. Be polite and courteous. Introduce yourself and
explain why you are there- the tests to be made. Inquire if your patient has
allergies, is taking any medications, which might interfere with test results and
even in the stoppage of bleeding (warfarin, heparin or aspirin). ALWAYS make
your patient state their name.
 • Tourniquet should be placed 3-4 inches (4-5 finger widths) above the puncture
site. It should not be left on longer than 1 minute. Hemoconcentration results
from prolonged tourniquet application. Hemolysis can also be due to prolonged
or too tight application of tourniquet as well as the appearance of petechiae.
• Locate or palpate a vein of a good size that is visible, straight and clear. The
median cubital vein lies between muscles and is usually the most easy to
puncture. This is the first choice since it is in the middle, is large and well
anchored. The cephalic vein, on the same side of the arm as the thumb, is the
second choice. It can be hard to locate and is not that well anchored, so it has a
tendency to move. The basilic vein, on the same side of the arm as the pinky
finger, is the third choice. Under the basilic vein runs an artery and a nerve, so
puncturing here runs the risk of damaging the nerve or artery and is usually
more painful. DO NOT insert the needle where veins are diverting, because this
increases the chance of a hematoma. Blood can also be drawn from wrist and
hand veins, but these require smaller needle gauge or butterfly.
• Anchor the vein 1-2 inches below the venipuncture site and support by using the
thumb of your other hand. Hold the needle with your dominant hand, angle the
needle 15-30O above the skin.
• In using the ETS, push in the tube with the hand that anchored the vein. Use
your thumb to push the tube in, but be sure to pull back with your fingers on
the body of the adapter to prevent the needle in further.
• The tourniquet must be removed before the needle to prevent hematoma.

Figure 8a. The veins of the antecubital fossa

Skin Puncture

For routine tests requiring small amounts of blood, skin puncture is a simple
method by which to collect blood samples in pediatric patients, less than 2 years old
especially neonates. In the neonate, the heel is the preferred site. In older children, the
finger is the preferred site. The large amount of blood required for repeated
venipunctures may cause iatrogenic anemia, especially in premature infants.
Venipuncture of deep veins in pediatric patients may rarely cause (1) cardiac arrest, (2)
hemorrhage, (3) venous thrombosis, (4) damage to organs or tissues accidentally
punctured, (5) infection, (6) injury caused by restraining an infant or child during
collection and (7) reflex arteriospasm followed by gangrene of an extremity.

Skin puncture is also performed in extremely obese adults, burn patients,

patients with increased risk with thrombosis, point-of care-testing, geriatric patients
because their skin is thinner and less elastic to avoid hematoma.

However not all tests can be done using this method, such as blood culture and
coagulation tests. It should not be performed in swollen or edematous sites or where
circulation is compromised. Blood collected from skin puncture is a mixture of venous
blood and arterial blood, small amounts of tissue fluid may also be present especially
in the first drop of the blood.

Skin puncture devices are lancets- usually 2 mm (1.75 mm-preferred) depth, for
premature infants it is 0.65-0.85 mm. To minimize the risk of inflammation or infection,
the lancet should never penetrate more than 3 mm. Puncture width should not exceed
2.4 mm. At the right site, this achieves adequate blood flow but remains well above the
bone. Puncture width is actually more important than depth in determining blood flow,
because capillary beds may lie close to the skin, especially for newborns.

Microcollection tubes are used for small volumes, they hold up to 750 µL to 1 mL
blood. The tubes are also color coded just like the evacuated tubes. Capillary tubes or
microhematocrit tubes that hold 75 µL are also used in skin puncture. The order of
draw is as follows:
1. Blood gases
2. EDTA tubes
3. Other additives
4. Serum

Procedure for skin puncture

1. Select an appropriate puncture site.

a. For infants younger than 12 months old, this is most usually the lateral or
medial plantar heel surface.
b. For infants older than 12 months, children, and adults, the palmar surface of
the last digit of the second, third, or fourth finger may be used.
c. The thumb and fifth finger must not be used, and the site of puncture must
not be edematous or a previous puncture site because of accumulated tissue
fluid.
2. Warm the puncture site with a warm, moist towel no hotter than 42° C; this increases
the blood flow through arterioles and capillaries and results in arterial-enriched blood.
3. Cleanse the puncture site with 70% aqueous isopropanol solution. Allow the area to
dry. Do not touch the swabbed area with any nonsterile object.
4. Make the puncture with a sterile lancet or other skin-puncturing device, using a
single deliberate motion nearly perpendicular to the skin surface (fig. 9). For a heel
puncture (fig. 10), hold the heel with the forefinger at the arch and the thumb proximal
to the puncture site at the ankle. If using a lancet, the blade should not be longer than
2 mm to avoid injury to the calcaneus (heel bone).
5. Discard the first drop of blood by wiping it away with a sterile pad. Regulate further
blood flow by gentle thumb pressure. Do not milk the site, as this may cause hemolysis
and introduce excess tissue fluid.
6. Collect the specimen in a suitable container by capillary action. Closed systems are
available for collection of nonanticoagulated blood and with additives for whole blood
analysis. Open-ended, narrow-bore disposable glass micropipets are most often used
up to volumes of 200 μL. Both heparinized and nonheparinized micropipets are
available. Use the appropriate anticoagulant for the test ordered. Mix the specimen as
necessary.
7. Apply pressure and dispose of the puncture device.
8. Label the specimen container with date and time of collection and patient
demographics.
9. Indicate in the report that test results are from skin puncture.

Figure 9. Skin puncture, finger Fig. 10. Heel puncture

Arterial Blood Collection

Arterial blood collection are technically more difficult to perform. It is not usually
performed for routine blood tests. The samples collected are for arterial blood gas
analysis (ABG) which measures blood pH, level of oxygen (pO 2) and carbon dioxide
(pCO2) and bicarbonate (HCO2). It is also much more dangerous and painful than
venipuncture to the patient and requires in-depth training beyond routine phlebotomy
skills. It is usually performed by doctors and respiratory therapists. Increased pressure
in the arteries makes it more difficult to stop bleeding, with the undesired development
of a hematoma. In order of preference, the radial, brachial and femoral arteries are the
sites of collection. Unacceptable sites are those that are edematous, near a wound or
in an area of an arteriovenous shunt (AV) of fistula. Arterial spasm is a reflex
constriction that restricts blood flow with possible severe consequences for circulation
and tissue perfusion. Although small, the radial artery has good circulation and is easily
accessible along the thumb side of the wrist. Radial artery puncture can be painful and
associated with symptoms such as aching, throbbing, tenderness, sharp sensation and
cramping. The brachial artery is large and easy to palpate. It is located in the
antecubital fossa, below the basilic vein and near the insertion of the biceps muscle.
Despite its advantages, it is deep and is close to the median nerve. Puncturing the
median nerve is a significant risk in brachial artery collection. The femoral artery is the
largest artery located in the groin area above the thigh. Because of its large size, it has
the tendency to bleed more.

Before proceeding with the arterial puncture, the modified Allen test must be
performed to assess the adequacy of collateral circulation in the radial artery.

Modified Allen Test:ed Allen Test

1. Have the patient make a fist and occlude both the ulnar (opposite the thumb side)
and the radial arteries (closest to the thumb) by compressing with two fingers over
each artery.
2. Have the patient open his or her fist, and observe if the patient’s palm has become
bleached of blood.
3. Release the pressure on the ulnar artery (farthest from the thumb) only, and note if
blood return is present. The palm should become perfused with blood. Adequate
perfusion is a positive test indicating that arterial blood may be drawn from the radial
artery. Blood should not be taken if the test is negative. Serious consequences may
occur if this procedure is not followed, which may result in loss of the hand or its
function.

Materials for arterial blood collection would include heparinized syringe to

prevent coagulation (0.05 mL heparin/mL blood). Syringes must be either glass or gas-
impermeable plastic. Since the puncture is deeper, iodine and alcohol must be used for
disinfecting.

Arterial blood sample must be delivered to the laboratory immediately for

analysis. Blood cells continue to respire after collection and this may cause
considerable changes in analyte values. It must be analyzed within 30 minutes of
collection. Specimen transport requires ice. A delay in specimen transportation causes
increase pCO2, decrease pH & pO2. While introduction of bubbles or air to the sample
causes decrease pCO2, increase pH & pO2.
Complications of arterial puncture:
1. Arteriospasm
 2. Embolism or blood vessel obstruction, due to an air bubble or dislodged clot
in the artery.
3. Hematoma
4. Hemorrhage
5. Infection from skin flora
6. Nerve damage
7. Thrombosis or clot formation
8. Severe pain

*Arterial blood sampling should only be performed by health workers for whom the
procedure is in the legal scope of practice for their position in their country and who
have demonstrated proficiency after formal training.

Procedure for Arterial Puncture

1. Prepare the arterial blood gas syringe according to established procedures. The
needle (18–20 gauge for brachial artery) should pierce the skin at an angle of
approximately 45–60 degrees (90 degrees for femoral artery) in a slow and deliberate
manner. Some degree of dorsiflexion of the wrist is necessary with the radial artery, for
which a 23–25 gauge needle is used. The pulsations of blood into the syringe confirm
that it will fill by arterial pressure alone.
2. After the required blood is collected, place dry gauze over the puncture site while
quickly withdrawing the needle and the collection device.
3. Compress the puncture site quickly, expel air from the syringe, and activate the
needle safety feature; discard into sharps container.
4. Mix specimen thoroughly by gently rotating or inverting the syringe to ensure
anticoagulation.
5. Place in ice water (or other coolant that will maintain a temperature of (1°–5° C) to
minimize leukocyte consumption of oxygen.
6. Continue compression with a sterile gauze pad for a minimum of 3 to 5 minutes
(timed). Apply an adhesive bandage.

Complications in Phlebotomy

Objectives:
After completing this chapter, you should be able to:
1. Discuss the common complications encountered in phlebotomy.
2. Explain the actions to be taken if the patient has complications.

Although phlebotomy is routine, complications can arise and may interfere with
the procedure and test results (specimen integrity). The phlebotomist must be
knowledgeable about these complications and ways on how to handle them.

Problems in locating the vein

1. Difficulty in finding a vein
- Check both arms, inquire about sites of previous successful phlebotomy
- Massage gently, apply heat, rotate the wrist (to expose the cephalic vein), gently
tap the antecubital fossa with the index and middle finger to enhance vein
 prominence
- Use an alternative site when suitable vein cannot be found in the antecubital
fossa, the phlebotomist may have to collect from the hand, foot or leg. Care must
be employed when using the leg or foot because these are prone to infection and
clots, plus these are not recommended for diabetics and those on anticoagulant
therapy. The phlebotomist must ask permission first from the physician or
nurse.

2. Mastectomy patients
- Lymphostasis (lack of flow of lymphatic fluids in the affected area) results from
removal of lymph nodes adjacent to the affected breast tissue. It may affect
laboratory results. Venipuncture must not be performed on the same side as the
mastectomy.

3. Edematous tissue and hematomas

- Look for other suitable sites as fluids coming from these will affect laboratory
values.

4. Burns or scars
- Areas with burns or scars are prone to infections and maybe painful and difficult
to extract. Look for alternative sites or skin puncture maybe done.

5. Occluded veins
- Veins that are blocked or hardened due to some conditions such as
inflammation, chemotherapy or repeated venipunctures may be a challenge.
Look for alternative sites or skin puncture maybe done.

6. Dialysis patients or patients with vascular access device

- They pose special problems in locating the vein because of limited vein access.
Remember that blood should never be drawn from a vein in an arm with a
cannula (temporary dialysis access device) or fistula (a permanent surgical fusion
of vein or artery). A trained medical staff member (physician or nurse) can draw
blood from a cannula. The preferred venipuncture site is a hand vein or a vein
away from the fistula on the underside of the arm. In this case a tourniquet
maybe used below the fistula but should be released as soon as the vein has been
located. It should be noted that some dialysis patients are also on anticoagulant
medications thus special precautions should be taken.

- Some patients have vascular access device (VAD) or indwelling line in place that
may affect your collection. It is a tube inserted into either a vein or artery and is
used to administer fluid or medications, monitor blood pressure or draw blood.
Drawing blood from any of these sites is only performed by a physician or a nurse.

Examples are:
 a. central venous catheter- inserted in the subclavian vein and pushed into the
superior vena cava, proximal to the right atrium
b. implanted port- chamber located under the skin and connected to an
indwelling line
c. peripherally inserted central catheter- threaded into the central vein after
insertion in a peripheral vein, usually the basilic or cephalic, access from the
antecubital fossa
d. arterial line- placed in the artery for continuous monitory of blood pressure
e. heparin lock or saline lock- tube temporarily placed in a peripheral vein to
administer medicine or draw blood. These devices are most commonly inserted
in the lower arm just above the wrist and maybe left in place upto 48 hours. To
prevent a clot from blocking the line, it is flushed with saline (more commonly
used) or heparin.
f. arteriovenous shunt- artificial connection between an artery and a vein
g. external arteriovenous shunt- consists of a cannula with a rubber septum
through which a needle maybe inserted for drawing blood.

If blood to be tested is drawn from any of these sites, the first 10-20 mL
(depending on the site) of blood is first discarded since the site is often flushed
with saline or heparin.

Immediate local complications

1. Syncope
- It is the medical term for fainting. The phlebotomist must always ask before
extraction of the patient has any fear of needles or has had prior episodes of
fainting during or after collection. If the patient begins to faint, the phlebotomist
should remove the tourniquet and needle immediately and apply pressure to the
site; lower the patient’s head and apply cold compress to the back of the patient’s
neck and loosen any constrictive clothing. The patient should take some deep
breaths and be offered some cold water to drink. The patient should sit for at
least 30 minutes before leaving.

2. Hemoconcentration
- Increase in the number of formed elements in blood resulting either from
decrease or increase in plasma volume. This affects large molecules such as
plasma proteins, enzymes and lipids. Also increasing red cell counts, iron and
calcium. It can also alter potassium and lactic acid levels.

3. Hematoma
- It results from leakage of blood around the puncture site causes the area to
swell. If swelling occurs, remove the tourniquet immediately and apply pressure
to the site for at least 2 minutes. Hematomas may also result in bruising of the
patient’s skin around the puncture site if the pressure site is not maintained.
Blood that leaks out of the vein under the patient’s skin may clot and result in
nerve compression and permanent damage to the patient’s arm. A cool cloth or
cold pack can slow swelling from blood and ease pain.
- Most common causes of hematoma:
• needle goes through the vein
• bevel of the needle is only partially in the vein
• phlebotomist fails to apply pressure
 • excessive probing
• failure to remove tourniquet before needle
• bending the elbow while applying pressure

Figure 11. Proper and Improper Needle Insertion

Image source: www.calgarylabservices.com

4. Failure to draw blood

- Reasons:
• The vein is missed, most often due to improper positioning of the needle
(Fig 11). If this is the case:
a. the needle has passed through both sides of the vein, slowly
pull back on the needle
b. the needle is not advanced far enough into the vein, slowly
advance the needle
c. the vein was missed completely, pull the needle out slightly,
palpate to relocate the vein and redirect the needle
d. incorrect bevel position (bevel down)
• Excessive pull of the plunger- too much vacuum might cause collapsed
vein.
• Lack of vacuum of the evacuated tubes
5. Ecchymosis (bruising)
- Most common complication encountered in phlebotomy. It is caused by the
leakage of a small amount of fluid around the tissue. This can be prevented by
applying direct pressure to the site.
6. Petechiae
- Small red spots indicating that small amounts of blood have escaped into the
skin epithelium. Petechiae indicate a bleeding problem and should alert the
phlebotomist.

7. Puncture of the artery

- May cause pulsing or spurting of the blood. Apply direct pressure for at least
10 minutes.

Late local complications

1. Thrombosis
- Abnormal vascular condition in which thrombus develops within a blood vessel
of the body

2. Thrombophlebitis
- Inflammation of the vein often accompanied by a clot which occurs as a result
of trauma to the vessel wall

Late general complications

1. Infection
- The patient may acquire infection due to improper aseptic technique. Infections
would also include serum hepatitis and HIV due to needle injury.

2. Anemia
- Some patients are more prone in developing iron deficiency anemia due to
frequent phlebotomy and removal of large volume in respect of their total blood
volume.

3. Nerve damage
- Nerves in the antecubital area can be damaged if hit during collection. The
patient will experience pain down the arm or tingling/numbness. To prevent
nerve damage, avoid excessive or blind probing during venipuncture.

Top 10 errors in blood collection

1. Misidentification of patient
2. Mislabeling of specimen
3. Short draws or wrong blood to anticoagulant ratio
4. Mixing problems or clots
5. Wrong tubes or wrong anticoagulants
6. Hemolysis or lipemia
7. Hemoconcentration from prolonged tourniquet use
8. Exposure to light or extreme temperatures
9. Improperly timed specimens or delayed delivery to laboratory
10. Processing errors: incomplete centrifugation, incorrect log-in, improper storage

Reasons for specimen rejection

1. Hemolysis
- Causes of hemolysis:
a. using needle that is too small
b. pulling a syringe plunger too fast
c. expelling blood vigorously into a tube
d. forcing blood from a syringe into an evacuated tube
e. shaking or mixing tubes vigorously
f. extracting before antiseptic has dried up
2. Clots present in an anticoagulated specimen
3. Nonfasting specimen when test requires fasting
4. Improper blood collection tube
5. Short draws, wrong volume
6. Improper transport conditions (ice for blood gases)
7. Discrepancies between requisition and specimen label
8. Unlabeled or mislabeled specimen
9. Contaminated specimen/leaking container