Use to break the chain of infection Prevent transmission of disease

Hand hygiene
Washing of hands Antiseptic hand cleanser

Gloves Gowns Face protection Sharp disposal Respiratory hygiene and cough etiquette

NOTE: All specimen must be treated as potentially hazardous.

Controllable variables
Physiologic variables Diet Lifestyle Drug administration Biologic influences Environmental factors Long term cyclic changes Underlying medical conditions

Non-controllable variables

Posture

supine to upright position reduction of individual blood volume (10% -600-700mL of blood) INCREASE: proteins, enzymes, and protein hormones Drugs, calcium and bilirubin that partially circulate with proteins.
INCREASE: Potassium with 30mins of standing

Prolonged bed rest

Result to fluid retention DECREASE: INCREASE:
TP and albumin by an average of 5-3g/L urinary nitrogen excretion, Calcium, Sodium and Potassium and Sulfate excretion

Exercise
Effect is related to the intensity of the activity INCREASE: ALT, CPK, LDH and aldolase, lactate, ammonia, GH, prolactin, testosterone and LH. INCREASE: creatinine DECREASE: Cholesterol and TAG Athletes generally have higher level of serum activity for enzymes of skeletal musclular origin at rest than non-athletes INCREASE: urea, UA, creatinine, thyroxine, HDL DECREASE: Cholesterol, LDL, TAG

Physical training

Circadian variations(having 24 hours cycle)/ Diurnal variation (happening daily)

Serum iron, potassium, corticotropin secretion, testosterone, GH

Blindness
Plasma Na and Cl are often low in blind due to decreased aldosterone secretion DECREASE: glucose, uric acid excretion, SLIGHTLY INCREASE: serum creatinine, BUN

Travel
Travel across several time zones affects circadian rhythm 5 days-required to establish new and stable diurnal rhythm During flight: increase in glucose and TAG Prolonged flight:
increase: fluid and Sodium retention

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Food ingestion

The biggest increase: Glucose Fatty meal: Inc: ALP Protein rich meal: Inc: BUN, phosphate and UA Chole and GH Large Protein meals: Inc: chole and Growth Hormone Effects of meal may be long lasting

Ingestion of beverages and specific foods

decrease glucose, insulin response Stimulates adrenal medulla

BRAN: decrease absorption of calcium, chole and TAG SEROTONIN: (bananas, avocados, onions) CAFFEIN

Inc: excretion of cathecolamines, glucose 2 cups of coffee: INCREASE: Free fatty acids, glycerol, Lipids and Lipoproteins Potent stimulant of gastric secretion of HCl and Pepsin

Vegetarianism
In long term
Decrease: Lipoproteins, urea levels and albumin concentration

Obesity
Increase: Lactate dehydrogenase

AST, Creatinine, TP, Calcium, cortisol

Decrease: phosphate, GH

Malnutrition

INC: gamma globulin DEC: TP, albumin, and all the activities of most commonly measured enzymes Body attempts to conserve protein at the expense of other source of energy such as fat Within the 1st 3 days of the start of a fast blood glucose dec by as much as 18mg/dL (1mmol/L) Lipolysis result to ketogenesis Serum TAG increase after 48hours of fasting
INC: ketone, fatty acids and glycerol.

Fasting / starvation

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Smoking
The extent of effect is related to the number of cigarettes. Increase: lactate, insulin, epinephrine, GH Increase: RBC ct, carboxyhgb, WBC (30%) Albumin, chole, glucose, TAG, urea and phospholipid.

Alcohol ingestion
Increase: glucose, UA, TAG Decrease: testosterone Gamma glutamyl transferase marker of persistent drinking bac

Example:
Chemotherapy drugs: decrease in blood cells Toxic to liver: inc AST, ALT, ALP and LDH Opiates (morphine): inc. Liver enzymes and pancreatic enzymes Steroids and diuretics: amylase and lipase

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Age Sex

RBC and WBC are normally higher in newborns than adults RBC, Hgb and Hct NV are higher for males than females Blacks have higher TP than whites

Race

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Altitude

Higher altitude: higher Hgb, RBC 2,3DPG, GH

Ambient temperature Place of residence

Sweating: hemoconcentration

Heavier automobile: high carboxyhgb INC: serum chole, TAG and Mg in individual living in area with hard water.

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Seasonal influences
Composition of body fluids related to seasonal dietary changes and altered physical activity.

Menstrual cycle
Female sex hormones Ex: plasma corticosteroid is higher in Luteal phase than in Follicular phase.

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Fever
Increase: Glucose, Glucagon, TP and GH

Shock and trauma Transfusion

Increase in plasma proteins depending on the amount of blood administered

Whole blood Plasma Serum

Venipuncture Arterial puncture Skin puncture

A.

B.

C.

Evacuated tube system vacutainer two-way needle, plastic tube holder and evacuated tube Syringe method: barrel and plunger to which needle is attached Butterfly infusion set

Patient Interaction

Patient identification Note isolation restrictions Reassure patient Position the patient

Assemble supplies and equipment Venipuncture

Select the site Cleanse the area Inspect the needle Perform the venipuncture Protecting the puncture site

Specimen preparation

If syringe is used, fill the tubes Discard the needle Label specimens Transport the specimen

Conscious inpatients/ hospitalized patients Sleeping patients Unconscious/ mentally incompetent patients Infants and children Outpatients / ambulatory patients

Sleeping / unconscious patients Presence of visitors Apprehensive patients Language problem Patient refusal

Observe infection control and isolation policies

Prevent the spread of disease Protect the patient

Adhere to the dietary restrictions.

Gain the patients confidence Never give false reassurance

Needles Evacuated tubes Tourniquet Syringe Transfer device Tube holder Winged infusion sets Solution for skin preparation Needle disposal container

For syringe For evacuated system

Single sample needles: w/o rubber sleeve Multisample needles: with rubber sleeve Single sample needle

* The most appropriate needle gauge and lenght depends on the size and depth of the patients vein and the amount of blood to be drawn.

Used to provide a barrier against venous blood flow. Help locate the vein

Additives in collection tubes: -preserve a specific blood constituent or aid in the separation of serum from cell. -indicated by color of rubber stopper
Antiglycolytic agent
Sodium fluoride, lithium iodoacetate

Anticoagulant Clot activator Separator gel

Short needle with a thin tube with attached plastic wings For infants and children

70% isopropyl alcohol Iodine Chlorhexidine gluconate/isopropyl alcohol Benzalkonium chloride (zephiran chloride)

7.5-10 cm (4-5 inches) above the selected site. Increase the venous filling

Newborns
External jugular veins Temporal vein Superior longitudinal sinus

18months to 3 years
External jugular vein Temporal vein Femoral vein Long saphenous vein Popliteal vein Ankle vein

Check the other arm Enhance the vein prominence Use an alternative site

IV lines in both arms Burned or scarred areas Areas with hematoma Thrombosed veins Edematous arms Partial/ radical mastectomy on one or both arms Arms with arteriovenous (AV) shunt or fisula Casts on arms

Presence of the following conditions may alter the quality of a specimens / cause harm to the patient. In case another site may be chosen Occluded veins (blocked veins) / sclerosed veins (hardened)
Inflammation, disease, repeated venipuncture, chemotherapy Can obstruct the vein, slowing blood flow

Hematomas

Edematous tissue Burns / scars Mastectomies (removal of one or two breast)

Can result to lymphostasis.

Site should be rubbed vigorously in a circular motion starting from the center moving outward. Allow the area to dry

No hooks or obstruction Expel air

Anchor the vein Align the needle (bevel up) Insert the needle

Release tourniquet Remove needle and apply pressure Discard needle Transfer specimen Label specimens

Name of the patient Hospital number Age and sex Birthday Date and time collected Phlebo initials

Defective evacuated tubes Improperly positioned needle

The bevel is stuck to the vein wall The needle has passes through the both sides of the vein The needle is partially inserted Needle beside the vein
Movable veins

Collapsed vein
Too much vacuum on small veins Excessive pull of plunger. Tourniquet tied too tight or too close to the puncture site When the tourniquet is removed during the blood draw.

Inadvertent puncturing the artery Failure to collect on first try

Syringes or butterfly may be advantageous Gauge 23-25

Allergies to equipment and supplies Excessive bleeding Fainting / syncope :

Nausea and vomiting Pain Seizures / convulsion

Rare event

2nd most common Loss of consciousness due to insuff. Blood flow to brain Use ammonia inhalants to revive the patient Extreme pain remove the needle for any reason. The veni should be terminated immediately

Ecchymoses (bruises): most common

Due to the leakage of small amount of fluid around the tissue PREV: apply pressure to the site/ do not bend

Hematoma

Most common complication REASONS:

Excessive pull of plunger Blowing the vein Inadequate pressure application Bending the elbow while applying pressure

Ice applied in the first 24hrs helps manage swelling and discomfort After 24hrs apply warm compress

Iatrogenic anemia: Iron deficiency anemia Inadvertent arterial puncture: Infection

IATROGENIC:use to describe an adverse condition brought on the effects of treatment Rare Can result to compression injury to nearby nerve AIDS Hepatitis Formation scar

Vein damage

Compartment syndrome

Pressure in the tissue prevents the blood from flowing freely. In patients receiving anticoagulants Permanent damage to nerves Nerves contacted by needle. Improper vein selection SIGNS:
Extreme pain Burning / electric shock sensation Numbness of arm Radiating pain

Nerve injury

Tourniquet application: if blood pressure cuff is used as tourniquet, it is inflated to 6o mmHg Disinfection of the site for puncture: no traces of alcohol should remain on the skinn because it may cause hemolysis and may contaminate glucose testing. For ethanol testing, to prevent contamintaion use benzalkonium chloride solution as skin cleansing agent.

Needle specification and bevel position: the gauge of the needle is inversely related to the size of the needle, the larger the gauge the smaller the needle bore and length; 21 and 22 used for blood collection; 23 for children; 21,23 and 25 for butterfly needle; Needle lenght: 1-1.5 inches ( to inches butterfly needle) The color coding for needles indicates the gauge

INDICATIONS:
pediatric patients Geriatric Patients with fragile veins, poor circulation obese thrombotic tendencies Glucose monitoring

Lancet Automatic puncture devices:

puncture to a predetermine depth

Microsample containers
Microcollection tubes bullets Micropipette Caraway or Natelson pipette Capillary tubes

Heel warmer/ warming device

Lateral or medial plantar heel Plantar surface for the big toe 3rd and 4th finger Earlobe

Warm the site Punctures should not be made more than 2mm deep for infants; for adults 2-3mm deep First drop should be wiped away

Osteochondritis Osteomyelitis

measure oxygen and CO2 tension and to measure pH. Ammonia, lactic acid

Radial artery Brachial artery Femoral artery Scalp artery Umbilical artery

Glass or plastic syringe Needles Heparin Warm towel Rubber cap Iced water bath Alcohol or iodine lidocane

Arteriospasm: spontaneous constriction of

artery

Nerve damage Hematoma Thrombosis Hemorrhage infection

Pediatric Geriatric Patients requiring chronic blood draws Patients in ICU and ER

Provide ready access to the patient circulation. Ex.: Central venous catheter

Most common TYPES:

Broviac Groshong Hickman Triple lumen

Proper patient identification Proper patient preparation Specimen collected in the correct order and labelled correctly Correct anticoagulants and preservatives used Specimen not hemolyzed Timed specimens drawn at the correct time

Most common anticoagulants: EDTA Citrate Heparin Oxalate Special use anticoagulants Acid citrate dextrose Citrate phosphate dextrose Sodium polyanethanol sulfonate

Prevents coagulation by binding with Calcium Used as disodium, dipotassium or tripotassium Conc: 1-2mg/mL

Chelates calcium Widely used for coagulation Inhibits: AMS and LPS Concentration: 3.4-3.8g/dL in a ratio of 1:9 parts of anticoagulant to blood

Inhibits coagulation by chelation For immunohematology test DEXTROSE: acts as preservative and nutrient of RBC

Used for collecting blood for transfusion

Prevents coagulation by inhibiting thrombin and thromboplastin Universal anticoagulant It is a mucoitin polysaccharide Concentration: 0-2mg heparin/mL of blood Available as
Sodium, potassium and lithium ammonium salts

Uses:

Prevents coagulation by precipitating calcium Potassium oxalate: most widely used It is commonly added to tubes containing glucose preservatives Inhibits: LDH, ACP, AMS, LPS Concentration: 1-2 mg/mL of blood Uses: hgb and hct, rbc & wbc count, coagulation studies

Prevents coagulation by chelating calcium For blood collection tubes Inhibits:

Phagocytosis activity of complement Activity of certain antibiotics

Sodium fluoride
Weak anticoagulant Inhibits glycolytic enzyme enolase Concentration: 10 mg/mL of blood Interferes with Na, K, and most BUN

Lithium iodoacetate

Hemoconcentration Hemolysis Partially filled tubes Specimen contamination

Minimize:
Additive carryover/ cross contamination Tissue thromboplastin Microorganism

1. 2. 3. 4. 5. 6.

Sterile tubes Coagulation tubes Serum tube Heparin tube EDTA tube Glycolytic inhibitor tube

Time constraints Temperature consideration Protecting specimens from light

Quality = time bet drawing of sample and analyzing it Glycolysis Sample should be delivered to the laboratory within 45 mins STAT : immediately SERUM/ PLASMA separation: not >2hrs

Keeping the specimen warm Keeping the specimen cool

Light sensitive analytes

Bilirubin Vitamin B12 Carotene Folate Urine porphyrin

No requisition form Unlabelled or incompletely labelled Incompletely filled tubes Defective tubes Hemolysis Clot in tubes with anticoagulant Contaminated specimen Improper handling

Cold agglutinins Test requiring chilled specimens Light sensitive specimens Time sensitive specimens Legal ROH collection

Clotting Centrifuging Removing a stopper Aliquot preparation